24 - Special Issue 1 PDF

Scientific Journal Published by the
College of Dentistry University of Baghdad
Vol. 24 No. Special Issue 1 2012

ISSN
ISSN
1680-0087
A quarterly peer reviewed published scientific journal of the College of Dentistry,
University of Baghdad.
Editor in chief: Prof. Dr. Nabil Abdulfatah Hatoor, M.Sc
Vice editor in chief: Prof. Dr. Hussain Faisal Al-Huwaizi M.Sc., PhD
National Members International Members

Prof. Dr. Khulood Al-Safi MSc, PhD Prof. J. L. Gutmann D.D.S., Ph.D.(USA)
Prof. Dr. Adel Farhan MSc Prof. Dr. M. Goldberg PhD (France)
Prof. Dr. Zainab Al-Dahan MSc
Prof. Dr.Abbas Sabri M.Sc., PhD
Prof. Dr.Wasan Hamdi M.Sc, PhD
Assist. Prof. Dr. Fakhri Al-Qaisy M.Sc
Assist. Prof. Dr. Sabah Nema M.Sc., PhD
Prof. Dr. Nidhal Hussain MSc
Assist. Prof. Dr. Sahar Shaker MSc
Assist. Prof. Dr. Ghassan Abdulhameed
MSc
Board of editorial consultants:
1- Prof. Dr. Majida Al-Hashimi MSc 5- Prof. Dr. Shatha Saleem MSc
Assist. Prof. Dr. Akram Al-Huwaizi MSc, 6- Assist. Prof. Dr. Maha Shukri MSc
PhD
3- Prof. Dr. Mohammad Al-Qaisi MSc 7- Assist. Prof. Dr. Abbas Fadhil PhD
4- Prof. Dr. Raja Hadi MSc, PhD 8- Lecturer Dr. Jamal Abid MSc
Secretarial committee:
1- Lecturer Dr. Mohammad Nahidh
2- Lecturer Yassir AbdulKadum
3- Assist. Lecturer Ahmed Fadhil
4- Assist. Lecturer Ayad M. Al-Obaidi
For consultation, please contact:
Website: www.codental.uobaghdad.edu.iq
E-mail: baghdad_dentistry@yahoo.com
Telephone: (+9641)4169375 Fax: (+9641)4140738
i
Contents
i Editor and Editorial Board
ii Contents
v Instructions for the Authors
Restorative Dentistry
Evidence for feasibility of aluminum potassium sulfate (alum) solution as a root canal irrigant. Bestoon
1 M. Faraj
Microleakage of class II packable resin composite lined with flowable composite and resin modified glass
6 ionomer cement: An in vitro study. Haitham J. AL-Azzawi, Nagham A. AL-Hyali, Firas J. M. Al-Dabbagh
A comparison between the arbitrary and kinematic intercondylar distances of full mouth rehabilitation
11 patients (An in-vivo study). Ma'an R. Zakaria, Hussain F. Al-Huwaizi, Widad A. Alnakkash
A clinical comparison between maxillary and mandibular posterior teeth using local anesthesia and
18 normal saline by the periodontal ligament injection (An in vivo study). Majidah K.W. AL-Hashimi,
Raad S. Al-Doori
Comparative study of wettability of different lining, tissue conditioning and denture base materials (in-
24 vitro study). Mostafa S. M. Al-Shaikhli, Amir H.M. Khamas
Evaluation of different techniques used in non surgical endodontic retreatment for teeth with different
31 obturation techniques (An in-vitro study). Nsar Muhyaddin Aziz, Dara Hamarashed Saeed
The effect of addition of calcium hypochlorite disinfectant on some physical and mechanical properties of
36 dental stone. Shorouq M. Abass, Ibrahim K. Ibrahim
Comparison the tensile strength of heat cure and visible light cure acrylic resin denture base. Zahraa N.
44 Al- Wahab, Bassam A. Hanna, Shakwaan K. Kadir
Oral Diagnosis
Evaluation of the effect of Nigella sativa oil and powder on healing process, histologically and
48 radiographically (An experimental study on rabbit). Hani Sh. Mohammed, Athraa Y. Al-Hijazi
ii
Evaluation of topical versus systemic medications in the treatment of neuropathic orofacial pain
53 A prospective study. Ihsan A. Kumail
Assessment of cadmium levels in Blood, hair, saliva and teeth in a sample of Iraqi workers and
60 detection of dental findings. Raja H. Al-Jubouri, Ammar Issa Bashbosh
Changes in oral flora of newly edentulous patients, before and after complete dentures insertion.
65 Saeed Abdul Latteef Abdul-Kareem
Topical treatment of herpes simplex lesion by lavender cream. Tagreed Altaei, Shaheen Ali Ahmed
70
Oral and Maxillofacial Surgery and Periodontology

The prevalence of overhanging m a r g i n s in posterior filling restorations and periodontal
77 consequences. Alaa'Omran , Abdul Karim Abed Ali
Biochemical analysis and periodontal health status in type 1 and type 2 diabetes (Comparative study)
80 Salah Mahdi Ibrahim, Leka'a M. Ibrahim
The correlation between hemoglobin level and generalized moderate chronic periodontitis. Suzan Ali
85
Orthodontics, Pedodontic, and Preventive Dentistry

Oral hygiene and gingival condition among epileptic patients 5-15 year-old (A comparative study)
89 Azhar A. Hussien, Athraa M. AL-Weheb
The reliability of bisecting interpupillary perpendicular line, facial and dental laterality and
94 coincidence in adult normal occlusion Iraqi sample (A photographic, cross sectional study). Dina A.
Hassan, Nidhal H. Ghaib
Dental arches dimensions, forms and the relation to facial types in a sample of Iraqi adults with
99 skeletal and dental class I normal occlusion. Haider M.A. Ahmed, Fakhri A. Ali
The relationship between the dental caries and the blood glucose level among type II non insulin
108 dependent diabetic patients. Hawraa Khalid Aziz
Dental knowledge and behavior among technical medical institute students in Baghdad governorate
115 Jinan Mohammed Rashad
A new calibration procedure for expectation of arch length. Mustafa M. Al-Khatieeb, Layth M. K.
120 Nissan, Mushriq F. Al-Janabi
Oral health status among children Downs syndrome in Sumawa city, Iraq. Raya R. Al-Dafaai
127
Effects of Pimpinella Anisum extract on salivary counts of Streptococci and Mutans Streptococci in
131 comparison to Chlorhexidine in vivo. Sabreen S. Abd Al- Muhsen, Wesal A. Al-Qbaidi
iii
The characteristics of profile facial types and its relation with mandibular rotation in a sample of
135 Iraqi adults with different skeletal relations. Sara M. Al-Mashhadany, Nagham M.J. Al- Mothaffar
Dental calculus in relation to idiopathic calcium renal stone. Shaimaa Kh. Yaser, Mohammed S. Al-
140 Casey
Psychological impact of dental aesthetics for Kurdish young adults seeking orthodontic treatment.
146 Trefa M. Ali Mahmood, Fadil A. Kareem
Basic Sciences
Antibacterial efficiency of salvia officinalis extracts and their effect on growth, adherence and acid
153 production of oral Mutans Streptococci. Hadi A. Hmeem Al-Lamy, Abbas S. Al-Mizraqchi
Relationship between Herpes simplex Virus Type-1 and Candida albicans in Pregnant Women with
158 Aphthous Stomatitis in the oral cavity. Mohammad T. Abdul Hussin, Sana A. AL-Shaikhly
Study the role of proinflammatory and anti- inflammatory cytokines in Iraqi chronic periodontitis
164 patients. Zahraa F. Shaker, Batool H.Hashem
iv
Instruction for the Authors
The Journal of the College of Dentistry accepts manuscripts that address all topics related to
dentistry. Manuscripts should be prepared in the following manner:
Typescript. Type the manuscript on A4 white paper, with page setup of 2.5 cm margins. Type the
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stability.etc).
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Number references consecutively in the order in which they are first mentioned in the text. Identify
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sentence as superscription ex. (2).
Use the style of the examples given below in listing the references at the end of the manuscript :
Book
1. Hickey JC, Zarb GA, Bolender CL. Bouchers prosthodontic treatment for edentulous patients. 9th
ed. St. Louis: CV Mosby; 1985. p.312-23.
Journal article
4. Jones ER, Smith IM, Doe JQ. Occlusion. J Prosthet Dent 1985; 53:120-9.
Tables. All tables must have a title placed above the table. Identify tables with Arabic numbers (e.g.
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original and two copies) and a (CD) containing the article.
v
J Bagh College Dentistry Vol. 24(special issue 1), 2012 Evidence for feasibility
Evidence for feasibility of aluminum potassium sulfate

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

various food preparation processes such as
It is known that removal of vital and necrotic
pickling and fermentation and as a flocculants for
remnants of pulp tissues, microorganisms, and
water purification among other things.
microbial toxins from the root canal system is (13)
Moreover the FDAs over the Counter
essential for endodontic success. (1, 2) Although
Advisory Panel has recommended alum as
this might be achieved through chemomechanical
category I active ingredient in mouthwashes. (14)
debridement. (3) An uninstrumented area with
Potassium aluminum sulfate (Alum) in
organic and inorganic debris still present and it is
concentrations of 10% and 100% is used in
impossible to shape and clean the root canal
mechanico- chemical gingival displacement. (15, 16)
completely. (4, 5) Therefore, irrigation is an
The purpose of this study was to evaluate, in
essential part of root canal debridement because it
vitro, the aluminum potassium sulfate (alum)
allows for cleaning beyond what might be
solution, in respect to their antibacterial action
achieved by root canal instrumentation alone. (6, 7)
against common bacterial isolates found in
During mechanical root canal instrumentation,
infected root canals, including facultative
formation of a smear layer occurs which consists
anaerobic microorganisms (Staphylococcus
primarily of fine inorganic particles, along with
aureus, Escherichia coli and klebsiella sp), and
some organic material from necrotic and/or viable
aerobic bacteria (Pseudomonas aeruginosa), using
pulp tissue, odontoblastic processes, bacteria and
agar well diffusion test , and to investigate their
blood cells. (8, 9) Despite controversy over
debridement and smear layer removing efficiency
maintaining the smear layer, it has been shown
from the prepared root canals on freshly extracted
that the smear layer itself may contain bacteria
human teeth, by a scanning electron microscopy
and protect the bacteria within the dentinal
study.
tubules. The smear layer has also been shown to
hinder the penetration of intracanal disinfectants
and sealers into dentinal tubules and can MATERIALS AND METHODS
potentially compromise the seal of the root canal This study received approval from the ethics
filling. (10, 11) committee of the University of Sulaimani,
Natural products have been used for centuries Sulaimani, Iraq.
in treating human diseases and they contain Preparation of alum solutions
components of therapeutic value. Natural products Seven hundred grams of alum material were
are environmentally safer, easily available, and purchased from the local botanical market of
cheap. (12) Alum (Aluminum potassium sulfate), Sulaimani, and were identified in the College of
the crystallized double sulphates with the formula Science, Department of Chemistry, Sulaimani
KAl(SO4)2.12H2O, are generally odourless, University. Crystals of alum
colourless crystalline solids that turn white in air, KAl(SO4)212(H2O).dissolved completely in hot
(1) Lecturer,Conservative Department, School of Dentistry, (distilled) water at 92Co, to obtain a final
Faculty of Medical Sciences, University of Sulaimani. concentration of 1 gm /mL, at pH 3.6
Restorative Dentistrty 1
Bacterial samples the root canals were filled with the tested
The bacterial isolates used in this experiment endodontic irrigants through the pulp chamber
were obtained from the College of Science using 3 ml disposable syringes and 30-gauge
(Department of Biology), University of needles, which were placed to approximately 34
Sulaimani. These bacteria were: Staphylococcus mm from the working length without binding as
aureus, Klebsiella sp., Psedomonus aerogenosa described by Monika and Izabel. (20) Each time the
and Escherichia coli. All the isolates were files were substituted, the canals were thoroughly
collected from infected root canals and cultivated rinsed with alum solution, aspirated and refilled
in suitable culture medium; Staphylococcus with a new quantity of this solution.
aureus in Muller-Hinton agar and the other After final irrigation with 5.0 ml of distilled
isolates were cultivated in Mackoncky agar. water to terminate the action and eliminate any
Evaluation of antibacterial activity of the alum precipitates from the irrigants according to
solution methodology described by Manuele et al. (21) The
Agar well diffusion method was used to root canals were carefully dried with paper points.
evaluate, in vitro, the antibacterial effect of the Then, by using a diamond disk mounted on a low-
alum against the common bacterial isolates found speed handpiece, with a constant water spray,
in infected root canals, by means of agar-well longitudinal and transversal grooves, which did
diffusion assay. (17, 18) Fifteen milliliters of the not penetrate into the canal, were prepared along
molten agar (45 C) were poured into sterile petri the buccal and lingual surfaces of each root.
dishes ( 90 mm).50 l from each bacterial Afterwards, the roots were carefully fractured
isolate (Cell suspensions containing 108 CFU/ml with the aid of a chisel and a surgical mallet. The
cells), were taken separately and evenly spread cervical, middle and apical thirds were divided,
onto the surface of the agar plates of Mueller- thereby providing three sections from each
Hinton agar using a micropipette as described by portion. The roots were mounted on stubs, put in a
Bauer et al. (19) Wells (6mm diameter, and 4mm vacuum chamber, sputter coated with gold-
height) were bored using a sterile cork borer. palladium ~35 nm thick with a sputter coater for
Different concentrations of the test solution were SEM evaluation. After that an observation with a
placed into the wells and the plates were scanning electron microscope is given.
incubated aerobically and under CO2 incubation Specimen grading
at 37C for 24 h. After 24 hours of incubation, the Randomly assessment in each third of each
plates were removed from the incubator and are half-root at a magnification of 1000x was done.
examined for the inhibition zone around each well One photomicrograph for each specimen was
(if present), by using the ruler (minimum taken to visualize the coronal, middle, and apical
calibration: 1mm). portion of the root canal system. The areas
Scanning electron microscopy study examined for each sample were standardized
The goal of this part of the study is to assess by using parameters similar to those proposed by
mean of scanning electron microscopy, the AL-Hadlaq et al. (22), and Soares et al. (23) with
debridement and smear layer removing ability of some modifications.
alum solution tested as an irrigants, on the A total of 36 images were analyzed by a
cervical, middle and apical thirds of root canals of calibrated, blinded evaluator using the following
human extracted teeth.Six freshly extracted scoring system : Score 1, clean surface with very
human single-rooted teeth with straight roots, little to no debris, presenting open dentinal
mature apex and less than 5 degree curvature, tubules throughout the canal wall (figure 1A);
were selected for this part of the study. The crown Score 2, clean surface with some scattered debris
of each tooth was removed at the cemento-enamel and/or thin homogenous smear layer with some
junction using a diamond disk. The working open or partially open dentinal tubules (figure
length of each canal was determined by placing 1B); Score 3, mostly unclean surface containing
and moving a #15 K file apically in the canal until debris and smear layer with few visible open or
it exited from the apical foramen. partially open dentinal tubules (figure 1C); Score
Root canals were manually instrumented 4, unclean surface with large amount of debris and
according to a step-back type of instrumentation smear layer with no visible dentinal tubules
using sequential K-type files up to size #40. First, (figure 1D).
A B C D
Figure 1: (A) This sample received a score of 1. It shows most of the dentinal tubules are open
with a clean surface and very little debris. (B) This sample received a score of 2. It shows a clean
surface with very little debris, a thin homogenous smear layer, and some partially open dentinal
tubules. (C) This sample received a score of 3. It shows a mostly unclean surface containing
debris and smear layer and few open dentinal tubules. (D) This received a score of 4. It shows an
unclean surface with large amounts of debris and smear layer with no open dentinal tubules.
RESULTS
Agar well diffusion assay mm against Staphylococcus aureus, Pseudomonus
The mean diameters of the zones of bacterial aerogenosa ,Eschericia coli, and Klebsiella sp.
inhibition for the tested solution against the respectively. The results revealed that the wider
bacterial isolates are shown in Table 1. Alum inhibition zone was seen against Staphylococcus
solution were able to demonstrate antibacterial aureus, and the least inhibition zone was against
activity against all the bacteria tested, and Klebsiella sp.
produced inhibitions zones of 27, 25, 24 and 22
Table 1: The mean diameters of the zones of bacterial inhibition for the tested solution against
the bacterial isolates
Inhibition zones (in mm)
Bacterial isolates produced by test solution
Mean
Staphylococcus aureus 27
Pseudomonus aerogenosa 25
Eschericia coli. 24
Klebsiella sp 22
Scanning electron microscopy study the coronal and middle level than the apical level.
The data is summarized in Table 2. The tested (figure. 2)
solution removed debris and smear layer better at
Table 2: The effect of alum solution on the debris and smear layer at the three locations in the root
canals
Score 1 Score 2 Score 3 Score 4
Coronal third 9 3 - -
Middle third 7 3 2 -
Apical third 3 4 3 2
A B C D
Figure 2: Representative SEM photomicrographs of samples attributed to different root thirds:
A) Score 1-coronal third, B) Score 2-Apical third, C) Score 3-Middle third, D) Score-4 Apical
third.
DISSCUSION CONCLUSIONS
A biocompatible irrigant with antimicrobial Based on the results of this study, it seems that
activity and which removes smear layer along alum solutions have acceptable antimicrobial
with necrotic and organic debris is desirable, as effect on tested bacterial isolates, however this
long as predictable and complete bacterial finding is promising and warrants further
elimination does not appear to be possible, either laboratory experiments on different types of
with traditional hand instrumentation or with bacteria, including strict anaerobic and species has
newer rotary NiTi systems. With the latter at been significantly found to persist after treatment
least 35 per cent of root canal surfaces still remain procedures. The degree of cleanliness obtained
uninstrumented. (24) with alum solution (concerning debris and smear
This study is the first to report the feasibility of layer), was highly satisfactory, however the
alum as an endodontic irrigant, based on the most cleaning effect was more pronounced in the
important requirements of an ideal root canal coronal and middle thirds than in the apical parts
irrigant, which are antimicrobial activity, of the root canals.
debridement and smear layer removing activity. Finally, other properties beyond antimicrobial
Two facultative anaerobic bacterial isolates were and debridement activity must also be
tested (S. aureus and E. coli), which are best investigated before the final choice of an irrigant
representing endodontic infections and were good solution for clinical use, such as tissue dissolution
models to be tested for antibacterial sensitivity, capacity, and acceptable biologic compatibility.
because these are present in all phases of the
development of an infection in root canals. (25, 26) REFERENCES
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during the treatment. 2. Siqueira JF Jr, Rocas IN. Clinical implications and
microbiology of bacterial persistence after treatment
In this study, no attempt was made to test all procedures. J Endod 2008; 34:291301.
associated organisms, because endodontic 3. European Society of Endodontology. Consensus report
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data, also no absolute correlation has been made 4. 4.Ferreira RB, Alfredo E, Porto de Arruda M, Silva
Sousa YT, Sousa-Neto MD . Histological analysis of
between any specific microbial species or the cleaning capacity of nickel-titanium rotary
combination of species with clinical signs and instrumentation with ultrasonic irrigation in root
symptoms. (27, 28) canals. Aust Endod J 2004; 30:568.
Analysis of the dentinal walls of all the 5. Gutarts R, Nusstein J, Reader A, Beck M . In vivo
specimens demonstrated that cleaning have been debridement efficacy of ultrasonic irrigation following
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than on the apical third. It is possible that the size 6. Svec TA, Harrison JW. Chemomechanical removal of
of the canals in these thirds, allowed better pulpal and dentinal debris with sodium hypochlorite
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Luigi C . A Comparative study of smear layer
J Bagh College Dentistry Vol. 24(special issue 1), 2012 Microleakage of class II
Microleakage of class II packable resin composite lined

with flowable composite and resin modified glass ionomer
cement: An in vitro study
Dr. Haitham J. AL-Azzawi, B.D.S., M.Sc. (1)
Dr. Nagham A. AL-Hyali, B.D.S., M.Sc. (2)
Dr. Firas J. M. Al-Dabbagh, B.D.S., M.Sc. (2)
ABSTRACT
Background: Packable composites most commonly used as posterior restorative materials, however, disadvantages
like polymerization shrinkage limited their use, so the aim of this an in vitro study was to investigate the microleakage
of posterior packable composite(Filtek P-60) using different liner materials; flowable resin composite(Filtek Flow)
and resin modified glass ionomer cement (Vitrebond TM 7150) using open sandwich technique at the proximal box of
class II preparation located above the cemento-enamel junction (CEJ)in enamel.
Materials and Methods: Twenty four recently extracted human upper premolars were prepared with standardized
Class- II cavities as follows; Occlusal Outline Form: 2mm in bucco-lingual width and 1.5 mm in depth measured from
occlusal fissure to pulpal floor. Proximal Boxes: The depth of the proximal box from the proximal cavo-surface margin
to the axial wall was 2mm, so as the bucco-lingual width (2mm). The proximal box margin located 1 mm coronal to
the CEJ (in enamel). The teeth were assigned into 3 groups (n=8): Group-I (control): acid etching (H H3PO4) + bonding
agent (Adoper Single Bond 2 Adhesive) + posterior packable composite (Filtek P-60), Group-II (RMGIC): acid
etching + resin modified glass ionomer cement (Vitrebond TM 7150) + posterior packable composite; Group-III
(Flowable): acid etching + bonding agent + flowable composite (Filtek Flow) + posterior packable composite.
The teeth were immersed in distilled water at 37C for 24 h., then thermocycled (1000X, 5-55C, 30 sec. dwell time)
and immersed in 1% methylene blue solution for 24 h., after that the teeth were sectioned longitudinally in mesiodistal
direction and dye penetration in millimeters were measured in each cavity by using stereomicroscope. Data
obtained were analyzed using ANOVA and LSD tests at 0.05 significance level.
Results: The microleakage of posterior packable composite (group-I) significantly (P<0.05) decreased by the two
liners used (group-II and group-III), but there is no statistically significant differences (P>0.05) in enamel microleakage
in respect to dye penetration were detected between the two liners used (group-II and group-III), with the
association flowable composite Filtek flow (group-III) showing the best results.
Conclusion: The use of flowable composite (Filtek Flow) and resin modified glass ionomer(Vitrebond TM 7150) in the
open sandwich technique decrease the microleakage of posterior packable composite(Filtek P-60) with margin
located in enamel surface and better results with flowable composite.
Keywords: Flowable, microleakage, RMGIC and packable composite. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):6-
10).
INTRODUCTION
Composite restorations have become a popular Packable composites are indicated for stress
alternative to amalgam restorations in posterior bearing posterior restorations with improved
teeth. Increase patients demand for better handling properties. (1-4)
esthetic, possibility of mercury toxicity from Packable composites use amalgam techniques
amalgam and improvements in composite for placement and produce acceptable
materials has significantly contributed the interproximal contacts and because of the high
popularity of these materials. However posterior depth of cure and low polymerization shrinkage
composite restorations have many clinical of packable composites, a bulkfilling technique
problems including: severe leakage, secondary may be possible.(1)
caries, loss of anatomic form and high rate of Clinicians are concerned with poor
wear. To overcome these short comings, adaptations of the material to tooth structure
Packable composites have been introduced to the when placing posterior restorations. A materials
dental market.(1) The increased viscosity of these ability to seal cavity preparations can be
materials permits for greater packability with less influenced by its composition, plastic
slumping characteristics and lower deformation flow, coefficient of thermal
polymerization shrinkage as compared to expansion, modulus of elasticity and the
conventional universal composites. mechanical stresses caused by cavity preparation
(1)Professor, Conservative Department, College of Dentistry, and shape.(2)
Baghdad University. Composite resins have an initial
(2)Assistant Lecturer, Conservative Department, College of polymerization shrinkage ranging from 1.67-
Dentistry, Baghdad University.
5.68%. This shrinkage leads to the pulling of the
Restorative Dentistry 6
resin material from the walls of the preparations unprepared tooth surface using dispensing tips
and results in a gap between the restoration and for application. Then the gel was removed with
the tooth structure and causes microleakage. (3) water spray for 10 sec. (7)
Another factor affecting microleakage
directly is the difference between the co-efficient Bonding
of thermal expansion of the resin and the tooth Immediately after blotting excess water, two
structure. Temperature change also causes coats with fully saturated brush tip of Adoper
varying volumetric changes in the resin and tooth Single Bond 2 Adhesive ( see Table-1 for
structure leading to marginal leakage. (4) However composition and manufacture ) was applied onto
concerns related to the ability of these stiffer the etched tooth surface for 15 sec. with gentle
materials to adequately adapt to internal areas
and cavosurface margins have been raised. To Table 1: Materials used in the study: composition
offset this problem, materials with low viscosity
and manufacturers.
and better adapt to the cavity used under
packable composites. (1)
Material Type Composition Manufacturer
So, the purpose of this an in vitro study was
Resins: BisGMA,
to evaluate the microleakage of posterior UDMA and
packable resin composite restorations with and Filtek Bis-EMA
without liner using open sandwich technique at P-60 Packable Fillers: Zirconia/
3M ESPE, St.
Posterior composite silica - 61%
the proximal box of class II preparation located Restorative by volume. The
Paul, MN,
above the cemento-enamel junction (in enamel). USA
particle size range
(0.01 3.5 m)
Resins- BisGMA
MATERIALS AND METHODS ,TEGDMA and
Twenty four caries-free recently extracted Bis - EMA
human upper premolars were selected for this Filtek Flowable Fillers- Zirconia/ 3M ESPE, St.
Flow composite silica - 47% Paul, MN,
study. The teeth were cleaned and stored in by volume. The USA
normal saline until sample preparation. (5, 6) particle size range
Sample Preparation (0.01 to 6.0 m)
Powder: ion-
The teeth were sealed with a composite resin leachable
(Swiss Tec Composite, Coltene Whale dent) at fluoroaluminosilicate 3M ESPE, St.
the root apices and each tooth embedded in Resin glass powder Paul, MN,
VitrebondTM modified glass Liquid: modified USA
acrylic mould to hold the tooth during cavity 7150 ionomer polyacrylic acid
preparation, restorative and testing procedures. (5) cement With pendent
Cavity Preparation methacrylate group,
HEMA, water and
In each tooth, standardized Class II cavities photo-initiator
prepared as follow:
Occlusal Outline Form: 2 mm in bucco- Water/ethanol
HEMA, ethanol,
Adoper water, bis-GMA, 3M ESPE, St.
lingual width and 1.5 mm in depth measured single bond
solvent based
functional copolymer Paul, MN,
from occlusal fissure to pulpal floor. adhesive
2 adhesive of polyacrylic and USA
Proximal Boxes: The depth of the proximal polyitaconic acids
box from the proximal cavo-surface margin to
the axial wall was 2 mm, so as the bucco-lingual Super etch 37% Phosphoric acid
Total Etching SDI, Australia
width (2mm). The proximal box margin located gel etchant gel
1 mm coronal to the CEJ (in enamel).(5)
The cavity preparations were prepared by
using high-speed hand piece with water spray
and #1090 diamond fissure bur (Diatech Dental agitation, then gently air dried for 5 sec. to
AG, Heerbrugg, Switzerland). The teeth were evaporate solvents and light cured for 10 sec.,
divided into three groups of 8 cavities each. according to manufacturer's instruction.(5)
Restorative Procedure Sample grouping

Etching Group- I (control): The cavities were filled with
Enamel and dentin were etched with Super packable posterior composite (Filtek P-60, see
etch gel ( 37% phosphoric acid, see Table-1 for Table-1 for composition and manufacture) only
composition and manufacture) for 15 sec., without lining according to manufacturer
etching gel was applied to all of the prepared instructions. (1)
cavity wall approximately 0.5 mm beyond
Group-II (RMGIC): Resin modified glass RESULTS

ionomer cement ( VitrebondTM7150, see Table-1 The mean and standard deviation of
for composition and manufacture) was placed in microleakage values are presented in (Table- 2)
0.5 mm thick layer in axial wall and gingival and (Figure- 1). The data showed that there is
margin using open sandwich technique and light statistically significant difference (p<0.05)
cured for 20 sec.(7) between all groups in microleakage values by
Group-III (Flowable):- Flowable composite using ANOVA test (Table- 3). When the mean
(Filtek Flow, see Table-1 for composition and values of microleakage of the groups compared
manufacture) was applied in 0.5 mm increment by LSD test, the result showed that microleakage
depth in axial wall and gingival margin using of posterior packable composite in control group
open sandwich technique and light cured for 20 (Group-I) significantly decrease by using of
sec.(2) RMGIC (Group-II) or flowable composite
Filling (Group-III) as a lining, and the higher reduction
The matrix band was adjusted in the matrix was in group-III, but there was no statistical
retainer Ivory no. 8, then the retainer and the significant difference (P>0.05) between group-II
band were seated around the tooth which was and III in microleakage reduction (Table- 4).
held in the acrylic mold.(5) The cavities were
filled with packable composite as a restorative
material in bulk technique by using the plastic MICROLEAKAGE OF PACKABLE COMPOSITE
instrument and light cured for 20 sec. to restore
the cavities. All materials were polymerized
using a halogen light curing unit (Dentsply,
0.8
United Electronic Co.). Finishing procedure was
0.7
performed with a fine diamond bur (Diatech 0.6
Dental AG, Heerbrugg, Switzerland), then 0.7875 0.5
polished with a graded series of Sof-Lex discs 0.55
0.6375 0.4
(3M ESPE, St. Paul, MN, USA). Care was taken 0.3
to avoid polishing the cervical margin. (7) 0.2

0.1
Testing procedure 0
All teeth were stored in distilled water at 3 2 1
37C for 24 hours using incubator (JRAD,
China), then thermocycled for 1000 cycles, with Figure 1: Graphical presentation of
baths held between 5C and 55C, a dwell time microleakage values of all groups of the
of 30 sec. The teeth were previously sealed with study.
a composite resin at the root apices, and two
coats of nail varnish were applied on the tooth DISCUSSION
within 1mm of the restoration margins.(5) The Packable composites most commonly used as
teeth were then immersed in a 1 % methylene posterior restorative materials, however,
blue solution (Gain land Chemical Company, disadvantages like polymerization shrinkage,
UK) for 24 hours at room temperature. high co-efficient of thermal expansion and
Subsequently they rinsed with tap water and increased wear, limited their use. Further
dried at room temperature (7). All specimens were research led to improvements in wear resistance
sectioned longitudinally in mesiodistal using a and strength but the problem of polymerization
water-cooled; slow-speed diamond saw ISO 524 shrinkage remained.
(Top Dent, Swiss Made). The lengths of the dye Polymerization shrinkage resulted due to the
penetration in millimeters were examined with a contraction of the resin during curing and is in
stereomicroscope (40X magnifications, the range of 1.67-5.68%. This polymerization
Hamilton, BioVision 320). (5) shrinkage results in the formation of a marginal
Statistical analysis was performed with SPSS gap which can ultimately lead to increased
software package (version 19.0). Analysis of microleakage, (8) so various techniques and
Variance test (ANOVA) and least significant modifications in the material were proposed to
difference (LSD) were performed to test for any overcome and minimize polymerization
significant difference between the groups in shrinkage and microleakage. These included
microleakage values. The mean difference is changes in filler content, use of expanding resin
significant at the 0.05 level. matrices and modifications in curing techniques
like soft curing, ramped curing and delayed
curing.(9) They observed that when the material is
in more rigid state, most of the polymerization group in this study showed that using of flowable
cannot be observed and is transmitted to the composite as liner under packable composite
adhesive interface. Here, the contraction stress significantly reduced microleakage more than
can become responsible for opening marginal RMGIC, this result due to low filler loading of
gap. It has been proposed that an elastic layer flowable composite (47% by volume) that
at the restoration base be incorporated to act as a enhanced flow and reduced elastic modulus.
stress absorber, not only of the functional loads These two characteristics reduce microleakage by
but also of the internal tensions induced by increasing adaptation and forming an elastic
composite polymerization. (8, 10) stress-absorbing layer (8) These results in
In our study, the concept of using various agreement with studies by, Leevailoj et al.(1),
liners as stress absorbing cushions to minimize Peutzfeldt and Asmussen (8) and Stefanski and
polymerization shrinkage was proposed; two van Dijken (12) .
types of materials (resin modified glass ionomer The reduction in microleakage values by
cement and flowable composites) were using two types of liners, measured when the
experimented as stress absorbing liners. The use margin of class II cavity located at enamel
of GIC as lining material in conventional surface. Enamel has homogeneous structure,
sandwich restoration reduces considerably the hydrophobic character and strong adhesion
bulk resin composite used, thus the amount of achieved with its inorganic tissue. (13) In the
polymerization shrinkage of the composite resin future, further clinical studies and researches
is decreased and the marginal adaptation may be needed to compare between these two liners at
improved. A further advantage of the sandwich margin located in dentin surface.
technique is the fluoride-release property of
GICs, which is considered to have some
inhibitory effect on caries formation and CONCLUSIONS
progression around the restoration. The sandwich Under the conditions of this an in vitro
restorations using RMGIC showed significantly study:
less dye penetration than control group (packable None of groups tested were able to totally
composite without lining), this result in prevented microleakage at enamel margin.
agreement with the results of Chuang et al.(6) Microleakage of packable composite
and Donly et al.(11). RMGIC obtained by adding significantly decreases by using of RMGIC
a resin, usually the water-soluble polymerizable and flowable composite as lining.
2-hydroxyethyl methacrylate (HEMA), to the Microleakage of flowable composite with
liquid and its bonding process to tooth structure margin located at enamel surface less than
takes place by micromechanical retention, like in resin modified glass ionomer in open
resin composites. The setting reaction of RMGIC sandwich technique.
follows two distinct mechanisms: resin There were no significant differences
polymerization and acid-base reaction. The better between two liners tested in term of
sealing produced by RMGIC is a result of the
microleakage.
formation of resin tags into the dentinal tubules
allied to the ion exchange process present in the
interface between dentin and RMGIC, this REFERENCES
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the presence of HEMA in the RMGIC is Dent. 2001; 26 (3): 302-7.
responsible for the increased bond strengths to 2. Neme AL, Maxson BB, Pink FE, Aksu MN.
resin composite and prevent dye penetration Microleakage of Class II packable resin composites
through the interface of these materials, as lined with flowables: an in vitro study. Oper Dent.
demonstrated by the results of the present study. 2002; 27 (6): 600-5.
3. Tung FF, Hsieh WW, Estafan D. In vitro
The shrinkage stresses of resin composites microleakage study of a condensable and flowable
during polymerization create forces that compete composite resin. General Dent. 2000; 48 (6): 711-5.
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bond to cavity walls, which is one of the main condensable resin composite: an in vitro
causes of marginal failure and, subsequent, investigation. Quintessence Int. 2000; 31: 430-34.
microleakage. The main rationale behind the use 5. Sensi LG, Marson FC, monteiro S J. Flowable
Composites as Filled Adhesives, A Microleakage
of flowable composites is the formation of an Study. J Cont Dent Prac. 2004; 5(4): 1-5.
elastic layer that may compensate for the 6. Chuang SF, Jin YT, Lin TS, Chang CH, Garcia-
polymerization shrinkage stresses.(5) The third Godoy F. Effects of lining material on
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based composite restorations. American J Dent.

2003; 16 (2): 84-90.
7. Bona A, Pinzetta C, Rosa V. Effect of acid etching Table 2: Descriptive Analysis: Mean, Standard
of glass ionomer cement surface on the deviation of microleakage values of the groups.
microleakage of sandwich restorations. J appl oral
sci. 2007; 15(3): 230-4. Groups N Means SD Min. Max.
8. Peutzfeldt A, Asmussen E. Composite restorations: Group-I
Influence of flowable and self curing resin 8 0.78 0.124 0.6 1
(Control)
composite linings on microleakage in vitro. Oper Group-II
Dent. 2002; 27: 569-575. 8 0.63 0.106 0.5 0.8
(RMGIC)
9. Goracci G., Mori G. and de Martinis L.C. Curing
light intensity and marginal leakage of resin Group-III
8 0.55 0.119 0.4 0.7
composite restorations. Quintessence Int. 1996; 27: (Flowable)
355-362.
10. Beznos C. Microleakage at the cervical margin of Table 3: One Way- ANOVA Test for all groups
composite Class II cavities with different
restorative techniques. Oper Dent. 2001; 26: 60-69. Sum of Mean P-
11. Donly ZR, Segura A, Donly KJ. In Vitro D.f F Sig.
Squares Squares Value
Microleakage of Two Glass Ionomer Cements.
IADR/ AADR/ CADR 85th General Session and Between
0.231 2 0.115
Exhibition (March 21-24, 2007); Seq#71 (Internet Groups
site:http://iadr.confex.com/iadr/2007orleans/techpro Within 8.43 0.002 S
0.287 21 0.014
gram/abstract_88957.htm. Date of access: Groups
01/11/2011). Total 0.518 23
12. Stefanski S, van Dijken JWV. Clinical performance S: significant
of a nanofilled resin composite with and without an
intermediary layer of flowable composite: a 2-year
evaluation. Clin Oral Invest. 2012; 16(1):147153. Table 4: LSD test compare between the groups in
(IVSL) microleakage values (mm)
13. Loguercio AD, Bauer JR, Reis A. Microleakage in
class II composite resin restorations: total bonding P- Level of
and open sandwich technique. J Adhes Dent. 2002;
Groups
value significant
4(2): 137-44. I vs. II 0.018 S
I vs. III 0.001 S
II vs. III 0.150 NS
NS: non- significant, S: significant
J Bagh College Dentistry Vol. 24(special issue 1), 2012 A comparison between
A comparison between the arbitrary and kinematic

intercondylar distances of full mouth rehabilitation
patients (An in-vivo study)
Ma'an R. Zakaria, B.D.S., M.S., Ph.D. (1)
Hussain F. Al-Huwaizi, B.D.S., M.Sc., Ph.D. (1)
Widad A. Alnakkash, B.D.S., M.Sc. (2)
ABSTRACT
Background: The intercondylar distance can change the radius of movement and affect the arcs traveled by the
cusps during lateral mandibular excursions in the horizontal plane. The aim of this study was to record and compare
the intercondylar distances of male and female patients requiring full mouth rehabilitation by using arbitrary and
kinematic face-bows.
Materials and methods: Interfacial widths of fifty asymptomatic male and female full mouth rehabilitation patients
were recovered from arbitrary and kinematic face-bows. Intercondylar distances were recorded and statistically
compared.
Results: Results indicated that arbitrary and kinematic intercondylar distances of male patients were significantly
greater than females indicating asymmetry in locating the condylar axes of rotation in both sexes.
Conclusion: The majority of intercondylar distances of patients were more than 110 mm indicating that an articulator
with an adjustable intercondylar distance would be more anatomically correct for the treatment of full mouth
rehabilitation cases.
Key words: Arbitrary, Kinematic, Intercondylar distance. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):11-17).
INTRODUCTION The importance of the ICD has been stressed

The intercondylar distance (ICD) is "the by Mahan et al. (4) in that both the immediate and
distance between the rational centers of each progressive side shifts were sensitive to recording
condyle" (1). Within the confines of each condyle point location of mandibular hinge axis where
there is an area defined as "the rotation center" positions forward
which is an imaginary geometric point through and above the true hinge axis created the
which the three axes of rotation trisect at right greatest variations. Their study showed that it
angles to each other when the condyles are in their would be difficult to compare condylar
most distal, unstrained, retruded positions in their movements across subjects if recording points
respective fossae: the horizontal, vertical and were different which necessitate locating the
sagittal axes of the mandible and condyles. terminal hinge axis with kinematic face-bows.
During 3-dimensional movements of the jaw, the The mediolateral location of the centers of
condyles rotate around and linearly translate along rotation (i.e. the intercondylar distance) can also
these axes thus the name hinge axis, or terminal change the radius of movement and affect the arcs
hinge axis (2). traveled by the cusps during lateral mandibular
The terminal hinge axis is a fixed anatomic excursions in the horizontal plane. If the
and geometric reference axis that can be relocated intercondylar width is accurately measured and
repeatedly by mechanical methods. This point is duplicated on the articulator and if the casts are
stable in a healthy, physiologically functioning mounted accurately, the arc of movement of the
adult joint and can be used as a reference point articulator will approximate that of the mandible.
with accuracy for mounting casts or measuring Accurate location and size of morphologic
jaw movement. Although the condyles in most features on the occlusal surface of the restoration
people do not function from the terminal hinge are more easily achieved (3).
position, it is biologically considered a Slight errors appear in the arcs of movement of
physiologic position when there is an absence of the cusps between the articulator and the mandible
both premature occlusal tooth contacts during when the ICD of the articulator is less than or
mandibular closure and dysfunction in the greater than that of the mandible. Errors of similar
stomatognathic system (3). magnitude occur when the casts on the articulator
are moved closer to the condyles or farther from
them. However, when the casts are mounted on a
small hinge articulator, the error produced on the
1. Professor, Department of Conservative Dentistry, College of
Dentistry, University of Baghdad. nonworking side is of a much greater magnitude.
2. Professor, Department of Prosthetic Dentistry, College of In this situation, there is an increased likelihood
Dentistry, University of Baghdad.
of producing a nonworking occlusal interference patients receiving multiple fixed restorations on

in the restoration (5). natural teeth or fixed full arch prosthesis on
When the ICD of the articulator is greater than implants where the OVD determination is
that of the mandible, the paths of movement on essential for achieving better esthetics and
the articulator will slightly be distal to the paths function (9).
traced in the mouth. The cusp paths traveled on The aim of this study was to record and
the articulator will be distal to those in the mouth compare the intercondylar distances of male and
when the casts are moved close to the condyles on female patients requiring full mouth rehabilitation
the articulator. On the small hinge articulator, by using arbitrary and kinematic face-bows.
there is a major discrepancy between the
nonworking cusp path and that in the mouth (5). MATERIALS AND METHODS
An important relationship between the path of Fifty asymptomatic adult patients (25 females
lower teeth and the ICD exists; if anterior and 25 males) aged 30 to 65 years who required
guidance is determined and fabricated from extensive occlusal rehabilitation treatment
articular settings, differences in ICD would result (patients with either generalized loss of incisal
in significantly enough difference in the path of and occlusal morphology due to attrition and
the lower incisal edges to affect the lingual faceting of teeth, extensive defective restorations,
contours of the upper anterior teeth (2). or multiple missing teeth, associated with
It has been reported that the "Pantronic" moderate or severe OVD collapse) participated in
electronic pantograph (Denar Corp., USA) records this study. Full mouth rehabilitation patients were
mandibular movements and computes the recruited from patients seeking fixed
articulator settings but it does not determine the prosthodontic work at the Department of
ICD hence it approximates it from the interfacial Conservative Dentistry, College of Dentistry,
width at the condyles. An average distance of 12.5 University of Baghdad. The criteria for patients'
mm was calculated to be subtracted from each selection concentrated on the status of being
side to determine the ICD (6). To confirm that, healthy with no oral pathology or history of TMJ
Mandilaris et al. (7) recorded 45 patients' pain or dysfunction. Full series of periapical x-
articulator ICDs that had been set from a rays and a panoramic radiograph were taken for
"mechanical pantograph" and they were compared each patient. Arbitrary mandibular hinge axis
with the Pantronic's approximation. The location was achieved by placing the index finger
mechanical pantograph recordings were tip over the TMJ area and asking the patient to
transferred to a Denar D-5A fully adjustable open wide so that when the condyle translated
articulator with a telescoping mounting axis forward, the finger tip dropped into the depression
positioned between them. This instrument where the condyle was. The patient was asked to
indicates the transfer of the ICD as it directly close and as the condyle translated back; its
subtracts 12.5 mm x 2 from the subject's position was located by the finger tip. The
interfacial width. The mean ICD for the subjects procedure was repeated to feel the condyle
was 113.2 mm and a statistically significant rotation and locate the axis within an average of 2
difference was found between the mean ICDs of mm or less since the axis generally occurs near
men and women. Their conclusion was that an the center of the depression felt by the finger tip.
asymmetry in the location of the condylar axes of When that point was located, it was marked as a
rotation should be expected in most patients (7). dot by an indelible pencil (2). A measurement
The relationship between the ICD and the method was applied by placing a ruler on an
interdental widths of the upper and lower canines imaginary line running from the patient's superior
and first molars were clinically studied to aid in border of the tragus of the ear to the outer canthus
denture teeth positioning. Results indicated that of the eye. The arbitrary axis was marked on the
ICD measurements can be used for setting up skin at eleven mm anterior to the tragus (10).
canines and first molars in complete dentures Arbitrary face-bow record was performed
since ICD remains fairly static throughout life using the Hanau face-bow (Fascia-Bow 132-2SM,
unlike setting teeth according to anatomical Teledyne-Hanau Co., NY, USA). A piece of
landmarks which are few and far from posterior softened modeling wax was placed on the bite
teeth and are subject to the unusual constraint of fork and pressed against the upper teeth and held
soft tissue anatomical landmarks which may in position by the patient's thumbs. The face-bow
change as a result of resorption or ageing (8). was attached to the bite fork with its bow parallel
It has been concluded that the ratio of occlusal to the patient's eyes and its axis locator rods were
vertical dimension (OVD) to intercondylar width set to touch the skin marks on both sides at the
could be helpful in determining the OVD for same setting. The set screw was tightened to lock
the bite fork into the correct relation with the face-
bow (Fig.1). The face-bow assembly was
removed and the distance between the tips of its
two axis locator rods was measured by an
electronic caliper (Prokit's Industries Co., Ltd,
Taiwan) to verify the interfacial distance (Fig. 2).
Figure 3. Marking the terminal hinge axis at

the tip of the stylus of the kinematic face-
bow.
The kinematic face-bow assembly was
detached from the universal clutch which was
taken out of the patient's mouth and the interfacial
width (IFW) was measured by the electronic
Figure 1. Arbitrary face-bow registration. caliper (Fig.4).
Figure 2. Measuring the IFW scored by the Figure 4. Measuring the IFW scored
arbitrary face-bow using the electronic by the Kinematic face-bow.
caliper.
Intercondylar distance was then determined by
Terminal mandibular hinge axis location was the graduated scale on the TMJ fully adjustable
performed using the TMJ kinematic face-bow articulator (TMJ Instrument Co., Inc., USA) after
(TMJ Instrument Co., Inc., USA) following the subtracting 12.5 mm from the measured readings
manufacturer's instructions. Adjustments were on both sides (i.e. 25 mm)(6). The 12.5 mm is the
made by the micro-adjustment screws of the distance between the center of condyle ball and
kinematic face-bow to allow for superior/inferior tip of condyle pin. The condyle posts were locked
adjustments of the side arms until the stylus didn't at the determined final measurements (Fig.5).
translate when the mandible was arced indicating
the pure rotational axis of the condyle thus
locating the terminal hinge axis of the mandible.
The procedure was performed on each side of the
patient.
When the axis locator pin of the stylus achieved
a pure rotational movement, its pin point location
was marked on the hinge axis flags' graph paper
grids on both sides. The hinge axis flags were
removed, styli moved out to mark its tip with
graphite pencil and with holding the supported Figure 5. Face-bow styli engaged into
mandible in terminal hinge position, and each
condyle pin holes of the TMJ articulator.
stylus was moved toward the skin to mark it (Fig.
3).
RESULTS
Descriptive statistics of the arbitrary interfacial
width (AIFW) and the arbitrary intercondylar
distance (AICD) are shown in Table 1 and Fig.6.
ANOVA test results revealed a highly significant
difference between the tested groups (Table 2).
Table 1: Descriptive statistics of (AIFW) Table 5: ANOVA test results of (KICD).

& (AICD) of females & males (in mm). KICD Sum of Mean
Groups Mean S.D. Min. Max. Groups Squares df Square F Sig.
AIFW, F 135.09 9.666 115.0 153.1 Between
1355.53 1 1355.53 24.276 HS
AICD, F 110.58 9.294 90.0 128.1 Groups
AIFW, M 145.59 6.033 135.4 159.3 Within
2680.25 48 55.839
AICD, M 120.67 5.917 110.4 134.3 Groups
Total 127.98 15.555 90.0 159.3 Total 4035.79 49
Student's t-test results of the KIFW and the

KICD scored also highly significant differences
between males and females (Table 6).
Table 6: Group Statistics (Student's t-test)

results of (KIFW) & (KICD).
Mean P
Group
(mm) S.D t value Sig.
KIFW F 131.4 8.78
Figure 6: Means of (AIFW) & M 141.8 5.87 -4.92 0.000 HS
(AICD) of females & males (in mm). KICD F 106.4 8.78
M 116.9 5.87 -4.92 0.000 HS
Table 2: ANOVA test results of (AIFW) &
(AICD). Investigating the source of the difference via
AIFW & the Student's t-test revealed no significant
Sum of Mean
AICD differences between the females' arbitrary
Squares df Square F Sig.
Groups intercondylar distance (AICD) and kinematic
Between intercondylar distance (KICD) (P>0.05). On the
17926.5 3 5975.5 95.14 HS
Groups contrary, significant differences were evident
Within when comparing the AICD of male patients to
6029.5 96 62.8
Groups their KICD (P<0.05) (Table7).
Total 23956.0 99
Table 7: Student's t-test results of (AICD) &
The descriptive statistics and ANOVA test (KICD).
results of the kinematic interfacial width (KIFW) Mean P-
and kinematic intercondylar distance (KICD) of Groups (mm) S.D. t value Sig.
females and males (in mm) are shown in Tables 3, AICD, F 110.58 9.294
4 & 5. Highly significant differences were present vs. 1.599 0.116 NS
KICD, F 106.48 8.786
between females and males.
AICD, M 120.67 5.917
vs. 2.263 0.028 S
Table 3: Descriptive statistics of (KIFW) & KICD, M 116.90 5.871
(KICD) of females & males (in mm).
Groups Mean S.D. Min Max. By comparing the mean values differences of
F, KIFW 131.48 8.786 112.23 147.90 the AICD and KICD of female and male patients,
M, KIFW 141.89 5.870 131.41 155.68 non significant results were evident (P>0.05),
F, KICD 106.48 8.786 87.23 122.90 (Fig. 7&Table, 8).
M, KICD 116.90 5.871 106.41 130.68
Table 4: ANOVA test results of (KIFW).

KIFW Sum of Mean
Groups Squares df Square F Sig.
Between
1354.49 1 1354.4 24.25 HS
Groups
Within
2680.11 48 55.83
Groups
Total 4034.60 49
Figure 7: Difference between (AICD)
& (KICD) mean values of
females & males (in mm).
Table 8: ANOVA test results of the were more than 110 mm, a finding that coincided
difference between the (AICD) & (KICD) with Laurell et al. (12) conclusions that an
mean values. articulator with a variable ICD would be more
Diff. of anatomically correct. Those findings were based
AICD & on their results that the ICD measurements of 50
Sum of df Mean Sig.
KICD F human dried skulls at the lateral poles were 123
Squares Square
Groups mm as a maximum which were close to our
Between females' KICD maximum range of 122.90 mm.
0.027 1 0.027 0.041 NS
Groups Also, our mean KICD value of both sexes was
Within 111.6964 mm which strongly corroborates Laurell
31.668 48 0.660
Groups et al. (12) mean ICD value of 111.40 mm. It has
Total 31.695 49 been concluded that varying the patient's ICD to
match that of the articulator produced a significant
Concerning the AIFW and AICD, KIFW and change in the anterior horizontal table tracing, i.e.
KICD, all male patients' mean values were greater the Gothic arch tracing, which explains why
than those of the females. Total means of the patients' greater ICDs simulation cannot be
AICD (115.6282 mm) were more than the KICD precisely duplicated in articulators with fixed
(111.6964 mm) with a difference of 3.9318 mm ICDs (13).
(Table 9). In this study, the mean KICD of both male and
female patients (111.6964 mm) was close to that
Table 9: Total means of (AIFW recorded by Mandilaris et al. (7) (113.2 mm) who
& KIFW) & (AICD & KICD). also found statistically significant differences
Measured between the male and female patients which was
distances attributed to asymmetry in the location of the
Female Male Total mean condylar axes of rotation in most patients.
(mm)
AIFW 135.0964 145.5960 140.3462 Dawson (2) stated that "the width of human
AICD 110.5804 120.6760 115.6282 faces is surprisingly consistent and very few
KIFW 131.4896 141.8992 136.6944 patients will have an intercondylar distance that
KICD 106.4896 116.9032 111.6964 varies more than 10 mm from the average 110
mm." In our study, the maximum mean of AICD
of males was 120.676 mm which agreed with
DISCUSSION Dawson's statement.
In this study, estimation of the AICD and
Tradowsy (14) found that the mean KICD was
KICD for each patient was performed following
108.0 mm for men and 102.0 mm for women, a
Clayton and Beard (6) who, by applying the
difference reported to be significant. Based on the
Pantronic pantograph, had tested the average
data gathered, Tradowsy concluded that a
distance between the vertical condylar axes of
semiadjustable articulator with a fixed average
rotation and the surface of the skin at the condylar
ICD of 110 mm is better suited for men than for
region and found it to be 12.5 mm which was
women while an articulator with a lowerlimit of
recommended by the Denar Corp., USA. This
96 mm ICD such as the Denar D-5A fully
finding was accurate for 60% of their study
adjustable type (Denar Corp., USA) won't be
patients. The authors recommended subtracting
adjustable for 20% of women and 5% of men
12.5 mm x 2 from the subject's interfacial width to
having a smaller ICD. An adjustment range of 80
determine his ICD. The results of our study
to 130 mm was suggested since it would miss
revealed that the arbitrary and kinematic
only one woman in 10,000 at the lower limit (with
interfacial widths of the male patients were
an ICD smaller than 80 mm), and one man in
greater than the females, a difference which was
10,000 at the upper limit (with an ICD larger than
highly significant. Such finding may be attributed
130 mm). Since the TMJ fully adjustable
to the large craniofacial skeleton measurements of
articulator used in our study possesses an ICD
the males compared with the females.
ranging between 80 to 160 mm, therefore, it can
The intercondylar distance (ICD) of the Hanau
be considered adjustable for most cases.
H-2 semiadjustable articulator is fixed at 110 mm
Our results concerning the KICD were
and patient simulation with an ICD greater that
different in the mean value of both sexes
110 mm couldn't be precisely duplicated (11).
(111.6964 mm) from that of dos Santos and
On the other hand, the TMJ articulator is
Ash(15) (102.0 mm). On the other hand, the AICD
provided with an adjustable ICD of a range up to
mean values scored by the Hanau arbitrary face-
160 mm which was suitable with most of the
measured ICDs in our study since the majority
bow (115.6282 mm) were close to that of dos posterior reference point and located with a
Santos and Ash (114.667 mm). kinematic terminal hinge axis locator since the
Comparing our results to those of Biserka et mouth rehabilitation requires organized approach
al. (16) the means of the KICD of both male and to regain the lost function, comfort and esthetics
female patients were greatly different. Our mean of the patient (19).
KICD of both sexes was 111.6964 mm compared
to 126.0 mm of Biserka et al. study who referred CONCLUSIONS
their highest scores, compared to other studies, to From the observations made in this study, the
the larger craniofacial skeleton of the Croatian following conclusions were formulated:
subjects. On the other hand, our findings 1. Arbitrary and kinematic intercondylar
concerning the significant differences which lied distances of male patients were significantly
between the KICDs of the male and female greater than females indicating asymmetry in
patients coincided with those of Biserka et al. locating the condylar axes of rotation in both
results. sexes.
In a study designed by Keshvad et al. (8) to 2. Careful location of the terminal hinge axis as
investigate the relationship between ICW and the posterior reference point instead of depending
interdental widths of the upper and lower canines upon an arbitrary marking is recommended to
and first molars to aid in denture teeth avoid potential sources of error in mounting casts
positioning, the mean of the KICD of the female on the adjustable articulator thus preventing
and male subjects was 104.0 mm and 117.9 mm statistically different articulator settings which
respectively which was close to that of our study could critically affect the occlusion of the final
(106.4896 mm for females & 116.9032 mm for fixed restorations.
males). The group means of the KICD of both 3. The majority of intercondylar distances of
sexes in our study (111.696 mm) was also close to patients were more than 110 mm indicating that
that of Keshvad et al. study (112.19 mm). Also, in an articulator with an adjustable intercondylar
our study, the female patients had a significantly distance would be more anatomically correct for
shorter KICD than the males which agreed with the treatment of full mouth rehabilitation cases.
Keshvad et al. findings.
In our study, the mean of the AICD of males
(120.6760 mm) was significantly higher than that REFERENCES
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estimated by Keshvad et al. (110.54 mm) which pp.238-60.
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of articulators:The contributions of Rudolph L.Hanau and S, Zoran A. Intercondylar distances of the human
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J Bagh College Dentistry Vol. 24(special issue 1), 2012 A clinical comparison
A clinical comparison between maxillary and mandibular

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

Painful treatment has been shown to be pulpal anesthesia of one or more adjacent teeth
important in the etiology of dental fear. People, and surrounding periodontium. Attaining local
who were hurt while receiving dental care, are anesthesia for the treatment of teeth diagnosed
more likely to avoid dental treatment (1). Local with irreversible pulpitis ("hot" tooth) can be a big
anesthesia is the primary method used in dentistry challenge (4). Supplementary injected anesthesia is
to control patients pain. However even in the particularly suited for providing effective pain
presence of an adequate soft tissue anesthesia control of teeth diagnosed with irreversible
after the standard injection by block or pulpitis (5). It was concluded that when the inferior
infiltration, there may be incomplete pulpal alveolar nerve block failed to provide profound
anesthesia (2). pulpal anesthesia in mandibular posterior teeth of
Several methods of providing local anesthesia patients presenting with irreversible pulpitis, the
are available. These include the periodontal intraligamentary injection was successful
ligament injection (PDL) or intraligamentary approximately 56% of the time (6). The PDL
injection, the intraseptal injection, intraosseous injection and the IO injection are effective
anesthesia, and the intrapulpal injection. The PDL anesthetic techniques for managing nerve block
or the bone-tooth fibrous joint is an intricate and a failures and for providing localized anesthesia in
dynamic system with a cross-talk between several the mandible (7). A great advantage of this
mineralized and soft tissue (3). The PDL injection injection is its ability to achieved nearly
technique is fundamentally intraosseous injection. instantaneous anesthesia of one or two teeth in the
A small amount of anesthetic solution is deposited mandibular arch without use of the mandibular
adjacent to the tooth to be anesthetized, and block technique.
considerable diffusion of the anesthetic solution PDL injection is used primarily when
(1) Professor, Department of Conservative Dentistry, College of conventional anesthesia is not fully effective,
Dentistry, University of Baghdad. when dentists require only a short duration of
(2)Assistant lecturer, College of Dentistry, University of anesthesia, and when a patient wants to avoid the
Sulaimani.
lip and tongue numbness associated with Group IIa: each subject received a PDL injection
mandibular block injections (8). The use of this in maxillary first premolar and first molar right or
technique in the maxillary arch is possible but less left side with 2% Lidocaine injection and pulp
frequent, except in the incisal area, where tested each minute by EPT and Ethyl chloride.
supraperiosteal injection can be painful (9). Group IIb: each subject received a PDL injection
Successful use of the PDL injection technique in maxillary first premolar and first molar right or
depends on generating a considerable amount of left side with normal saline injection and pulp
pressure during the use of a fine short needle to tested each minute by EPT and Ethyl chloride.
engage the entrance to the PDL of individual The saline cartridges were prepared in the
teeth. The ligmaject syringe possesses the following manner: Empty anesthetic cartridges
advantages of a measured (0.2 ml) delivery of and plungers were washed for 5 minutes with
solution with each trigger pull, with a protective soap and water using a nylon brush. All cartridges
shield around the anesthetic cartridge to protect and plungers were then rinsed twice with distilled
against accidental glass breakage. water for 1 minute and autoclaved for 50 minutes.
Unlike supraperiosteal (infiltration) or block Each cartridge was filled with 1.8 mL of sterile
anesthetic techniques, there is little or no saline and the plungers were replaced.
sensations of soft-tissue anesthesia of the nearby PDL injections were given using ligament
mucosa, lip, chin, and so forth (10). syringe with 30-gauge ultra short needle. The
The aim of this study was to compare the needle was inserted through the mesial and distal
effect of PDL injection in producing pulpal gingival sulcus of (maxillary and mandibular first
anesthesia, using 2% Lidocaine with 1:80000 premolars) and through the mesial, distal and
Epinephrinc and Saline, in human maxillary and palatal or lingual gingival sulcus of (maxillary
mandibular posterior teeth by using electrical pulp and mandibular first molar) to a point of
tester and ethyl chloride (cold application). maximum penetration. The bevel of the needle
was directed toward the crestal bone surface, at
MATERIAL AND METHODS 30-degree angle to the long axis of the tooth. The
trigger of the syringe was pulled firmly until
Forty adult volunteers, 23 Males and 17
backpressure was achieved and this pressure was
Females, participated in this study. The age of
sustained for 20 seconds, this procedure delivered
subjects ranged from 18-25 years with average
0.1 ml of the tested solution, (Figure 1).
age of 22 years. All subjects were in good health
and were not taking any medications, which might
alter their pain perception. No subject had contra-
indications or sensitivities to a PDL injection with
any of the solutions tested.
The subjects had maxillary and mandibular
first premolars and first molars free of caries, deep
restorations, and had no exposed dentine. Any
tooth exhibited mobility, more than 0.5 mm in any
direction, was excluded. All subjects had
mandibular first Premolar and first molar or Figure 1: Injection technique.
maxillary first premolar and first molar, left or
right sound and not inflamed. Each tooth was pulp The pain rating of the initial needle penetration
tested by electrical pulp tester and ethyl chloride and injection of solution were obtained and it was
before and after anesthesia, or normal saline as follows: score zero (no pain), score one (mild
injections to verify a base line data of vitality. The pain pain which was recognizable but not
subjects were divided into four groups (10 discomforting), score two (moderate pain pain
subjects each):- which was discomforting, but bearable), score
Group Ia: each subject received a PDL three (severe pain pain which caused
injection in mandibular first premolar and first considerable discomfort and was difficult to
molar right or left side with 2% Lidocaine bear), all injections were given by the principle
injection and pulp tested each minute by EPT and investigator, another operator recorded the scores
Ethyl chloride. of pain rating and of the EPT.
Group Ib: each subject received a PDL injection Each tooth was isolated and dried with air for
in mandibular first premolar and first molar right 10 seconds. A small quantity of Sanino tooth
or left side with normal saline injection and pulp paste was applied at the tip of the EPT probe and
tested each minute by EPT and Ethyl chloride. the probe tip was placed on the middle third of the
buccal surface at experimental teeth. The EPT
used in this study was mains-operated unipolar Table 3: Percentages of solution

constant- current generator. A spring-loaded deposition pain ratings
micro switch was attached to the hand electrode Groups None Mild Moderate Severe
and was operated by the subject to start and stop PDL A 2.5 % 40 % 55 % 2.5%
the current. A micro-ammeter measured the PDL N 7.5 % 37.5 % 52.5 % 2.5%
current flow and it was calibrated from 0 to 10
micro-amps. Table 4: Statistical comparisons of solution
Two consecutive reading were obtained as deposition pain ratings
base line vitality readings, and immediately after None Mild Moderate Severe
the completion of each injection, a stop watch p- p- p- p-
Groups
value value value value
timer was started. The depth of anesthesia was
U4A & U4N 1.00 0.178 0.34 1.00
monitored by pulp testing the teeth and Ethyl U6A & U6N 1.00 0.424 0.227 0.391
chloride stimulation (the second reading of Ethyl L4A & L4N 0.850 0.476 0.396 1 .00
chloride obtained at the minute of complete L6A & L6N 0.551 0.151 0.561 0.391
anesthesia). The experimental teeth were tested at U4A & L4A 0.391 0.677 0.641 1.00
postinjection times of 1, 2, 3, 4, 5, 6... until U4N & L4N 0.198 0.796 0.726 1.00
complete anesthesia obtained, which is the U6N & L6N 1.00 0.795 0.515 0.391
absence of the patient response at the maximum U6N & L6N 0.357 0.347 1.00 0.391
output of the pulp tester. At this minute the
Table 5 represents the mean onset time in
second reading of Ethyl chloride was obtained.
minutes and standard deviation for anesthetic
The electrical pulp testing was repeated each
PDL injections.
minute until the effect of anesthesia was finished
and the tooth returned to the normal status.
Table 5: Mean onset
time for anesthesia only
Mean
RESULTS Variable
(mm)
S.D.
Using anesthesia, the percentages of needle U4.A 4.30 1.34
insertion pain ratings are compiled in Table 1. U6.A 4.60 1.35
Chi-square test showed no significant difference L4.A 6.70 2.50
between two types of injections regarding the pain L6.A 5.90 2.08
of initial needle insertion except in score two
(moderate) there was a significant difference at Tables 6, 7 and 8 show statistical comparisons
the level (p<0.05), (Table 2). of mean (anesthetic, normal saline, and the both
together) onset time in minutes.
Table 1: Percentages of needle insertion pain
ratings Table 6: Statistical comparisons of
Groups None Mild Moderate Severe mean anesthetic onset time (minutes)
Anesthesia 15% 55% 27.5% 2.5% Groups Mean t P Sig.
N. Saline 5% 52.5% 37.5% 5% U4.A 4.30
0.50 0.62 NS
U6.A 4.60
Table 2: Statistical comparisons of needle
U4.A 4.30
insertion pain ratings L4.A 6.70
2.68 0.019 S
None Mild Moderate Severe
Groups U4.A 4.30
p-value p-value p-value p-value 2.05 0.059 NS
L6.A 5.90
U4 & U6 1.00 0.505 0.3 17 1.00
U6.A 4.60
U4 & L4 0.391 0.639 0.640 1.00 2.34 0.036 S
L4.A 6.70
U4 & L6 0.551 0.371 0.038 * 0.391
U6.A 4.60
U6 & L4 0.391 0.827 0.640 1.00 1.66 0.12 NS
L6.A 5.90
U6 & L6 0.551 0.801 0.157 1.00
L4.A 6.70
L4 & L6 0.357 0.639 0.09 1 1.00 0.78 0.45 NS
L6.A 5.90
* Significant difference at level P<0.05.
The percentages of solution deposition pain
ratings followed by the Chi-square test which
showed no significant difference regarding pain of
solution deposition at the level (p<0.05), are seen
in Tables 3 and 4.
Table 7: Statistical comparisons of Table 10: Statistical comparisons of

mean normal saline onset time (minutes). mean anesthetic duration time in minutes.
Groups Mean t-value p-value Sig. Groups Mean t P Sig.
U4.N 0.00 U4.A 3.10
1.43 0.19 NS 2.03 0.059 NS
U6.N 1.10 U6.A 4.20
U4.N 0.00 U4.A 3.10
0.00 1.00 NS 1.73 0.11 NS
L4.N 0.00 L4.A 4.70
U4.N 0.00 U4.A 3.10
1.48 0.17 NS 4.25 0.001 HS
L6.N 0.70 L6.A 8.30
U6.N 1.10 U6.A 4.20
1.43 0.19 NS 0.54 0.60 NS
L4.N 0.00 L4.A 4.70
U6.N 1.10 U6.A 4.20
0.44 0.66 NS 3.34 0.007 HS
L6.N 0.70 L6.A 8.30
L4.N 0.00 L4.A 4.70
1.48 0.17 NS 2.50 0.024 S
L6.N 0.70 L6.A 8.30
Table 8: Statistical comparisons Table 11: Statistical comparisons of

of mean anesthetic and normal normal saline duration time in minutes.
saline onset time (minutes). Groups Mean t-value p-value Sig.
Groups Mean t P Sig. U4.N 0.00
1.50 0.17 NS
U4.A 4.30 U6.N 0.20
10.17 0.000 HS U4.N 0.00
U4.N 0.00 0.00 1.00 NS
U6.A 4.60 L4.N 0.00
3.99 0.001 HS U4.N 0.00
U6.N 1.10 1.41 0.19 NS
L4.A 6.70 L6.N 0.30
8.49 0.000 HS U6.N 0.20
L4.N 0.00 1.50 0.17 NS
L6.A 5.90 L4.N 0.00
6.42 0.000 HS U6.N 0.20
L6.N 0.70 0.40 0.70 NS
L6.N 0.30
Table (9) represents the mean duration time in L4.N 0.00
1.41 0.19 NS
minutes and standard deviation for anesthetic L6.N 0.30
PDL injections.
Table 12: Statistical comparisons
Table 9: Mean anesthesia of mean anesthetic and normal
duration in minutes. saline duration time in minutes.
Variable Mean(mm) S.D. Groups Mean t P Sig.
U4.A 3.10 1.20 U4.A 3.10
8.19 0.000 HS
U6.A 4.20 1.23 U4.N 0.00
L4.A 4.70 2.67 U6.A 4.20
9.73 0.000 HS
L6.A 8.30 3.68 U6.N 0.20
L4.A 4.70
5.57 0.000 HS
Tables 10, 11, and 12 represent statistical L4N 0.00
comparisons of mean (anesthetic, normal saline, L6.A 8.30
6.76 0.000 HS
and the both together) duration time. L6N 0.30
DISSCUSION
In this study, the pain rating regarding needle
insertion and solution deposition pain was mild to
moderate discomforting. Several factors may
explain the results of this study. First, no topical
anesthetic was used. Second, pain perception can
be modified by psychological, social, and
situational factors. These factors can modify the
normal response evoked by a relatively constant
noxious stimulus so that the resulting pain
sensation may be enhanced or reduced. Fear and
anxiety may lower the pain threshold resulting in
that the non- painful stimuli will be experienced of bone more than the other and so less solution
as painful stimuli (11). It is well known that will be lost on infiltration.
previous painful treatment is very important in the Zakaria proved that the success rate of PDL
etiology of dental fear (1). Some patients may have injection anesthesia for crown preparation was
a good dental experience and generally find the 73.33% as a primary injection technique (16). The
injections painless. Others may have bad PDL injection may be safer to patients of high
experience with both solutions and fear of the blood pressure with ischemic heart diseases
PDL injection because of the gun-like appearance compared with IAN block injection which may be
of the syringe and generally find both solutions of a higher risk of rapid anesthesia diffusion into
painful. Pain on injection of the anesthetic the general circulation (16).
solution could be due to the low pH of the The results of this study demonstrated that 2%
solution, which have been thought to cause lidocaine with 1:80000 epinephrine produced
burning sensation and thus the use of anesthetic significantly higher rates of successful pulpal
solution with more neutral pH could reduce pain anesthesia than saline. The highest success rate of
during injection of solution (12). pulpal anesthesia for 2% lidocaine with
Also, some of the discomfort caused during epinephrine was 79.45%.
the injection could result from distension of the
tissue and a local rise in pressure. Pain threshold CONCLUSIONS
and tolerance of each patient may vary and the 1. Periodontal ligament injection is an effective
results should be considered subjective evaluation technique in providing profound pulpal
of local anesthesia techniques (13). anesthesia for upper and lower posterior teeth
The results of this study demonstrated that 2% especially for lower first molars.
lidocaine with 1:80000 epinephrine produced 2. Pain association with insertion of needle and
significantly higher rates of successful pulpal deposition of solution was acceptable.
anesthesia and the duration of anesthesia for lower 3. Anesthesia produces significantly higher rates
first molars was greater than other teeth, which is of successful pulpal anesthesia than saline, so
may be due to the adjacent compact bone, saline is not enough to produce profound
therefore, there will be less amount of anesthesia anesthesia.
infiltrated to adjacent bone and tissue, so more 4. Good anesthesia may be gained with less
amount of anesthesia will reach the apex of the amount of anesthetic solution.
tooth.
In the present study, the success rate of
injection of the anesthetic agent was 79.45%; REFFERENCES
1- Nakai Y, Milgrorn p, Manci L, Coldwell SE, Domoto
indicating that the most important factor in the PK, Ramsy DS. Effectiveness of local anesthesia in
success of the PDL injection is the local pediatric practice 2000; J Am Dent Assoc. (131): 1699-
anesthetics injected under strong backpressure. It 705.
was reported that, when PDL injection was given 2- Cohen HP, Spangberg LS. Endodontic anesthesia in
under a strong backpressure, the injected material mandibular molar: a clinical study. 1993; J Endod. (19):
would spread throughout the PDL, periapical 370-3.
3- Hurng JM, Kurylo MP, Kurylo MP, Marshall GW,
tissues, medullary bone, and puips of injected and Webb SM, Ryder MI, Sunita PHo. Discontinuities in the
adjacent teeth (10). human bone-PDL- cementum complex. Biomaterals 2011;
It was documented that the duration of PDL 32(29): 7106-7117.
anesthesia was unpredictable in some cases 4- Nusstein JM, Reader A, Drum M. Local anesthesia
lasting just for few minutes but the depth of strategies for the patient with a "hot" tooth. Dent Clin
anesthesia was generally sufficient for both North Am 2010; 54(2):237-47.
5- Clark TM, Yagiela JA. Advanced techniques and
operative and endodontic procedures (14). A armamentarium for dental local anesthesia. Dent Clin
clinical study has shown that profound pulpal North Am 2010; 54(4): 757-68.
anesthesia durated up to 20 minutes (using 2% 6- Nusstein J, Claffey E, Reader A, Beck M, Weaver J.
Lidocaine with epinephrine) (15). In this study, the Anesthetic effectiveness of the supplemental
mean duration time for PDL anesthesia was intraligamentary injection, administered with a computer-
approximately 10 minutes using 2% lidocaine controlled local anesthetic delivery system, in patients
with irreversible pulpitis. J Endod. 2005; 31(5):354-8.
with 1:80000 epinephrine. 7- Moore PA, Cuddy MA, Cooke MR, Sokolowski CJ.
The results of this study, regarding the onset Periodontal ligament and intraosseous anesthetic injection
time, demonstrated that the onset time for techniques: alternatives to mandibular nerve blocks. J Am
mandibular first premolar was greater than the Dent Assoc. 2011; 142 Suppl 3:13S-8S.
other teeth and this was due to its place on the 8- Bower JS Jr, Barniv ZM. Periodontal ligament
corner of the mouth that has the amount of density injection: review and recommended technique. Gen Dent
2004; 52(6):537-42.
9- Jastak JT, Yagiela JA, Donaldson D. Local anesthesia 14- Walton RE. The periodontal ligament injection as a
of the oral cavity. 5th ed., 1995, Philadelphia WB primary technique. 1990, J. Endo.; I6 (2): 62-6.
Saunders; p. 23, 61, 87. 15- Schieder JR, Reader A, Beck M, Meyers WJ. The
10- Smith NG, Walton RE, Abbott BJ. Clinical evaluation Periodontal ligament injection: a comparison of 2%
of periodontal ligament anesthesia using a pressure Lidocaine, 3% mepivacaine with 1:100000 Epinephrine in
syringe. 1983, J Am Dent Assoc; (107): 935-56. human mandibular premolars. 1988, J. Endo.; 14(8):397-
11- Quinn CL. Injection techniques to anesthetize the 404.
difficult tooth. 1998, J. Calif. Dent. Assoc. (Sept.); 1-5. 16- Zakaria MR. A clinical evaluation of the periodontal
12- Wahi MJ, Schmitt MM, Overton DM, Gordon MK. ligament injection as a primary technique in preparing
Injection of bupivacaine with epinephrine vs. prilocaine mandibular molar abutment teeth for crowns and bridges
plain. 2002, J. Amer. Dent. Assoc.; (133): 1652-6. among Iraqi patients. 1998; J. of College of Dentistry; (2):
13-Eriksen HM, Aarndal, II, Kerekes K: Periodontal 171-83
ligament anesthesia. A clinical evaluation. 1986, Endod
Dent Traumatol. (2): 267-9.
J Bagh College Dentistry Vol. 24(special issue 1), 2012 Comparative study of
Comparative study of wettability of different lining, tissue

conditioning and denture base materials (in-vitro study)
Mostafa S. M. Al-Shaikhli B.D.S. (1)
Amir H.M. Khamas B.D.S., MSD (2)
ABSTRACT
Background: Wettability of denture base and denture relining materials is one of the most important properties for
denture retention, because it provides a condition in which saliva will spread over the surfaces with ease. Contact
angle has been highlighted as the most important parameter concerning wettability of materials. This angle is
characteristic of the substances due to the surface tension of the liquid and the surface energy of the solid
Materials and methods: One hundred and twenty specimens were prepared in six major groups (light cure acrylic,
hot cure acrylic, flexible acrylic, soft liner, hard liner and tissue conditioner) with dimension of (25mm X 25mm X4mm)
each group consists from 20 specimens. The wettability was measured using digital microscope and the retention
force was measured using specially designed equipment.
Results: The results obtained in the present study showed that there is a highly significant difference on the contact
angle between different materials, different type of fluids (distilled water and synthetic saliva). The contact angle
value of light cure acrylic is smaller than heat-cure acrylic, tissue conditioner, hard liner, flexible acrylic and soft liner
respectively; it was greater for synthetic saliva than those for distilled water,
Conclusion: In conclusion, Light cure acrylic had the best wettability followed by hot cure acrylic and tissue
conditioner respectively. There is an effect of the viscosity on the contact angle, and the contact angle has an
effect on the retention force. When the contact angle value was small the surface retention was higher than when
these angles were large.
Key words: Wettability, contact angle, retention, digital microscope. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):24-
30).
Wettability properties of denture base and
INTRODUCTION denture soft-lining materials are important
Retention and stability of complete dentures because they give an indication of the ease that
depend upon physical, mechanical, chemical, saliva will spread over their surfaces, thus
and biologic factors. Physical factors are mainly forming a lubricating layer for extra comfort (2).
related to the atmospheric pressure, weight, and Wetting measurements can also give an
forces of cohesion and adhesion. For a denture to indication of the degree of denture retention (3).
exhibit adequate adhesion to the supporting To produce adequate adhesion of a denture to
mucosa, the saliva must flow easily over the the supporting tissues, saliva must flow easily
adherent surfaces to ensure their wetting. Good over the entire surface to ensure wetting of the
wetting characteristics of denture materials are adhered surface. The fundamental requirement
thus important. The retention of a denture relies for good adhesive performance is initiate
on the physical properties of the wetting medium molecular contact between adhesive and the
(saliva) and on the ability of the denture material adhered surface (4).
to be wetted. The speed by which a liquid The aim of this study is to evaluate in vitro
spreads over a solid depends partly on the the wettability of different soft lining, tissue
viscosity of the liquid, the roughness of the solid conditioner and denture base materials using
surface, and whether this surface is homogenous different viscosity liquids (synthetic saliva and
in respect of free surface energy. Thus, materials distilled water) and the effect of wettability on
having different surface energies will have adhesion force.
different wettability(1).
MATERIALS AND METHODS
One hundred and twenty (120) specimens
were made divided into 6 major groups they are
heat cure acrylic , acrylic soft liner, hard liner,
flexible acrylic, tissue conditioner and light cure
(1) MSc student, dep. of prosthetic dentistry, college of
dentistry, Baghdad University.
acrylic, the each group were divided into 2
(2) Assistant Professor dep. of prosthetic dentistry, college of subgroups 10 samples for wettability test and 10
dentistry, Baghdad University. samples for retention test.
The materials that were tested are listed
below:
Heat cure acrylic resin powder and liquid Curing was carried out by placing the
(Superacryl plus -Spofa Dental Czechoslovakian clamped flask in a water bath and processed by
Europe). heating at (100c) for (30) minutes, following
Thermoplastic resin granular material completion of curing the flask was allowed to
(bre.crystal HP-Bredent Germany). cool slowly at room temperature for 30 minutes
Heat cure soft acrylic reline (ACROSOFT SL then immersed in water for 15 minutes. After
Iran). that the specimens (which consisted of 3mm of
GC reline chairside hard denture liner (GC hot cure acrylic and 1mm of acrylic soft liner)
AMERICA INC.-USA). were removed from the stone mould carefully.
Tissue conditioner (ACROSOFT TC Iran). Tissue conditioner samples and hard liner
Light cure acrylic (MEGATRAY samples were prepared with same previous
MEGADENTA Dentalprodukte GMbH technique. For light cure acrylic samples glass
Germany). mold was prepared consisted of three plates of
Four metal patterns was constructed with the glass with the dimensions of
dimensions of (25mm25mm4mm) length, (140mm120mm4mm).All of the plates were
width, thickness respectively (Neelam Sharma drilled at the top and bottom so they can be held
et al, 2008 (5) with modifications made to fit the together using screws and nuts, on the middle
current study requirments) used for hot cure glass plate four square shapes were cut with the
acrylic samples, four metal patterns was dimensions of (25mm25mm) (Figure 1).
constructed with the dimensions of
(25mm25mm3mm) length, width, thickness
respectively (so there was a 1 mm difference
with the other mold to provide space for
materials that were added during the study)used
for hot acrylic samples to which the lining and
tissue conditioning materials were added.
The conventional flasking technique for
complete dentures was followed in the mold
preparation.
Four metal patterns were coated with
separating medium and allowed to dry before
investing them in the lower half of the flask, the
flask contained stone mixed according the Figure 1: glass mold for light cure acrylic
manufacturer instruction then allowed to set. The samples preparation.
set lower half was coated with separating
medium and allowed to dry and then the upper The material was supplied as plates that
half of the flask was assembled and filled with were molded into the glass mold then the mold
stone mixture and allowed to set, the flask then is was placed in the ultra violet light curing unit for
opened and the metal patterns removed, the two (10) minutes (5 minutes for the top side and 5
halves of the mold were coated with separating minutes for the bottom side)
medium to be ready for packing. The screws of the glass mold then were
Samples were prepared by packing dough unbolted and the specimens were carefully
into preformed stone molds (using the metal removed from the mold and wiped with cotton
patterns), with a conventional dental flasking pieces soaked with medical alcohol (12%) to
technique. Mixing, packing, and curing were remove the residual inhibitor. Thermoplastic
performed according to the manufacturers' (Flexible) acrylic samples were prepared using
recommendations. This technique was used to conventional injection technique.
prepare 20 samples of hot cure acrylic with Determination of the Wettability
(4mm) thickness and 60 samples of hot cure To determine the wettability of the test
acrylic with (3mm) thickness to which the lining samples, Static sessile drops were observed. The
and tissue conditioning materials were added. sessile drop method is measured by an optical
The soft acrylic liner samples were prepared subsystem to capture the profile of a pure liquid
by packing dough into in the mold above the on a solid substrate. The angle formed between
previously prepared hot cure acrylic sample and the liquid/solid interface and the liquid/vapor
the mold was closed and put under pressure (25)
Kg for (5) minutes.
1. Wooden stage with the dimensions of (69cm,

43cm, 2cm) length, width and thickness.
2. The base of stage is composed of three
adjustable screws to ensure the device was at
zero level when making the measurements.(Fig
2)
3. Metal beam (23cm, 0.5cm) length and thickness
that is attached to the base with four screws and
at it is end is a hook. (Fig 2 part 1)
4. A horizontal arm is hanged to the hook (50cm
length) that simulates the horizontal arm of a
weight scale (Fig 2 part 2), at one end a plastic
container is attached with fine thread in which
the weights were put (Fig 2 part 3), on the other
end a glass plate (30mm30mm4mm) is
attached with fine thread.( Fig 2 part 4)
5. A specimen stage with holding mechanism to
hold the specimens during the test located below
the glass plate. (Fig 2 part 5)
interface is the contact angle. A high resolution 6. Two metal bars at both sides of the arm to
camera (1024768 pixel) and software to capture prevent the rotation of the arm during the
measurement. (Fig 2 part 6)
Figure 2: Equipment used in the retention 7. Movable small bar for cancelling equilibrium
measurement state of the horizontal arm by sliding it below the
weight container. (Fig 2 part 7)
and analyze the contact angle was used in this Table 1: Descriptive statistics and t-test of
study. The sessile drop technique is generally static contact angle for distilled water and
used to estimate wetting properties of a solid
synthetic saliva
surface (6). the contact angles of synthetic saliva
Synthetic Distilled p-
and distilled water were recorded. Materi t- Si
saliva water val
The equipment that was used to measure the al test g.
n mean SD n mean SD ue
contact angle was (Dino-Lite digital Acrylic
microscope), the equipment was used to take a 1 85.11 0.64 1 75.96 0.57 33.3 0.0 H.
Soft
magnified pictures (45X magnification) of the 0 10 852 0 50 527 63 00 S
Liner
profile of the specimens with a drop of liquid on Flexible 1 80.20 0.46 1 70.60 0.18 60.8 0.0 H.
its surface, the size of the drop (40l) was acrylic 0 05 462 0 30 154 43 00 S
standardized with the use of pipette then the Hard 1 75.51 0.19 1 68.49 0.16 85.1 0.0 H.
contact angles were determined by analyzing the Liner 0 60 769 0 80 999 20 00 S
picture in the specialized software( DinoCapture) Hot
1 70.39 0.43 1 64.69 0.27 35.2 0.0 H.
of the digital microscope by drawing a tangent, Cure
0 00 178 0 00 333 72 00 S
The angle between the baseline of the drop and acrylic
the tangent at the three-phase-line solid/liquid/air Light
1 67.52 0.21 1 60.53 0.17 78.6 0.0 H.
was measured. For advancing and receding Cure
0 80 972 0 35 578 05 00 S
angles an inclined metal surface was used (24 acrylic
inclination) then placing the specimen on it Tissue
1 73.55 0.18 1 65.50 0.18 97.8 0.0 H.
followed by using the pipette to make a drop on Conditi
0 25 597 0 45 177 66 00 S
the surface of the specimen, the measurements of oner
the angles were done in the same method
described above. The surface retention of each material was
Determination of the Surface Retention of the determined on the machine described above; first
test samples to Plane Glass the level of the device must be zero. This was
The surface retention of each material was ensured by using platform scale for ( both axis Y
determined by using specially designed and X ) samples were placed and attached with
equipment which was based in it is design on the holding mechanism on the stage against
weight scale (Figure 2). The design consists of: plane glass then a drop (40l) of distilled water
and synthetic saliva between the surfaces was
pipetted on the sample. The glass plate then was Table 2: Analysis of variance (ANOVA) for
lowered (cancelling equilibrium state of the static contact angles (distilled water)
horizontal arm by sliding a movable small bar Distilled water p-
Materia Si
below the weight container), then the glass plate F val
l n mean SD g.
came down with the effect of it is weight and ue
came into contact with the test sample and film Acrylic
1 75.92 0.621
of liquid (either synthetic saliva or distilled Soft
0 32 01
water) between them.Small metal nails (0.5 gm) Liner
were used as weights, the nails were carefully Flexible 1 70.60 0.181
added to the weight container with the use of acrylic 0 30 54
twizer until separation occurred between the
glass plate and the specimen, the force (weight) Hard 1 68.49 0.169
required to break each assembled specimen was Liner 0 80 99
2904. 0.0 H.
recorded through taken out nails of the container Hot
1 64.69 0.273 842 00 S
and their weight calculated using Digital Jewelry Cure
Scale Professional (digital weight scale),the 0 00 33
acrylic
specimen and the glass plate were wiped dry Light
with soft paper tissues and the procedure were 1 60.53 0.175
Cure
repeated for three times for each of (10) 0 35 78
acrylic
specimens of each material. Tissue
1 65.50 0.181
Statistical analysis Conditi
0 45 77
Descriptive statistics including: oner
arithmetic mean, standard deviation, Statistical
tables and Graphical representation by bar charts Table 3: Analysis of variance (ANOVA) for
were used. The data were collected and analyzed static contact angles (synthetic saliva)
using SPSS (version 15) for statistical analysis. Synthetic Saliva p-
One-Way Analysis of Variance (ANOVA) was Materia Si
mea F val
used to determine whether there is a statistical l n SD g.
n ue
difference among the groups and Student t-test Acrylic
was used to evaluate the significance of 85.1 0.648
Soft 10
difference between each group. In the above 110 52
Liner
tests, Level of significance was set at P < 0.05.
Flexible 80.2 0.464
10
acrylic 005 62
RESULTS
The mean and standard deviation of the data Hard 75.5 0.197
10
obtained for different denture base and lining Liner 160 69
2639. 0.0 H.
material test are listed in (Table 1) and The Hot 734 00 S
result indicated that the mean of static contact 70.3 0.431
Cure 10
900 78
angles for synthetic saliva was greater than those acrylic
for distilled water on different materials with the Light
67.5 0.219
highest value was for acrylic soft liner Cure 10
280 72
(85.1110) and the lowest value was for light acrylic
cure acrylic (60.5335). Tissue
73.5 0.185
One way analysis of varience test Conditi 10
525 97
(Anova) revealed a statistically highly significant oner
difference among the different type of denture
base and lining materials, It appeared that the The mean of weight (force) that is required to
acrylic soft liner (75.9232, 85.1110) had the break the seal between the specimens and the
highest mean value of static contact angle glass slab using different fluids (distilled water
followed by flexible acrylic, hard liner, tissue and synthetic saliva) and different type of
conditioner, hot cure acrylic then light cure materials present in figure 3.
acrylic (60.5335, 67.5280) (Table 2), for
distilled water drop and (Table 3) for synthetic
saliva drop.
In a bulk of a solid or a liquid the molecules are

subjected to attractive forces in all directions
such that the molecule is in dynamic equilibrium
with it is surrounding molecules. At the surface,
however, this delicate balance is destroyed,
resulting in a net inward attraction, directed
towards the large number of molecules in the
mass of the material. It is this inward force
which gives rise to the surface energy of a
material. In liquids, the surface energy is known
as the surface tension. The contact angle is
dependent upon the surface tension of the liquid
and the surface energy of the solid. Noort (4).
Value of contact angle of synthetic
saliva and distilled water on light cure acrylic is
lower than those for hot cure acrylic, tissue
Figure 3: Histogram of retention force for conditioner, hard liner, flexible acrylic and soft
distilled water and synthetic saliva. liner, respectively, this may be due to that the
surface energy for light cure acrylic is greater
than those for hot cure acrylic, tissue
DISCUSSION conditioner, hard liner, flexible acrylic and soft
The Static Contact Angle The static liner, respectively. So that when a drop of
contact angles of synthetic saliva at the left and distilled water or synthetic saliva deposit on the
right boundaries of the drop of synthetic saliva surface the molecules are subjected to attractive
were not significantly different for different forces in all directions. In case of light cure
materials used in the study. Similarly, these acrylic this attractive forces is greater than the
static contact angles at the left and right other materials, which leads to more spreading of
boundaries of drop of distilled water were not the liquid drop and then lower contact angle(9).
significantly different for different materials The Advancing and Receding Contact Angle
used in the study, These results could be due to The contact angle observed when a liquid
that the test surfaces of the specimens were boundary advances for the first time over a dry
homogenous because of the use of cleaning solid surface is called the advancing contact
method which was recommended by Stowers angle (A) while the contact angle observed
and Patton (7) which effectively removed when a liquid boundary recedes from a
contaminants from the test surfaces and made the previously wetted surface is called the receding
surface homogenous. This is in agreement with contact angle (R) These angles can be obtained
Kilani (8). when the measurement of contact angle is done
The Effect of Viscosity on the Contact Angle at 24 tilt to promote the advancing and receding
The static contact angle data for to occur. The advancing contact angles of
synthetic saliva and distilled water on the synthetic saliva and distilled water at 24 tilt
different test specimens showed that the were significantly greater than the receding
differences between the values of contact angle contact angles for different materials used in the
in both fluids were statistically significant. The study. These findings are in accordance with
results revealed that the angles obtained for those previously reported by padday(10).
synthetic saliva are greater than those for It has been reported by owens(11) that the
distilled water this may be due to the viscosity of differences between advancing and receding
synthetic saliva is greater than that of distilled contact angles (hysteresis) were due to the
water, so that the resistance of synthetic saliva to presence of pores or crevices on the adherend
flow is greater than that of distilled water.The surfaces which resulted in the entrapment of the
results obtained were in agreement with the fluid as it flowed over the solid surfaces. A
findings of Kilani (8). and Noort (4). who showed surface which had previously been wetted by a
that the value of contact angles are directly fluid will exhibit a lower contact angle of the
proportional to the viscosity of the adhesive. fluid than a surface which had not previously
The Effect of Type of Material on Contact been wetted by the same fluid. Craige et al (11)
Angle (Wettability) Peyton (13) suggested that the differences
between the advancing and receding contact
angle resulted from the differences in adhesion tissue conditioner, hard liner, flexible acrylic and
between the liquid drop and the solid and the soft liner also the force increased with better
liquid drop and liquid film on previously wetted wettability (lower contact angle) This result
surface. could be due to the increase in wettability
The Surface Retention (Table 4) promotes better adhesion, there are two main
The ability of a denture material to be wetted types of adhesion mechanical attachment or
gives an indication of the degree to which the chemical adhesion, In mechanical attachment the
lubricating effect of saliva will be enhanced, adhesive simply engages in undercuts in the
thereby promoting denture retention and patient adherend surface. In the case of chemical
comfort(1). The surface retention data for adhesion the adhesive has a chemical affinity for
synthetic saliva was greater than those for the adherend surface. Whichever mechanism of
distilled water. This is due to the differences in bonding is utilized the adhesive must be capable
the viscosity between the two fluids. There is a of wetting the adherend surface. In the case of
relationship between adhesion and viscosity, that mechanical attachment the adhesive must flow
the increase in viscosity produces increase in readily across the adherend surface and enter
adhesion of glass plates. This is in agreement into all the surface undercuts in order to form the
with ostlund (14),Kilani (8) and O'Brien(15). The bond. For chemical adhesion the adhesive must
driving force that causes capillary action must wet the adherend surface in order that intimate
also work against the pressure of the air that is contact between the adhesive and adherend may
trapped by the adhesive and must overcome the result in the formation of specific links which
viscous resistance forces. However, the surface cause bonding(17, 18, 9, 19, 6).
tension of the liquid must also be sufficiently
low to wet the substarte perfectly. Hence, the REFERENCES
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Dent 1960;10: 658-63. 19. McCabe JF. Applied dental materials. 9th ed.
15. O'Brien WJ Ryge. An outline of dental materials and Blackwell scientific publications. Oxford London,
their selection. Philadelphia, London, 1978. 2008.
16. Buonocore, MG. Principle of Adhesive Retention
and Adhesive Restorative Materials. J Amer Dent
Assoc 1963; 67: 382-91.
J Bagh College Dentistry Vol. 24(special issue 1), 2012 Evaluation of different
Evaluation of different techniques used in non surgical

endodontic retreatment for teeth with different obturation
techniques (An in-vitro study)
Nsar Muhyaddin Aziz BDS, MSc (1)
Dara Hamarashed Saeed BDS,MSc, PhD (2)
ABSTRACT
Background: Retreatment procedures in endodontic practice require complete removal of the original root filling
materials. The aim of this study was to evaluate the efficacy & time required for rotary Nickel titanium NiTi instruments
(Pro-Taper) with and without solvent in the removal of obturation materials during root canal retreatment in
comparison with hand instruments using Hedstrom files with solvent in relation to different obturation techniques.
Materials and method: Ninety extracted human roots were instrumented by ProTaper rotary files to (F3) ISO # 30 and
the samples were randomly divided into three groups of 30 roots for each group A: obturated by cold lateral
condensation technique, group B: obturated by Injectable thermoplasticized technique, group C: obturated by
carrier based gutta-percha technique (Soft Core) obturator. Each main group of roots was randomly subdivided into
three subgroups, 10 roots each. Removal of gutta-percha was performed the following techniques; (1) Pro-Taper
without solvent, (2) Pro-Taper with solvent and (3) Hedstrom files with solvent. The roots were split longitudinally. The
area of remaining filling was evaluated by using stereomicroscope at three levels in the canal and time of
retreatment was determined in each group.
Results: One-way ANOVA test indicated that the rotary NiTi instruments Pro-Taper with and without solvent left
significantly less remaining filling materials (P < 0.001) compared to Hedstrom files with solvent while there was no
significant difference at (p<0.05), between Pro-Taper with solvent and without solvent. In groups obturated by cold
lateral condensation and injectable thermoplasticized techniques left significantly less remaining filling materials at
(p<0.05), than group obturated by soft core obturators. The retreatment time was significantly less at (P < 0.001)
when the rotary NiTi Pro-Taper instrument was used compared to hand.
Conclusion: ProTaper rotary instrument with and without solvent was found to be effective and faster than hand
instruments and Cold lateral condensation technique and inject able thermo plasticized technique better removed
in retreatment than Soft Core obturator technique.
Keywords: retreatment; rotary instruments; residue material; obturation techniques. (J Bagh Coll Dentistry 2012; 24(sp.
Issue 1):31-35).
INTRODUCTION A solvent can facilitate the removal of gutta-

Gutta-percha has been used in endodontic percha by softening it. Among the organic
therapy for more than 100 years and is still the solvents more frequently used in endodontic
principal material for filling root canals. Thus, retreatment are: chloroform, xylol, halothane,
endodontic retreatment fundamentally consists of eucalyptol, orange oil, and rectified turpentine (4).
the removal of gutta-percha cones from inside The purpose of the present study was to
root canals (1). evaluate the efficiency of NiTi rotary instruments
Gutta-percha, in combination with sealer cements (Pro-Taper) with & without solvent compared
can be removed with several techniques such as with manual Hedstrom files with solvent for
solvents, K-type or Hedstrom files, Gates Glidden removal of gutta-percha from root canal during
drills, heated pluggers, ultrasonic technique and endodontic retreatment in relation to different
lasers (Nd:YAP laser) (2) . obturation techniques. Also to calculate time
Currently, nickel titanium rotary instruments needed for different retreatment techniques in
(NiTi) like Reamer with alternate Cutting edges relation to different obturation techniques.
(RaCe), Pro-Taper, K3 and Greater Taper (GT)
rotary have an important role in the removal of MATERIALS AND METHODS
gutta-percha for their ability to simulate curved Sample selection and preparation: Ninety
canals & effectively produce well tapered root extracted single-rooted human teeth with a single
canal form requiring less time, although complete straight root canal (less than 30 curvatures),
removal of gutta-percha has not been attained were selected and stored in a special container
with these instrument, Also Care must be taken to containing 50% alcohol solution until use. The
avoid fracturing these rotary instruments inside collected teeth had been subjected to de-
the canal, thus further complicating the coronation process using a slow speed
retreatment (3). conventional hand-piece with diamond cutting
(1) Assistant Lecturer, Department of Conservative Dentistry, disc with water coolant for disking. Working
College of Dentistry, Hawler Medical University. length was standardizing to 12 mm and apical
(2) Lecturer, Department of Conservative Dentistry, College of
Dentistry, Hawler Medical University. patency was confirmed with a size 15 K-file.
Instrumentation: coronal 3mm was flared with Subgroup 3 (n=10): retreatment using Hedstrom
Gates Glidden drills 1, 2 and 3 in a telescopic files (Manual) and solvent: three drop of Xylol
preparation. The apical thirds were prepared by solvent was introduced into each canal for 2
the crown down technique using ProTaper rotary minute to soften the gutta-percha. Two additional
system by Dentsply engine at 300 rpm with torque drop of solvent were applied as required to reach
number 3to F3 files (finishing files) and 4% of the working length for 2 minute. Then, ISO size
chlorhexidin solution used for lubricating canal 15 and 20 Hedstrom files were used for deep
and instrument. The teeth were then dried and penetration until they reach the working length
divided into three groups. Group A: Thirty roots and after that removal of gutta-percha was
obturated with gutta-percha cone using cold completed using size 25 - 30 Hedstrom files in a
lateral compaction technique. Group B: Thirty circumferential quarter-turn push-pull filing
roots were obturated with injecting thermo- motion (to engage the GP). After removing the
plasticized gutta-percha mass using Bee-fill filling material, the roots were marked at the
device. Group C: Thirty roots were obturated with middle of mesial and distal sides with longitudinal
Soft-Core thermo plasticized obturators. After line by a permanent marker. Then the roots were
obturation, the samples were radiographed in both cut into 2 halves buccal and lingual using a
bucco- lingual and mesio-distal aspects to diamond cutting disc via slow-speed conventional
evaluate the homogeneity, compaction, adaptation hand-piece with water cooling, and the roots were
& extension of the obturation at 2- dimension split with aid of chisel for evaluation in thirds.
view in which one film was used to take Cleanliness wall was scored with the aid of a
radiograph for one tooth Then the roots were stereomicroscope which was adopted for the
wrapped in saline moistened gauze in closed glass evaluation of residual gutta-percha and sealer on
tubs allowing the sealer to set for one month with the canal Walls, as it was considered a simple and
100% humidity at 37C for aging (5). efficient assessment method.
Re-treatment Techniques: At the end of the one Both halves of each split tooth were divided into
month, 3 mm of obturation material was removed coronal, middle, and apical thirds, measuring from
from the coronal part of the root canal of all roots the cemento-enamel junction to the terminus of
using Gates Glidden drills 2 and 3. Sodium the apical preparation, using a permanent pencil.
hypochlorite 5% irrigation was used after each The evaluation scales was used as follow :
instrument (1ml for each root). Then each group Score 1: None to slight remaining (<25%)
including (30 samples) has been subdivided for obturating material and debris on the dentin
retreatment as follow: surface (fig. 1).
Subgroup 1 (n=10): using ProTaper NiTi rotary Scores 2: Some remaining (25-50%) obturating
instruments without solvent: Rotary instruments material and debris on the dentin surface (fig. 2).
were driven with a torque-controlled motor Scores 3: Moderate remaining (50-75%)
according to the manufacturers instructions 300 obturating material and debris on the dentin
rpm (round per minutes), the gutta-percha was surface (fig. 3).
removed by the following sequence using light Scores 4: Heavy remaining (>75%) obturating
apical pressure: Finishing files F3= (ISO size 30, material and debris on the dentin surface (fig. 4).
taper O.O9-O.O5), F2= (ISO size 25, taper 0.08- The data were collected and analyzed using
0.055), and F1= (ISO size 20, taper O.O7-O.O55) ANOVA-test. P value of =<0.05 was regarded as
was used in a crown-down technique to remove statistically significant.
the gutta-percha until the working length was
reached. Finishing files F2 and F3 was used again RESULTS
to the working length to complete gutta-percha
1. Stereomicroscopic evaluation
removal and cleaning of the canal walls.
By using ANOVA test, generally there was a
Subgroup 2 (n=10): using ProTaper NiTi rotary
significant difference between HSF/Solvent
instruments with solvent: three drop of Xylol
retreatment techniques compared with RNT-PT
solvent was introduced into each canal for
with & without Solvent in three obturation
2minute to soften the gutta-percha. Two
techniques at p<=0.05. While, there was no
additional drop of solvent was applied as required
significant difference between the HSF\Solvent
to reach the working length for 2 minute then
retreatment technique in three obturation
Rotary instruments was driven with a torque-
techniques at p<=0.05 By using ANOVA-test
controlled motor according to the manufacturers
there was significant difference between the SC
instructions 300 rpm (round per minute) , then the
obturation techniques in compared with CLC &
gutta-percha was removed as sub group 1.
ITT obturation techniques at p< o.o5, While there
was no significant difference between CLC & ITT
obturation techniques during endodontic remaining of root canal filling materials after
retreatment(table 1), (fig. 5). By using ANOVA- retreatment techniques. These results may be due
test, generally, there was highly significant to: First: the presence of the core materials which
difference between the HSF\Solvent in compared make the removal of GP harder & difficult.
with RNT-PT with & without Solvent in Second: better seal ability of soft core obturator
retreatment at P< 0.001. While, there was no to the canal walls than other techniques so during
significant difference between uses of RNT-PT, retreatment exert some difficulty in removing titer
with & without solvent in removing obturation seal gutta-percha from canal walls (9).
materials during endodontic retreatment at the findings of the present investigation showed
p>0.05(table 2) (fig. 5). By using ANOVA- test, that the rotary NiTi ProTaper instruments are with
generally, there was significant difference & without solvent highly significantly more
between apical & coronal third in amount of effective in removing gutta-percha from the whole
remaining obturation materials in each techniques root canals compared to hand instruments at
at p<o.o5. While, there was no significant (p<0.001), these results consistent with the
difference between middle in compared with previous studies (7) (10). All the retreatment
apical & coronal in amount of remaining techniques left less remaining filling materials in
obturation materials in each techniques during the coronal third followed by the middle third &
endodontic retreatment at p>0.05. By using the apical third showed the highest ratio of
ANOVA- test, generally, there was highly remaining filling materials. These findings were
significant difference between the retreatment similar to several studies (11) (12). This may be due
techniques at P=<0.001. i.e., highly significant to increased anatomical variability and difficulty
difference between times required for uses of of instrumentation and retreatment in this region.
RNT-PT, RNT-PT\Solvent compared to Different solvents have been used for GP
HSF\solvent techniques in removing obturation removal, like xylene, chloroform, eucalyptol,
materials during endodontic retreatment (table 3), rectified turpentine oil & white pine oil. Although
(fig. 7). xylene and chloroform are excellent solvents of
GP, but chloroform proved to be toxic and
carcinogenic (13). Finding of the studies revealed
DISCUSSION that there was not significant different between
The main goal of retreatment is to regain access to the use of Pro Taper with solvent & Pro Taper
the constriction by complete removal of the root without solvent, since the using Pro Taper without
canal filling material, thereby facilitating solvent also more effective in cleaning canal
sufficient cleaning and shaping of the root canal walls. This result consistent with the previous
system and final obturation. study performed by some authors (14) (15). The
In the present study root canal preparation was better performance of proTaper retreatment files
done by one operator following predetermined may be due to, their flute design which pulls GP
protocol using Rotary NiTi Pro-Taper and the out and directs it to the orifice, Also the frictional
canals were instrumented to a size F3= Iso size heat plasticizes GP and allows its easy removal
#30 as master apical file, as did by (5) (7). (13)
.
Although cold lateral condensation is one of the In the present investigation, the time recorded for
most accepted canal obturation techniques, the retreatment techniques was significantly less
gutta-percha does not adapt to the canal walls when using the Pro-Taper rotary NiTi instruments
especially in irregular canals, Injected thermo with & without solvent when compared to the
plasticized gutta-percha can adapt more hand instruments (Hedstrom files) with solvent.
effectively to irregularities in the canal, thus These results were in accordance with previous
replicating the root canal system, also carrier reported studies (5) (16) (17).
based gutta-percha technique showed good
adaptation to the canal walls and all parts of the
canal regardless of the presence or absence of a
CONCLUSIONS
ProTaper rotary instrument with and without
smear layer (8). This fact may affect the
solvent was found to be effective and faster than
retreatment techniques, since the obturation
hand instruments. Cold lateral condensation
material that inters the canal irregularity may not
technique and inject able thermo plasticized
be so easy in removing sufficient amount during
technique better removed in retreatment than Soft
re treatment.
Core obturator technique.
In this study there was significant difference
between cold lateral compaction technique &
inject able thermo-plasticized technique compared
to soft core obturator technique at (p<0.05), in
Oral Med Oral Pathol Oral Radiol Endod 2003; 96:

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1. Oyama K, Sianeira E & Santos M. Invitro study of
10. Hammad M, Qualtrough A, Silikas N. Three-
effect of solvent on root canal retreatment. Braz Dent J
dimensional evaluation of effectiveness of hand and
2002; 13(3): 208-11.
rotary instrumentation for retreatment of
2. Saad A, Al- Hadlaq S & Katheeri N. Efficacy of two
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rotary Ni- Ti instruments in the removal of Gutta
34: 13703.
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11. Barletta F , Rahde N , Limongi O, Moura A , Zanesco
33(1): 38-41.
C & Mazocatto G. In vitro comparative analysis of 2
3. Scelza M., Coil J, Maciel A, Oliveira L & Scelza P.
mechanical techniques for removing gutta-percha
Comparative evaluation of three solvent used in
during retreatment. J Canad Dent Asso 2007; 73, 65
endodontic retreatment: An Exvivo study. J Appl Oral
65e.
Sci 2008; 16(1): 24-9.
12. Fenoul1 G, Meless G. & Pe rez F. The efficacy of R-
4. Magalhaes B, Johann J, Lund R, Martos J & Pino F.
Endo rotary NiTi and stainless-steel hand instruments
Dissolving efficacy of some organic solvents on gutta-
to remove gutta-percha and Resilon. Int Endod
percha. Braz Oral Res 2007; 21(4): 303-7.
J2010; 43, 135141.
5. Al- Katheeri N. Efficacy of two rotary NiTi
13. Sandhya U, Nainan M, Mangala T & Kamat Sh. To
instruments in the removal of gutta-percha
treat & to retreat Pro Taper universal rotary system,
during root canal retreatment. A in vitro study.
the double delight. Endodontology 2009; 41: 42-7.
2005, Master thesis. University of King, Saudi.
14. Betti L & Bramante C. Quantes S rotary instruments
6. Zarei M, Shahrami and Vatanpour M. Comparison
versus hand files for gutta-percha removal in root
between gutta-percha & resilon retreatment. J Oral
canal retreatment. .Int Endod J 2001; 34(7): 514-9.
Scien; 51(2): 181-2.
15. Takabasbi C, Cunba R, Demartin A & Fontana C. In
7. Ahmed E. The effectiveness of rotary & hand
vitro evaluation of the effectiveness of Pro-Taper
instrumentation on the removal of gutta-percha
universal Rotary retreatment system for gutta percha
during endodontic retreatment using two type of
removal with or without solvent. J Endod 2009;
solvents (comparative study). 2010, Master Thesis.
35:1580-83.
University of Baghdad. Iraq.
16. Hulsmann M & Bluhm V. Efficacy, cleaning ability &
8. Kqiku L, Weiglein A & Stadtler P. A comparative
Safety of different rotary NiTi instruments in root
study of five different obturation techniques. Acta
canal retreatment. Int Endod J 2004; 37(7): 468-76.
Stomatol Croat 2006; 40: 3-11.
17. Somma F, Cammarota G, Plotino G, Grande N &
9. Gencoglu N. Comparison of 6 different gutta percha
Pameijer C. The effectiveness of manual and
techniques, (part II): thermafil, Js Quick-fill, soft core,
mechanical instrumentation for the retreatment of
microseal, system B & lateral condensation. Oral Surg
three different root canal filling materials. J Endod
2008; 34: 466 9.
Figure 1: Score 1 Figure 2: Score 2
Figure 3: Score 3 Figure 4: Score 4
Table 1: The Descriptive statistic & ANOVA-test of the obturation techniques in endodontic
retreatment Stereomicroscopic evaluation)
ANOVA- P value Test
Group
test Sig Bonferroni
1 CLC 31
0.012
2 ITT 4.617 32
S
3 SC
Table2: The descriptive statistic & ANOVA for the three retreatment techniques
(Stereomicroscopic evaluation).
p-Value
Groups ANOVA-test (Bonferroni)
Sig
RNT-PT
0 31
RNT-PT\S 15.03
HS 32
3 HSF\S
Table 3: The Descriptive statistics, ANOVA & Bonferroni test for time of the retreatment of the
nine groups.
Obturation Retreatment ANOVA
(Bonferroni)
techniques techniques P value
1 13
RNT-PT 16
2 19
1 CLC
RNT-PT\Solvent 23
3 HSF\Solvent 26
4 29
RNT-PT 43
5 46
2 ITT RNT-PT\Solvent 49
6 53
43.293
HSF\Solvent 56
7 59
RNT-PT 73
0.001
8 76
HS
RNT-PT\Solvent 79
3 SC 83
9 86
HSF\Solvent 89
1.8
2
1.6
1.8
1.4 1.6
1.2 1.4
S co res
1 1.2
S co res
0.8 1
0.8
0.6
0.6
0.4
0.4
0.2
0.2
0
0
CLC ITT SC
RNT-PT RNTPT\S HSF\S
Techniqes Techniques
Fig. 5: Bar chart showing the Fig. 6: Bar chart showing the
obturation techniques in retreatment techniques used in
endodontic retreatment endodontic retreatment,
(stereomicroscopic evaluation) (Stereomicroscopic evaluation).
J Bagh College Dentistry Vol. 24(special issue 1), 2012 The effect of addition
The effect of addition of calcium hypochlorite disinfectant

on some physical and mechanical properties of dental
stone
Shorouq M. Abass, B.D.S., M.Sc. (1)
Ibrahim K. Ibrahim, B.D.S., C.E.S., D.S.O. (2)
ABSTRACT
Background: The potentially damaging effects of the immersion technique, the difficulty in covering the entire
surface of the cast with the spray disinfecting solution, and the inability to assume that every impression presented to
the laboratory has been disinfected has led to the need for incorporating a disinfectant directly into the calcium
sulfate hemihydrate. This study was designed to evaluate the effect of the addition of Calcium Hypochorite
disinfectant on some physical and mechanical properties of the dental stone.
Materials and methods: Calcium Hypochlorite disinfectant in aqueous solution in different concentrations 0.5, 1.0, 1.5
and 2.0% was added to type III dental stone. Setting time, setting expansion, reproduction of details, compatibility
with impression materials and consistency are physical properties which were evaluated. The compressive strength
and surface hardness as mechanical properties were also determined.
Results: The results of this study showed that the addition of 1 % of calcium hypochlorite improved some of the
physical and mechanical properties of dental stone (Setting Expansion, Compressive Strength and Surface Hardness)
while its adversely affected the other properties (Setting Time)
Conclusions: The 1 % of calcium hypochlorite disinfectant solution could be used to disinfect dental cast with the
least effect when compared with the other concentrations of calcium hypochlorite .
Key words: Dental stone, disinfectants, calcium hypochlorite. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):36-43).
INTRODUCTION Study by Abdelaziz et al.6 and Ivanoveski et

7
Dentists, dental assistants and laboratory al. reported a reduction in strength values with
technicians are always at risk of cross- most of the gypsum products tested especially
contamination, especially those who do not wear those mixed with povidone iodine, glutaraldyhde,
gloves because of their sensitivity to latex rubber sodium hypochlorite. Recently, a study done by
or due to the reduction in their working skills as a Twomey et al.8 showed that the addition of
result of glove-wearing.1,2 calcium hypochlorite as a disinfecting agent to
Dental impressions become contaminated dental stone, was microbiologically effective at
with microorganisms from the patient's saliva and 0.5%.
blood, which can crossinfect stone casts poured In this study the calcium hypochlorite
against them.3 A number of these microorganisms disinfectant solution was used in different
cause infectious diseases that may be incurable, concentrations (0.5%, 1.0%, 1.5%, and 2% by
such as those caused by the hepatitis C and HIV weight) to disinfect dental stone and to determine
viruses.4 Practically, sterilization of either the the effect of each concentration on some physical
impression or gypsum cast is considered and mechanical properties of dental stone.
unacceptable because of its adverse effects on the
properties of materials used in construction of the MATERIAL AND METHODS
impression/cast system. A type III dental stone (Elite model,
American Dental Association (ADA) and the Zherwack SPA, Rovigo, Italy) was used to
Centers for Disease Control and Prevention prepare the samples. The calcium hypochlorite
suggested methods for the disinfection of dental (BDH, Laboratory prepared, England) was used to
casts, including immersion in or spraying with a prepare the testing solutions.
disinfectant.5 The stone samples were prepared and divided
The potentially damaging effects of the into five groups, according to the concentration of
immersion technique, the difficulty in covering calcium hypochlorite 0, 0.5, 1.0, 1.5, 2.0%.
the entire surface of the cast with the spray Group A Stone powders were mixed with
disinfecting solution, and the inability to assume Distilled water
that every impression presented to the laboratory Group B Stone powders were mixed with
has been disinfected has led to the need for 0.5%Calcium hypochlorite solution
incorporating a disinfectant directly into the Group C Stone powders were mixed with 1
calcium sulfate hemihydrate. % Calcium hypochlorite solution
(1) Lecturer, dep. of prosthetic dentistry, college of dentistry,
Baghdad University.
Group D Stone powders were mixed with
(2) Retired Professor dep. of prosthetic dentistry, college of 1.5%Calcium hypochlorite solution
dentistry, Baghdad University.
Group E Stone powders were mixed with The average percentage of five specimens,
2% Calcium hypochlorite solution for each group, was considered as the
percentage of the setting expansion.
Setting time test
the setting time was conducted according to Reproduction of details test
the ADA specification No.25 for gypsum product The ability of the test specimens to reproduce
by using Standard Vicat Apparatus. 9 Setting time details was conducted according to the method
was determined by bringing the tip of the 1mm described in the ADA specification No.25 for
needle of the vicat apparatus into contact with the gypsum by using a test block. 9
surface of the test material and locked in position The rubber ring was placed over the test
with the thumb screw. The needle was then block so that the intersection of cross line and the
released and allowed to penetrate the specimen at groove 0.5 mm wide was in the center of the ring,
15 second intervals by one minute prior to the the prepared mix was poured into ring while the
anticipated setting time (usually at loss of glass or block with the ring was vibrated.
excess water). After each penetration, the needle The ring and the stone specimen were
was wiped cleaned with a piece of gauze and the separated from the test block after 1 hour, and
mold was moved to allow for the next penetration then ready to be evaluated.
to be in a new area. The evaluation was conducted by10 dentists
The total elapsed time, from the start of mix who observed and scored the testing specimens
until the needle failed to penetrate the specimen twice, the time separated between the 1st reading
completely, was taken as the vicat setting time. and 2nd reading was 10 14 days according to
The test was repeated five times to determine the WHO.
average value of the setting time. The evaluations were made in random order
and the evaluators were unaware of the type of
Setting expansion test specimen being evaluated. Each specimen was
the setting expansion was conducted evaluated on the bases of a I IV scoring system.
according to the ISO specification No. 6873 150, Criteria for evaluation of reproduction ability
through the use of the extensometer apparatus. 10 of stone specimens was arranged to evaluate the
The stopper was fixed to provide a trough 0.5mm line which scored as follows:
of not less than 100mm in length. The standard Score I: The line was continuous and clear
mix of 300gm of stone powder was added to 90 for the full width of the ring.
ml of test solutions. The mix was prepared and Score II: The line was continuous and clear
poured into the trough until it was filled for more than half the width of ring.
completely. Score III: The continuity and clearness of the
The initial reading (IR) was done with line was less than half the width of the ring.
Score IV: The line failed to be reproduced
testing device at 1minute before the setting
along the width of the ring.
time.
One end of the specimen was allowed to
expand unrestrained for 2 hours, after that the Compatibility with Impression Materials
final reading (FR) was taken. Determination of the compatibility with the
The setting expansion as percentage of the impression materials was conducted according to
ADA specification No. 25 for gypsum products. 9
original gauge length was calculated to the
Three types of impression materials were
nearest 0.01%.
used; alginate, silicone and Zinc Oxide Eugenol
The Difference between FR and IR was impression material.
considered as the change in length of the
specimen, and the percentage of the setting
expansion was calculated from the following
Consistency Test
The determination of the consistency was
formula: -
according to the British Standard Specification for
FR - IR
L% = 100 dental gypsum products ISO NO.6873, by using
L Modified Vicat Apparatus. 10
The apparatus consisted of a rod, plunger and
L%: percentage of setting expansion. additional weights such that the total mass is
L: actual length of specimens 100_+0.1g (Figure 3.5)
300 g of stone powder was added to 90 ml of Statistical analysis

the testing solutions, the mix was poured in to the The Descriptive statistics included
conical ring mold (large upper most) (Arithmetic mean, Standard deviation and
Penetration commenced after 3 Minutes, 4 Graphical presentation) and the Inferential
Minutes and 5 Minutes from the start of the statistics which included (oneway ANOVA test
mixing and the results was recorded. and the multiple comparison tests utilizing the
The average of nine penetrations (three mixes) LSD, Least Significant Difference test, were used
was taken as a measure of consistency. in this study.
Compressive strength test RESULTS AND DISCUSSION

Compressive strength values were determined Setting test
according to the ADA specification No. 25 for The incorporation of the calcium hypochlorite
gypsum.9, 10 compressive strength specimens for disinfectant solution in different concentrations,
each group were prepared by vibrating the mixed from 0.5 to 2% by weight, with dental stone
material in to cylindrical molds 20mm in diameter resulted in a significant retardation in the setting
and 40mm length. The constructed specimens time of the testing groups when compared with
were released from the mold at one-half hour the control group, table (1, 2), figure (1). The
from the start of the mixing. Half of these retardation effect increased as the concentration of
specimens were stored in air at room temperature calcium hypochlorite increased, this finding is in
23.0 2.0 oC and 50 10 % relative humidity until agreement with that of Harcourt &
they were crushed at one hour after the start of Lautenschlager, 12 Saso et al., 13, Al-Shakily, 14
mixing. This measured wet compressive strength. Al-Fahdawy & Al-Ameer 15, and Berko 16.
The other half of specimens were stored in the The retardation effect of the addition of
same conditions for 24 hours, and then they were calcium hypochlorite to dental stone may be due
incubated at 37oC for seven days before they were to the fact that the retarder may work on the
subjected to the test. This measured dry principle of changing the solubility of the hemi-
compressive strength. Calculation of the hydrate and dihydrate crystals so that the
compressive strength was determined from the conversion of the hemihydrate to dihydrate
value of the maximum load at the point of decreases causing the chemical reaction to slow
specimen fracture according to the following down. 17
formula: 11 Poisoning of growing crystals with chlorite
Surface area = Area of circle= cm2 ions led to retardation in crystal growth and
accordingly improper intermeshing. This can also
Force Kg explain the retardation effect of calcium
C.S. = =
area cm 2 hypochlorite disinfectant solution. 18
Surface hardness test Setting expansion test

10 specimens for each group were prepared. The results of this study showed that the
Each specimen had a diameter of 20mm and a incorporation of the calcium hypochlorite
length of 40mm. Half of the specimens were disinfectant solution in different concentrations
tested after 24 hours and the other half after 7 with dental stone mixture produced an
days. advantageous effect. Table (3, 4)
All the specimens were tested with the Brinell All the testing groups showed lower setting
hardness tester expansion than the control group with exception
The resulting hardness value, known as the for group E (2%), which had no data because of
Brinell hardness number (BHN), was calculated the delayed setting time of more than 120
from the following formula: 11 minutes, this finding is in agreement with the
results of Al-Shakily 14, Berko 16 and disagree
L Kg with the results of Breault et al 19, Ivanovski et
BHN = =
D
2
(
D - D2 d2 ) mm 2
al.20 , & Edwards et al. 21.
Change in the morphology of the resulted
gypsum crystals produced changes in the crystal's
L load in Kg
thrust and consequently tendency for expansion
D diameter of ball =2.5mm will change. 13
d diameter of indentation in mm
Reproduction of details test Consistency test

It was found that the addition of calcium The results of this study showed that the
hypochlorite disinfectant solution in different addition of calcium hypochlorite disinfectant
concentrations produced a significant effect on the solution to dental stone produced a change in the
reproduction of details of dental stone, except for consistency of dental stone. This finding is in
group B (0.5%) and group C (1.0%) in which agreement with the results of Spratley and Combe
23
there was no significant effect on the reproduction and in disagreement with the results of Twomey
of details of dental stone, table (5,6). This finding et al 8, table (12, 13).
is in agreement with the results of Edwards et al. According to our knowledge, the explanation
21
, Al-Shakily 14, &Berko 16 and in disagreement of this phenomenon was not found in any
with that of Saso et al. 13. published data concerning the effect of this
According to our knowledge the explanation disinfection method. However, it can be presumed
of this phenomenon was not found in any that the additive may have altered the water
published data concerning the effect of this requirement of a particular stone by changing the
disinfection method on the detail reproduction of strength of the surface forces on the particles in
dental stone. However, it may be attributed to the the suspension. This led to reduction in the
change in the water requirement of dental stone as adhesive forces amongst them and so the
a result of incorporation of calcium hypochlorite resistance to flow arising from contact of
disinfectant solution leading to a change in the individual particles in the suspension resulting in
recommended consistency for satisfactory detail reduction in viscosity. 24
reproduction. Another explanation is that the
bleaching effect of the chlorine on the cast surface Compressive strength test
may have masked the lines from the evaluator The test for compressive strength was
during scoring. conducted in different time intervals after the
beginning of the mixing process (1 hour and after
Compatibility with impression materials 7 days).
The compatibility of the dental stone The specimens for the wet compressive
specimens mixed with calcium hypochlorite strength failed in testing after1 hour. It was
disinfectant solution in different concentrations expected from the theory of setting that the
with different impression materials can be seen in strength of stone increases rapidly as the material
the following: hardens after the initial setting time.10 In this
With Alginate Impression materials they study it was found that the addition of calcium
were compatible at all testing hypochlorite had a retarding effect on the setting
concentrations of calcium hypochlorite time and the specimens for the testing groups did
disinfectant solution, table (7). not reach the initial setting time after 1 hour, so
Similar results were found with silicone the specimens failed after 1 hour. While the
impression materials except the results for the specimens tested after 7 days for
concentration of 1.5 % which was not the dry compressive strength showed that the
compatible, table (8, 9). addition of calcium hypochlorite caused a
reduction in strength except for group C (1.0%),
With the ZOE impression material they
which found no significant effect on the
were compatible at 0.5% and 1.0% of
compressive strength when compared with the
calcium hypochlorite while for 1.5% and
control group. Table (14, 15,16,17).
2.0% they were incompatible, table (10,
The reduction in compressive strength of
11).
dental stone mixed with calcium hypochlorite is
According to our knowledge the explanation of
in agreement with the results of Saso et al.13, Al-
these phenomena were not found in any published
Shakily 14 Al-Fahdawy & Al-Ameer 15, and Berko
data concerning the effect of this disinfection 16
and in disagreement with those of Al-Shakily 14
method on the compatibility of dental stone with
Al-Fahdawy & Al-Ameer 15, Craig et al.26
impression materials. However, it may be due to
The improvement in the compressive strength
some kind of interaction of calcium hypochlorite
with 1% concentration of calcium hypochlorite is
with that of impression materials leading to
in agreement with Twomey et al.8
reduction in the sharpness of the line reproduced.
The reduction in compressive strength for the
It also might have been related to the low wetting
other concentrations could be attributed to the
behaviors of the disinfected dental stone against
reduction in the inter crystalline cohesion.27 It
the surface impression materials. 22 These results
may also be due to the alteration in the crystal
in agreement with results of Berko. 16
morphology which could affect the ability of the
crystals to intermesh and grow leading to 11. Craig RG. Restorative dental materials. 10th ed.
improper intermeshing and reduction in inter Mosby Co. 1997.
12. Harcourt JK and Lautenschlager EP. Accelerated and
crystal cohesion.28
Retarded Dental plaster setting Investigated by X-ray
Diffraction. J Dent Res 1970;49(3):502-507.
Surface hardness test 13. Saso I, Savage NW, PeterJB and Bird PS. Disinfection
Our investigation showed that incorporation of dental stone casts : Anti-microbial effects and
of calcium hypochlorite disinfectant solution in physical property alterations. Dent Materials
1995;11:19-23.
the stone mixture improved the surface hardness 14. Al-Shakily GA. The effect of disinfectant solutions on
of the dental stone samples when tested after 24 some properties of dental stone cast. A master thesis,
hours. The highest BHN was recorded at 1% but University of Baghdad 1995.
with no significant effect. However, a significant 15. Al-Fahdawy IH and Al-Ameer SS. The effect of 0.2%
reduction in the surface hardness was obtained chlorhexidine solution incorporated, on the setting
when the concentration increased up to 1.5 %. time, setting expansion and compressive strength of
Iraqi stone. Iraqi Dent J 2000.
For the samples tested after 7 days, the 16. Berko RY. Effect of Madacide disinfectant solution on
addition of calcium hypochlorite at different some of physical and mechanical properties of dental
concentrations had no significant effect on the stone. A master thesis, University of Baghdad 2001.
surface hardness of the dental stone, table (18, 19, 17. Craig RG. Restorative dental materials. 11th ed.
20, 21).This finding was in agreement with Al- Mosby Co. 2002.
shakily 14 and Paul et al. 25, but they were in 18. Kenneth JA. Phillip's Science of dental materials. 10th
ed. Philadelphia W.B. Saunders Co. 1996.
conflict with the results of Berko16 19. Breault LG,Paul JR , Hondrum SO, & Christensen LC.
The discrepancy in the results may be due to Die Stone disinfection :incorporation of sodium
the different concentrations of calcium hypochlorite. J Prosthodontics 1998;7:13-16.
hypochlorite used which may greatly affected the 20. Ivanovski S, Savage NW, Brockhurst PJ and Bird PI.
inter crystalline pattern and eventually reduced Disinfection of dental stone casts: antimicrobial
the inter crystalline cohesion as demonstrated by effects and physical property alterations. Dent Mater
1995; 11:19-23.
Skinner and Philip's.18 21. Edwards CC, Khalid AM and Attia A. Evaluation of
disinfected casts poured in gypsum with gum Arabic
REFRENCES and calcium hydroxide additives. J Prosthet Dent
1. Council on dental therapeutics, Council on prosthetic 2004; 92:27-34.
services and dental laboratory relations. Guide lines 22. Donovan T and Chee W. Preliminary investigation of
for infection control in the dental office and the a disinfection gypsum die stone. Inter J Prosthet
commercial dental laboratory. J Am Dent Assoc 1985; 1989;2(3):245-248.
110: 969-972. 23. Spratley MH and Combe EC. A comparism of some
2. Hamann CP, Turjanmaa K and Rietschel. Natural polymer containing die materials. J Dentistry
rubber latex hypersensitivity: incidence and 1973;1(14):158-162.
prevalence of type I allergy in the dental professional. 24. Combe EC and Smith DC. Improved stones for the
JADA 1998; 129:43-54. construction of models and dies. J Dent Res 1971;
3. Leung RL and Schonfeld SE. Gypsum casts as a 50:897-901.
potential source of microbial crosscontamination. J 25. Ridge NJ: Mechanism of setting of gypsum plaster.
Prosthet Dent1983; 49(2): 210-211. Rev Pure Appl Chem 1960;10:243.
4. Alter MJ, Kruszon Moran D, Nainan OV, McQuillan 26. Craig RG, O'Brien WJ and Power JM. Dental material.
GM, Cao F, Moyer LA., Kaslow RA. and Margolis Properties and manipulation. 6th ed. St. Louis: Mosby.
HS. The prevalence of hepatitis C virus infection in 1996.
the united states, 1988 through 1994. N Engl J Med 27. Skinner EW & Phillips RW. Science of dental
1999; 341:556-562. materials. 7th ed. Philadelphia W.B. Saunders Co.
5. American Dental association. Guide to dental 1973.
materials and device. 1975; PP: 86-90. 28. Mahler DB & Asgarzadeh K. The volumetric
6. Abdelaziz KM, Combe EC and Hodges JS. The effect contraction of dental gypsum materials on setting. J
of disinfectant additives on the properties of dental Dent Res1953; 32(3): 359-361
gypsum: 1. Mechanical properties. J Prosthet Dent
2002; 11(3): 161-167. Table 1: one-way analysis of variance for
7. Ivanovski S, Savage NW, Brockhurst PJ and Bird PI. setting time
Disinfection of dental stone casts: antimicrobial
d.f. F P Sig.
effects and physical property alterations. Dent Mater
1995; 11:19-23. Between groups 4 1612.665 0.000 H.S.
8. Twomey JO, Abdelaziz KM and Combe EC. Calcium Within groups 20
Hypochlorite as a disinfecting additive for dental Total 24
stone. J Prosthet Dent2003; 90:282-288.
9. American Dental association. Guide to dental
materials and device. 1975; PP: 86-90.
10. International standard. Dental gypsum products. ISO
No. 6873, 1st ed. 1983.
Table 2: LSD for the setting time Table 9: LSD for the compatibility of dental
stone with silicone impression materials
Test groups Mean P Sig.
Test groups Mean difference P Sig.
Difference
A-B -47.53000** 0.000 H.S. A-B 0.5000 0.659 N.S.
A-C -82.30000** 0.000 H.S. A-C -0.6000 0.596 N.S.
A-D -90.13000** 0.000 H.S. A-D -6.4000** 0.000 H.S.
A-E -129.59000** 0.000 H.S. A-E -0.7000 0.537 N.S.
** The mean difference is highly significant when the ** The mean difference is highly significant at the .01
P < .01 level The mean difference is N.S when P > .05
Table 10: oneway analysis of variance for
Table 3: one -way analysis of variance for the compatibility of dental stone with ZOE
the setting expansion impression materials
d.f. F P Sig. d.f. F P Sig.
Between groups 3 20.044 0.000 H.S. Between groups 4 16.865 0.000 H.S.
Within groups 16 Within groups 45
Total 19 Total 49
Table 4: LSD for setting expansion Table 11: LSD for the compatibility of dental
stone with ZOE impression materials
Test groups Mean Difference P Sig. Test Mean P Sig.
A-B 0.0140** 0.002 H.S.
A-C 0.0140** 0.002 H.S. groups difference
A-D 0.0300** 0.000 H.S. A-B -1.7000 0.219 N.S.
** mean difference is highly significant when P < A-C -0.6000 0.662 N.S.
0.01
A-D -3.1000* 0.028 S.
Table 5: one-way analysis of variance for A-E -9.8000** 0.000 H.S.
details reproduction * The mean difference is significant at the .05 level
(P < .05) ** The mean difference is highly significant at
d.f. F P Sig. the .01 level (P < .01)The mean difference is not
Between groups 4 16.281 0.000 H.S. significant when (P > .05).
Within groups 45
Total 49 Table 12: one way analysis of variance for
consistency test
Table 6: LSD for the reproduction of details
d.f. F P Sig.
Test groups Mean Difference P Sig.
Between groups 4 6.897 0.003 H.S.
A-B -3.00 0.21 N.S
Within groups 40
A-C -3.00 0.21 N.S.
Total 44
A-D -9.50** 0.00 H.S.
A-E -17.50** 0.00 H.S.
** mean difference is highly significant when P < 0.01 Table 13: LSD for consistency test
Table 7: oneway analysis of variance for the Test groups Mean difference P Sig.
compatibility of dental stone with alginate
impression materials A-B -5.7778** 0.000 H.S.
d.f. F P Sig. A-C -3.6667** 0.002 H.S.
A-D -3.7778** 0.002 H.S.
Between groups 4 0.616 0.654 N.S.
A-E -4.0000** 0.001 H.S.
Within groups 45
** Mean difference is highly significant when P < .01
Total 49
Table 14: one way analysis of variance for
Table 8: oneway analysis of variance for the dry compressive strength of dental stone
compatibility of dental stone with silicone d.f. F P Sig.
impression materials Between groups 4 59.780 0.000 H.S.
d.f. F P Sig. Within groups 11
Between groups 4 12.545 0.000 H.S. Total 15
Within groups 45
Total 49
Table 15: LSD for the data of dry Table 21: LSD for the data of surface
compressive strength of dental stone hardness of dental stone (after 7 days)
Test groups Mean difference P Sig. Test groups Mean difference P Sig.
A-B 0.0635 0.834 N.S.
A-B 313.16367** 0.000 H.S.
A-C -0.1632 0.591 N.S.
A-C 26.53833 0.266 N.S.
A-D -0.2298 0.452 N.S.
A-D 95.54175** 0.001 H.S.
A-E -0.1964 0.519 N.S.
A-E 79.61800** 0.005 H.S.
The mean difference is not significant when (P >
** The mean difference is highly significant at the
.01 level (P < .01)The mean difference is not significant at .05).
the .05 level (P > .05).
Table 16: oneway analysis of variance for
wet compressive strength data of dental
stone
d.f. F P Sig.
Between groups 4 715.812 0.000 H.S.
Within groups 10
Total 14
Table 17: LSD for the wet compressive

Figure 1: Setting time of dental stone
strength of dental stone
A-B 103.4091** 0.000 H.S.
A-C -143.1818** 0.000 H.S.
A-D 2.6515 0.588 N.S.
A-E 31.8182** 0.000 H.S.
Table 18: one way analysis for variance for

hardness test (after 1 day)
d.f. F P Sig.
Between groups 4 5.608 0.003 H.S. Figure 2: Setting expansion of dental stone
Within groups 20 P<0.01
Total 24
Table 19: LSD for data of hardness test

(after 1 day)
A-B 0.2274605 0.409 N.S.
A-C -0.0476219 0.862 N.S.
A-D 0.6797824* 0.020 S.
A-E 0.9926396** 0.001 H.S.
* mean difference is significant when P < .05 Figure 3: Reproduction of details of dental stone
** mean difference is highly significant when P <
.01, mean difference is not significant when P > .05
Table 20: one way analysis of variance for

the data of surface hardness test of the
dental stone
d.f. F P Sig.
Between groups 4 0.373 0.825 N.S.
Within groups 20
Total 24
Figure 4: The compatibility of dental stone with alginate
Figure 5: The compatibility of dental stone with

silicone impression materials Figure 9: Surface hardness of dental stone
Figure 6: The compatibility of dental stone with ZOE

impression materials
Figure 7: Consistency of dental stone
Figure 8: Dry compressive strength of dental stone
J Bagh College Dentistry Vol. 24(special issue 1), 2012 Comparison the tensile
Comparison the tensile strength of heat cure and visible

light cure acrylic resin denture base
Zahraa N. Al- Wahab, B.D.S., M.Sc. (1)
Bassam A. Hanna, B.D.S., M.Sc. (2)
Shakwaan K. Kadir, B.D.S., M.Sc. PhD. (2)
ABSTRACT
Background: Visible light cured acrylic resin denture materials are one of the developed polymeric acrylic denture
base and are manufactured in the form of sheets and rapes, and also in powder and liquid system, they can be
adapted for various dental uses and provides rapid service at low cost. This study aimed to compare the tensile
strength of heat cured acrylic resin and visible light cured acrylic resin.
Materials and Methods: Twenty samples of acrylic denture base materials were prepared, ten samples of heat cured
acrylic denture base materials and ten samples of visible light cured acrylic denture base material. After curing of
both groups, the materials were subjected to tensile strength test with the use of Instron universal testing machine.
Results: The results of the present study showed a high significant difference comparing between the two groups;
heat cured acrylic denture base material showed a high significant tensile strength than the visible light cured acrylic
denture base material.
Conclusion: heat cured acrylic denture base resin showed superiority in the tensile strength values than the visible
light cured acrylic denture base material.
Key words: heat cures acrylic, visible light cure acrylic, tensile strength. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):44-
47).
INTRODUCTION In 1984, visible light cured base resins

The general upgrading of resin in dentistry became available to profession and marketed
regarding their physical and mechanical properties under the trade name " triad " which was suitable
render the use of resin based restorative materials for many prosthodontic applications , removable ,
to rise exponentially, as dental clinician are fixed and maxilla facial prosthesis . (4)
always looking for the ideal restorative dental Since then the use of these materials has
material, also dental community in its search for increased with new products being used for the
better, less expensive, easier to handle materials, relining and repair of dentures. (5,6,7) The light
is often quick to adapt a rising technology for new output of light curing units is designed to promote
and different purposes.(1) an intensity great enough to cure the deeper parts
The development and continued evolution of of the body of the resin, the conversion from soft
photo polymerizable dental materials represents a to solid material relies on the ability of the light to
significant practical advance for dentistry. Photo access and initiate the curing in all parts of the
polymerization had become an integral restorative material , so high intensity light results
component in the practice of dentistry since the in deep polymerization of the material to a depth
commercialization of this technology in the late of (6mm).the cure of visible light cure resin
1960s. (2) material is most effectively initiated by light in
Later, in 1980 the visible light activated the wave length range 450-500 nm .( 8 )
system was introduced and dominates the world Tensile strength is the resistance of the
market and has proved its efficiency and material to a tensile or stretching force (9 ). The
acceptance through its rapid evolution. Initially, elongation, in combination with ultimate strength
visible light curing materials were used to restore is an indication of the toughness of the plastic
only anterior teeth and to seal pits and fissure. .The larger the area under the stress; the tougher
With time the use and application of these the material , while a material with less
materials has been expanded with a large variety elongation will be brittle. (10). This study aimed to
of materials including cavity liners , die materials compare the tensile strength of heat cured acrylic
, provisional crown and bridge materials , surgical resin and visible light cured acrylic resin.
cements , orthodontic resins and adhesive system
with composite resins for posterior and anterior MATERIALS AND METHODS
restorations , In 1983 , anew visible light cured Specimens grouping
resin technology was developed for use in Twenty specimens were prepared, light cured
removable prosthodontic .(3 ) acrylic denture base resin (Palatray, RXL,
(1) Lecturer, Department of Dental Technologies, College of Germany) and heat cured acrylic denture base
Health and Medical Technologies
(2)Lecturer, Department of Conservative Dentistry, College of
resin (Vertex Netherland) and divided into (10)
Dentistry, Sulaimaniya University
specimens for each of the following group : heat the hydraulic press. The pressure was slowly
cured , and light cured acrylic resin . applied to allow even flow of dough throughout
the mould space. The pressure was released. The
Metal pattern preparation flask was opened and the over flowed material
The metal pattern was constructed with (flash), surrounding the mould space was removed
dimensions of [65mm, 10mm, 2.5mm] length, with wax knife.
width, depth, respectively according to ADA A second trial closure was preformed; the stone
specification (11). surface was again coated with the separating
media. The two halves of the flask were finally
closed until an intimate contact had been
established, and it was left under the press (1500
psi) for 5 minutes before clamping was done.
Then the flask was placed in a flask clamp
maintaining undisturbed pressure during
)
processing.(12
Curing and cooling

Curing was carried out by placing the
clamped flask in a thermostatically controlled
water bath and processed by long curing cycle is
established by heating at 74C for 8 hours in
Figure 1: materials used in the study water bath .after completing the curing process,
the flask was allowed to cool slowly at room
temperature for 30 minutes followed by complete
cooling of the flask with tap water for 15 minutes
before deflasking .The acrylic patterns were then
removed from the stone mould.
Preparation of test specimens of light cured

acrylic denture base resin mold preparation
Stone mold was prepared following the same
Figure 2: showing the metal pattern method used for conventional denture base
acrylic. Metal block was used with dimensions of
Mold preparation (65mm X 10mm X 2.5mm) length, width, and
The lower portion of dental flask was filled depth according to the ADA specification (11).
with dental stone (Zeta, Italy) mixed according to The metal is placed on a flat glass plate,
manufacture instruction; metal block was coated separating medium is applied. Stone slurry was
with stone mix to avoid air trapping during prepared by mixing correct water/powder ratio
insertion the metal block into the stone mix after and it was poured onto the metal block. A second
coating with separating medium. When stone set, glass plate was placed over the stone mix , so the
both the stone and metal patterns were coated stone was sandwiched between the two glass plate
with separating medium (Vertex, Netherland), the .after setting of the stone .the glass plates were
upper half of the flask was then placed on top of removed and metal block was removed , layer of
the lower portion and filled with stone. Stone was separating medium was applied on the mould
allowed to harden for 60 minutes before the flask cavity and all set stone surface.
was opened. The metal patterns were invested for
each sample to be prepared. The flask was then Packing
opened and metal patterns were removed from the Light cured sheet was taken out of its light
mould carefully. proof packing and positioned into the stone mold
.the material was adapted well in the mold using
Flasking finger pressure, excess material was removed by
Pink heat cured acrylic resin was mixed cutting with sharp wax knife and then the top
according to manufactures instructions surface of the stone mold was flattened with a
(powder/liquid ratio is 3/1). The acrylic resin glass plate.
dough was packed in the mould which had been
treated with separating medium. The two halves
of the flask were closed together and placed under
Curing Where:
The material was polymerized in the light TS = Tensile strength (N/m2) (then converted to
curing unit (Engen, Germany) for 5 minutes MPa)
according to manufactures instruction. Then the F = force at failure (N)
material was then removed from the mold, A= Area of cross section at failure (m2)
inverted and exposed to the light cured unite again
immediately for additional (5minutes) to ensure RESULTS
complete polymerization, so the total time of
curing is 10 minutes. (13)
I-Descriptive statistics:
Mean (M) and Standard Deviation (SD) are
presented in Table 1. The hot cured acrylic
showed higher tensile strength values than visible
light activated acrylic.
Table 1: showing the mean, standard

deviation for both group expressed in MPa
Group Mean SD
Group 1 ( hot cured acrylic) 51.2 0.341
Group 2 (visible light activated
16.7 0.636
acrylic)
Figure 3: Showing the light cure device
Finishing and polishing

All flashes of acrylic were removed with an
acrylic bur to get a smooth surface. The acrylic
bur should be used followed by (120) grain size
sandpaper to remove any remaining small
scratches with continuous water cooling.
Polishing was accomplished by using bristle brush
and pumice with Lathe polishing machine. A
glossy surface was obtained with wool brush and
polishing soap on dental Lathe using low speed Figure 5: Graphical representation of means
(1500 rpm) and the specimens were continuously by bar chart
cooled with water to avoid overheating, which
may lead to distortion of the specimens, then the
II- Inferential statistics
final measurements of the specimens were
In Table -2, student t test compared between
obtained using the vernier. After finishing and
tensile strength values of hot cured acrylic and
polishing, the specimens were measured again to
visible light cured acrylic and this table revealed
ensure exact measurement
that there is a high significant difference when
comparing between the two groups, and the hot
Mechanical tensile strength test cured acrylic produced higher tensile strength
Test equipment and procedure values than visible light cured acrylic.
The tensile strength was tested using Instron
testing machine with grips suitable for holding the Table 2: student t test comparing between
test specimens .Each specimen was set at across the two groups
head speed of 0.5 mm/min. chart speed. The load Group 1 (hot Group 2 (visible T
cell was measured by a tensile load cell, with a cured acrylic) light cured acrylic) value
maximum capacity of 200 kg. Each Specimen was 51.2 16.7 27.41
loaded until fracture, and the load of fracture was HS highly significant at P value < 0.01
recorded from the Instron graph reader in
kilograms (kg) which were converted into Newton
(N). DISCUSSION
Visible light cured acrylic denture base
The values of tensile strength were calculated material had been used in this study because it has
for each sample according to the following many applications such as the fabrication of
formula:- complete and partial dentures, relining material,
TS = F/A transitional prosthesis, provisional splints, denture
repairs and orthodontic appliances, record bases, 5. Havakawa I, Nagao M, Matstumoto T, Masuhara E.
special trays and obturators. (14) Properties of a new light polymerized relining material
.Int J Prosth 1990 ;3:278-284
One of the mechanical properties of dental
6. Mitrani R, Rubeenstein JE, Kois JC, Phillips KM.
material is tensile strength. It had been chosen in Alternative uses of a visible light polymerized
this study because the material is much weaker in materials .J Prosth Dent 2001;85 :501-503.
tension than in compression, which may 7. Williamson DL, Boyer DB, Aquilino SA, Leary JM.
contribute to failure of the material in service.(15) Effect of polythelene fiber reinforcement on the
In the present study, two types of acrylic resin strength of denture base resins polymerized by
microwave energy .J Prosthet Dent 1994;72:835-8.
denture base were had been used: the traditional
8. Noort RV. Introduction to dental materials .2th edition
hot cured acrylic resin and the visible light cured ,Hong Kong ,RDC com., 2002,Ch.2.3
acrylic resin denture base material, and the tensile 9. Sakaguchi RL, Powers JM. Craigs restorative dental
strength of both materials was compared. The materials. 13th ed. ELSEVIER MOSBY; 2012, p86.
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11. ADA American Dental Association. specification no.
the two groups, since hot cured acrylic resin
for denture base polymer guide to Dental materials
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Prosthodontics .2005.
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interpenetrating polymer network, with less the fatigue strength of five acrylic denture resins .J
homogenicity, and giving brittle nature . Mechan Behave Biomed Mater 2010 ;3(8) :636-639.
These results have agreement with Elian (18) 16. AL-Mulla MAS, Huggett R, Brooks SC, Murphy WM.
who found that this reduction is due to the Some physical and mechanical properties of a visible
light activated material. Dent Mater 1988;4:197-200.
composite nature of the visible light cured acrylic
17. Dar-Odeh NS, Harrison A, Abu-Hammad O. An
resin, it is completely different polymer from evaluation of self cured and visible light cured
other acrylic resin, so this leads to such reduction denture base materials when used as a denture base
in tensile strength. According to the knowledge of repair materials. J Oral Rehabel 1997 ;24:755-760.
the authors, there are no previous studies disagree 18. Elian AA. Evaluation of transverse and Tensile
with the results of the present study. strength of different Acrylic Denture base materials
After Relining and Repair with a visible light
polymerized material. A thesis submitted to the
CONCLUSION college of Dentistry , University of Baghdad in partial
It can be concluded from this study that heat Fulfillment of the requirement for the Degree of
cured acrylic denture base resin showed Master of Science in Prosthodontics.2005
superiority in the tensile strength values than the
visible light cured acrylic denture base material.
REFERENCES
1. Rueggeberg FM. Form vulconite to vinyl,a history of
resins in restorative dentistry. J Prosth. Dent 2002;87:
864-879.
2. Stansbury JW. Curing dental resins and composites by
photopolymerization .J Esthet Dent 2000 ;12:300-
308.
3. Barateri LN. Esthetic, direct adhesive restoration on
fractured anterior teeth 2nd edition, Quintesssence
editor .Lt. 1998.
4. Andreopoulos AG, Polyzois GL, Demetrious PP.
Repairs with visible light curing denture base
materials. Quint Int, 1991; 22:703-706.
J Bagh College Dentistry Vol. 24(special issue 1), 2012 Evaluation of the effect
Evaluation of the effect of Nigella sativa oil and powder on

healing process, histologically and radiographically
(An experimental study on rabbit)
Hani Sh. Mohammed, B.D.S., M.Sc. (1)
Athraa Y. Al-Hijazi, B.D.S., MSc., Ph.D. (2)
ABSTRACT
Back ground: Todays world is increasingly seeking ways to replace the synthetic drugs with the therapeutic power of
natural products to decrease the percentage of many side effect which result from conventional treatment; one of
these products was Nigella sativa (NgS) which was used so extensively that it became known as the seed of blessing
Habbatul Barakah due to its powerful healing qualities for many ailments. The aim of this study was to evaluate the
therapeutic effect of Nigella sativa (powder and oil) on the healing process of extracted teeth sockets.
Materials and Methods: The sample of our study consist of Forty eight rabbits to extract there upper two central
incisors under general anesthesia. The left side filled once with Nigella sativa powder and once with Nigella sativa oil
material, and the right side left for normal healing as a control group. The two sockets were sutured. The results were
studied radiographically and histologically after 1,2,4,6 weeks postoperatively. The radiographic examination was
performed by using parallel technique in a digital radiographic examination and histological examination was
performed under light microscope for the section stained with heamatoxiline and eosin.
Results: Radiographically we found that NgS powder showed more radiopacity with complete disappearance of
lamina dura in 6 weeks duration compared with NgS oil and control groups, while histologically we found that the
Nigella sativa (NgS) groups (powder and oil) illustrate an early apposition of osteoid tissue in 1st week duration with
numerous osteoblast and osteocyte in comparision to control group.In six weeks duration well developed bone filled
all the portions of the socket in treated socket with NS powder with obvious complete epithelization of socket surface
Conclusion: Nigella sativa (powder or oil) seems to be bioactive materials that enhance differentiation and
proliferation of progenitor cells to specialized bone formative cells, with no signs of inflammation.
Keyword: Healing process, Nigella sativa. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):48-52).
INTRODUCTION
Repair of bone tissue is a complex process This mild aromatic herb is indigenous to the
involving a number of cellular functions directed Middle East where it has been used as a
towards the formation of a scaffold and traditional remedy for over 2000 years. It was
mineralization of the defect followed by an used so extensively that it became known as the
eventual remodeling of the defect site to attain the seed of blessing "Habbatul Barakah" .(3)
original structure .(1) Its therapeutic use was initiated after the advent of
Todays world is increasingly seeking ways to Islam since Prophet Mohammed (peace and pray
replace the synthetic drugs with the therapeutic upon him) mentioned its therapeutic efficacy and
power of natural products. potential of cure, when said that "there is cure for
Interest in medicinal plants has burgeoned due to every disease in black seed except death".(4)
increased efficiency of new plant-derived drugs Its chemical composition contains volatile
and the growing interest in natural products. and non-volatile oils in addition to many other
Because of the concerns about the side effects of active ingredients including proteins, alkaloids,
conventional medicine, the use of natural products coumarines, saponins, minerals, carbohydrates,
as an alternative to conventional treatment in phenolic compounds, steroidal compounds, and
healing and treatment of various diseases has been other ingredients .(5)
on the rise in the last few decades.(2) Many studies have been conducted on the effect
Many wonderful helping plants surfaced of Nagilla sativa seed extracts on varies body
when the cultures of our world started to share systems in vitro or in vivo. The pharmacological
trade and teach their herbal medicines to each investigation of the seed extracts reveal abroad
other. One such plant was Nigella sativa spectrum of activities including
commonly known as black seed. immuneopotentiation, antihistaminic, antidiabetic,
antihypertensive, antinflammatory, antitumor,(6)
antiparasitic, antibacterial, antifungal and
antioxidant (7). In recent study, the black seed
1)
Lecturer, department of Oral Histology & Biology, Ministry of
Heath, Baghdad, Iraq.
(2)
Professor, department of Oral Histology & Biology, College of induced bone healing as manifested by faster bone
Dentistry, University of Baghdad. trabeculae formation and mature bone formation
(8)
and as when a tooth is extracted, the healing
process was done by two processes
Oral Diagnosis 48
A.Osteogenesis
B. Epithelization
Therefore the present study was designed to:

1. Evaluate the effect of Nigella sativa
(powder or oil) on healing process of the
socket of extracted teeth.
2. Study the comparison effect of Nigella
sativa (powder or oil) on healing process in
different weeks.

The samples of the present study consist of Forty
eight rabbits subjected to extract their upper two
central incisors under general anesthesia. The left
side filled once with Nigella sativa powder and Figure1: Conventional radiographic view of
once with Nigella sativa oil material, and the right sockets for rabbits anterior teeth of six
side left for normal healing as a control group. weeks duration shows radio-opacity filled
The two sockets were sutured. The animals were coronal, middle and apical portion of
grouped into: experimental (powder and oil) side (left) and
1st group (24) rabbits, left socket of each rabbit the lamina dura shows to be disappear
filled by (0.068g) of Nigella sativa powder till 2/3 internally and externally partially
of socket length which had average length disappeared, while in the control (right) side
(2.3mm) after removal of blood clot by using
the radio-opacity extended to the middle
blugger instrument.
portion and the lamina dura partially
2nd group (24) rabbits, left socket treated with
Nigella sativa oil by using a piece of cotton
disappeared internally and externally
impregnated in oil then inserted inside the socket
till 2/3 of socket length after removal of blood clot Histologically
and waiting for five minutes then removed it. The result showed active proliferation of cellular
The control group of (24) rabbits in which their connective tissue with early deposition of osteoid
sockets had been left for normal healing process tissue and presence of osteoblast cells (OB) in the
without removal of blood clot after extraction coronal portion of the experimental socket treated
process. with Nigella sativa powder and oil in 1st week in
Each group divided into four subgroups ( 5 in comparison to control (Figures 2,3)
number); these subgroups are sacrified for each of
four healing periods; 1week, 2weeks, 4weeks and
6weeks respectively and the socket examined
radiographically and histologically .
The radiographic examination was performed by
using parallel technique in a digital radiographic
examination and histological examination was
performed under light microscope for the section
stained with hematoxiline and eosin.
RESULTS
Radiographically. Nigella sativa NgS showed
more radiopacity with complete disappearance of
lamina dura in 6 weeks duration compared with
control group (Figure 1) Figure 2: Coronal portion of extracted tooth
socket of the rabbit (control) one week
duration shows formation of granulation
tissue H&E *200
Oral Diagnosis 49
Figure 5: Coronal portion of rabbit left

socket treated with (NgS) oil 6weeks
Figure 3: Micrograph view for coronal duration shows mature bone trabiculae
portion of rabbit left socket treated with covered with connective tissue and epithelia
NgS, one week duration show active (EPI) H&E *40.
proliferation of osteoid tissue(OT) H&E *
100
At Six Weeks postoperatively

Experimental group treated with NgS powder
showed that mature bone filled all cervical regions
and covered with epithelial layers (Figure 4). On
other hand experimental group treated with NgS
oil showed that mature bone trabeculae covered
with connective tissue and incomplete
epithelization; also remodeling process shows
osteoclast (OCL) cells occupied howships
lacunae (Figure 5).
Histological findings for control showed that
bone (lamellated and haversian) filled cervical
portion with fibrous connective tissue lay over it Figure 6: Coronal portion of rabbit right
and superficial layer of epithelial tissue (Figure 6) socket 6weeks duration shows bone filled the
cervical portion with fibrous connective
tissue lay over it and superficial layer of
epithelial tissue (Epi.T) H&E *40.
DISCUSSION
The results of the present study showed early
detection of osteoid formation in 1st week and
bone trabeculae formation in 2nd, 4th and 6th weeks
in sockets treated with NgS (powder and oil).
Active cell proliferation (osteoblast, osteocyte
and even Osteoclast) was illustrated too in these
sockets in comparison to control one; it was
indicated that NgS acts as bioactive and
Figure 4: Coronal portion of rabbit left bioinductive materials that enhance bone
socket treated with (NgS) powder 6 weeks formation. This could be attributed to presence of
duration shows mature bone filled all the following components:
cervical region and covered with epithelial 1. Protein and amino acids:
layers (EPI) H&E *40. Nigella sativa seed had 22.6 % - 26.7 %
protein and amino acid, Glutamic acid(Gla,),
Arginine(R) and Aspartic acid(D) were the
Oral Diagnosis 50
main amino acids present (9) in addition to play roles in cell adhesion and binding of
other like glycine(G), leucine, etc (10) mineral because they contain Arg Gly
These mentioned amino acid play important Asp and poly acidic sequences (14). It was
role in the formation and function of the reported that it stimulates the adhesion of
following ECM proteins: - osteoblasts and,therefore, to improve the
A. Osteocalcin: also known as bone Gla osseointegration process (15,16).
protein is one of the most abundant non These proteins and amino acid functionated a
collagenous proteins (NCPs) in bone receptor specificity, binding affinity and signaling
(comprising up to 20 % of the NCPs) (11). It of cell responses (17).
has 49 amino acid residues containing three 2. Minerals:
glutamate (Gla) residues, which are critical The induction of bone formation by the black
for the ability of osteocalcin to bind seed oil extract seen in this study
calcium (12). Its binding to HA through as manifested by faster bone formation could be
orientation of the Gla residues with the Ca attributed to the presence of calcium and
ions in the mineral lattice (11). It has been phosphorous in the chemical composition of the
reported that osteocalcin involved in bone black seed oil extract which are necessary for
growth & repair (13). bone formation.
B. Bone Sialoprotein (Bsp): comprises 15 % 3. Vitamins
of the total non collagenous protein (NCP) Vitamins are low molecular mass
in bone (11). organic compound that cant be synthesized by
C. Osteopontin: One of the important NCPs humans or are synthesized in inadequate amounts
that includes in bone formation (12). Bone for example:
sialoprotien and osteopontin are belived to
Vitamin Biochemical function

* Thiamine (B1) Co-enzyme in phosphgluconate path way.
* Pyridoxine (B6) Amino acid transamination
Niacin Hydride-transfer reaction.
Foliate Thymidylate synthase; purine biosynthesis.
Ascorbate (C) Prolyl and lysyl hydroxylases (collagen); dopamine hydroxylase.
Retinol (A) Form 11-Cis-retinal with rhodopsin.
It appears that Vitamins are important because sitosterol, cycloeucalenol, cycloartenol, sterol
they play a central role in metabolism. (18) esters and sterol glucosides).
NgS contain the a above mentioned vitamins so it From the histological examination of the treated
possess nutritional value (19) and has been reported sockets with NgS (specially powder) showed
to possess a favorable effect on growth rate and early proliferation of epithelia covered the
health of human and animal (20). cervical portion of the socket, compared to
In histological study we found that the effect of control, this can be explained that NgS has
Nigella sativa (NgS) powder more effective than inductive power to epithelial cells as if it has
oil in formation of bone inside the socket of induction to connective tissue cells (mesenchymal
extracted tooth because there is no any component cells).
of Nigella sativa will be lost such as in oil extract 4. Radiographic findings:
and the minerals present without any defect which Radiographic results of the present study showed
help in faster bone formation, also the absorption radiopaque patches appeared in the middle
of Nigella sativa oil require more time for (specifically) and apical portions of treated
complete absorption which applied by apiece of sockets with NgS (powder and oil) groups as it
cotton for only 5 minutes and then removed. This supported histological findings which showed
could be attributed to the low percentage of trabeculae formation in these portions more than
volatile oils (0.4-0.45%) in the chemical in coronal one and more than in control group.
composition of the cold-pressed oil as compared In 6th week duration NgS powder showed
with the higher percentage of fixed oils (32-40%) radiopacity filled whole socket (coronal, middle
including the unsaturated fatty acids (arachidonic, and apical portion) with disappearance of lamina
eicosadienoic, linoleic, linolenic, oleic and dura, this related to apposition of mature bone
almitoleic acid) and the saturated fatty acids filled the socket as it illustrated histologically, and
(palmitic, stearic and myristic acid, Beta- that lamina dura landmark be obscured as the new
Oral Diagnosis 51
bone interdigited and coalesce with the original implant surfaces. Pharmaceutical Research 2008;
bone. This result is in agreement with others who 25(10): 235769.
18. Anyakora C, Afolami I, Ehianeta T, Anwnmere F.
found increase in bone formation and reported
HPLC analysis of nicotinamide, pyridoxine, riboflavin
anabolic effects of NgS oil on bone loss and thiamin in some selected food products in Nigeria.
radiographically (21). African J Pharmacy and Pharmacology 2008; 2 (2):
2936.
19. Takruri HR, Dameh MA. Study of the nutritional
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perforation on periosteal destruction. J Maxillofacial
20. AbuDieyeh ZHM, AbuDarwish MS. Effect of
Surgery 2009; 67(7): 1478-85.
feeding powdered black cumine seeds (Nigella Sativa)
2. Sogut B, Celik I, Tuluce Y. The effect of diet
on growth the performance of 4 8 week old Broilers.
supplemented with the Black cumin upon Immune
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potential and antioxidant marker enzymes and lipid
21. Valizadeh N, Zakeri HR, Shafiee A, Sarkheil P,
peroxidation in broiler chicks. J Animal and
Heshmat R, Larijani B. The effect of Nigella sativa
Veterinary Advances 2008; 7(10): 1196-990.
Extract on biochemical bone markers in osteopenic
3. Randhawa MA, Al-Ghamdi MS. A review of the
postmenopausal women. European J of Scientific
pharmaco-therapeutic effects of Nigella sativa.
Research 2009; 10(6): 57080.
Pakistan J Med Res 2002; 41(2).
4. Sahih Bukhari. 7; 71: 592.
5. El-Tahir KH, Bakeet D. The Black seed Nigella
Sativa: Aplea for urgent clinical evaluation of its
volatile oil. J T U Med Sc 2006; 1(1): 1-19.
6. Mbarek LA, Mouse HA, Elabbedi N, Bensalah M,
Gamoyuh A, Aboufatima R et al. Anti-tumor
properties of black seed (Nigella sativa) extracts.
Brazil J Medical and Biological Research, 2007.
7. Abdulelah H, Zainal-Abidin B. In vivo anti-malarial
test of Nigella sativa (black seed) different extracts.
Ameri J Pharm & Toxicol 2007; 2: 46-50.
8. Majeed M. Assessment of the black seed oil extract as
an intracanal medicament. A PhD thesis, Department
of Conservative Dentistry, College of Dentistry.
University of Baghdad, 2006.
9. AlJassir SM. Chemical compositionad microflora of
black cumin (Nigella Sativa L.) seeds growing in
Saudi Arabia. Food Chemistry 1992; 45(4): 23942.
10. Gilani A, Jabeen Q, Ullahkhan M. A review of
medicinal uses and pharmacological activities of
Nigella sativa. Pakistan J Biological Sciences 2004;
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11. Hing KA. Bone repair in the twentyfirst century:
biology, chemistry or engineering? Phil Trans R Soc
Lond 2004; 362: 282150.
12. Stanford CM, Keller JC, Solursh M. Bone cell
expression on titanium surfaces is altered by
sterilization treatments. J Dent Res 1994; 73 (5):
106171.
13. Nagai M, Ota M. Pulsating electromagnetic field
stimulates mRNA expression of bone morphogenetic
protein2 and4. J Dent Res 1994; 73 (10): 16015.
14. Puleo DA, Nanci A. Understanding and controlling the
bone implant interface. Biomaterials 1999; 20: 2311-
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15. Alt V, Bitschnau A, Osterling J, Sewing A, Meyer C,
Kraus R, Meissners et al. The effect of combined
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Organic inorganic surface modifications for titanium
Oral Diagnosis 52
J Bagh College Dentistry Vol. 24(special issue 1), 2012 Evaluation of topical
Evaluation of topical versus systemic medications in the

treatment of neuropathic orofacial pain
A prospective study
Ihsan A. Kumail, B.D.S., M.Sc., Ph.D. (1)
ABSTRACT
Background: Neuropathic orofacial pain is a multifactorial condition and mainly treated by systemic anticonvulsant
and antidepressant medications which result in unpleasant side effects and may contradict or interact with other
medications especially in elderly. This study demonstrates preparation of alternative topical treatment and
evaluation of its efficacy versus systemic treatment in respect to period taken for pain reduction and side effects.
Sample and Method: A prospective study was conducted on systemically healthy 41 patients treated for
neuropathic orofacial pain attended the Oral Medicine Clinic/ Dentistry College/ Mustansiria University and private
clinic. Patients were divided into 2 groups of almost similar ages, genders and pain severities. Microemulsive gel was
prepared to carry specific concentrations of active agents by transdermal permeative vehicle to the affected sites.
The first group received topical medications only (n = 21), while the second group was treated with systemic
medications only (n = 20). The intensity of pain was recorded for each on a Visual Analog Scale (from 0= no pain to
10= intolerable pain) at diagnosis, and at 4 successive weeks after initiation of treatment. Reduction in pain severity
was considered only if it equals 30% or more. The two methods of treatment were evaluated according to the period
required for 30% pain reduction and side effect(s) caused by each type of treatment.
Results: After initiation of treatment, 81% of patients (no= 17) on topical treatment showed 30% reduction in
neuropathic orofacial pain levels (which is considered a good response) within 2 weeks, the rest 4 patients (19%)
reached 30% pain reduction within the third week. In systemic group, 50% of patients (no= 10) showed 30% pain
reduction within 2 weeks, 4 patients (20%) showed 30% reduction in the third week and 6 patients (30%) of the same
group did not experienced 30% pain reduction until the fourth week. Ten patients of systemic group experienced
side effects, while patients on topical treatment did not complain of any side effect along term of treatment.
Conclusion: Topical medication as a single treatment is more efficient in reduction of neuropathic orofacial pain
within shorter period and no side effects than systemic medications. Younger patients ( 40 years) responded to
treatment better than elderly in both groups.
Key words: Neuropathic orofacial pain, systemic treatment, topical treatment. (J Bagh Coll Dentistry 2012; 24(sp.
Issue 1):53-59).
INTRODUCTION
Neuropathic orofacial pain is a chronic pain the nerve (the myelin sheath) (6), TN may be due
initiated or caused by a primary lesion or to central pathology (e g multiple sclerosis in ages
dysfunction in the nervous system (1). Etiologies less than 50 years) or a part of the normal aging
of this pain vary from peripheral trauma to central process, as blood vessels lengthen, rest and
nervous system pathologies (1,2). Peripheral pulsate against a nerve which results in
pathology is due to two main causes: 1- Chronic demeylination of the nerve and changes in sodium
peripheral nociceptor irritability, as a result of channels located at peripheral terminals of that
neuronal injury following trauma, dental needles, cranial nerve, those channels lose their activity to
extractions, endodontic treatment, and dental close resulting in extremely sensitive area on the
implant insertion, this is called traumatic neuroma face (trigger zone) which will lead to severe
which is characterized by chronic facial pain with shocking pain if exposed to a stimulus normally
periods of exacerbations to sever form (2,3). 2- does not provoke pain (allodynia) (7), (facial and
Demyelination of afferent peripheral sensory glossopharyngeal are not uncommon) (7). The
nerves or vascular compression occurs subsequent treatment for neuropathic pain in most cases is
to a release of local excitatory or inflammatory pharmacological with medications that include
mediators which is called deafferentation pain and antidepressants, analgesics, and antiepileptics, the
characterized by intermittent symptoms which efficacy of these medications varies from patient
may be referred to orbit, temporal region and back to another depending on a variety of factors such
of the neck (4). In types discussed above, a painful as pain location, age of the patient, and systemic
stimulus will result in exaggerated response of diseases (8,9). Pharmacologic treatment is often
pain (hyperalgesia) (5). And a central cause as accompanied with unpleasant side effects such as
trigeminal neuralgia (TN) which may be due to sedation and dizziness. Moreover, interaction with
pressing of a blood vessel on the trigeminal nerve other medications may contradict the use of these
as it exits the brainstem, this compression causes medications or prevent their use in the medically
the wearing away of the protective coating around compromised or elderly patients (9-11). Topical
(1) Lecturer, Department of Oral Diagnosis, College of medications is an alternative method which has
Dentistry, Al-Mustansiria University been reported by several authors to be clinically
Oral Diagnosis 53
useful for neuropathic pain with minimal or no by topical treatment only (n=21) and group B
systemic effect, but studies targeting orofacial were given systemic treatment only (n=20). The
region were few (12-14). Topical medications need systemic medications prescribed were
transdermal compounds which should be designed medications commonly used to treat neuropathic
to transport active agents harmlessly through the pain conditions: anticonvulsants which are
skin as an alternative to oral or parenteral carbamazepine (Novartis) (200 mg) and
administration (15). This article described a new gabapentin (Park Davis) (100 mg) one tablet of
preparation of transdermal permeating gel each per day for neuralgic pain (trigeminal
containing active medications for topical use and neuralgia associated with trigger zone whether
a prospective comparison between results of this zone provokes pain as mild or sever) (18, 19), or
topical versus systemic treatment for 41 patients tricyclic antidepressant which is amitryptyline tab
with neuropathic orofacial pain and evaluation of 25 mg (Novartis) and baclofen tab 25 mg
the outcome of each method in respect to period (Novartis) daily for patients without trigger area
of pain reduction and side effect(s). which could be either deafferentation pain or
traumatic neuroma (20). Studies stated that
combination of medications above results in
PATIENTS AND METHOD synergism between those two medications which
A prospective study with informed consent leads to higher response and reduced adverse
was conducted from December 2009- October effects (19, 21, 22).
2011 on systemically healthy 41 patients (21 In order to apply topical medications, there
males and 20 females with ages ranging from 33- should be a vehicle that penetrates cutaneous
63 years) suffering from neuropathic orofacial tissue to carry active agents to the affected site,
pain conditions of durations ranged from 3 this vehicle must contain oil/ water
months- 2 years, they admitted Oral Medicine microemulsion system (23). (Preparation of topical
Clinic/ Dentistry College/ Mustansiria University medication gel was under supervision and control
and private clinic. A thorough medical and dental of specialist pharmacist*). The vehicle was
history was taken with a precise description of represented by 5 gm sodium carboxymethyl
pain, careful intra and extra oral examination was cellulose (NACMC), this amount of vehicle was
performed and medications taken were recorded added to 20 gm glycerin (oil phase) and 2 ml Di
for each patient. Radiographic views (OPG and methyl sulphoxide liquid (water phase) (24). After
PA) were taken for each patient to exclude any mixing 5 gm NACMC with 20 gm glycerin in a
intra or extra osseous lesion. A precise intra and graded glass containe, 50 ml of distilled water
extra oral examinations had been carefully heated to 70 C was added to the mixture with
performed for all patients to detect any possible vigorous stirring for 15 minutes, then the 2 ml of
cause of facial pain. The diagnosis was done Dimethyl sulphoxide was added, the result is clear
based on the history provided by the patient and transdermal gel of 77 gm (25, 26). A sum of 20 gm
the International Association for the Study of Pain row material of active agents which are
guidelines which stated that neuropathic orofacial Amitriptylin (Novartis), Baclofen (Novartis),
pain is a chronic pain lasts more than 3 months Cabamazepin (Novartis) and Gabapentin (Park
expressed as hyperexcitation to painful stimulus Davis) (5 gm of each) was added, and then 3 ml
or to shocking pain at a trigger zone which is of distilled water was added to complete 100 gm
provoked by a stimulus that normally does not (13,27-29).
Each patient of topical group was given a
cause pain (allodynia), both correlate to plastic container of 100 gm of the mixture and
abnormality in branches of V2 and /or V3 but asked to apply 4 times daily to the painful area (13,
does not correlate to any detectable local, referred 15, 29).
All previous trials of topical treatment to
or systemic disease (1, 2, 16). Patients who had a neuropathic pain contained anaesthetic (lidocaine
diagnosis of neuropathic orofacial pain along with gel 1%) and NSAID (ketoprofen 4%) (12-15,23,24). In
TMJ dysfunction or psychologic conditions were this study neither analgesic nor anaesthetic agent
excluded from the study. Diagnosis of TMD was was used, so that to clarify the specific
performed according to Research Diagnostic mechanism of medications used to reduce pain
Criteria of temporomandibular disorders (RDC) faraway from anaesthesia or analgesia which are
(17).
Patients were divided into 2 groups, each considered as non specific pain reducers. Pain
group almost showed similarity in age (group A level was recorded at the first visit on a 10 cm
33- 63 years mean= 46.2, group B 34- 60 years visual analogue scale (VAS) (0= no pain 10
mean= 48.5), gender (A: 12 males and 9 females, intolerable pain) for each patient, and after start of
B: 9 males and 11 females) and pain description treatment, all patients have been followed weekly
(as shown in tables 1 & 2). Group A were treated until 30% reduction of pain was obtained and the
Oral Diagnosis 54
period taken for this amount of reduction as well (who received Carbamazepin and Gabapentin) in
as the side effect(s) experienced by the patient systemic group (no= 5) experienced side effects
were recorded for each. In other word, 30% (table 5, figure 2).
reduction of pain was chosen to represent the time Results also showed that patients in both
for onset of action of the medication; accordingly, groups whose ages 40 years (8 in group A and 6
a fair evaluation for the efficiency of treatment in group B) with no trigger area showed 30% pain
method will be the shorter treatment period to reduction within 2 weeks except one in the
obtain 30% pain reduction with minimal side systemic group whose 30% pain reduction was
effects. obtained in the third week after initiation of
treatment, besides, they did not experienced any
RESULTS side effect along treatment period except 5 of 15
Results showed that all patients were not patients from group B (table 5).
complaining of brain lesion or multiple sclerosis
(they did not suffer from any associated disorder DISCUSSION
that may give hint about such diseases). In younger patients, the main cause of
Radiographic views did not clarify any intra or orofacial pain was either deafferntation of nerves
extra bonny lesion. There was similarity in mean or traumatic neuroma rather than trigeminal
of ages between the two groups (A: 46.2 & B: neuralgia which mainly seen in more than 50
48.5 years), gender (A: 12 males and 9 females, years old patients, otherwise, there may be central
B: 9 males and 11 females) and severity of pain pathology (e g multiple sclerosis, brain tumor)
(A: 6.4 & B: 6) (tables 1 & 2). In patients with (1,2,4,5),
and this may explain the good and quick
unilateral facial or intraoral trigger zone, response of those patients to both types of
diagnosis was trigeminal neuralgia, they were 9 treatments (8,14), moreover, the severity of their
patients, 4 in group A (mean age 58 years) and 5 complain was less than older patients. Side effects
in group B (mean age 54.8 years) (table 3). have been gradually experienced by 10 subjects in
Deafferntation (demyelination of afferent nerve systemic group with time, 5 of them who received
terminals) or traumatic neuroma was the diagnosis Carbamazepin and Gabapentin and the rest 5
of patients without trigger zone and they were 32 received the other combined systemic medication.
patients (table 3), 17 in group A (mean age 43.5 This was expected and mentioned in the leaflet of
years) and 15 in group B (mean age 46.6 years) each medication. Side effects were not sever
(table 3). Although pain relief felt by the patients because of low doses of drugs combination
was based on their subjective feeling and was not strategies used and the short period of treatment
standardized, but the most important finding of (3- 4 weeks) which may explain the limited
this study is that 81% of patients (no= 17) on adverse drug reaction or drug tolerance (8,11,14,18-
topical treatment showed 30% reduction in 21).
While topical medications did not result in side
neuropathic orofacial pain levels (which is effects because their action is local rather than
considered a good response) within 2 weeks, the systemic (13). Patients with TN in both groups took
rest 4 patients (19%) who suffered from more time for 30% pain reduction. This may be
trigeminal neuralgia reached 30% pain reduction due to that the main pathology was not at the site
within the third week (table 1, 4 and figure 1). In of pain, it was at the root of the 5th cranial nerve
systemic group, 10 patients (50%) showed 30% but experienced at a site that is faraway from
pain reduction within 2 weeks, 4 patients (20%) exact pathology, so stabilization of abnormally
showed 30% reduction in the third week and 6 opened Na+ channels at the nerve terminals
patients (30%) (5 of them with trigeminal needed more time to return them back to normal
neuralgia) did not experience 30% pain reduction closure (4,7). Moreover, those patients were older
until the fourth week (as shown in figure 1 and in age which may delay the response (9), also they
table 2 and 4). presented with longer pain duration and higher
No patient (0%) of topical treatment group intensity than others which needed more time for
experienced any side effect along the period of considerable reduction.
treatment (2- 3 weeks), while side effects (nausea, Amitriptylin is an antidepressant that induces
dry mouth, dizziness, drowsiness, headache and analgesia centrally by modulation of gamma-
heart burn) were experienced by patients of amino-butyric acid (GABA) and serotonin
systemic group as follows: 2 patients at the 1st systems and peripherally by blocking Potassium,
week, increased to 4 at the 2nd week, increased to Calcium and Na+ channels of peripheral nerves
8 at the 3rd week and became 10 patients (50%), at and thus resulting in pain relief especially in
the last week of treatment, as shown in (figure 2, traumatic neuroma or demyelination of afferent
table 5) . All patients with trigeminal neuralgia nerves (hyperalgesia) (20-22). Baclofen is skeletal
Oral Diagnosis 55
muscle relaxant, but it is capable of inhibiting CONCLUSION

both monosynaptic and polysynaptic reflexes at The effective ingredients concentrations of
the spinal level, possibly by depolarization of topical medication 5% Carbamazepin, 5%
afferent terminals (8), also, Baclofen is an analog Gabapentin, 5% Amitriptylin and 5% Baclofen in
of the inhibitory neurotransmitter gamma-amino- anhydrous gel is more efficient in reduction of
butyric acid (GABA) (10, 11). Combination and low neuropathic orofacial pain than combined
doses of both medications may result in systemic medications in respect to shorter onset of
synergistic effect and reduced side effects (19, 21, action and no adverse effects. This study can
22).
Anticonvulsant medications (Carbamazepin serve as a basis for further prospective studies and
and Gabapentin) act centrally by blocking GABA trials on this issue.
receptors, thus suppressing paroxysmal discharges
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Oral Diagnosis 56
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Table 1: shows degree of pain at diagnosis of group A, the period taken by treatment to obtain
30% pain reduction and side effects of treatment
Oral Diagnosis 57
Table 2: shows degree of pain at diagnosis of group B, the period taken by treatment to obtain
30% pain reduction and side effects of treatment
Table 3: shows the distribution of patients in both groups in respect to diagnosis and ages with
mean VAS
Topical Mean Mean Systemic Mean Mean Systemic Mean Mean
Diagnosis
Treatment VAS Age Am+ Bac VAS age Car+ Gab VAS Age
Deafferntation & TRN 17 5.94 43.5 15 5.46 46.6
TN 4 8.25 58 5 7.6 54.8
Total 21 6.4 46.2 20
(Systemic) Mean VAS= 6
Mean age= 48.5
*Am=Amitriptylin , Bac=Baclofen, Car=Carbamazapin, Gab=Gabapentin, TRN=traumatic neuroma,
TN=trigeminal neuralgia
Table 4: shows number of patients showed 30% pain reduction in both groups during treatment
period
No of patients showed 30% pain reduction
during period of treatment
Group 1st week 2nd week 3rd week 4th week
Topical ( no= 21) 1 16 4
Systemic (no= 20) 0 10 4 6
Oral Diagnosis 58
Table 5: shows the time needed for both treatment methods in reducing 30% of pain symptoms
Side effects of
Treatment Topical treatment Systemic treatment
period (no= 21) (no= 20)
1st week 0 2 (Car+ Gab)
2nd week 0 2(Car+ Gab)
3rd week 0 1(Car+ Gab)+ 3 (Am+Bac)
4th week 0 2 (Am+Bac)
Total 0 10
*Car= Carbemazepin, Gab= Gabapentin, Am= Amitriptylin, Bac= Baclofen
Mean of
pain
records
on VAS
Figure 1: Efficiency of topical and systemic treatments in reducing 30% of pain and the time
taken for this reduction. Numbers above columns represent number of patients still need to
treatment
No. of patients
experienced side
effects
Figure 2: shows side effects experienced by patients in both groups along treatment period
Oral Diagnosis 59
J Bagh College Dentistry Vol. 24(special issue 1), 2012 Assessment of cadmium
Assessment of cadmium levels in Blood, hair, saliva and

teeth in a sample of Iraqi workers and detection of dental
findings
Raja H. Al-Jubouri, B.D.S., MS.c., Ph.D. (1)
Ammar Issa Bashbosh, B.D.S., MS.c. (2)
ABSTRACT
Background: Cadmium considered one of the heavy metals, by time can be accumulate in plants, animals and
humans. This study aimed to using some biomarkers (blood, hair, saliva and teeth), that can be easily obtained and
processed for measuring the cadmium concentration in human body and assessment of DMF/t which may result
from accumulation of cadmium.
Subjects, Materials and methods: This study had been done between April October of 2010 at Al-kufa Cement
Factory in Najaf , the numbers of exposed subjects were 55 and control subjects were 44, blood, hair ,saliva and
teeth were taken as biomarkers then DMF/t were calculated. After processing of these biomarkers (blood, hair, saliva
and teeth) cadmium analyzed by using atomic absorption spectrophotometer device (AAS).
Results: The study reported that blood ,hair ,saliva and teeth are good biomarker for measuring the concentration of
cadmium in addition to effect of some factors like smoking habit , residency, age and in accumulation of that
heavy metal in addition to increasing of the numbers of decayed and missing teeth with increasing of cadmium but
without increasing in numbers of the filling teeth. Also there was significant difference in cadmium concentration
between exposed and control people
Conclusions: This study reported that there was significant increased in cadmium concentration among exposed
subject if compared with control subject. Also indicated that factors like smoking habit, residency and age could led
to increasing the cadmium concentration. In addition to increased the numbers of decay and missing teeth when
the cadmium concentration was increased in these biomarkers.
Keywords: Cadimum, saliva, blood, hair teeth. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):60-64).
INTRODUCTION
Heavy Metals are chemicals with a specific two groups, the first group consist of 55 cadmium
gravity that is at least 5 times the specific gravity exposed subjects (43 males, 12 females) at Al-
of water. Specific gravity of water is 1 at 4. (39o kufa cement factory in Najaf providence and this
F). (1). regarded to study group, the second group consist
Many human biomarkers can reflect cadmium of 44 from out of that factory (29 males, 15
deposition in it's content like (blood, urine, saliva, female).
human milk, sweat, hair and nail, and teeth) All the subjects answered a questionnaire
which can easily obtain from participants than regarding their name, gender, age, type of
some vital tissues as kidney or liver or bones, working, residency, smoking habit and systemic
blood is useful biological indicator of recent disease.
cadmium exposure (2), hair useful for long period Oral examination
of cadmium exposure (3,4,5), teeth, also good bio- Oral examination, was done using sterile
indicator and stable record of environmental mirror and probe& dental chair light, oral finding
exposure and incorporate the metal into dental limited to DMFt (8), the study compared decay,
tissue at the time of exposure (6). missing and filling teeth of subjects separately
Dental findings which may appear after long with each biomarkers.
duration of environmental exposure to cadmium is Saliva collection and measurement procedure
dental decay (7). 5ml mixed un-stimulated saliva was collected
in polypropylene vials by direct collection. The
samples that contaminated with food , blood or
SUBJECTS, MATERIALS AND nasal discharge were discarded. The mixed
METHODS: saliva was then frozen and stored in a freezer at -
A prospective study has been done between 20C. Prior to sample preparation, the saliva
(April October 2010). The sample consist of 99 samples were defrosted and allowed to equilibrate
subjects, with age ranged between (18- 62 years) to room temperature then 20 ml of 2% nitric
of both sexes (72 males, 27 females), divided into acid (HNO3) was added. This solution was
(1) Professor Oral medicine, College of dentistry, Baghdad filtered with Whatman no. 42 filter paper into a
University.
(2) Specialist in Ministry of health.
volumetric flask and diluted to a final volume of
100mL with DDW (9).
Oral Diagnosis 60
The 100 ml solution was then stored in a plastic being digested completely with acids. And stored
container until analysis with an AAS . in plastic tube for time of analysis (11).
Blood, collection and measurement procedure Analysis of samples
Five milliliters of blood from vein putted in The heavy metal concentration in the final
EDTA tube after labeling the tube with digest solution was determined by AA-6300 in
information alcoholic pen then put it in ice box laboratory at kufa University, Cd was determined
Preparation of samples for analysis at 228.8nm, and at a slit width of 0.5 nm for
1- Shaking 5 cc of blood specimen on an metal. (12, 13). The hollow cathode lamps for Cd
electrical shaker for 1 hours. was operated at 8mA. A minimum of three
2- Mixing the specimen with nitric acid and replicates was employed in each case. The
diluted with Titron X-100 (sigma). calibration curve Cd was prepared using
3- The specimen left for 1 hour to ensure that all calibration standards prepared by several dilutions
cells and protein have dissolved and of a stock solution (1000g/g) with deionized
precipitated. water. Recovery experiments were carried out by
4- Centrifugation 4500 r.p.m. adding measured volumes of aqueous standard
5- Taking the supernatant by using micropipettes solutions of Cd metal to measured volumes of a
with disposable tips and put it in a dry, solution containing the tooth or hair dissolved in
sterilized plastic plain tube for cadmium the acid mixture.
examination with AAS. Statistical analysis:
Statistical analysis has been done by using
Teeth collection and measurement procedure. software technique (SPSS) programmed (version
The teeth were collected from the exposed 13)
subjects after checking the subject's dental status
in the health center of Al-kufa cement factory.
Extracted teeth from control subjects was RESULTS
collected all that teeth were label in dry containers Distribution of exposed and control group as
for 2-3 days. shown in table (1).
All the vials in which the teeth were collected Mean concentration of cadmium in human
were cleaned with detergents and (DDW) and biomarkers related to the gender between two
then immersed in 10% HNO3 overnight and groups as shown in table (2).
washed several times with DDW and finally DMF/t related to the gender between two groups
rinsed with deionizer water. Teeth were stored in and among the study group as shown in table (3).
refrigerators at 4C until the time of analysis. Mean concentration of cadmium in human
Preparation of samples for analysis biomarkers related to the smoking habit as shown
Each tooth was cleaned with a 3% solution in table (4).
of H2O2 or sodium hypochlorite to remove Mean concentration of cadmium in human
organic material, and washed several times with biomarkers related to the residency as shown in
DDW and demonized water. The tooth was placed table (5).
in an oven at 50C to dry and be weighed, then it Mean concentration of cadmium in human
was dissolved in an a liquor of 3 ml of ultrapure biomarkers related to the age as shown in table
70% HNO3 and 1.0 ml of 70% perchloric acid (6).
(HCIO4). Each mixture was poured in 50-ml
beaker and evaporated until nearly dry. After that DISCUSSION
the digest was rinsed with 1% HNO3, and made Despite the mean concentration of cadmium in
up to 10mL, and returned to the vial (10). males were higher than in females, but there was
Hair collection and measurements procedure no a statistical significant difference between the
Hair samples were cut at the scalp at 6 two genders in the study group (P>0.05), this
different locations on the head.. The total amount result agreed with (14).
of hair collected from each individual and then In this study mean concentration of cadmium
analyzed ranged from 0.1to 0.5g. Hair samples in hair among males were higher than females
were rinsed with alcohol followed by triple despite that ,there was no a statistical significant
rinsing with water and then a repeated rinsing difference (P>0.05), this result agreed with (11).
with alcohol. Washed hair was dried at 105oC. Blood considered important biomarker
Dried samples were weighed and then mineralized because it can reach to all tissues and renewed
using a mixture of concentrated nitric and continuously and have large quantity in the body,
perchloric acids (mixed at a ratio of 5:1)until .In this study the mean concentration of cadmium
in blood among males were higher than females
Oral Diagnosis 61
but there was no a statistical significant difference women in some biomarkers (blood, hair and teeth)
(P>0.05), and this result agreed with (15). this is in agreement with (7).
Saliva has been taken as a biomarker for
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mercury in blood, urine, hair, and nails among
Table 1: Distribution of Exposed and control group

Exposed Control
No. % T. % No. % T. %
Male 43 78.2% 29 65.9%
Gender 100%
Female 12 21.8% 55 15 34.1% 44 100%
Smoking Smokers 32 58.2% 19 43.2%
100%
habit Non-smoker 23 41.8% 55 25 56.8% 44 100%
Urban 36 65.5% 22 50%
Residency 100%
Rural 19 34.5% 55 22 50% 44 100%
Young 29 52.7% 23 52.3%
Age 100%
Elder 26 47.3% 55 21 47.7% 44 100%
T.: total numbers, %: percentage
Table 2: Mean concentration of cadmium in human biomarkers related to the gender between
two groups and among the study group.
Exposed Control
X SD SE No. X SD SE No. Sig A Sig B
Blood M 0.58 0.26 0.3 43 0.26 0.9 0.1 29 <0.01
(g/dl) F 0.42 0.25 0.07 12 0.16 0.06 0.01 15 <0.01 >0.05
Hair M 0.61 0.20 0.03 43 0.37 0.14 0.02 29 <0.01
(g/g) F 0.50 0.10 0.03 12 0.24 0.09 0.02 15 <0.01 >0.05
Saliva M 0.57 0.08 0.1 43 0.22 0.06 0.1 29 <0.01
(g/dl) F 0.51 0.09 0.02 12 0.17 0.05 0.01 15 <0.01 >0.05
Teeth M 0.74 0.15 0.02 43 0.41 0.15 0.2 29 <0.01
(g/g) F 0.66 0.11 0.03 12 0.30 0.09 0.02 15 <0.01 >0.05
X: mean concentration of Cd, (SD): standerd deviation, (SE):Standerd error (No.): numbers of
Participants , M : males , F :females. Sig A: p-values between exposed and control groups, Sig B:
p-value between males and females in the study group
Table 3: Mean numbers of decay, missing and filling teeth (DMFt) related to the gender between
Exposed Control
X~ SD SE No. X~ SD SE No. Sig A Sig B
M 4.8 1.7 0.2 43 2.3 2.3 0.4 29 <0.01
Decay teeth No.
F 2.1 1.1 0.3 12 1.6 1.1 0.3 15 >0.05 <0.01
M 5.4 2.1 0.3 43 2.9 2.7 0.5 29 <0.01
Missing teeth No.
F 2.9 1.3 0.3 12 1.9 1.6 0.4 15 >0.05 <0.01
Filling M 3.1 1.9 0.3 43 2.9 1.5 0.2 29 >0.05
teeth No. F 3.7 1.9 0.5 12 2.5 2.4 0.6 15 >0.05 >0.05
X~: mean numbers of decay , missing and filling teeth, (SD): standerd deviation, (SE):Standerd error,
(No.):numbers of Participants , M : males , F :females. Sig A: p-values between exposed and control groups, Sig
B: p-value between males and females in the study group.
Oral Diagnosis 63
Table 4: Mean concentration of cadmium in human biomarkers related to the smoking habit
between two groups and among the study group.
Exposed Control
Blood S 0.72 0.21 0.03 32 0.27 0.09 0.02 19 <0.01
(g/dl) Z 0.31 0.10 0.02 23 0.19 0.07 0.01 25 <0.01 <0.01
Hair S 0.69 0.17 0.03 32 0.39 0.14 0.03 19 <0.01
(g/g) Z 0.44 0.07 0.01 23 0.28 0.11 0.02 25 <0.01 <0.01
Saliva S 0.59 0.07 0.01 32 0.24 0.06 0.01 19 <0.01
(g/dl) Z 0.50 0.08 0.01 23 0.17 0.04 0 25 <0.01 <0.01
Teeth S 0.77 0.15 0.02 32 0.43 0.16 0.03 19 <0.01
(g/g) Z 0.65 0.09 0.01 23 0.33 0.11 0.02 25 <0.01 <0.01
X: mean concentration of Cd, (SD): standard deviation, (SE): Standard error (No.): numbers of
Participants, S: smoker, Z: non-smokers. Sig A: p-values between exposed and control groups, Sig B:
p-value between smoker and non-smoker in the study group
Table 5: Mean concentration of cadmium in human biomarkers related to the residency between
Exposed Control
Blood U 0.59 0.26 0.04 36 0.28 0.08 0.01 22 <0.01
(g/dl) R 0.47 0.25 0.05 19 0.17 0.06 0.01 22 <0.01 >0.05
Hair U 0.62 0.17 0.02 36 0.41 0.13 0.02 22 <0.01
(g/g) R 0.52 0.19 0.04 19 0.25 0.09 0.02 22 <0.01 <0.05
Saliva U 0.57 0.08 0.01 36 0.25 0.04 0.09 22 <0.01
(g/dl) R 0.52 0.08 0.01 19 0.15 0.04 0 22 <0.01 >0.05
Teeth U 0.75 0.10 0.01 36 0.47 0.12 0.02 22 <0.01
(g/g) R 0.67 0.19 0.04 19 0.28 0.09 0.01 22 <0.01 <0.05
Participants, U: Urban, R: Rural. Sig A: p-values between exposed and control groups, Sig B:
Table 6: Mean concentration of cadmium in human biomarkers related to the Age between two
groups and among the study group.
Exposed Control
Blood Y 0.36 0.19 0.03 29 0.15 0.05 0.01 23 <0.01
(g/dl) E 0.76 0.15 0.03 26 0.31 0.05 0.01 21 <0.01 <0.01
Hair Y 0.46 0.14 0.02 29 0.23 0.10 0.01 23 <0.01
(g/g) E 0.72 0.13 0.02 26 0.43 0.10 0.02 21 <0.01 <0.01
Saliva Y 0.51 0.08 0.01 29 0.16 0.05 0.01 23 <0.01
(g/dl) E 0.61 0.06 0.01 26 0.25 0.04 0 21 <0.01 <0.01
Teeth Y 0.63 0.15 0.02 29 0.27 0.07 0.01 23 <0.01
(g/g) E 0.82 0.05 0.01 26 0.49 0.09 0.02 21 <0.01 <0.01
Participants, Y: Young, E : elder. peoples Sig A: p-values between exposed and control groups, Sig B:
p-value between young and elder subjects in the study group
p-value between Urban and Rural subjects in the study group
Oral Diagnosis 64
J Bagh College Dentistry Vol. 24(special issue 1), 2012 Changes in oral
Changes in oral flora of newly edentulous patients, before

and after complete dentures insertion
Saeed Abdul Latteef Abdul-Kareem, B.D.S., M.Sc. (1)
ABSTRACT
Background Investigation of the oral flora of edentulous subjects is becoming increasingly important because of recent
wide spread use of implants in the treatment of edentulism.
Materials and methods Twenty eight newly edentulous patients with age ranged between (40-80) years were included
in this study. Saliva samples were collected at two intervals; before taking the primary impression, and after one month
of functional use of the complete dentures, and assessed microbiologically.
Results; indicated that the total numbers of microorganisms were decreased within the post insertion period with non
significant variation in their types, newly edentulous mouth harbored Neisseria species which disappeared after denture
insertion, while E coli, Klebsiella, and Moraxella (Branhamella) were observed after one month of denture wearing.
Other microorganisms include Streptococci and Candida was reduced. On the other hand, Staph. aurous,
Diphtheroids, Veillonella and Acinetobactor were considered as a part of the normal flora of edentulous patient that
unchanged by denture wearing.
Conclusion; Although denture can serve as a colonization site for the various microorganisms with short period of
denture use and good oral hygiene the microorganisms did not increased in the oral cavity.
Key word: oral flora, saliva, edentulous, complete dentures. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):65-69).
INTRODUCTION More than 300 microbial species coexist in the

Normal oral flora is taking an important role in oral cavity, with Streptococcus spp. and
keeping the oral mucosa in a health status (1). It is Actinomyces spp. being the predominant
important to fully define the human microflora of cultivable flora in early plaque (4, 12).Yeasts such
the healthy oral cavity before one can understand as Candida albicans are usually a minor
the role of bacteria in oral diseases. Recent studies component of the oral flora, except in situations
reveal that more than 700 bacterial species of where the host is compromised, and then oral
phylotypes of which over 50% have not been candidosis may be evident (4,12). Increased
cultivated, have been detected in the oral cavity. numbers of Candida albicans also occur in denture
There is a distinctive predominant bacterial flora stomatitis (13).
of the healthy oral cavity that is highly diverse Adhesions present on the surfaces of oral
and site and subject specific(2). microbial cells are considered necessary for there
As the completely edentulous patients are growth and survival in the mouth (12-15). Probably
usually in elderly status, so the age related change best characterized are the adherence of oral
in salivary flow will affect the health of oral tissue Streptococci and Actinomyces that enable these
(3,4)
,as well as functional use of the complete organisms to attach to salivary pellicle (12-16).
dentures will affect the salivary flow by changing Candida albicans adhere to mucosal surfaces, to
the occlusal forces. Previous studies suggested plastic, and to acrylic, but modes of attachment
that proper replacement of full complete dentures are less clearly defined than those in oral
will increase the salivary flow rate along with Streptococci (14,15). In view of the importance of
improved occlusal force (4-6), at the same time it interbacterial coaggregation in the establishment
enhances the accumulation of dental plaque and and maintenance of bacteria such as Strep.
bacteria on the surface of the dentures. Studies viridians with Candida albicans may influence
revealed bacteria which depend on hard surfaces colonization of the oral cavity by the yeast (12). A
for attachment and growth will in part re-colonize number of oral and non-oral bacteria can
the mouth if a denture is worn (7,8) . Investigations agglutinate with Candida albicans cells (13).
and researches revealed that a number of The complete loss of teeth may eliminate some
pathogenic microorganisms which were present in pathogenic bacteria for lack of a suitable habitat
the mouth when the patient was dentate, they were for colonization, such as tooth surfaces and
harbored in the oral cavity even when they are in subgingival sites (4, 10). For instance, Strep.
the edentulous state (8-10). Microbial samples from mutans, the primary etiological agent in caries
the tongue and saliva suggested that black- development and found in oral cavity of dentate
pigmented Gram-ve anaerobic microorganisms people, Strep. mutans cannot be found in
were present as indigenous oral flora in mouth edentulous subjects (15). The prevalence of
with or without dentures (11). selected putative periodontal pathogens
(1)Department Oral Medicine, College of Dentistry-University of colonizing oral mucous membranes was
Sulaimani. investigated in 26 denture-wearing subjects with a
history of periodontitis, while other previous
Oral Diagnosis 65
studies suggested that none of subjects examined The data were analyzed by using Chi-Square
harbored Prophyromonas gingivalis and up to test, P-value <0.05 was regarded as statistically
now P. gingivalis has not been found in the significant.
healthy oral cavity. Also a high numbers of black-
pigmented Gram-ve anaerobes may belong to the RESULTS
indigenous oral flora in edentulous subjects with The result clarify that when microorganisms
or without dentures (11, 16, 17). were grouped according to Gram stain bacteria
Different studies suggested that with loss of and fungi, the total frequency of positive cultures
teeth, bacteria associated with hard subjects for in these groups among all the studied cases were
attachment and growth (e.g. Strep. mutans), strict slightly decreased (from 68 patients to 54) within
anaerobes generally found in periodontal pockets the post insertion period in comparison to newly
(black-pigmented Gram-ve anaerobes of the edentulous mouth (Figure: 1), with no significant
genera P. gingivalis and Prevotella, and variation in their types (P=0.11, Table: 1).
Spirochetes) will in part recognize the mouth if Thus before denture insertion, Hemolytic and
the denture is worn (4, 11, 16,18) . The prevalence of Non-hemolytic Streptococcus as well as Staph.
salivary Strep. mutans and Lactobacilli, salivary aureus were the more predominant Gram+ve
flow rate and the type of dentition were studied in bacteria. After one month period of functional use
connection with a medical survey of 76-86 year- of complete dentures the positive cases with Non-
old inhabitants of Helsinki living at home. High hemolytic Strep. increased from 8 to 13 patients,
counts of Strep. mutans were found in 68% of while the -hemolytic type decreased from 24 to
wearers of full dentures, as compared with 53% of 14 patient. On the other hand Staphylococci and
subjects having natural teeth. High counts of Diphtheroids were unchanged. Yet there were no
lactobacilli were found in 44% in subjects having statistical difference in frequencies of Gram +ve
removable partial dentures and 39% in subjects microorganisms existence before and after denture
having natural teeth. The bacterial counts did not insertion (Table 1, P=0.09).
correlate with medicines taken daily nor with Regarding Gram-ve bacteria, newly
diseases among the studied population (19) . edentulous mouth was characterized by Neisseria
Spp.(15 53.6%). However after denture insertion
PATIENTS AND METHOD these microorganisms were absent, and instead of
Twenty eight newly edentulous patients (16 them E.Coli, Klebsiella pneumonia and Moraxella
males and 12 females), their age ranged between (Branhamella) catarrhalis were detected (Table
(40-80 years) who were non-smokers, non- 1). Nevertheless, the differences not reach the
alcoholic, devoid of systemic diseases and did not statistical level (P=0.24).
use antibiotics before six months included in this Concerning fungi, the existence of Candida
study. They visited prosthodontic clinic in the albicans after one month of complete denture
College of Dentistry-University of Sulaimani for insertion was slightly reduced from 10.7% to
construction of complete dentures. Each patient %7.2 (Table 1).
was asked to intake 5 ml distal water and vortex
mix it inside the mouth for 1 minute then recollect DISCUSSION
it in sterilized plastic cups, by spiting method, at Investigation of the oral flora of edentulous
two intervals; before construction of the dentures subjects is becoming increasingly important
(group1, newly edentulous) and after a month of because of recent wide spread use of implants in
functional use of their complete dentures (group the treatment of edentulism. The aim of this study
2). All patients received similar instruction during was to compare the recovery rate of certain
complete dentures insertion and along the regular microorganisms that are able to survive in the
checking and follow up visits. The samples were changed oral ecology of edentulous subjects
directly sent for microbiological examination at wearing dentures. Previous studies (4, 11, 16, 18, 19)
Sulaimani Public Health laboratory Teaching suggested that with loss of teeth, bacteria
Hospital , and the following culture media were associated with hard subjects (e.g. Strep. mutans),
performed; 1-Blood agar aerobically for strict anaerobes generally found in periodontal
Streptococcus , Staphylococcus, and pockets (black-pigmented Gram -ve anaerobes of
Pneumonococcus. 2-Blood agar anaerobically for the genera P.gnigivalis and Prevotella and
Pepto-streptococcus, Peptococcus, and Veillonella Spirochetes), and very fastidious organisms tend
3-Chocolate agar and CO2 for Hymophilus and to disappear from the oral cavity. Bacteria that
Neisseria .4-Maconkey agar for Gram ve depend on hard surfaces for attachment and
bacillae. 5 Sabauroid dextrose agar for Candida. growth will in part recognize the mouth if the
denture is worn (4, 18).
Oral Diagnosis 66
Concerning Gram +ve microorganisms, saliva, dental plaque) that have no pathologic
literature indicated that Strep. mutans is a potential (22). Using culture independent molecular
predominant microorganism isolated from mucosa technique, Sreebny indicated that it was among
and saliva of denture wearing edentulous subjects the species common to all sites of healthy human
(10, 19)
, it is common inhabitant to all oral sites (3) . mucosa (3). In our study Veillonella was detected
In our study, Hemolytic and non hemolytic in edentulous patient with or without wearing
Streptococcus were also predominant in saliva dentures, similar to previous mentioned studies (11,
18)
before and after denture wearing, its level was . Thus it belongs to the endogenous oral flora in
higher in saliva compared to its previous reported edentulous subjects.
frequency in mucosa (20). Furthermore, Strept. Klebsiella together with E coli are indigenous
pneumoniae are considered as normal commensal to the human respiratory and intestinal tract
in the human upper respiratory tract, up to 4% of respectively, and occasionally isolated from the
the population carry these bacteria in small oral cavity, however, they are considered to be
numbers, they induce inflammatory response and transient oral commensals (22). E coli, however,
associated with sinusitis (22). Newly denture are a major agent of sepsis (urinary tract infection
wearers according to our study had no chance to and diarrheal disease, as well as neonatal
harbored these microorganisms in comparison to meningitis and septicaemia) (22). Their level in
its existence in previously reported healthy saliva of complete denture wearers was just like
mucosa of complete denture wearers (39%) (20). that reported previously in mucosa of similar
On the other hand, Staph. aureus are found in patients (20). Although we did not isolate them
saliva of healthy subjects older than 70 years (22) from edentulous mouth, this greatly remark to its
as well as in the oral mucosa of denture wearer association with denture wearing even for the
(20)
. In this study it exists in saliva of both short period of one month. On the other hand
edentulous patients with or without dentures. Klebsiella occasionally isolated from the oral
Several studies indicate that the level of cavity and hence are considered transient oral
Lactobacillus in the saliva of edentulous mouth is commensals. However their percentage like E.coli
very low (4, 5, 9, 10, 18). It constitutes less than 1% of also increased after denture wearing similar to Al-
the total flora (22). This is just in line with our Aswad findings (20).
result. But they also remark that these There is hardly any observation on the
microorganisms return to the same or rise even to presence of Actinobacillus
higher level than in dentate mouth when dentures actinomycetemcomitans (Aa.) in the edentulous
are worn (19). However, we did not record the later mouth (10, 18). The oral cavity of edentulous
finding, subjects do not contain A. a and P. gingivalis as
Diphtheroids are normal habitant of skin and normal habitant (11, 16), even they were absent
dental plaque (22). In this study they were isolated around implant in complete edentulous patients
(21)
from edentulous mouth, and constitute 10% of the . Also Prevotella spp. black pigmented
total flora. Their level was unchanged after bacteroids seems to be a preferable habitant at the
denture insertion. This is in contrast to its higher oral mucosa (16, 10) and it considered as normal
level (21%) reported by Al-Aswad study (20). oral flora of edentulous subjects wearing dentures
(10)
Regarding Gram-ve bacteria, commensals . Prevotella intermedia were recovered in full
Neisseria (Sicca, Flava, and Mucosa) are common denture wearer for longer period time (mean 20
habitants in the oral cavity both in the saliva and years) and did not detected in subjects of 6.6 years
mucosa. While Moraxella are commensal of period. This suggested that absence of Prevotella
human respiratory tract that associated with intermedia shortly after extraction may reflect
maxillary sinusitis (22). In general, Neisseriaceae only a temporary event (16). However; Kulekci et
family, Moraxella Branhamella, and al. identify black pigmented Gram-ve anaerobes
Acinetobactor were disappear after denture in the saliva of both edentulous patients with or
insertion, i.e.; edentulous patient without denture without dentures (11).
had great percentage of these microorganisms, Candida albicans are usually minor component
and all of them disappeared after one month of of the oral flora (4) .It increased in denture
denture use. This is in contrast to Al-Aswad stomatitis (13) and medical compromised patient
(12)
findings that indicate greater percentage of . Candida albicans adhere to mucosal surfaces,
Neisseria (39%) in mucosa of denture wearer, and to plastic, and to acrylic (14,15). In this study
they did not specify other members of this family Candida albicans were detected in the saliva in
(20)
. 10.7% of the pre insertion samples and
Veillonella species are obligate anaerobic unexpectedly slightly decreased within the post
frequently isolated from oral samples (tongue, insertion samples to be far less than the level
Oral Diagnosis 67
registered from oral mucosa in denture wearer in 5. Shklair IL, Mozzarella MA. Effect of full-mouth
Al- Aswad study (20). The colonization of the oral extraction of oral microbiota. Dent. Prog 1961; 1:275-
280.
cavity by the yeast may be influenced by the
6. Yurdukoru B,Terzioglu Y,Hilmaz T. Assessment of the
importance of interbacterial coaggregation in the whole salivary flow rate in denture wearing patients.
establishment and maintenance of bacteria such as J Oral Rehabil.2001; 28:109-12.
Strep. viridians with Candida albicans (12) also; the 7. Kaplan I, Zuk-Paz L and Wolff A.Association between
number of oral and non oral bacteria can salivary flow rate ,oral symptoms, and oral mucosal
agglutinate with Candida albicans cells (13-15). status .Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2008 ;106:235-41.
It seems that the prevalence of oral flora in
8. Matsuda K, Ikebe K, Ogawa T, Kagawa R, Maida Y.
edentulous patients revealed a great variation Increase of salivary flow rate along with improved
regarding site and method of sample collection, occlusal force after the replacement of complete
selective medium and enrichment cultivation and dentures. Oral Surg Oral Med Oral Pathol Oral Radiol
interpretations. As well it is affected by day time Endod 2009; 108: 211-215.
and period of denture use and period of hours 9. Carlsson J, Soderholm G, Almfeldt I. Prevalence of
Streptococcus sanguis and Streptococcus mutans in
wearing per day. Our patients were new cases
the mouth of persons wearing full dentures .Arch Oral
who use denture for one month only and wear it at Biol 1969 ;14: 243.
day only. They also keep good oral hygiene as a 10. Kononem E. Asikainen S, Kononem M, Summanen P,
result of frequent motivation through the period of Kanervo A, Jousimies-Somer H. Are certain oral
follow up. Thus denture can serve as a pathogens part of normal oral flora in denture-wearing
colonization site for the various mentioned edentulous subjects ?Oral Microdiol Immunol 1991;
6:119-122.
microorganisms when there is neglecting oral
11. Kulekci G, Bilgim T, Egimez S.Turfaner M and Ang
hygiene with prolong denture use. O.The presence of black-pigmented anaerobes in oral
cavity of edentulous subjects. FEMS Immunol Med
CONCLUSION Microbiol 1993; 219-222.
12. Jenkinson HF, Llala HC and Shepherd MG.
Newly complete edentulous patients after one Coaggregation of Streptococcus sanguis and other
month period of functional use of dentures Streptococci with Candida albicans Infection and
showed no significant difference in type of Immunity. Am Society Microbiol 1990;1429-1436.
microorganisms than before insertion. Staph. 13. Bagg J and Silverwood RW .Conglutination reactions
aurous, Diphtheroids, Veillonella and between Candida albicans and bacteria. J Med
Acinetobactor were part of the normal flora of the Microbiol 1986; 22:165-169.
14. Demuth DR, .Davis CA, Corner AM, Lamont RJ,
edentulous patient that unchanged by denture Leboy PS and Malamud. Cloning and expression of a
wearing. While E coli, Klebsiella, Moraxella Streptococcus sanguis surface antigen that interact
Branhamella started to be observed after with human salivary agglutinin. Infect Immun.1988;
denture wearing. Other microorganisms include 56:2484-2490.
Streptococci and Candida were reduced and 15. Rotrosen D, Calderone RA and Edwards JE.
finally Neisseria disappeared. Adherence of Candida species to host tissues and
plastic surfaces. Rev Infect Dis Jr 1986; 8:73-85.
16. Danser MM, vanWinkelhoff AJ, de Graff J, van
ACKNOWLEDGEMENT derVelden U.Putative periodontal pathogens
My appreciations go to Professor Nazar colonizing oral mucous membrane in denture-wearing
Talabani and Ass.Prof. Balkees T.Garib subjects with a past history of periodontitis. J Clin
Periodontol 1995;22:854-9.
,Dr.Sherko Ali Omer ,Dr.Fawaz Al-Aswad and, to
17. Van-Winkelhoff A.J, Van-Steenbergen TJM and
all staff of Sulaimani Public Health laboratory- deGraff J. The roll of black-pigmented bacteriodes in
Teaching Hospital especially Mr.Mahmood human oral infections. J Clin Periodontol
Qaradaxi for their continuous help and support to 1988;15:145-155.
achieve this study . 18. Theilade E and Budtz-Jorgensen E. Predominant
cultitative microflora of plaque on removable dentures
in patients with denture- induced stomatitis.Oral
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1. Dodds MWJ, Johnson DA, Yeh CK .Health benefits of 19. Narhi To, Alnamo A, Meurman JH. Mutans
saliva: a review. J Dent 2005; 33:223-233. streptococci and lactobacilli in the eldery. Scand J
2. Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Dent Res 1994 ;102:97-102.
Defining the normal oral flora of the oral cavity. J Clin 20. Al-Aswad FD. Prevalence and microbiology of oral
Microbiol 2005; 43: 5721-5732. mucosal lesions in a sample of complete denture
3. Sreebny LM. Saliva in health and disease an appraisal wearers. A thesis submitted to College of Dentistry,
and update.Int Dent J 2000; 50: 140-61. Univrrsity of Baghdad, Iraq .MSc. Oral Medicine. 30,
4. Socransky SS, Manganiello SD. The oral microbiota of 62- 72 -1999.
men from birth to senility. J.Periodontal 1971;42:482- 21. Samaranayake LP. Essential Microbiology for
494. Dentistry.2nd ed. Churchill Livingstone; 2002
Oral Diagnosis 68
22. Kocar M, Seme K, Hren NI. Characterization of the and completely edentulous patients. Int. J oral
normal bacterial flora in peri-implant sulci of partially maxillofacial implant. 2010; 25: 690-8.
Table 1: The number and percentage of positive cultures for different Gram positive and Gram
negative microorganisms in 28 completely edentulous patients before insertion and after a
month period of functional use of full complete dentures arranged in descending manner.
Pre insertion Post insertion
Types Microorganisms P value
No. % No %
-hemolytic streptococci 24 85.7 14 50
Non -hemolytic streptococci 8 28.6 13 46.4
Staph.aureus (coagulase-ve) 6 21.4 6 21.4
Gram +ve 0.09
Diphtheroids 3 10 .8 3 10.8
Streptococcus pneumoniae 1 3.6 0 0
Lactobacillus 1 3.6 0 0
Neisseria Spp. 15 53.6 0 0
Veillonella 4 14.3 3 10.8 0.11
Acinetobactor Spp. 2 7.2 2 7.2
Gram -ve Escherichia coli 1 3.6 4 14.3 0.24
Klebsiella pneumoniae 0 0 4 14.3
Moraxella (Branhamella)
0 0 3 10.8
catarrhalis
Fungi Candida albicans 3 10.7 2 7.2
Total 68 54
Figure 1. The frequency of positive cultures for different groups of microorganisms in 28

completely edentulous patients before and after one month of functional use of full complete
dentures.
Oral Diagnosis 69
J Bagh College Dentistry Vol. 24(special issue 1), 2012 Topical treatment
Topical treatment of herpes simplex lesion by lavender

cream
Tagreed Altaei, M.Sc., Ph.D. (1)
Shaheen Ali Ahmed, B.D.S., M.Sc. (2)
ABSTRACT
Background: Herpes simplex virus is a common human pathogen that establishes life-long latent infections. The
development of new antiviral drugs, especially herbal preparations remain desirable. Lavender has been shown to
possess antibacterial, antifungal, antiviral actions.
This study was designed to compare the safety and efficacy of topical Lavender cream, acyclovir cream, with
placebo for the treatment of herpes simplex labialis patients.
Patients and Methods: Randomized, double blind, placebo-controlled study for herpes simplex labialis treatment, a
total of 75 enrolled patients divided to three groups and given study medications; group I: Lavender cream, group II:
Acyclovir cream, group III: placebo, applied topically to the lesion three times daily for 5 days. Patients responses to
treatment were followed by clinical evaluation of healing time, size of the lesion and pain sensation, and safety of
using the topical treatment. Patients assessed themselves the day of the scab fell off. They also graded, on a daily
basis, their perception of relief from pain and the overall benefit from treatment. Also evaluating levels of the
Immunoglobulin (IgG, IgE, IgM, IgA, and IgD) in the serum of herpes simplex labialis patients.
Results: Herpes simplex patients showed a significant reduction in the healing time, size of lesions, and significant pain
relief from the first topical dose as a result of treatment with lavender cream associated with immunity state
improvement.
Conclusions: Lavender cream is a new candidate as a safe and effective topical treatment for herpes simplex labialis
lesions.
Key wards: Lavender, herpes simplex labialis. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):70-76).
INTRODUCTION Immune system deficiencies that are subtler, but

Herpes labialis is a commonly occurring ailment not necessarily associated with a serious disease,
(1)
. Approximately one-third of all infected patients might also increase the risk of experiencing
suffer relapses (2). It is a rash of the skin and Herpes simplex infections. For that reason, a
mucous membranes (in particular, the lips) and is comprehensive prevention-and- treatment plan
characterized by erythema and blisters that are should include measures designed to enhance
preceded and accompanied by burning pain. It is a immune function (7).
harmless but often annoying ailment in The name lavender is derived from the Latin
immunocompetent patients and it usually heals lavare, which means to wash. The fragrant
spontaneously within 10 days. Herpes labialis is flowers were used in ancient Rome and North
contagious for individuals who have not been Africa to scent public baths and were carried by
previously infected by the virus and for those with the Roman army for use as a disinfectant (8).
weakened immune systems (e.g., those with HIV Lavenders in Medieval and Renaissance times
infection or undergoing chemotherapy) (3). In were used for the storage of laundry. The Ancient
addition, herpes labialis infection can result in Egyptians are said to have used the flower in the
genital herpes through orogenital contact (4). Mummification process (9).
Research has shown that while recurrences of Several therapeutic effects of lavender, such as
infections are spontaneous, they are associated sedative, relaxant, carminative spasmolytic,
with various triggers such as physical or emotional antioxidant, antiviral and antibacterial activities as
stress, fever, exposure to ultraviolet light, nerve or well as several gastrointestinal nervous and
tissue damage, immunosuppressant, heat, cold, rheumatic disorders have been reported (10-13).
menses, concurrent infection, and fatigue (5). Both The aims of the present study was to compare the
herpes simplex type 1 and herpes simplex type 2 efficacy in healing of herpes simplex lesion, pain
are responsible for primary oral herpes simplex relief, and safety of topical Lavender cream,
infections, with HSV-1 accounting for 75 to 90 acyclovir cream, with placebo, also study the
percent of the cases (6). levels of immunoglobulins.
PATIENTS AND METHODS

This study was conducted in a double-blind
(1)Assistant professor College of Pharmacy / Hawler Medical
University
technique randomized, placebo-controlled. 76
(2)Assistant Lecturer, College of Dentistry/ Hawler Medical patients were participating in this study, 45 of
University them were female & the other 31 were males. The
Oral Diagnosis 70
age varied between 15 to 45 yrs., patients were Statistical evaluation of data was performed
randomized to 3 groups; group I (G I): Lavender utilizing Chi-square test, Students t-test and
cream, group II (G II): Acyclovir cream, group III ANOVA test to compare between means.
(G III): placebo, applied topically to the lesion Differences were considered significant at P values
three times daily for 5 days. <0.05. SPSS computer program was used for this
Inclusion criteria were; the patients should have a purpose.
history of recurrent herpes simplex, not suffer
from any chronic debilitating disease, and not RESULTS
receive any antibiotics or steroids medication. Thirty-one of the 76 treated patients received
While exclusion criteria were; Pregnant & nursing topical lavender cream, 29 Acyclovir cream, and
mothers, patients with Known systemic diseases 16 were treated with the placebo. Mean age was
that may be associated with herpes simplex. 38, distribution of lesion in female more than
At the beginning of the study each patient was males, and the number of lesion occurrence per
given enough information about the nature of the year was 10. The patient characteristics and
study to gain maximum cooperation. clinical data are shown in Table 1 by treatment
Each patient was followed up regularly by daily groups.
inspection during the period of application of the Healing time (scab loss) occurred in a mean 4.1
tested medications to the lesion to determine the 0.2 days for lavender treated group, 6.1 0.5 days
end point time of healing process, size of the for acyclovir group, and 8.4 1.5 days for placebo
lesion, and the degree of pain (by measuring visual group. The difference observed for healing time
analog scale VAS), in addition to the self between the treated groups and placebo was
assessment on a daily basis, their perception of statistically significant (P =0.0001), table (1).
relief from pain and the overall benefit from There was a significant reduction of the size of
treatment. Also safety of using these studied lesions in lavender and Acyclovir treated groups
topical treatment. compared to placebo, while there is no
Preparation of the Formula: Cream base formula significance difference between G I and G II, the
for topical application of Lavender was prepared difference only in the time to healing, as showed in
according to B.P. (1997) (14), Placebo is a cream fig. (1).
base free from active constituent. Acyclovir cream This study showed a highly significant difference
(Zovirax, GlaxoWellcome) was used as a between G I and G II in pain score, VAS
reference for comparison. decreased significantly in lavender treated group
Blood Samples Collection: Five ml of venous from the first applied dose more than Acyclovir
blood was drawn from 50 patients who are treated treated and placebo groups, (P=0.0002), fig. (2).
with studied medications, after diagnosis and This study showed a significant reduction in the
randomization, and before starting drug treatment serum levels of the immunoglobulins; IgG, IgE,
as a pre-treatment sample, and after 5 days of IgM, IgA, and IgD compared to baseline levels in
treatment as post-treatment sample. Blood samples both Lavender and Acyclovir treated groups
were left for clotting and then centrifuged for 15 (p=0.001), while placebo treated group did not
minutes at 2000 rpm for separation of serum, showed any significant change among
which was kept frozen unless analysed immunoglobulins level, table (2).
immediately. Patients ranked the benefit of their topical
Determination of Serum Immunoglobulin: treatment on a daily basis and graded the overall
Determination of serum level of the benefit from the medications. The ranking was on
Immunoglobulin (IgG, IgE, IgM, IgA, and IgD) a 1 to 10-index scale (1 = no benefit at all; 10 =
was made using a ready-made kit for this purpose. very effective treatment). At the final visit there
Equal volumes of reference sera and test samples was a statistically significant difference in the
were added to wells in an agarose gel containing a benefit index for both Lavender and Acyclovir
monospecific antiserum. The samples diffused cream versus placebo for this subjective
radially through this gel and the tested compound evaluation, Lavender index 9.2 0.1, Acyclovir
(antigen) being assayed as forming a precipitin index 8.5 0.1, and placebo index 5.3 0.2, (P=
ring with the monospecific antiserum; rings 0.01), table (1). There were no side effects
diameters were measured, and concentrations were detected from using the tested drugs in this study.
determined using standard curve prepared for this
purpose (15).
Statistical Analysis: DISCUSSION
Infections with herpes simplex virus (HSV) recur
despite high levels of neutralizing antibodies (16, 17)
Oral Diagnosis 71
and apparent active virus-specific cellular The results of this study indicated that lesion size
immunity (18, 19). Both humoral and cellular areas decreased at a significantly greater rate
immunities have been shown to be important in among lavender treated patients with complete
preventing infections in experimental animals and healing. In addition to the significant healing time
humans. reduction earlier than the other two tested groups.
Antiviral medications are a commonly prescribed It seems that lavender has an anti allergic effect
treatment for HSV. Treatment with antiviral on mast cell-mediated immediate-type allergic
medications can help lesions heal faster during an reactions, and some concentration-dependent
initial outbreak, lessen the frequency and duration inhibition impact on histamine release from the
of symptoms during recurrences, reduce the peritoneal mast cells in mice and rats (31).
frequency of outbreaks, and decrease viral Lavender enhance Free radical scavenging
shedding. Acyclovir is a specific inhibitor of HSV- activity and decrease the stress hormone, cortisol,
1, HSV-2 virus replication, with little toxicity for which protects the body from oxidative stress (32)
host cells (20). It requires a virus encoded Coumarin found in L. angustifolia, and
thymidine kinase (TK) for efficient intracellular caryophyllene oxide have anti-inflammatory
(33)
activation, which accounts, in part, for its effects , while Rosmarinic acid,
selectivity. However, resistance to this antiviral hydroxycinnamic acid, 1,8-cineole, and beta-
drug has already been reported (21, 22). pinene may contribute antioxidant activity to
Topical therapy offers the benefit of minimal Lavender (34, 35), this may be a mechanism of
systemic exposure of the patient to the agent, and a action that explains Lavender activity in re-
route of application for useful antiviral agents, epithelialization and healing process faster than
which cannot be given by a systemic route because other groups, in addition to its actions as anti-
of toxicity or poor absorption. Topical acyclovir inflammatory, and immunity enhancer. Other
has poor skin penetration (23). There is no ideal mechanism of action is that the antiviral activity of
topical treatment for herpes simplex labialis. The essential oils may be due to the direct interaction
aim of this study was to search for new natural with virions.
product scaffolds with potential antiviral activity Concerning the fast pain relief in lavender group
and without harmful or side effects. This is the more than the other treated groups, is referred to
first study of using topical lavender cream for the the lavender active constituents; linalool is the
treatment of Herpes simplex lesions. major pharmacologically active constituent
The main chemical components of lavender oil involved in the anti-anxiety effect of lavender oil
(36)
are a-pinene, limonene, 1,8-cineole, cis-ocimene, , Eugenol has local anesthetic effect (37, 38), and
trans-ocimene, 3-octanone, camphor, linalool, Linalyl acetate and linalool have sedative and local
linalyl acetate, caryophyllene, terpinen-4-ol, anesthetic effects (39-41).
eugenol and lavendulyl acetate (24). Following In Herpes simplex patients, antibodies to HSV are mostly IgG,
topical application of the essential oil of L. although HSV-specific IgA is also detectable (42-44). All the
angustifolia, linalyl acetate and linalool can be observations about the possible role of IgG, IgM, IgA and the
detected in the blood within five minutes, peak at complement protein components (especially C3) augment the
19 minutes, and are cleared within 90 minutes (25, concept of occurrences of immune complex vasculitis that is
26)
. They can also be detected in the blood found essential step in the pathogenesis of oral ulceration (45).
following inhalation of lavender oil (27, 28) and in When immunofluorescence microscopic techniques are used to
exhaled air following massage (29). identify Immunoglobulins and complement components in the
As the virus replicates and lyses epithelial cells, a
oral biopsy specimens of oral ulcers, the results revealed that
vesicle forms that contains the released virus
circulating immune complexes might play a role in the damage
particles. The fluids that then fill the vesicle result
from the immune reaction and the erythema that produced during the course of disease (46).
accompanies the virus replication. The dilation of Serum IgD was considered an early marker of B-cell activation
(47)
the blood vessels allow for the accumulation of . IgD can have a regulatory role, e.g., to enhance a protective
fluids and the migration of the immune cells to the antibody response of the IgM, IgG, or IgA isotype, or to interfere
vesicle. Lesions form as a result of destruction of with viral replication (48). IgD was increased (100 U/ml) in many
epithelial cells either through the lytic cycle of the children with periodic fever, aphthous stomatitis, pharyngitis,
virus itself or through the immune response and adenopathy syndrome (49). Lavender significantly reduced
destroying infected cells. The lesion usually IgE-induced histamine release and tumor necrosis factor-alpha
persists 7 to 10 days, but may continue for three to in a dose-dependent manner (50).
four weeks (30). Pain may persist after the skin is The results presented in this study concerning the changes in the
healed. levels of serum Immunoglobulins (IgG, IgE, IgM, IgA and
Oral Diagnosis 72
IgD) are compatible with some of the previously indicated Livingstone, Elsevier. Pharmaceutical practice. 3rd ed.
studies, where significantly differences between pre- and post- 2004; 213-214.
15. Kyle, R. A.: Classification and diagnosis of
treatment with topical Lavender cream were observed, monoclonal gammopathies. In manual of clinical
compared to the other studied groups. laboratory immunology, 3rd ed., 1986, 152. Edited by
The findings of this study showed that healing Rose, N. R., Friedman, H. and Fahey, J. L. Washington,
process, reduced healing time, instant pain relief DC: American Society for Microbiology.
16. Dougls, R. G., and R. B. Couch. A prospective study of
and enhance immunity among the lavender treated
chronic herpes simplex virus infection and recurrent
group was significantly better than the other herpes labialis in humans. J. Immunol. 1970; 104: 289-
studied groups. Treating Herpes lesions Naturally 295.
describes a safe and powerful natural remedy for 17. Nahmias, A.J., and B. Roizman. Infections with herpes-
such an infections. simplex viruses 1 and 2. N. Engl. J. Med. 1973; 289:
The authors suggest to study the treatment of 667-674.
18. Corey, L, W. C. Reeves, and K. K. Holmes. Cellular
herpes simplex lesion caused by oxidative stress.
immune response in genital herpes simplex
infection.N.Engl.J.Med. 1978; 299: 986-991.
ACKNOWLEDGEMENT 19. Lopez, C.,andR.J.O'Reilly.Cell-mediated immune
The authors offer thanks to all the patients who responses in recurrent herpes virus infections. I.
help us conducting this research. Lymphocyte proliferation assay. J. Immunol. 1977;
118: 895-902.
20. Schaeffer, M.J., L. Beauchamp, P. de Miranda, G.B.
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Oral Diagnosis 74
Table 1: Patients's characteristics and clinical data by treatment groups:
Variables G I: Lavender cream G II: Acyclovir cream G III: Placebo

No. of patients 31 29 16
Age (yr) 35 36 38
Sex [female/ male] 19/12 16/13 8/8
Year with disease 10 9 10
No. of lesion /yr 4 4 3
Family history (+ve/ -ve) 5/ 26 4/ 25 4/ 12
Location of lesion:
Skin upper lip 6 5 1
Angle of mouth 7 8 3
Upper lip 9 9 6
Lower lip 9 7 6
No. of current lesions:
Single 25 24 14
Double 6 5 2
Causes:
Stress 18 14 6
Fever 13 15 10
Time to healing (days) 4.1 0.2 5.7 0.5 8.4 1.5
Rank index 9.2 0.1 8.5 0.1 5.3 0.2
Data expresed as number or as mean, or as mean SD values.
Table 2: Serum immunoglobulins levels pre and post treatment in all studied groups:
Pre treatment Ig G Ig E Ig M Ig A Ig D
G I: Lavender 1411.0511 95014 191.6 2.4 266.212.2 937.412.2
G II: Acyclovir 143523 95518 202.1216 265.7816.2 940.211.1
G III: Placebo 1465.515.2 94516 207.6 2.9 265.914 939.111.5
Post treatment
G I: Lavender 340.4511.8 158.40.2 162.4 0.4 233.12.4 155.10.4
G II: Acyclovir 78035.2 167.90.6 171.65.8 245.816.4 160.94.5
G III: Placebo 1465.5615.2 94517 207.68 3.9 266.112.7 939.916.2
Data expressed as mean SD values.
Figure 1: Mean lesion size (mm2) by days of the tested groups.
Oral Diagnosis 75
Figure 2: pain score (VAS) of the three groups by days. (Pain score: 1, none; 2, mild; 3,
moderate; 4, severe).
Oral Diagnosis 76
J Bagh College Dentistry Vol. 24(special issue 1), 2012 The prevalence of
The prevalence of overhanging margins in posterior

filling restorations and periodontal consequences
Alaa' Omran , B.D.S., M.Sc. (1)
Abdul Karim Abed Ali, B.D.S, MSc. (1)
ABSTRACT
Background: The overhanging margins are responsible for much iatrogenic periodontal disease. May investigators
found that high proportions of restorations have reported over hanging margins.
Materials and methods: The prevalence of overhanging margins and associated periodontal status in patients who
attended periodontal department, college were assessed.
Results: The chance of a site bleeding on probing depended not only on the probing depth but directly on the
presence or absence of an over.
Conclusion: This study clearly identified a high prevalence of overhanging margins on amalgam's restorations,
especially at mesial distal sites, and prompt removal of overhanging margins of restoration of required in order to
minimize the risk of periodontal health.
Keyword: amalgamposterior filling periodontal. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):77-79).
INDRODUCTION Overhanging were measured clinically using a

Overhanging margins are said to be responsible fine sharp sickle probe and (Pack, 1990) the
for much iatrogenic periodontal disease; many method for scoring:
investigators have reported upon the adverse 0 = Unrestored surface.
effects of poor restorations on the health of the 1 = Restoration with in 1mm. of the gingival
adjacent periodontal tissues (1-11). margin or below, but without clinically detected
Many investigators found that high proportions of overhanging.
restorations have been reported as having 2 = Restoration within 1 mm. of the gingival
overhanging margings: 57% noted by Wright (5), margin or below, but with a clinically I detected
75% by Bjorn et. al. (7), 32% by Gilmore and ledge indicative of a 1 overhanging margin.
Sheiham (8), 52% by Coxhead et al., (9), 74% by Proximal surface were scored from the
Gorzo, Newman and Strahan (12), 48% by radiographs as I follows:
Hakkaranein and Ainamo (14), 76% by Coxhead 0 = Unrestored surface.
(11)
. 1= Restoration without I visible overhanging
The study reported in this paper was designed to margin.
determine: 2= Restoration with visible overhanging margin in
A. The prevalence ofoverhanging margins and a tooth 1 adjacent to an other tooth.
associated periodontal status in patients who 3= Restoration with I
had attended Periodontal Department, College visible overhanging margin in a I
of Dentistry, University of Baghdad. tooth adjacent to an edentulous I
B. The status of periodontal tissues adjacent to space.
tooth surfaces which were either unrestored, 8 = Unable to make a radiographic assessment
restored without overhanging margins, or owing to either overlapped approximal surfaces,
restored with overhanging margin. or missing surface on the radiograph.
Statistical Analysis
Computations for the contingency label analysis
MATERIALS AND METHODS (X2) were performed using the statistical package
One hundred subjects who had attended the SPSS, probability and T-test to see the significant
periodontal department seeking periodontal or non-significant effecton periodontal tissues.
treatment they have posterior teeth at least in two
quadrants. Patients with complicated medical RESULTS
conditions were excluded. In this study of 100 subjects with a mean age of
Oral examination in which premolar and molar 42.1+20.833 (min. 30 years, Max. 56 years), 25
teeth (excluding third molars) were evaluated for subjects having no missing teeth, 75 have missing
probing depth and bleeding on probing at six sites teeth. 2405 teeth were assessed in which 2078
around each tooth. restored surfaces evaluated from 4831 surfaces
were examined.
(1) Lecturer, Department of Periodontology, University of The mean number of restored tooth surfaces per
Baghdad.
subject was 20.78 + 11.891 (Min. 3 , Max 40 ) of
all the 2078 restored surfaces were evaluated
Oral and Maxillofacial Surgery and Periodontology 77

.1301 (62.6% ) had overhanging margins, 1188 probing depth, but also involves these other
overhanging margins were found clinically and/or factors.
radiographically on proximal restorations. This
was 70.25% of all proximal restored surfaces DISCUSSION
examined. Clinical data alone revealed that 20.9% The results of this study emphasize the effects of
oflingual and 18.46% of buccal restored surface iatrogenic factors on periodontal inflammation.
had overhanging margins. The discovery that (62.6%) of
Table 1 shows the number of overhanging margins posteriorrestorations (and 70.25% of approximal
detected c l i n i c a l l y and/or radio graphically restoration) in 100 patients, had overhanging
when comparing the restorative status of mesial, margins, indicates the prevalence of overhanging
distal, buccal or lingual surfaces, very significant margins in patients attendedperiodontal
differences existed in the distribution of status department in University of Baghdad did not
across the sites. A much greater proportion of differ significantly from that found in other
approximal restorations had overhanging margins investigator in university clinic in New Zealand .
(9)
compared with buccal or lingual restoration. In a radiographic study, reported 52% of
(12.9%) of distal restoration, (11.65%) of mesial restored posterior approximal surfaces in 184
restoration, (4.61%) of buccal restoration and patients taken from four New Zealand private
(1.24%) of lingual restoration had overhanging practices. (11) used combined radiographic and
margins. Also, there is a significant difference clinical assessment of 50 patients reveal that
between restorative with overhanging and 67.5% of posterior approximal restoration had
restorative without overhanging margin especially overhanging margins. Many authors have shown
in proximal sites and non proximal sites. that overhanging margins contribute to
Table 2 shows comparison of pocket depths and periodontal disease (5,7,8,10,12).
restored status of teeth, high percentage of deep When the distribution of overhanging margins
pocket more than 3 mmin proximal and non- was examined, buccal and lingual surfaces had
proximal sites in restored with overhang and there fewer restorations and fewer overhanging margins
is a significant difference between the sites. While than did d i s t a l and mesial surfaces. Single
high percentage of s h a l l o w pocket in non- surface buccal and lingual restorations do
approximal area in restored without overhanging notrequire matrix bands. Surfaces of restorations
margin and unrestored. (65.8%) of all pockets with no adjacent tooth are more easily accessible
adjacent to overhanging margins were >3 mm. for carving, trimming and polishing. This may
compared with (29.1%) of pockets adjacent to explain why fewer overhanging margins were
unrestored surfaces and (50.6%) of pockets found on buccal and lingual surfaces than
adjacent to restorations without overhanging approximal, although lingual surfaces are more
margins, these findings indicated a highly inaccessible than buccal surfaces. In addition,
significant difference between restoration with lingual restorations present more difficulties in
overhanging margins and non. control of moisture contamination because of the
Table 3 shows a comparison of bleeding site and close proximity of the tongue.
restored status of teeth. Also, high percentage of Amalgam contaminated with moisture will
pockets bleeds easily in areas adjacent to expand when setting. The observation that more
restorative sites than restored with overhang and pockets, bleeding , restorations and overhanging
unrestored. (40.1%) of all pockets adjacent to margins were found at approximal sites, was not
overhanging margins bleed on probing margins unexpected as interdental regions are know to be
bleed on probing compared with (20.5%) of plaque retentive unless specific cleaning
pockets adjacent to unrestoredsurfaces and mechanisms are used. it has already been reported
(33.1%) of pockets adjacent to restorations that amalgam restorations may encourage plaque
without overhanging margins, a similar highly to accumulate because of the relatively rough
significant association was found between surfaces of amalgam , and the possibility of
restorative status and the prevalence of bleeding deficiencies existing between restoration and tooth
(1, 3, 4)
sites, thus both restorative and overhanging . Hakkaranein and Ainamo (14) and Gilmors
margins are significantly related to bleeding. The and Sheiham (8) showed that alveolar bone loss is
chance of a site bleeding on probing depends not associated with large subgingival overhanging
only on the probing depth, but also directly on the margine.
presence or absence of an overhanging margin In the present study, non-restored tooth surfaces
and the location of the site. That is, the effect of were associated with fewer deep pockets and less
overhanging margins on the chance that bleeding tendency for bleeding than was the case adjacent
will occur, can not be explained simply by to restored surfaces. When overhanging margins
were present these features were more pronounced.

Periodontal status related to overhanging margins 6. Alexander AG. Periodontal aspects of conservative
was worse lingually than buccally, and distally than dentistry. BDJ 1967; 123: 542-3.
7. Bjorn AL, Bjorn H, Grokovic B. Marginal hit of
mesially in this study, from which it is concluded
restorations andits relation to periodontal bonelevel.
that possibly greater p l a q u e stagnation Part 1 Metal fillings. Odontologic 1969; 20: 311-21.
occurring had a stronger influence on periodontal 8. Gilmore N, Sheiham A. Overhanging dental
status than did the restorative state of those tooth restorations and periodontal disease. J Periodontol
surfaces. 1971; 42: 8-12.
In conclusion, this study clearly identified a high 9. Coxhead LJ, Robetson JB, Simpson EF. Amalgam
overhangs: A radiographic study. New Zealand Dent J
prevalence of overhanging m a r g i n s on
1978; 74: 145-7.
amalgam restorations, especially at mesial and 10. Jeffcoat MK, Howell TH. Alveolar bone destruction
distal sites , and prompt removal of overhanging due to overhanging amalgam in periodontal disease. J
margins of restoration of required in order to Periodontol 1980; 51, 599-602.
minimize the risk of periodontal health. 11. Coxhead LJ. The role of general dentalpractitioners
inthe treatment ofperiodontal disease. New Zealand
Dental Journal 1985; 81: 81-5.
REFERENCES 12. Gorzo I, Newman HN, Strahan JD. Amalgam
1. Waerhaug J, Zander HA. Reaction of gingival tissue to restorations, plaque removal and periodontal health. J
self-curingacrylic restorations. J Americ Dent Assoc Clinical Periodontol 1979; 6: 98-105.
1957; 54:760-8. 13. Bjorby A, Loe H. The relative significance different
2. Zander HA. Effects of dental materials on the periodontal local factors in the initiation and development of
tissues. IADR 1956; 34: 65. periodontal inflammation. Scandinavian Symposium
3. Zander HA. Effect of Silicate cement and amalgam on on Periodontology. J Periodontal Res 1967; 2: 76-7.
the gingiva. J Americ Dent Assoc 1956; 55: 11-5. 14. Hakkaranien K, Ainamo J. Influence of overhanging
4. Zander HA. Tissue reactions to dentalcalculus and to posterior tooth restorations on alveolar bone height in
filling materials. J Dent Medicine 1958; 13: 101-4. adults, J Clinical Periodontol 2000; 7: 114-20.
5. Wright WJ. Local factors in periodontal disease
periodontics. 1963; 1: 163.
Table 1: Comparing the restored status of the different posterior tooth surfaces
status No. of sites Percentage
Distal Mesial buccal lingual Total Mean+sd t-test
424 395 839 1004 2753 2.6595
Unrestored surfaces 323.5
8.77 6.17 19.25 20.78 56.98 6.0127
201 302 170 104 777 -8134
Restored without overhang 194.2582.43
4.16 6.25 3.51 2.15 16.08 6.2235
625 553 53 60 1301 1.6169
Restored with oyerhang 325.25311.35
12.9 11.65 1.09 1.24 62.6 6.0765
826 665 223 164 2078
No. of restoration
17.9 17.8 4.61 3.39 43.01
X2-1448df-6P< 0.0001
Table 2: Comparing of pocket depths & restored status of teeth
Percentage Of pockets
Status Mesial distal
lingual buccal Mean-+sd t-teast
=3 =3 =3 =3 dfprob
0.1078
Unrestored 30.5 69.5 22.6 77.4 70.6 29.4 50.9 39.1 51.25 21.44
14 4576
0
Restored no overhang 35.4 64.6 30.3 69.7 75.3 24.7 60.2 18.8 50.024.6
14 500
0.07
Restored with overhang 13.7 66.3 10.2 69.6 49.3 50.7 40.8 39.2 50.0 39.34
14 4682
x2-210.9805d.f-12P<0.0001
Table 3: Comparison of bleeding sites & restored status of teeth
percentage of Bleeding status
Status Mesial Distal Lingual Buccal Mean SD t-test
No Bleed bleed No Bleed bleed No Bleed Bleed No Bleed bleed d.f PROB
Unrestored 75.4 25.6 70.6 29.4 49.5 50.5 65.4 54.6 52.62-+18.0 14 0.195
Restored no
65.3 44.7 69.2 30.8 50.8 49.7 51.2 48.5 81.2_+11.64 14 0.112
overhang
Restored with
21.8 76.2 19.5 80.5 20.9 79.1 30.1 69.9 50.0+28.12 14 0.215
overhang
2
X =170.4df=12 P 0.001

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Biochemical analysis
Biochemical analysis and periodontal health status in type

1 and type 2 diabetes (Comparative study)
Salah Mahdi Ibrahim, B.D.S. (1)
Leka'a M. Ibrahim, B.D.S, MSc. (2)
ABSTRACT
Background: Diabetes mellitus is a group of metabolic disorders with one common manifestation: hyperglycemia.
This study aimed to evaluate the periodontal health status and cera reactive protein (C.R.P) in saliva in type1 and
type 2 diabetic patients and compared with healthy subjects.
Material and method: Total samples composed of eighty participants, the samples were divided to study group (60
diabetic patients) which include type 1 and type 2 diabetic patients and control group (20 healthy subjects).They
were non-smokers male patients of age range 25-55 years old. Periodontal health status was estimated by measuring
plaque index (PL.I), Gingival index (G.I), Bleeding on probing (BOP), Probing pocket depth (PPD) and Clinical
attachment level CAL).Five mls of un stimulated whole saliva was collected for estimation of C.R.P.
Result: The result showed that the mean C.R.P in saliva was higher in study group compared to control group.No
significant difference in PL.I and significant difference in G.I, BOP, PPD and CAL between type 1 and type 2 of
diabetes .There was weak correlation between clinical periodontal parameters and biochemical parameters.
Conclusion: salivary C.R.P may be involved in the interaction of periodontitis in type 1 and type 2 diabetic patients.
Keywords: Diabetic, C.R.P, periodontal disease, (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):80-84).
INTRODUCTION
Diabetes mellitus (DM) is a disease in which The prevalence of diabetes mellitus is more
levels of blood glucose, also called blood sugar, than twice as high in patient with periodontitis
are above normal. People with diabetes have compared to healthy subjects. Periodontal disease
problems converting food to energy (1). may contribute to systemic inflammation,
People develop diabetes because the pancreas worsening insulin resistance and diabetes due to
does not make enough insulin or because the cells the generation of inflammatory cytokines (4).
in the muscles, liver, and fat do not use insulin Poorly controlled subjects with diabetes
properly, or both. As a result, the amount of displayed more gingival bleeding sites compared
glucose in the blood increases while the cells are with those of subjects with diabetes with good or
starved of energy (1). moderate control (5).
The two main types of diabetes are called type In the presence of similar plaque levels,
1 and type 2. A third form of diabetes is called poorly controlled subjects with type 1 diabetes of
gestational diabetes. long duration (e.g. mean of 16.5 years) displayed
Glycosylated haemoglobin (HbA1C) is used to more severe attachment and alveolar bone loss (6).
monitor treatment in patients with diabetes The presence of similar plaque scores, young
mellitus. Measurements of glycated hemoglobin subjects with type 1 diabetes of long duration
have commonly been used to monitor the suffered from more severe gingival inflammation
glycemic control of persons already diagnosed and periodontal tissue destruction compared with
with diabetes mellitus (2). subjects with diabetes of short duration (7) or non-
Individuals, microbial challenges may diabetic subjects(8) .
overcome host defaces, leading to microbial Subjects with type 2 diabetes with
extension into the sub gingival epithelium. This periodontal disease suggested that the prevalence
leads to the development of a gingival pocket and of severe periodontal disease increased with
heralds the facilitation in growth of Gram- decreasing glycaemic control (9).
negative bacterial species. It has been well C-reactive protein is one of the best know
established that idividuals with diabetes have an members of a group of acute phase proteins,
increased risk of developing periodontal disease which increase their concentration during certain
compared with non-diabetics, and that they inflammatory disorders. It has widely been used
experience more severe and more rapid as a bio-marker of inflammation in the body .In
progression of the disease(3). recent years C.R.P has received a lot of attention
because of its apparent ties to cardiovascular
(1) Master Thesis, College of Dentistry, University of Baghdad. disease ,and it has also been linked to a number of
(2) Professor, Department of Periodontics, College of Dentistry, other disease ,including hypertension ,diabetes
,cancer and autoimmune disorders (10).
As elevated C.R.P values are always saliva kept frozen and store at -20oC for 1 week
associated with pathological changes, the C.R.P until C.R.P determination by using avitex aso kit
assay provides useful information for diagnosis, for semi-quantitative determination of C.R.P in
therapy and monitoring of inflammatory process saliva.
and associated disease (11).
Sick people admitted to a hospital had RESULTS
average salivary C.R.P levels 25 times higher than The result showed that the mean C.R.P in saliva
healthy people .salivary C.R.P may largely reflect was higher in study group compared to control
local inflammation in the mouth, but some serum group. It was highest in group 4 which was
CRP can enter saliva through gingival tissue 17.454 mg/ml 7.802 and lowest in group 5
,especially if periodontal disease is present(12) . which was 8.421 mg/ml 3.464 as shown in table-
Ongoing research is investigating the 1-
possibility that salivary C.R.P can be used to The means of plaque index were higher in group
monitor inflammation in other parts of the body 2, 4 compared with group 1,3,5. It was 2.12
(13)
. 0.655 in group 2 and 2.070.688 in group4, while
Periodontal infection results in higher C.R.P in in group 1, 3, 5 they were 1.450.529, 1.90.584
type 2 diabetes patient. This elevated and 1.320.512 respectively (table -1-).
inflammatory factor may exacerbate insulin The mean of gingival index in group 2,3,4
resistance and increase the risk for great vessels were higher compared with group 1,5. It was 1.97
complications of diabetes mellitus (14) . 0.636 in group 2, 1.90.672 in group 3 and
The present study aimed to evaluate the 1.870.748 in group 4 while in group 1 it was
periodontal health status in type 1 and type 2 1.270.562 and in group 5 the mean was
diabetic patients and compared with healthy 1.220.588 (table -1-) .
subjects. Also to evaluate the level of C.R.P in The comparison of PL.I, G.I and salivary CRP
saliva in type1 and type 2 diabetic patients and were highly significant for all groups as shown in
compared with healthy subjects. table -2-
Descriptive statistics for bleeding on
MATERIALS AND METHOD probing were described in table (3).it was clearly
Total samples composed of eighty participants, that the number of bleeding sites in type 1 and
the samples were divided to study group (60 type 2 of diabetes were higher than healthy
diabetic patient) and control group (20 healthy subjects
subjects).They were non-smokers male patients of The comparison of bleeding on probing
age range 25-55 years old. showed that there was highly significant
Study group sample included: difference for all groups as in table-4-
Group 1 (G1): Fifteen patients type 1 diabetes Table -5- showed the probing pocket depth was
with good control, HbA1c less than 7.5%. increase in scale 1, 2, 3 in group 1, 2, 3 compared
Group 2(G2): Fifteen patients type 1 diabetes with group 5 while scale 0 was increased in group
with poor control, HbA1c more than 7.5%. 5 in compared to other groups.
Group 3(G3): Fifteen patients type 2 diabetes The clinical attachment loss showed increase in
with good control, HbA1c less than 7.5%. scale 2, 3, 4 in group 1, 2, 3, 4 compared with
Group 4(G4): Fifteen patients type 2 diabetes group 5 while scale 1 increase in group 5
with poor control, HbA1c more than 7.5%. compared to other groups as described in table -6-
The control group sample (G 5) included 20 There was weak correlation between clinical
healthy subjects without any history for any periodontal parameters and biochemical
systemic disease. parameters for all groups as shown in table-7-
Periodontal health status was estimated by
measuring following clinical parameters: DISCUSSION
Plaque index (PL.I)(15) The level of CRP in saliva was found to be
Gingival index (G.I)(16) significantly higher in diabetic groups (type1) and
Bleeding on probing (BOP) (type 2) than of control group, the level of CRP in
Probing pocket depth (PPD) saliva highly in groups with periodontitis and
Clinical attachment loss (CAL) increase the percentage of ppd and attachment
Five to six mls of un-stimulated (resting) whole loss.
saliva was collected before the clinical This was accepted and in agreement with loos et
examination. The collected saliva was centrifuged al 2000(4), who reported elevated CRP levels
at 3000 r.p.m for 15 minutes, clear supernatant among those with periodontitis .
CRP in saliva detected as result of systemic For G.I there was a significant difference
inflammation result elsewhere in the body as well between type 1 and type 2 diabetes, and no
as systemic inflammation induce by periodontitis significant between type 1 and control group and
(17).
comparison between type 2 and control group
The level of CRP in saliva was found to be was significant .This was accepted by Giovani
significantly higher in diabetic groups (type2 ) Salvi,2005(22) who found no significant difference
than diabetic ( type 1). between type1 diabetic and control group;
It was in agreement with Aspriello and Ragaad,2006(19) who found a significant
Piemontese in 2010(18). difference between type 2 diabetics and healthy
No significant difference in PL.I between type 1 subjects .
and type 2 of diabetes and there was asignificant But disagree by al-saidy in 1996(23), who
difference between type 1 and control group and found ahigher gingival index scores in diabetics
there was ahighly significant difference between than non diabetics; khader,2010(21) ,also found
type2 and control group. no significant difference between type2 diabetic
This was in agreement with result of study and control group.
done by Raghad (19) ,who found that there was a According to our study, metabolic control
highly significant difference between type2 and play an important role in analysis of the
healthy subjects ; Bjelland and Bray (20) who relationship between periodontal disease and
found a significant difference between uncontrol diabetes mellitus.
diabetic and non diabetic. The worsening effects of inflammation are
And disagree with Khader (21) who found no also indicate a correlation between periodontal
significant difference between type 2 diabetic and inflammation on diabetic balance and insulin
control group ; Giovanni (22) who found no resistance syndrome(4).
significant difference between type1 diabetic and This evidence points to a vicious cycle in
control group . which diabetes and periodontitis exacerbate one
Nevertheless, there are several indications another.periodontal treatment may improve
from this analysis that diabetes is associated with diabetes control measured as a reduction in
poorer oral health. Among adults aged 3557 glycated hemoglobin.
years, several indicators of periodontal disease The gingival bleeding was observed to increase as
were elevated at least two-fold. This is an the level of metabolic control deteriorated(5) the
important age group, first because periodontal reason for the increase bleeding in diabetic groups
tissue destruction at multiple sites at this age may could be either due to inflammation or vascular
be indicative of a poor prognosis for subsequent changes in the gingival tissue ;this was in
tooth loss due to periodontal disease. It is also at agreement with Ervasti et al.(5) who found that
this age that Type 2 diabetes frequently develops, the inflammatory reactions are intensified during
yet remains undetected, and potentially poorly poor metabolic control ,as the same amounts of
controlled. In contrast, the lack of effect seen in plaque induced more gingival bleeding in groups
those aged under 35 may be due to them having of diabetic compared to control subjects.
Type-1 diabetes, which is more likely to be well- Significant diference was found between type 1
controlled than Type-2 diabetes. Diabetics and type 2 diabetic .Type 1 had 5.9% of sites with
showed evidence of more plaque and almost probing depth 4mmn compare to 8.3% of sites
double the degree of gingival inflammation in type 2 diabetics.
compared to non-diabetics. The increase pocket depth and root surface
The periodontal disease typically begins infection, bacterial impact and invasion of
with reversible inflammation of the gingival periodontal tissue, alveolar bone loss and local
tissues in response to dental plaque. In susceptible and systemic immune reaction all have negative
individuals, microbial challenges may overcome effects on diabetes. the association between
host defences, leading to microbial extension into diabetes and periodontal disease may be due to
the subgingival epithelium. This leads to the numerous physiological phenomena seen in
development of a gingival pocket and heralds the diabetes ,such as impaired (immune)resistance
facilitation in growth of Gram-negative bacterial ,vascular change ,altered microflora,and abnormal
species. It has been well established that collagen metabolism.this tend to support the
individuals with diabetes have an increased risk of higher incidence and severity of periodontitis in
developing periodontal disease compared with diabetic patients.there is direct causal or
non-diabetics, and that they experience more modifying relationship in which poor glycemic
severe and more rapid progression of the disease. control results in more severe periodontitis(9) .

Increase clinical attachment loss was significantly 8. Firatli et al. Etiology and Pathogenesis of Periodontal
higher in the type 1 and type 2 diabetic compare Disease, 1994.
9. Guzman S, Karima M, Wang HY, Van Dyke TE.
to control group this was in agreement with
Association between interleukin-1 genotype and
Thorstensson et al (24), who found that more periodontal disease in a diabetic population..J
attachment loss in long duration of diabetic Periodont 2003; 74:11831190.
compare to short duration diabetic and non- 10. Patlak M .New weapons to combat an ancient disease:
diabetic. treating diabetes, 2002.
Periodontal pocketing together with loss of 11. Kushner .C-reactive protein in rheumatology. arthritis
rheum 1991;34:1065-1068.
clinical attachment is indicative of periodontal
12. Giannobile WV,Beikler t,Kinney JS et al
bone loss that is not influenced by pseudo Saliva as adiagnostic tool for periodontal disease:
pocketing caused solely by gingival inflammation Current state and future directions J periodontal
or overgrowth. Furthermore, when the percentage 2000;50:52-64.
of sites with both pocketing and attachment loss is 13. Miller CS,FoleyJD.,Bailey A.L.Current developments
computed, yielding an extent score, comparisons in salivary diagnostics.biomark. Med 2010; 4:171-89.
14. Grant DA,Stern IB,Listegarten MA. Periodontitis in
can be made between groups in a way that adjusts
tradition of glottis and urban 6th edition .c.v.mos by
for differences in the number of teeth measured. comp 1988 p 135.
For all ages combined, the extent of combined 15. Silness Jand Loe H .Periodontal disease in pregnancy
pocketing and attachment loss was twice as large II.corelation between oral hygiene and periodontal
in diabetics compared to non-diabetics. condition. Acta Odotologica Scandinavica
In general there was weak correlation between 1964;22:112-135.
16. Loe H.The gingival index, the plaque index and the
clinical and biochemical parameters but no
retention index system. J Periodont,1967;38:610-616
reported to compare with it. 17. Paraskevas S,Hulzinga JD, Loose BG. A systemic
review and meta analysis on c-reactive protein in
REFERENCES relation to periodontitis.J Periodont.2008;35:277.
1. Singh VP, B Le, R Khode, KM Baker and R Kumar. 18. A Zizzi G,Tirabassi E, Buldreggini T et al. Diabetes
Intracellular angiotensin II production in diabetic rats mellitus-associated periodontits: difference between
is involved in cardiomyocytes apoptosis, oxidative type 1 and type 2 diabetes mellitus.J Periodont Res
stress and cardiac fibrosis. Diabetes, 2008; 57: 3297- 2011;46:164-169.
3306. 19. Raghad FA .Periodontal health status and biochemical
2. Davidson MB, Peters AL, Schriger DL. An alternative study of saliva and gingival fluid among diabetic and
approach to the diagnosis of diabetes with a review of non diabetic patients. Thesis presented to the College
the literature. Diabetes Care 1995; 8:1065-71. of Dentistry, Baghdad University for degree of master
3. Le H, Theilade E, Jensen SB. Experimental gingivitis science in periodontics 2006.
in man. J Periodontol 1993;36:177-187 20. Bjelland Sand Bray P .Dentists..Diabetes and
4. Loos, BG, Craandijk, J, Hoek FJ, Wertheim-van Periodontitis.Aust. Dent Res 2002;47:202-209.
Dillen, PM& Van Der Velden U. Elevation of 21. Khader Y et al .Diabetes and oral health: doctors
systemic markers related to cardiovascular diseases in knowledge, perception and practices Eval clin
the peripheral blood of periodontitis patients. J of Pract,2010;16:976-80.
Periodont 2000; 71: 15281534. 22. Giovann E, Salvi G and Persson. Experimental
5. Ervasti T,Matti K et al.Relation between control of gingivitis in type 1 diabetics controlled clinical and
diabetes and gingival bleeding .J microbiological study.J Clin Periodont.2005;32:310-
Periodont,1985;3:154-157 316
6. Seppl B, Seppl M& Ainamo J. A longitudinal 23. Al-saidy AH .Prevalence and severity of periodontal
study on insulin-dependent diabetes mellitus and disease in diabetes mellitus. Thesis presented to the
periodontal disease. J of Clin Periodont 1993; 20: College of Dentistry, Baghdad University for degree
161165. of master science in periodontics 1996.
7. Cianciolo K.D, Wadle Rb and Slick GL. Incidence, 24. Thorstensson H and Hugoson .Periodontal disease
etiology, diagnosis, and treatment of recurrent experience in adalt long duration insulin dependent
urolithiasis: results of a 5-year study at an osteopathic diabetics .J Clin Periodont 1993;20:352-358.
referral center. J. Am. Osteo. Assoc, 1983; 82:577-83.
Table 1: The mean and SD of PL.I, G.I and CRP in saliva for all groups
Groups PL.I G.I CRP in saliva
G1 1.45 0.529 1.27 0.562 12.60 7.720
G2 2.12 0.655 1.97 0.636 16.20 7.509
G3 1.9 0.584 1.9 0.672 14.727 6.214
G4 2.07 0.688 1.87 0.748 17.454 7.802
G5 1.32 0.512 1.22 0.558 8.421 3.464

Table 2: Comparison of PL.I, G.I and CRP in saliva for all groups
f- test P- value Sig
Groups
PL.I G.I CRP PL.I G.I CRP PL.I G.I CRP
G.1
G.2
G.3 -460.267 -457.524 -39.097 0.000 0.000 0.000 HS HS HS
G.4
G.5
Table 3: Number and percentage of BOP for all groups.

G1 G2 G3 G4 G5
Score
No % No % No % No % No %
0 632 37.1 324 23.4 466 38.3 412 25 1024 71
1 1053 62.9 1046 76.6 748 61.7 1218 75 415 29
Table 4: Comparison of BOP foe all groups.

Groups Chi-square P- value Sig
G.1
G.2
G.3 21.270 0.000 HS
G.4
G.5
Table 5: Number and percentage of PPD per site and Chi square among all groups.
G.1 G.2 G.3 G.4 G.5 Chi-square

Scale P-value
No. % No. % No. % No. % No. %
0 1600 95 1298 93 1148 94.4 1470 90 1399 98 31.952 S
1 40 2.5 43 3.2 48 3.7 106 7.1 24 1.6 39.677 S
2 28 2 31 2.6 12 1.4 42 3 11 0.8 11 S
3 8 0.5 8 1 6 0.5 12 0.9 5 0.3 34.131 S
Table 6: Number and percentage of CAL per site and Chi- square among all groups
Group1 Group2 Group3 Group4 Group5
scale Chi-square p-value
No. % No. % No. % No. % No. %
1 122 65.5 84 51.8 220 40.9 180 44.5 76 68.4 52.834 S
2 22 18 38 22.2 74 33.6 134 33.2 22 19.8 50.061 HS
3 12 9.8 28 17.2 42 19 58 14.3 11 9.9 52.834 S
4 4 6.7 12 8.8 14 6.5 32 8.0 2 1.9 16.094 S
Table 7: Intra group correlation between clinical periodontal parameter and CRP in saliva for
all groups
PL.I G.I BOP PPD CAL
G.1
CRP 0.234 0.023 -0.161 -0.031 -0.067
G.2
CRP 0.194 0.157 0.000 0.073 0.193
G.3
CRP 0.116 0.302 0.243 0.226 0.217
G.4
CRP 0.065 0.081 -0.183 -0.107 0.059
G.5
CRP -0.237 0.322 0.560 0.388 0.571

J Bagh College Dentistry Vol. 24(special issue 1), 2012 The correlation between
The correlation between hemoglobin level and generalized

moderate chronic periodontitis
Suzan Ali B.D.S, M.Sc. (1)
ABSTRACT
Background: As the periodontal tissues mount an immune inflammatory response to bacteria and their products,
systemic challenge with these agents also induces a major vascular response. Certain inflammatory cytokines
produced during periodontal inflammation, can depress erythropoietin production leading to the development of
anemia. (1) This study aimed to investigate the association between hemoglobin level and generalized moderate
chronic periodontitis.
Materials and Methods: Data were collected from 60 systemically healthy male of an age ranged (30-60 years old)
30 of them with generalized moderate chronic periodontitis (CAL =3-4 mm at 30% of sites) and 30 of them with
healthy periodontium as control group. Full mouth examinations (excluding third molars) were conducted for all
patients. Four sites were examined for each tooth (buccal, lingual, mesial and distal). Plaque index (PI) (2) ,Gingival
Index(GI) (3) , bleeding on probing index (BOP) (4), Probing Pocket depths (PPD), and Clinical attachment level (CAL)
were recorded using a marked periodontal probe (Williams probe) and measurement of hemoglobin (Hb)
concentration in the blood by colorimetric cyanomethemoglobin method(22)
Results: Mean of hemoglobin level was (12.527) for the study group whiles its (14.72) for the control group, highly
significant differences were apparent between the two groups regarding the hemoglobin level (P- value P<0.01).
About the Correlation between the hemoglobin level and the periodontal parameters, the PLI, CAL scores were
positively but non-significantly associated with the hemoglobin level. (P> 0.05).Correlation coefficient (r) between PLI
and hemoglobin level was (0.30). For the CAL The correlation coefficient (r) was (0.159).Strong and significant
correlation were found between BOP and the hemoglobin level (r = 0.343, P value = 0.049).
Conclusion: There is an association between hemoglobin levels and periodontal status.
Key words: hemoglobin level, chronic periodontitis, anemia. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):85-88).
INTRODUCTION
Extraordinary progress is being made in For thousands of years, blood has been
understanding the relationship between regarded as the ultimate body fluid that could
periodontal disease and systemic health. indicate disease process. In the past decade, there
Periodontitis, one of the oldest and most common has been a renewed interest to study the
diseases of humans, was once generally believed association of periodontitis and changes in the
to be an inevitable consequence of aging, and it is cellular and molecular components of peripheral
a chronic infection that produces a local and blood. For example the relationship of
systemic host response, as well as a source of periodontitis with leukocytes (14, 15), thrombocytes
(16)
bacteremia. (5) It is caused by a complex mix of , and red blood cells has been investigated (17)
anaerobic, Gram-negative bacteria. The clinical Anemia of chronic disease (ACD) has been
symptoms of this infection include swollen red described in the literature, and seems to be one of
gingiva, gingival bleeding and suppuration; the most common forms of anemia observed in
formation of periodontal pocket; gingival clinical medicine (18,19). ACD is defined as the
recession, and loss of alveolar bone. Prevalence of anemia occurring in chronic infections, chronic
periodontal diseases varies among different inflammatory processes or tumor formation that is
countries. In the US and Europe, moderate or not due to dysfunction of bone marrow cells or
severe forms of periodontal diseases affect 40% or other diseases, and occurring despite the presence
15%, respectively, of the adult population (6, 7), of adequate iron stores and vitamins (19). A
whereas in Japan a prevalence of 23.4% was characteristic finding of the disorders associated
reported (8) Epidemiologic studies suggested that with ACD was the increased production of the
periodontal deterioration increases the risk of cytokines that mediate the immune or
systemic problems such as cardiovascular inflammatory response; such as tumor necrosis
diseases (9) atherosclerosis (10), diabetes mellitus factor, interleukin-1, and the interferon. All the
(11)
, and preterm low birth weight of infants (12). processes involved in the development of ACD
These associations suggest that periodontal can be attributed to these cytokines, including
diseases have systemic effects. In addition, some shortened red cell survival, blunted erythropoietin
studies had found that periodontal infection elicits response to anemia, impaired erythroid colony
systemic blood chemistry changes (13). formation in response to erythropoietin, and
abnormal mobilization of reticuloendothelial iron
stores (20). These cytokines are also released by
(1)Lecturer, Department of Periodontics, College of Dentistry, periodontal tissues in response to bacterial
University of Baghdad

infection, which suggests that periodontitis like Industries, Japan) based on the method of Van
other chronic disease may cause ACD Kampen and Zijlstra (22)
There are only a few studies that investigated Statistical Analysis
the red blood cell parameters, especially Data were analyzed using statistical package for
hemoglobin level, in relation to periodontitis so social sciences (SPSS, version 15). Means and
the aim of the present study is to investigate the standard deviations of the variables were
association between hemoglobin level and calculated. And Correlation of Hb with PLI, GI,
generalized moderate chronic periodontitis. CAL, PD, and BOP were calculated.
MATERIALS AND METHODS RESULTS

Study Design Sixty subjects have been involved in these
A cross-sectional double-blind study. The study 30 males with moderate generalized chronic
examiners were not aware of the hemoglobin level periodontitits represent the study group and 30
of the patients and the laboratory technicians were males with healthy periodontium as control group.
not aware of the periodontal status of the patients. Mean and standard deviation of the periodontal
Data were collected from 60 systemically healthy parameters (PLI, GI, BOP, PD, CAL) of the study
male of an age ranged (30-60 years old) 30 of and control groups were shown in table (1). Mean
them with generalized moderate chronic of hemoglobin level was (12.52) for the study
periodontitis (CAL =3-4 mm at 30% of sites) (21) group whiles its (14.72) for the control group,
and 30 of them with healthy periodontium as highly significant differences were appeared
control group. Patients were advised of their role between the two groups regarding the hemoglobin
in this study and asked to provide informed level (P- value P<0.01) as shown in table (2)
consent. Extensive medical and dental histories Correlation between the hemoglobin level and
were recorded for each patient. Patients with the periodontal parameters were shown in table
aggressive periodontitis or any systemic disorder (3). For the chronic periodontitis group, the PLI,
that may affect the periodontal tissue (such as CAL scores were positively but none significantly
diabetes, pregnancy and immunological associated with the hemoglobin level. (P>
disorders), anemic patient, and smokers were 0.05).Correlation coefficient (r) between PLI and
excluded from the study. Periodontal hemoglobin level was (0.30). For the CAL The
Examination; Full mouth examinations (excluding correlation coefficient (r) was (0.159).Strong and
third molars) were conducted for all patients. Four significant correlation were found between BOP
sites were examined for each tooth (buccal, and the hemoglobin level ( r = 0.343, P value =
lingual, mesial and distal). Plaque index 0.049 ).while weak and non significant correlation
(PI)(2),Gingival Index(GI) (3) and bleeding on were found between GI , PPD with the
probing index (BOP) mean The percentage of hemoglobin level. For the GI (r=0.09, P value
sites that bleed was recorded for each patient =0.62) and for PPD (r= 0.075, P value =0.688)
(%BOP). If bleeding occurs with in 30 seconds
after probing, the site was given score (1) where DISCUSSION
as (0) score for non-bleeding site. (4), Probing Anemia of chronic disease is the second most
Pocket depths (PPD) was measured from the free prevalent form of anemia after nutritional, iron-
gingival margin (GM) to the base of the pocket. , deficiency anemia, and can coexist together,
and Clinical attachment level (CAL) was causing additional anemic burden. ACD is a
determined at all sites by measuring the distance cytokine-mediated anemia characterized by
from the cemento-enamel junction (CEJ) to the hypoferremia, with adequate reticuloendotelial
GM, adding the PD at the same site: CAL = PPD iron stores and normal-to-elevated ferritin
+ (CEJ to GM). Data were collected and recorded concentrations. The current study investigates the
using a Williams's periodontal probe. Under correlation between hemoglobin level and the
aseptic conditions, venous blood was drawn from generalized moderate chronic periodontitis in
ante-cubital fossa (1.5ml). The blood was systemically healthy patients. This study support
collected in heparinized test tube and transported the hypothesis there is an association between
to a laboratory for processing within 2 hours after hemoglobin levels and periodontal status. A few
venepuncture. Erythrocytes and plasma were early reports in the literature have investigated the
separated by centrifugation and hemoglobin (Hb) bidirectional relationship between anemia and
concentration was measured by colorimetric periodontitis. Siegel (23), Lainson et al. (24) were
cyanmetheglobulin method using acommercial kit observe anemia in periodontitis. In this study the
(Hemoglobin test-Wako,WakoPure Chemical mean of hemoglobin level was lower in patients

with chronic periodontitis than their level in the and other diseases. Further longitudinal studies
control group. This result are in agreement with with larger sample size are needed to investigate
Wakai et al (8), Agarwal et al (25) Sukru Enhos et al the association between hemoglobin levels and
(26)
, Havemose-Poulsen et al (27), Gokhale SR. et different types of periodontitis, and the effect of
al (28) , Pradeep AR. et al (29) and Balwant Rai1 (30) periodontal treatment on hemoglobin level.
its due to .1. Strong evidence indicates that
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Table 1: Means and Standard deviations for the periodontal parameters of the two groups
Chronic periodontitis Control
Variables
Mean SD Mean SD
PLI 2.138 0.304 1.002 0.289
GI 2.179 0.281 0.97 0.202
BOP 0% 44.207 10.388 91.253 2.705
BOP 1% 55.95 10.132 8.745 2.706
PPD 4.015 0.553 1.641 0.452
CAL 2.88 0.546 0 0
Table 2: Means and Standard deviations for the hemoglobin level of the two groups, t- test were
performed to test the differences
Chronic Periodontitis Control
t-test P- value
group group
Mean SD Mean SD
P<0.01
HB 4.16
12.52 1.118 14.72 1.22 HS
Table 3: Correlation coefficient (r) between periodontal Parameters of the two groups and the
hemoglobin level
Chronic periodontitis Control group
Variables group (HB) (HB)
12.52 14.72
r p-value r p-value
PLI 0.30+ 0.087 0.05 0.792
GI 0.09 0.62 0.025 0.897
BOP 0.343+ 0.049 0.254 0.176
PPD 0.075 0.688 0.073 0.701
_ _
CAL 0.159+ 0.401

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Oral hygiene and
Oral hygiene and gingival condition among epileptic

patients 5-15 year-old (A comparative study)
Azhar A. Hussien B.D.S., M.Sc. (1)
Athraa M. AL-Weheb B.D.S., M.Sc. (2)
ABSTRACT
Background: Epilepsy is a chronic neurological disorder characterized by behavior that results from abnormal
electrical activity in the brain. The aim of this study was to investigate the distribution and severity of the oral hygiene
and gingival health condition concerning epileptic patients in some hospitals in Baghdad city, in comparison to
controls, matching with numbers age and gender.
Materials and method: Oral examinations involved epileptic patients with an age rang (5-15) year old, matched with
same number of controls from kindergarten and schools in Baghdad city. Plaque index, calculus index and gingival
index were used in this study and Ramfjord teeth were chosen for recording these indices.
Results: Epileptic patients demonstrated a statistically significantly higher mean value of plaque index and gingival
index compared to control group, while no statistical significant difference was found in mean value of calculus
index between both groups.
Conclusion: The condition of oral health status of the epileptic group is worse than matched group.
Key words: Epilepsy, seizure, gingival hypertrophy. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):89-93).
INTRODUCTION
Epilepsy is a chronic neurological disorder an underlying metabolic derangement or
characterized by behavior that results from systemic disease (hyponatremia, hyperosmolar,
abnormal electrical activity in the brain (1). The hypocalcaemia, uremia, hepatic encephalopathy,
word epilepsy is derived from Greek verb prophyria, drug overdose, drug withdrawal and
epilamvaneinn (to be seized or to be others) (7).
attacked" (2, 3). People have known about epilepsy Many drugs can use for treatment of epilepsy
for thousands of years but have not understood such as carbamazepine (tegretol), valproic acid
it until recently. The ancient Babylonians wrote (depakene), phenytoin, rivotril, Phenobarbital,
about the symptoms and causes of epilepsy 3000 lamicta and others (8).
years ago. They thought that seizures were caused Furthermore, no study has been carried out in
by demons attacking the person. Different spirits Iraq concerning the oral health status of the
were thought to cause the different kinds of epileptic patients, for this reason, a well planning
seizures (4). study is important regarding the oral health status
Epilepsy is a chronic neurological disorder that of epileptic patients. So this study is an attempt to
affects people of all ages. The estimated present some of the problems present in this type
proportion of the general population with active of population.
epilepsy ranges from 4-10 per 1,000 people.
However, study in developing countries suggest MATERIALS AND METHODS
that the proportion is range from 6-10 per 1, 000 The sample consists of:
people (5.) An approximate 724.500 people with 1-Study group: - Oral examinations involved 220
epilepsy live in the Arab world. This study report epileptic patients with an age range (5-15) years.
higher prevalence in males and the prevalence is These patients consulted the epilepsy disease
approximately 2- fold higher in children and clinic in Department of Neurology and Psychiatric
young adults, compared to the rates in middle age in Baghdad Hospitals. These hospitals are: - IBN-
(6)
. Rushd Teaching Hospital, AL-Yarmook Teaching
Seizures can result from either: Hospital, Teaching Hospital of Neurological
Primary central nervous system dysfunction Science, and Childs Center Teaching Hospital in
(benign febrile, idiopathic, head AL- Iscan.
t r a u ma , stroke, ma s s lesions, 2- Control group: - A comparative sample of
meningitis and cortical dysgenesis) or healthy individuals matching with age and gender.
This sample was chosen randomly from
kindergarten, primary, and secondary schools in
Baghdad city. The total number of examined
members in this study was 220.
(1) M.Sc. Student, Department of Pedodontic and Preventive The questionnaire was done before oral
Dentistry, Dental College, University of Baghdad.
(2) Professor, Department of Pedodontic and Preventive
examination, demographic information were
Dentistry, Dental College, University of Baghdad. obtained by interviewing each individual and their
Orthodontics, Pedodontics, and Preventive Dentistry89

parents. Plaque index (9), calculus index (10), and was recorded at zero score, mild score, and the
gingival index (11), were recorded in this study lower percentage at moderate and sever scores
according to examination included the buccal, were both of them (0%). Gingival hypertrophy
mesial, distal, and lingual surfaces of the six was seen only in epileptic patients with total
Ramfjored teeth. percentage (5%). Most of them used Depakene
Statistical analysis: - descriptive statistic (45.5%) with different duration (rang between 1-6
includes frequency, percentage, mean and years). Total girls showed higher percentage than
standard divation and for statistical analysis of total boys as shown in Table (7).
data using student t-test to detect significance of
relation between various variable. P-value <0.05
was considered as statistically significant. P-value DISCUSSION
>0.05 was considered as statistically not The current investigation revealed the mean
significant value of plaque index was significant higher in
epileptic patients than in control group. These
findings were agreed with some studies (12, 13). In
RESULTS addition these findings were in disagreement with
The total sample consist of 220 (136 boys, 84 other study (14) which found that the plaque index
girls) epileptic patients aged between (5-15) year was similar in epileptic patients and control group
old as well as control group matching with age .Data of the present study showed that the amount
and gender. The sample were subdivided to 5 of dental calculus is fairly very small in both
aged groups, 5 year old and 15 year old were groups with slightly higher in the epileptic
represented to index age group and the other (6- patients than in the control group. The difference
8), (9-11) and (12-14). The distribution of total was found to be statistically non significant. This
sample was seen in Table (1) which showed that is in agreement with study (15), also it was found
the percentage of boys higher than girls with ratio that there was increase in gingival mean values of
(1.6:1). Epileptic patients demonstrated higher gingival index in epileptic patients compared to
mean plaque index value compared to control control group, This differences in the total mean
group. The difference was found to be values of gingival index were found to be
statistically high significant. Concerning each statistically significant and These finding were in
gender, boys in epileptic patients showed higher agreement with other studies (12, 13, 14, 15) . The
mean value of plaque index than boys in controls condition of oral hygiene of epileptic patient in
with statistically significant difference between this study was found to be worse than matched
them, also for girls there was statistically control group and this may be related to the
significant difference between both groups as parents of epileptic patients as they more
shown in Table (2). A higher mean of calculus concerned about seizures problem of their child
index was recorded in epileptic patients than that and neglect their oral health status. In addition to
recorded for control group. The difference was that, most of epileptic patients and their parents
found to be statistically not significant. avoid visit to the dentists office because of fear
Concerning each gender, the differences were from pain and discomfort associated with being in
statistically not significant for boys and girls as the dentist chair which may be end with seizure
shown in Table (3). The total means of gingival attacked(16).
index were found to be higher in epileptic patients In this study the gingival hypertrophy had not
than that recorded in control group. The been reported in the control group, while the
difference was found to be statistically significant percentage of gingival hypertrophy in epileptic
between epileptic patients and controls as shown patients was found only (5%), most of them used
in Table (4). Concerning each gender, there were Depakene (45.5%) with different duration (rang
statistically significant differences for boys and between 1-6 years). These results were in
girls between both groups. Table (5) and Table (6) agreement with study (13) in Turkey which found
demonstrate the distributions of the sample that the Depaken group had a significant effect on
according to the severity of gingival index. In gingival enlargement, bout 42% of patients on
epileptic group the higher percentage was Depakene have gingival enlargement and this is
recorded at mild score, moderate score, zero may be due to that Depakene can cause gingival
score, and the lower percentage at sever score, bleeding, gingival hypertrophy and petechiae (17).
while in the control groups the higher percentage

Table 1: Distribution of total sample by age groups and gender

Age Boys Girls Total
Group
(years) No. % No. % No. %
5 38 17.27 20 9.10 58 26.37
6-8 36 16.36 18 8.18 54 24.54
Epilepsy 9-11 28 12.73 20 9.10 48 21.83
group 12-14 21 9.54 14 6.36 35 15.90
15 13 5.91 12 5.45 25 11.36
Total 136 61.82 84 38.18 220 100
Table 2: Plaque index in epileptic patients and control groups by age groups and gender
Age Epilepsy group Control group
Gender No. t-test P-value
groups Mean SD Mean SD
Boys 38 0.40 0.25 0.29 0.02 2.44 0.04
5
Girls 20 0.49 0.33 0.23 0.12 2.99 0.04
Boys 36 0.49 0.36 0.22 0.01 3.01 0.04
6-8
Girls 18 0.61 0.47 0.23 0.01 3.44 0.04
Boys 28 0.72 0.42 0.23 0.01 2.88 0.04
9-11
Girls 20 0.71 0.46 0.30 0.03 3.66 0.04
Boys 21 0.80 0.52 0.37 0.02 5.66 0.00
12-14
Girls 14 0.79 0.45 0.52 0.26 2.19 0.05
Boys 13 0.95 0.60 0.56 0.03 5.04 0.00
15
Girls 12 0.87 0.69 0.44 0.22 2.97 0.05
Boys 136 0.63 0.45 0.34 0.14 3.45 0.03
Total Girls 84 0.67 0.48 0.34 0.13 2.24 0.04
Total 220 0.64 0.46 0.34 0.13 3.89 0.01
Table 3: Calculus index for epileptic patients and control group by age groups and gender
Gender No. t-test P-value
Boys 38 0.01 0.01 0.00 0.00 0.06 0.92
5
Girls 20 0.00 0.00 0.00 0.00 0.01 1.00
Boys 36 0.00 0.00 0.01 0.00 0.01 1.00
6-8
Girls 18 0.00 0.00 0.01 0.00 0.01 1.00
Boys 28 0.02 0.06 0.00 0.00 0.01 1.00
9-11
Girls 20 0.04 0.19 0.03 0.01 0.03 0.88
Boys 21 0.00 0.00 0.00 0.00 0.00 1.00
12-14
Girls 14 0.02 0.04 0.02 0.00 0.02 0.97
Boys 13 0.07 0.13 0.01 0.00 0.10 0.32
15
Girls 12 0.07 0.19 0.00 0.00 0.01 1.00
Boys 136 0.01 0.05 0.01 0.01 1.99 0.09
Total Girls 84 0.02 0.12 0.01 0.02 1.68 0.17
Total 220 0.02 0.09 0.01 0.01 1.83 0.10
Table 4: Gingival index for epileptic patients and controls by age groups and gender
Gender No. t-test p-value
Boys 38 0.30 0.44 0.07 0.01 2.92 0.04
5
Girls 20 0.37 0.31 0.11 0.01 2.87 0.04
Boys 36 0.32 0.34 0.05 0.00 3.20 0.04
6-8
Girls 18 0.61 0.69 0.01 0.00 3.34 0.03
Boys 28 0.68 0.46 0.07 0.01 4.02 0.03
9-11
Girls 20 0.69 0.67 0.11 0.01 3.02 0.04
Boys 21 0.84 0.78 0.08 0.00 5.62 0.00
12-14
Girls 14 0.69 0.47 0.15 0.01 2.62 0.04
Boys 13 0.82 0.61 0.17 0.01 6.22 0.00
15
Girls 12 0.90 0.68 0.16 0.01 6.73 0.00
Boys 136 0.53 0.56 0.09 0.05 4.01 0.01
Total Girls 84 0.63 0.59 0.11 0.05 3.38 0.03
Total 220 0.57 0.57 0.11 0.05 2.01 0.05

Table 5: Distribution of the epileptic patients according to the severity of gingival index
by age groups and gender
Age 0 0.1-1 1.1-2 2.1-3
Gender
groups No. % No. % No. % No. %
Boys 6 15.79 31 81.58 1 2.63 0 0
5 Girls 6 30.00 13 65.00 1 5.00 0 0
Total 12 20.69 44 75.87 2 3.45 0 0
Boys 3 8.33 27 75.00 5 13.89 1 2.78
6-8 Girls 2 11.11 14 77.78 1 5.56 1 5.56
Total 5 9.26 41 75.93 6 11.11 2 3.70
Boys 0 0 22 78.57 4 14.29 2 7.14
9-11 Girls 0 0 14 70.00 4 20.00 2 10.00
Total 0 0 36 7500 8 16.67 4 8.33
Boys 0 0 14 66.67 3 14.29 4 19.05
12-14 Girls 0 0 10 71.43 4 28.57 0 0
Total 0 0 24 68.57 7 20.00 4 11.43
Boys 0 0 7 53.85 3 23.08 3 23.08
15 Girls 0 0 6 50.00 4 33.33 2 16.67
Total 0 0 13 52.00 7 28.00 5 20.00
Boys 9 6.62 101 74.27 16 11.76 10 7.35
Total Girls 8 9.52 58 69.05 14 16.67 4 4.76
Total 17 7.73 159 72.27 30 13.64 14 6.36
Table 6: Distribution of the control group according to the severity of gingival index by age
groups and gender
Age 0 0.1-1 1.1-2 2.1-3
Gender
groups No. % No. % No. % No. %
Boys 22 57.9 16 42.11 0 0 0 0
5 Girls 11 55 9 45 0 0 0 0
Total 33 56.91 25 43.1 0 0 0 0
Boys 22 61.11 14 38.89 0 0 0 0
6-8 Girls 14 77.78 4 22.22 0 0 0 0
Total 36 66.67 18 33.33 0 0 0 0
Boys 17 60.71 11 39.29 0 0 0 0
9-11 Girls 12 60 8 40 0 0 0 0
Total 29 60.42 19 39.58 0 0 0 0
Boys 10 47.62 11 52.38 0 0 0 0
12-14 Girls 7 50 7 50 0 0 0 0
Total 17 48.57 18 51.43 0 0 0 0
Boys 1 7.69 12 92.31 0 0 0 0
15 Girls 5 41.67 7 58.33 0 0 0 0
Total 6 24 19 76 0 0 0 0
Boys 72 52.94 64 47.06 0 0 0 0
Total Girls 49 58.33 35 41.67 0 0 0 0
Total 121 55 99 45 0 0 0 0
Table 7: Gingival hypertrophy: number and percentage in epileptic patients by age groups and
gender
Age Boys Girls Total
groups No. % No. % No. %
5 1 2.63 0 0 1 1.72
6-8 1 2.78 3 16.67 4 7.41
9-11 2 7.14 1 5.00 3 6.25
12-14 2 9.52 0 0 2 5.71
15 0 0 1 8.33 1 4.00
Total 6 4.412 5 5.95 11 5.00

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Elsevier, 2007. 11. Le H and Silness J. Periodontal disease in
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textbook of epilepsy. Newyork: Churchill 12. Percival T, Aylette S, Pool F, Bloch A, Zupan G,
livingstone, 1993. Roberts J, Lucas S. Oral health of children with
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J Bagh College Dentistry Vol. 24(special issue 1), 2012 The reliability of
The reliability of bisecting interpupillary perpendicular

line, facial and dental laterality and coincidence in adult
normal occlusion Iraqi sample (A photographic, cross
sectional study)
Dina A. Hassan B.D.S. (1)
Nidhal H. Ghaib, B.D.S., M.Sc. (2)
ABSTRACT
Background: One of the primary reasons for patients to seek orthodontic treatment is esthetic or cosmetic reasons.
The purpose of this study is to evaluate facial asymmetry which present in essentially all normal individuals and result
from a small size difference between the two sides, evaluate the correlation between maxillary and mandibular
dental midlines with facial midline and to determine if there is gender differences in Iraqi adults.
Material & method: The sample consist of 108 Iraqi adults (63 females, 45 males) aged 18-25 years with class I pattern.
Clinical examination and digital photograph with cheek retractor were performed for each individual. The facial
midline was determined by the perpendicular bisecting of interpupillary distance. Three linear soft tissue
measurements to evaluate facial asymmetry and two linear measurements to evaluate the correlation between
facial and dental midlines were measured for each photograph using AutoCAD program 2007.
Result: A correlation analysis was performed to determine the correlation between facial and dental midlines. The
following results were obtained:
1-The left side of the face is wider than the right side in 63.8% of sample, 0% equal sides and 36.1% wider right side.
2-Chin shifts to the left in 43.5% of the whole sample, 20.3% coincide with Fml and 37% shift to the right.
3-There is no significant relationship between facial and dental midline (maxillary and mandibular).
5-There is direct relationship between maxillary and mandibular dental midline.
6-There was no gender differences in both facial and dental asymmetry.
Key words: facial midline, dental midline, cheek retractor. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):94-98).
INTRODUCTION Various anatomic measurements have been

Symmetry means exact correspondence of proposed to help planning orthodontic, prosthetic,
form and constituent configuration on opposite or restorative treatments, with the objective of
sides of a dividing line or plane or about a center achieving a pleasant esthetic appearance (6).
or an axis (1). Alwazzan et al. (7) used from the nasion to
Facial aesthetics has exponentially increased its pognion passing over the midline of the philtrum
importance in all health fields (2). to determine facial midline, while Sharma et al. (8)
A study for Karl and Randy (3) is the first study used the middle of philtrum, both found that facial
to show that facial symmetry has a positive midline can be used as guide to determine the
influence on facial attractiveness ratings. While position of dental midline. While Cardash et al. (9)
Kowner (4) in his study he found that the low and Eskelsen et al. (10) used the midpoint of the
degree of facial asymmetry found in normal interpupillary line, or the line from the center of
people does not affect attractiveness ratings. the brows, is typically used to locate the facial
Facial symmetry is usually considered an midline, they found that it can be considered less
important component of a harmonious smile (5). attractive from an esthetic standpoint. So because
Esthetic appearance is intensified when the there is no previous Iraqi study about the
maxillary midline coincides with the midline of relationship between the facial midline and dental
the face although it is difficult to be achieved, midline, the present study had been established to
therefore many studied tried to determine how far find this relationship in both genders.
the maxillary dental midline could deviate from
the facial midline and still be considered
aesthetically acceptable. MATERIAL AND METHOD
The sample consist of 108 Iraqi adults age 18-25
(45 males, 63 females) all of them with Bilateral
Class I molar, canine and incisor classification,
(1) M.Sc. Student, Department of Orthodontics, Dental College, Class I skeletal relationship
(2) Professor, Department of Orthodontics, Dental College,

small rectangular reflecting panel, two flash

lights, with two umbrellas to diffuse and soften
the light. Photos that did not depict the patient
looking straight at the camera or those in which
the hair obscured the outline of the face or the
pupils were excluded. The subject was seated on a
stool and his head was fixed with the aid of the
cephalostat. The Frankfort horizontal plane was
parallel to the floor. Mouth retractor was used, the
subject asked to close in centric and look straight
to the camera (16).
For measurements Firstly, the photographs
were imported to the AutoCAD program.
Secondly, magnification correction was done in
reference to the attached ruler. After that,
Figure: 1: Soft Tissue Points landmarks were identified.
Soft tissue points used in this study include:
No crown and bridge prosthesis or large dental Points err and erl : were defined as points on the
fillings, No or minor crowding and spacing, No patients right and left sides where a line
previous orthodontic or facial surgical treatments, connecting the centers of the ear rods intersects
Absence of facial deformity due to ex: facial the outer contour of the face (17). Soft tissue
trauma, abnormal deviation of the nose, deformity menton (me) or gnathion: is the most inferior
of the eye & ear or due to congenital diseases like midpoint on the soft tissue contour of the chin (18)
Cleft lip & palate. and Pupil's of the eye (P): is a hole located in the
Every participant in the sample passed center of the iris of the eye that allows light to
through four steps: History, Clinical examination enter the retina (19) .
(Extra oral and Intraoral examination), Frontal Lines include: Interpupilary line: is a horizontal
view photograph, Upper & lower dental line that connects between the center of right and
impression. In History the subjects were asked left pupils (17). Facial midline (Fml): was defined
about name, age, origin, medical history. as the perpendicular bisector of the Interpupilary
Extraoral examination includes: line (10,17). Maxillary and mandibular dental
1.Tempromandibular joint examination includes midline (Max, Man. dml): can be described as an
deviation of the mandible from the normal path of imaginary vertical line that separates the two
closure (11-13). Any person with functional shift of central incisors (right and left central incisors) (20).
the mandible was excluded from the sample. 2. Linear Measurements: err, erl: The distances
Assessment of antero-posterior skeletal from facial midline to points err and erl , and the
relationship (14) . difference between them is defined as err-erl. if
the value of err-erl is zero that mean there is no
laterality, if the value of err-erl is less than zero
(minus) this indicate wider left hemi face, and the
facial midline shifts to the right, if the value of
err-erl is more than zero (positive) this indicate
wider right hemiface and facial midline shifts to
the left (17). dme: is the horizontal distance from
facial midline to soft tissue menton (me) (17) , if its
value is zero this mean (me) coincides with facial
Figure 2: Magnified view of maxillary, midline, if positive this mean (me) shifts to the
mandibular and facial midlines right, if negative this mean it shifts to the left (17) .
Max, Man: The horizontal distance from facial
Digital camera (Nikon D5000.AF-S DX NIKKOR midline to the maxillary and mandibular dental
18-55mm f/3.5-5.6G VR) was fixed in position midline to check the correlation between facial
and adjusted in height to be at the level of subject and dental midline (8). If the value is positive this
'eyes, The distance from the camera to the subject means that the dental midline shifts to the right, if
was 1.01 m (15). The camera and lens were set negative this mean that the dental midline shifts to
perpendicular to the line connecting bilateral ear the left. Max-Man: the horizontal distance
rods. In order to eliminate the problem of between Max and Man (8). Statistical Analyses
shadows on the sub mental region and under the which used are:
nasal base, the subject held with his/her hands, a

Descriptive statistics, and Inferential statistics me. This agrees with Haraguchi et al. (17) which
which include: Paired samples t- test, Independent explained by the environmental influence on
samples t-test and Pearson correlation mandible during the growth. There is moderate,
coefficients. direct, highly significant correlation between Max
and Man. This agrees with Sharma et al. (8).
Since The subjects in this study have Class I
RESULTS AND DISCUSSION molar, canine and incisor relationship, so it is
Descriptive statistics for the total sample. logical that there is there is significant
shows that: the left side of the face is wider than relationship between maxillary and mandibular
the right side and facial midline shifts to the right. dental midlines.
This agrees with Ercan et al.(21), but disagrees Independent t-test and probability value for
with Haraguchi et al.(17). This go under the comparison between females and males .Table
explanation of valence hypothesis which suggest (2) shows that: There is no significant difference
that the brain hemispheres differ in processing present between males and females in all variables
emotion (22), these emotions will be expressed in except the values of err and erl. This comes
the musculature action. As bone growth itself forward with Nasir (28) who found out that those
under loose genetic control and take place in females are slightly smaller than males in most
response to growth of the surrounding soft tissue dimensions.
(This according to functional matrix theory by Pearson correlation among all variables for
Moss) (23). Maxillary and mandibular dental both genders. Shows that there is Weak non
midline shift to the right. This agrees with the significant correlation between err-erl and Max,
result of Sharma et al. (8). Chin shifts to the left. Man. This agrees with Eskelsen et al. (10) and
This agrees with Haraguchi et al., (2008). disagrees with Alwazzan et al. (7) and Sharma et
Descriptive statistics for both genders shows al. (8). Weak non significant correlation between
that: The left side of the face is wider than the err-erl and me. This agrees with Haraguchi et al.
right side and facial midline shifts to the right in (17)
. Direct correlation between Max and Man.
both genders. This agrees with Ercan et al., (21) This agrees with Sharma et al.(8).
but disagrees with Haraguchi et al. (17). This goes The percentage of coincidence among facial
under the explanation of valence hypothesis and midline, maxillary and mandibular dental
functional matrix theory. Maxillary and midline in the total sample is shown in Table 3.
mandibular dental midline to the right in females. The percentage of subjects with wider left side
This agrees with the result of Sharma et al. (8). In in comparison with subjects with wider right
males they shift to the left which disagree with side of the face is shown in Table 4.
Sharma et al. (8). The teeth are appendages of the The percentage of coincidence and non
jaws and are supported by the alveolar bone, the coincidence between menton and Fml is shown
relationship between the upper and lower alveolar in Table 5.
bones is not necessarily the same as that between Direction of shift of Max and Man d ml to the
the upper and lower basal bones (14). Chin shift to right are 50%, 44.44% respectively and to the left
the right in females and to the left in males. It are 34.25%, 39.81% respectively. These results
agrees with that of Lundstrm and Woodside,(24) are close to that of Sharma et al, (8) study; the
and disagrees with the result of Haraguchi et al. difference may be due to number of the sample.
(17)
. This explained by the environmental The amount of shift of maxillary dental midline to
influence on mandible during the growth ex: facial midline, mandibular dental midline to facial
Unilateral chewing patterns (25), sleeping on the midline and maxillary to mandibular dental
stomach, resting the chin on the palm of the hand midline are: 0.46-5.38 mm, 0.33-6.08 mm, 0.5-
these may cause the chin (26), the morphology of 4.96 mm respectively.
the alveolar process and the vertical height of the
dentition (27).
Pearson correlation among all variables for the REFERENCES
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but significant correlation between err-erl with Facial Symmetry Detection Using Eigenvalue Method.
Juti 2009; 7(2): 43-8.
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(8) 2. Yanez-Vico RM, Iglesias- Linares AI, Torres-Lagares
, but agrees with the result of Eskelsen et al. D, Gutierrez-Perez J, Solano-Reina E. Diagnostic of
(10)
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difficult to distinguish between them (23 ). Weak attractiveness and sexual selection: The role of
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symmetry and averageness. J Comparative Psychology 15. Al-Ramahi SC. Evaluation of Buccal Corridor in
1994; Sep; 108(3): P. 233-42. Posed Smile for Iraqi Adults Sample with Class I
4. Kowner. Facial asymmetry and attractiveness Normal Occlusion.2009
judgement in developmental perspective. Rotem 16. Menenghini F. Clinical Facial Analysis: Elements,
Journal of Experimental Psychology: Human Principles, Techniques. Verlag Berlin Heidelberg:
Perception and Performance 1996; Jun: 22(3): 662-75. Springer; 2005. P. 28, 29, 46, 73.
5. Masuoka N, Muramatsu A, Ariji Y. Discriminative 17. Haraguchia S, Iguchib Y, Takadac K. Asymmetry of
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6. Gomes VL, Gonalves LC, Do Prado CJ. Correlation Dimentional Cephalometry. Verlag Berlin Heidelberg:
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Table 1: Pearson correlation among all variables for the total sample:
Variables r P-value sig
(err-erl) & Max 0.197 Weak 0.049 S
(err-erl) & Man 0.362 Weak 0.04 S
(err-erl) & menton 0.304 Weak 0.03 S
Max & Man 0.778 strong 0.000 HS
Table 2: Independent t-test and probability value for comparison between females and males:
Fml dml Menton
err erl (err-erl) Max Man Max-Man dme
t-test 7.989 2.65 0.72 1.756 0.337 0.229 1.068
P-value 0.007 0.043 0.40 0.086 0.736 0.820 0.287
Sig S S NS NS NS NS NS

Table 3: The percentage of coincidence among facial midline, maxillary and mandibular dental
midline in the total sample:
Coincide with err-erl Not coincide with err-erl Shift to right Shift to left Total
17 91 54 37 108
Max
15.7% 84.25% 50% 34.25% 100%
17 91 48 43 108
Man
15.7% 84.25% 44.44% 39.81% 100%
Table 4: The percentage of subjects with wider left side in comparison with subjects with wider
right side of the face:
No. Wider left side Left equal to right Wider right side
108 69 0 39
100% 63.8% 0% 36.1%
Table 5: The percentage of coincidence and non coincidence between menton and Fml:
No. Coincide with facial midline Not coincide with facial midline Shifts to left Shifts to right
108 22 87 47 40
100% 20.3% 80.5% 43.5% 37%

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Dental arches dimensions
Dental arches dimensions, forms and the relation to facial

types in a sample of Iraqi adults with skeletal and dental
class I normal occlusion
Haider M.A. Ahmed, B.D.S., M.Sc. (1)
Fakhri A. Ali, B.D.S., M.Sc. (2)
ABSTRACT
Background: The face is a three dimensional object, facial structures are arranged to give the face its normal form.
The teeth are arranged in an arch thats based on the jaw which is a part of the facial structure. The dental arch has
certain forms depending on several factors including the skeletal form of the jaw and it is calculated in terms of
different ratios of several arch dimensions. The aim of this study is to establish normative values for the Maxillary and
Mandibular Dental arches dimensions represented by dental arch width, length and to find out the most frequent
dental arch form and facial type and the role of gender differences and to find out if there is a the relationship
between the facial type and dental arches form and which is the most frequent facial type and dental arch form.
Materials and methods: The sample was selected from Baghdad University, college of Dentistry. A total of 72 Iraqi
adult Dental students fit the criteria of this research with an age range between 18 and 25 years. The sample
composed of one hundred forty four Dental casts, seventy two frontal photographs, seventy two profile photographs
and One hundred forty four Dental casts photographs six linear measurements for Maxillary dental cast and six linear
measurements for Mandibular Dental cast and two liner measurements for frontal and profile facial photographs.
Orthodontics is one of the fields that took advantage of high speed personal computers such as Pentiums by utilizing
specialized orthodontic programs (software) which have automated some of the more laborious tasks in diagnosis
and treatment planning, storage and sorting of information. So the use of computers is obligatory in our modern life
thats why it was used in almost everything in this study from obtaining the record and analyzing them for typing and
directing this thesis. Specialized computer software for orthodontic record analysis (AUTO CAD 2007) were used,
which simplified the analyzing process and reduced the time and effort spent on taking measurements directly from
the records to facilitate work and to gain more accurate results.
Results: It had been found that all of the maxillary dental arch dimensions are greater than mandibular dental arch
dimensions in the total sample and both genders and all of the measured dental arch dimensions have a
significantly greater mean value in males than in females also in general facial measurements were higher in females
than males with a high significant difference except in the nasion gnathion distance in which it was not significant
differences between both genders. The most frequent facial type in males and females is the Mesoprosopic one,
followed by the Euryprosopic while the least frequent is the Leptoprosopic face type while the mid arch form is the
most frequent arch form and it is usually associated with Mesoprosopic face type in both genders followed by the
wide dental arch form and the narrow dental arch form.
Conclusions: It was concluded that the relation between facial type and dental arch form is a perfect positive
correlation and as the facial type graduated from Leptoprosopic to Mesoprosopic to Euryprosopic then the Maxillary
Dental arch form increases from narrow to mid to wide.
Key words: facial types, dental arch dimensions. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):99-107).
INTRODUCTION From that time and up to date this direct facial

It might be expected that faces would display measurements is used in the clinical diagnosis and
some common features, but they are often as treatment planning. (2)
different from each other as they are from the rest
of us. If we are able to accept that appreciation of MATERIALS AND METHODS
facial beauty is innate, then presumably it must Sample
depend on recognizable difference in our faces. If The sample was selected from Baghdad
so then it should be possible to define and University, college of Dentistry. A total of 200
measure them. (1) Iraqi adult Dental students were clinically
One of the objectives of the orthodontic examined (100 female, 100 male) and only 72 of
treatment is the improvement of facial them (29 male and 43female) fit the criteria of this
appearance; therefore it is necessary to be able to research of class I skeletal and dental relationship
define the good looking face. The introduction of with an age range between 18 and 25 years old
anthropometric direct method, for measurement of were selected. The sample composed of 144
facial features was first practiced by Hellman for Dental casts, 144 Photographs of the dental casts,
orthodontic purposes. 72 Frontal photographs for the person and 72
(1) M.Sc. Student, Department of Orthodontics, Dental College, Profile photographs for the person.
(2) Professor, Department of Orthodontics, Dental College,

Criteria of the Sample compressive strength 1h 29 MPa.(Elite

1. Iraqi Arabs Dental subjects. Model thixotropic, Italy).
2. Age range between 18 and 25 years old. 16. Dental plaster (Plaster of Paris) Iraq.
3. Full permanent teeth excluding the third 17. A height adjustable tripod, used for fixing
molars (3). the camera in position.
4. Class I incisor classification (4). 18. Stool.
5. Bilateral Class I molar and canine 19. A blue background panel, 0.95 m width and
relationships (5). 1.10 m length.
6. Class I skeletal relationship, diagnosed 20. Two flash lights, with holders and two
clinically by using the two fingers technique umbrellas.
mentioned by (6). 21. A small rectangular reflecting aluminum
7. Free of local factors that disturb the integrity panel of 0.35 x 0.7 m.
of the dental arches. (Congenital missing teeth; 22. Electric vibrator (Quale Dental).
retained deciduous; supernumerary teeth) (7). 23. Dental surveyor base.
8. No crown and bridge prosthesis or large dental 24. Blue marker pen.
fillings (8). 25. Dental vernier (Dentarum).
9. Competent lips and absence of gross 26. Measuring tape.
asymmetry of the face and the jaws with Methods
acceptable facial esthetic (9). Standardization of the facial photographs
10. No or minor spacing or crowding (10). The camera was fixed in position and
11. No history of bad oral habits like thumb adjusted in height to be at the level of subject
sucking, tongue thrust or mouth breathing (11). 'eyes in the frontal photograph with a height
12. No previous orthodontic, orthopedic, or facial adjustable tripod. The distance from the camera to
surgical treatments (12). the subject was fixed at a distance of about 1.01m
13. No active periodontal diseases and gingivitis, measured from the tripods column to the ear rods
also no periodontal treatment except for that were fit in the external auditory meatus in
ordinary scaling and polishing (13). order to avoid the forward, backward, and tilting
14. No crossbite, no instanding incisor (14). of the subject head (Cephalostate based head
15. Overjet and overbite of 2-4 mm (8). position). The subject was asked to look to the
Materials and Equipment center of the lens of the camera in the frontal
1. Kidney dish. photograph and to look at a distant mirror which
2. Disposable Dental mirrors. is placed in front of his/her face in the lateral
3. Disinfectant agent (Ethyl Alcohol photograph with ear rods in the external auditory
75%solution). meatus (16).
4. Wooden ruler. Facial landmarks:(figure 1)
5. Perforated disposable plastic trays for 1. nasion (n) The point in the midline of both the
dentate arches (sizes 1, 2, 3). nasal root and the nasofrontal suture, always
6. Rubber base mold. above the line that connects the two inner
7. Rubber bowel and wide-bladed spatula canthi, identical to bone nasion (17).
(martin-Germany stainless). 2. Gnathion (gn): The soft tissue point
8. Cotton. corresponding to skeletal Gnathion (18) which
9. Digital camera (Sony Cyber Shot H 50, 9.1 is the most anterior and inferior point of the
Mega pixels, 15 X optical zoom, Sony soft tissue chin (19).
Corporation, Nagoya, Japan). 3. zygoin (zyg): The most prominent point on the
10. Lab Top (hp) (Pentium IV). cheek area beneath the outer canthus and
11. Analyzing software (AutoCAD 2007). slightly medial the vertical line passing
12. Dental cast photographic apparatus (15). through it; different from bony zygoin (17).
13. Fast setting irreversible hydrocolloid Linear measurements
impression material with w/p ration 1. Interzygomatic distance (IzD): It is the
14. 19g/40ml, mixing time 35 seconds, working transverse distance between soft tissue zygion
time 1 minute and 20 seconds and setting on both sides (20).
time 2 minutes at 23C room temperature 2. Anterior facial height (n-gn): It is the distance
using water at 23C (Alginmax, Italy). between soft tissue nasion and soft tissue
15. Dental stone with w/p ratio 30g/100g, gnathion (7).
working time 7 minutes, setting time 12
minutes, setting expansion 2h 0.04% and

Facial types Six dental casts measurements were divided into

Facial Form was determined using (21) three sagittal measurements, and three transverse
method by calculating the ratio between measurements were utilized to calculate three
interzygomatic distance and anterior facial height, independent ratios, which are:
and then the face type for each subject is 1. canine vertical distance / inter-canine
classified as follows: distance.
Euryprosopic IzD/n-gn. The facial index 2. Molar vertical distance / inter-first molar
is > 0.93 distance.
Mesoprosopic IzD/n-gn. The facial index 3. Total arch length / inter-second molar
is 0.93 and 0.83 distance.
Leptoprosopic IzD/n-gn. The facial index The standardize number was calculated for each
is<0.83 of three ratios for each subject by the excel
Standardization of the Dental casts photographs: program. Then the mean of these standardized
After taking the proper impression for the numbers was calculated for each subject which
maxillary and mandibular arches and preparing gave the base for classification as follows:
the casts, a photograph was taking to each dental 1. Narrow form the mean of standardized
cast using an apparatus designed by Dr.Saadi. number >+1.
Dental cast landmarks (figure.2) 2. Mid form the mean of standardized number
1. Incisal point: The point in the midway between (+1 and -1).
between the incisal edges of the two central 3. Wide the mean of standardized number <-1
incisors (22). (Jassim, 2010).
2. Canine point: The cusp tip of the right and left Statistical Analysis
permanent canines (10). All the data of the sample were subjected to
3. Mesiobuccal cusp tip of the first molars: the computerized statistical analysis using SPSS
mesiobuccal cusp tips of the right and left first version 15 (2006) computer program. The
permanent molars (23). statistical analysis included:
4. Distobuccal cusp tip of second molars: the A. Descriptive Statistics
distobuccal cusp tips of the right and left 1. Mean
second permanent molars (7). 2. standard deviation
Dental Arch Width 3. Standard error
1. The inter canine distance (ICD): The linear 4. Minimum and maximum values
distance from cusp tip of one canine to the B. Inferential Statistics
cusp tip of the other (7). 1. Independent- samples t-test for the comparison
2. Inter First Molar Distance(IMD): The linear between both genders(Levenes Test for
distance from the mesiobuccal cusp tip of one Equality of Variances).
first permanent molar, to the mesiobuccal cusp 2. Chi square test.
tip of the other (24). 3. Pearson's correlation coefficient to test the
3. Inter-second molar distance(I2ndMD): The correlation between the dental arches and
linear distance between the distobuccal cusp facial measurements r2. if r2 value is 1 then
tip of one second permanent molar, to the the relation is direct positive
distobuccal cusp tip of the other (7). While if r2 value is -1 the relation is reverse
Dental Arch Length In the statistical evaluation, the following levels
1. Canine vertical distance(CVD): The vertical of significance are used:
distance from the incisal point perpendicular to
a line joining the inter-canine distance at the Non-significant NS P > 0.05
cusp tips (22). Significant * 0.05 P > 0.01
2. Molar Vertical Distance(MVD): The vertical Highly significant ** 0.01 P > 0.001
distance from the incisal point perpendicular to
a line joining the mesiobuccal cusp tips of first RESULTS
permanent molars (7). Descriptive statistics for the maxillary dental
3. Total Arch Length(TAL): The inter incisal arch dimensions for the total sample and both
point to the mid distance of the maxillary and genders and Comparison between males and
mandibular inter second molar width at the females (table 1)
mesiobuccal cusp (25). All of the widths measurements have
Arch Form significantly greater mean value in males than
females. All of the lengths measurements have
greater mean value in male than females but the Explanation for the inter arches difference
difference is not significant. between both genders:
Since our sample is a class I normal occlusion
Descriptive statistics for the mandibular dental then maxillary dental arch should overlap the
arch dimensions for the total sample and both mandibular dental arch (28, 14).
genders and Comparison between males and
females (table 2) Explanation for the Descriptive statistics of the
All of the widths measurements have Facial measurements and Comparison between
significantly greater mean value in males than males and females Facial measurements
females. All of the lengths measurements have Our result was near to that of (14) but far
greater mean value in males than females but the from that of (29) since he used skeletal zygoin on a
difference is not significant except for the total frontal radiograph and because of fitness and
arch length in which the difference was highly obesity of the individual which was not
significance. considered in this study or the other studies since
it has a direct effect on the soft tissue thickness
Comparison between maxillary and that overlay the face bone and so affects on facial
mandibular arches in males, females and the measurements also ethnic variations and sample
total sample(table 3 and 4) size.
All of the widths and lengths measurements Inter Zygomatic Distance and Anterior
have significantly greater mean value in maxillary facial height (n-gn) Ratio is influenced directly by
arch than mandibular arch in males, females and (zy-zy) and (n-gn) measurements and since the
the total sample. (zy-zy) was larger in females than males and that
is why the ratio was higher in females than males
Descriptive statistics of the Facial which gives females faces toward an oval shape in
measurements and Comparison between males comparison with the males faces. This in
and females Facial measurements(table 5) agreement with (30) who found that the females
We can notice that females have higher face are more smooth and rounded contours,
mean value in all of the facial measurements while males face are angular and square with
(interzygomatic distance, nasion-gnathion accentuated ridges and prominence.
distance and interzygomatic distance / nasion-
gnathion distance ratio). Relationship between the Facial Type and
Dental arch Forms:
Spearmans rank correlation coefficient The most frequent facial type in males,
(r2)(figure 3). females and the total sample is the Mesoprosopic
By applying spearmans rank correlation one, followed by the Euryprosopic while the least
coefficient (r2) we gave the facial form the frequent is the Leptoprosopic face type. The most
following ranks: Leptoprosopic facial type rank 1, frequent arch form in males and females and the
Mesoprosopic facial type rank 2, Euryprosopic total sample is the mid arch form followed by
facial type rank 3, While we gave the Dental arch wide then narrow arch form. The mid arch form
form the following ranks: Narrow arch form rank which is the most frequent arch form is usually
1, Mid arch form rank 2, Wide arch form rank 3. associated with Mesoprosopic face type in both
genders. The relation between facial type and
dental arch form is a positive relation and as the
DISCUSSION facial type graduated from Leptoprosopic to
Explanation for the genders difference in Mesoprosopic to Euryprosopic then the
Maxillary and Mandibular dental arch mandibular Dental arch form increases from
measurement narrow to mid to wide. (Perfect positive
1. The smaller and smoother bony ridge and correlation).
alveolar process of females (26). This study agrees with 0ther studies (31, 32, 33,
2. The average weakness of musculature in 7, 10, 29)
in that the mid arch form was associated
females that play an important role in width with Mesoprosopic; Narrow arch forms with
and height of dental arch (26). Leptoprosopic and wide arch forms with
3. Longer growth period for males than females Euryprosopic face type This study is like a
(27).
support to these findings, however the result of
this study can be more confident since the only
study that uses the spearmans rank correlation

coefficient (r2) to determine the association Dental arch form. While (7) stated that the
between facial type and Dental arch form. It is association was not unexpected; (34) agrees on that
clear that there is a Perfect positive correlation there is no clear relationship between facial forms
between facial form and Maxillary/Mandibular and arch forms.
zygion
gnathion
Figure 1: Facial land marks
Figure 2: Dental cast land marks and linear measurements
Figure 3: The association between facial type and Maxillary-Mandibular dental arch form
(spearmans rank correlation coefficient r2).
Table 1: Descriptive statistics for the maxillary dental arch dimensions for the total sample and
both genders and Comparison between males and females.
Descriptive statistics Genders differences
Variables Sex Min-
Mean S.D. S.E. t-test p-value
Max.
7.18
Male 9.31 1.31 0.24
12.4
Canine
7 0.54
vertical Female 9.11 1.34 0.20 0.62
12.3 (NS)
distance
7
Total 9.19 1.32 0.16
12.4
33.6
Male 38.16 2.79 0.52
43.6
Inter
29.7 0.001
canine Female 35.60 2.32 0.35 4.24
40.6 ***
distance
29.7
Total 36.63 2.80 0.33
43.6
26.8
Male 30.13 2.24 0.42
34.9
Molar
25.3 0.17
vertical Female 29.41 2.10 0.32 1.39
35.3 (NS)
distance
25.3
Total 29.70 2.17 0.26
35.3
48.4
Male 57.32 4.11 0.76
63.8
Inter
47 0.001
molar Female 53.69 2.89 0.44 4.4
60 ***
distance
47
Total 55.15 3.85 0.45
63.8
41.3
Male 46.40 2.88 0.54
53.7
Total
39.9 0.27
arch Female 45.57 3.21 0.49 1.12
57.4 (NS)
length
39.9
Total 45.90 3.09 0.36
57.4
57.5
Male 64.81 3.95 0.73
73
Inter
53 0.001
second Female 60.03 3.37 0.51 5.5
68.7 ***
molar
53
Total 61.95 4.29 0.51
73
*N 72, 43, 29,d.f.=70,p<0.05,all measurements are in mm. N.S: No Significant difference at P > 0.05.

Table 2: Descriptive statistics for the mandibular dental arch dimensions for the total sample
and both genders and Comparison between males and females.
Variables Sex Min-
Max.
3.5
Male 5.32 1.03 0.19
7.4
Canine 0.33
2.3
vertical Female 5.06 1.13 0.17 0.99
8.2 (NS)
distance
2.3
Total 5.17 1.09 0.13
8.2
24.1
Male 28.77 2.54 0.47
34.4
Inter 0.014
23.3
canine Female 27.42 1.97 0.30 2.53
32.7 *
distance
23.3
Total 27.96 2.30 0.27
34.4
21.1
Male 25.11 2.05 0.38
28.5
Molar 0.14
20.4
vertical Female 24.36 2.05 0.31 1.51
28.8 (NS)
distance
20.4
Total 24.66 2.06 0.24
28.8
40
Male 49.11 3.67 0.68
55.3
Inter 0.001
40
molar Female 45.77 2.98 0.45 4.24
53.4 ***
distance
40
Total 47.12 3.65 0.43
55.3
37.8
Male 42.04 2.60 0.48
46.7
Total 0.02
35.4
arch Female 40.51 2.76 0.42 2.36
46.8 *
length
35.4
Total 41.13 2.78 0.33
46.8
51.4
Male 58.68 3.95 0.73
66.2
Inter 0.001
49
second Female 55.17 3.46 0.53 3.97
63.6 ***
molar
49
Total 56.58 4.03 0.48
66.2
* N 72, 43, 29d.f.=70,p<0.05,all measurements are in mm. N.S: No Significant difference at P > 0.05.
Table 3: Comparison between maxillary and mandibular arches in males
Descriptive statistics Arch differences
Variables Arch
Canine Maxillary arch 9.31 1.31 0.24 0.001
12.86
vertical distance Mandibular arch 5.32 1.03 0.19 ***
Inter Maxillary arch 38.16 2.79 0.52 0.001
13.4
canine distance Mandibular arch 28.77 2.54 0.47 ***
Molar Maxillary arch 30.13 2.24 0.42 0.001
8.92
8.03
molar distance Mandibular arch 49.11 3.67 0.68 ***
Total Maxillary arch 46.40 2.88 0.54 0.001
6.04
arch length Mandibular arch 42.04 2.60 0.48 ***
5.9
second molar Mandibular arch 58.68 3.95 0.73 ***
* 29, p<0.05,all measurements are in mm. N.S: No Significant difference at P > 0.05.

Table 4 Comparison between maxillary and mandibular arches in females

Descriptive statistics Arch differences
Variables Arch
Canine Maxillary arch 9.11 1.34 0.20 0.001
15.11
17.64
canine distance Mandibular arch 27.42 1.97 0.30 ***
Molar Maxillary arch 29.41 2.10 0.32 0.001
11.28
12.5
molar distance Mandibular arch 45.77 2.98 0.45 ***
Total Maxillary arch 45.57 3.21 0.49 0.001
7.82
arch length Mandibular arch 40.51 2.76 0.42 ***
6.59
second molar Mandibular arch 55.17 3.46 0.53 ***
* 43,p<0.05,all measurements are in mm. N.S: No Significant difference at P > 0.05.
Table 5: Descriptive statistics of the Facial measurements and Comparison between males and
females Facial measurements
Variables Sex
Min. Max. Mean S.D. S.E. t-test p-value
Male 95.47 112.53 104.60 4.12 0.77 0.001
IzD -4.86
Female 98.91 124.3 111.02 7.06 1.08 ***
Male 100.8 131.83 117.80 8.76 1.63 0.61
n-gn -5.16
Female 97.14 138.86 119.13 11.88 1.81 (NS)
Male 0.8 1.05 0.89 0.07 0.01 0.032
IzD/n-gn -2.19
Female 0.76 1.21 0.94 0.10 0.01 *
* N 72, 43, 29p<0.05,all measurements are in mm. N.S: No Significant difference at P > 0.05.
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J Bagh College Dentistry Vol. 24(special issue 1), 2012 The relationship between
The relationship between the dental caries and the blood

glucose level among type II non insulin dependent diabetic
patients
Hawraa Khalid Aziz, B.D.S., M.Sc. (1)
ABSTRACT
Background: Diabetes mellitus is one of the most common chronic diseases in the general population that effects the
oral cavity so the probability of detecting an increased of dental caries in diabetic patients is more controversial. The
aims of this study to compare the dental caries among the diabetic and non diabetic patients and its relation with
the blood glucose level, medical history and oral health behaviors among type II non-insulin dependent diabetic
mellitus patients.
Materials and methods: The samples were composed of 180 subjects of diabetic patients and 180 subjects of non
diabetes. Both gender and age range 40 -70 years for both groups. The data were gathered by questionnaire,
clinical examination and laboratory investigations included frequency of oral hygiene practices, caries experience
using the DMFT Index, blood glucose including the fasting blood glucose level, and random blood glucose level.
Independent t-test, Chi-square, correlation coefficient, as well as Z-proportion tests were used for statistical
comparisons.
Results: It indicated that there was no significant difference in DMFT between the diabetic and non-diabetic groups.
In addition to blood glucose level was higher in diabetes than non diabetes with increased dental caries with the
increase of blood glucose level either random or fasting blood glucose level.
Conclusion: This study indicated that the presence of dental caries is not significantly elevated in most diabetics but
the blood glucose level and the age effect on the dental caries as well as diabetic subjects should improve their oral
hygiene practices.
Key words: dental caries, diabetes mellitus, blood glucose level, oral hygiene. (J Bagh Coll Dentistry 2012; 24(sp.
Issue 1):108-114).
INTRODUCTION
Diabetes mellitus (DM) is a common chronic As a systemic disorder, the disease affects the
metabolic disorder which affects millions of oral cavity. Investigators have reported several
people. The prevalence of diabetes for all age oral lesions and conditions associated with the
groups worldwide was estimated to be 2.8% in disease. These include among others, xerostomia,
2000 and may reach 4.4% by 2030. Additionally, burning mouth, altered taste sensation, gingivitis,
the diabetic population is expected to rise from periodontal disease, candidal infection and lichen
171 million in 2000 to 3666 million by 2030 (1). planus (4-6) .
Roglic reported that the almost 3 million deaths However, among researchers there was a
per year are attributed to diabetes, equivalent to lack of consensus about the relationship between
5.2% of all deaths (2). There are two basic types of DM and dental caries. They reported increased (7-
9)
the diabetes mellitus: type I diabetes mellitus is , decreased (10) and similar (11,12) caries
caused by autoimmune damage to the pancreatic experiences between those with and without
beta cells resulting in failure of insulin production diabetes.
and secretion leading to absolute insulin Taylor and others concluded in their literature
deficiency. Hence individuals with type I diabetes review that there was insufficient evidence to
are prone to ketosis in the basal state and depend determine whether a relationship exists between
on life exogenous insulin injection to prevent diabetes and coronal or root caries risk,and they
ketosis and sustain health. It occurs primarily in recommended that further investigations should
persons younger than 40 years but also occur at be carried out (13) .
any age. While type II diabetus mellitus occurs as Beside the contradictory findings on caries
aresult of insuln resistance with relative isulin prevalence in diabetic populations, similarly
dificincy. Patients with type II are not ketosis- conflicting results have been reported on the
prone under normal condition. The majoraty of identity of the underlying risk factors of such
type II diabetes are adult above 40 years of age. relationships (14). It is not clear whether this
However occure in younger age groups. The variability is mainly related to different patho-
globel prevelance of young type II inceased in last physiologic changes of diabetes such as the type,
two decades (3) . duration or degree of control, or is in part a
reflection of racial and environmental differences
(1)Lecturer. College of Health and Medical Technologies among diabetic populations worldwide. Therefore
Foundation of Technical Education. Baghdad. the association between the variation of the blood
glucose level to assess the degree of the control of

the disease as well as the efforts should be made Clinical Examination

to evaluate the etiological risk factor of dental The clinical examination included an
caries such as oral health among diabetic groups evaluation of dental caries, by using dental mirror
(15)
. and dental probe under light source. The dental
By all of the above information, this study was caries was assessed using the decayed missing
carried out with the following objectives: filled teeth (DMFT) Index according to the
1. To compare between the distibution of the criteria and recommendations of the World Health
diabetic and control subjects according to the Organization (16).
age and gender and oral health status.
2. To evaluate the dental caries among the group Laboratory examination
of diabetics versus non-diabetic controls and The blood samples were collected from each
its relation to the age. participant diabetic and non diabetic. The fasting
3. To evaluate the blood glucose level among a blood glucose level (FBGL) and random blood
group of the diabetics and non-diabetic group glucose level (RBGL) were assessed by "One
and its effect on the caries experience. Touch TM" complete blood glucose monitoring
4. To evaluate some selected caries-risk factors system, Johnson & Johnson, California, USA. For
and its relation to dental caries in the sampled diabetic patients, the sample of blood was used to
diabetics. measure the glycosylated hemoglobin
concentrations (HbA1c) which assess the
MATERIALS AND METHODS glycemic control of that patient by measuring
Study Population three fasting blood glucose level (17). Those with
One hundred eighty diabetic patients and 180 values measures of less than or equal to 7 mmol /
healthy controls participated in this study. The ml (< 120 mg/dl) were classified as indicating
diabetic group was recruited from the diabetic satisfactory ( good ) control of diabetes while the
patients of health care centers and Al-hussain values more than 7 mmol / ml (>120 mg/dl) were
hospital in Karbala city with age range from 40- classified as poor control of diabetes (18).
70 years old during sampling day were asked to Statistics
participate and 100% of those who were invited to Data were collected and analyzed using SPSS
participate in the study agreed. The control group program version 12. The data were analyzed
included age and gender-matched healthy descriptively and comparison between the groups
volunteers with no history of diabetes. Individuals was done using independent t-test, Chi-square,
who had received antibiotics or steroid therapy or correlation coefficient, as well as Z-proportion
had been using antiseptic mouthwashes during the test whenever applicable.
previous 3 weeks were excluded from the study.
Also they had no history of any other systemic RESULTS
disease, or under medication therapy, no The distribution of participating subjects
orthodontic treatment or wearing any according to the age, gender is shown in (Table1).
prosthodontic appliance. The caries experience and its components showed
the mean of DT component for diabetes group
Data Collection was higher than the mean for the non diabetic,
The data were gathered through questionnaire, also the mean of MT component for the diabetes
clinical examination and laboratory was higher than those for non diabetes, while the
investigations. The questionnaire included mean of the FT component for diabetes was lower
questions on medical history and oral health than those for control group, finally the mean of
behaviors. Medical history records were included the DMFT for diabetes was more than those for
duration of the diabetes, physician follow up, the non diabetes group. The statistical comparison
degree of the control of the diabetic state well of studied variables between the diabetes and non
controlled or poor controlled. The oral health diabetes showed that there were no significant
behaviors included the frequency of the tooth differences of the caries experience DT, and
brush per day and the type of oral cleaning DMFT (P > 0.05) except that there was a
methods tooth brush only or both tooth brush with significant difference of MT among diabetes and
dental floss. Also they asked about the regular control groups (P < 0.05) and highly significant
dental visit and if they are smokers or not which difference of FT between the two groups (P<0.01)
are rated on scale yes or no. (Table 2).
On the other hands, the result of the
distribution of the caries experience (for both
groups) according to the age showed the mean

values of DMFT index were increased when the As well as the comparison of caries
age increased from 40 years to 70 years as shown experiences among the diabetic patients according
in (Figure1). Statistically the correlation between to the degree of the control the results showed that
the DMFT teeth and age showed there was highly the mean values of the DMFT was higher in well
significant correlation for both diabetic and non controlled group than poorly controlled group, but
diabetic groups (P<0.01) (Table 3). statistically there was non significant difference
The results of the oral health behavior between the two groups (P<0.05) (Table 8).
questionnaire are illustrated in (Table 4). The
results showed better oral health habits regarding DISCCUSION
brushing frequency among the non diabetic group Studies that address the association between
in comparison to the diabetic patients. The diabetes mellitus (DM) and dental caries are
majority of subjects who brushed twice daily were many, but their results have not revealed any
in the non-diabetic group with high significant strong pattern of association (8-11). Diabetes
difference in distribution regarding to tooth brush mellitus is a chronic disease that may impact on
frequency between the two groups (P<0.01), personal behavior. Therefore, caution should be
while the results showed there were no taken when assessing the impact of the
association regarding to the cleaning methods as pathophysiology of diabetes on oral health status
well as the dental visits among the studied groups. when these factors are not considered (12) .
The result of the tobacco use showed there was The results of this study showed that there was
higher percentage of the smoking among the no significant differences of dental caries between
diabetic group than non diabetic with high the diabetic and non diabetic groups this result
significant difference in distribution between agreed with other studies (11,19) and disagreed
diabetic and control groups. with other who found that an increase in
The mean values of the blood glucose level dental caries in permanent teeth was observed
both fasting and random blood glucose level for among diabetics (18). One more study showed
both group diabetic and non diabetic group were that diabetics have higher DMFT values as
shown in (Table 5) that was showed the mean compared to control group children (20). Also a
values of both the fasting and random blood study demonstrated that diabetic patients have
glucose level was higher in the diabetic group more active dental caries than control subjects (21).
than the non diabetic group with high significance This may be attributed to low-carbohydrate
between them. In the relation of the blood glucose diabetic diets should theoretically reduce caries
level and the dental caries the results showed the prevalence. As well as authors usually attribute it
caries experience (DMFT) was increased with the to the fact that diabetics have traditionally been
increase of the blood glucose level either fasting counseled to consume a diet low in refined
or random blood level among the diabetic group carbohydrates, especially sucrose, and have been
as shown in (Figure 2). Statistically, there were advised to have an increased protein intake which
highly significant correlations between the DMFT enhances the buffering capacity of saliva(13).
teeth and fasting blood level and significant On the other hands, the result of the
relation of dental caries and random blood level distribution of the dental caries for both groups
among the diabetic group (Table 6). according to the age showed the mean values of
The distribution of diabetic patients in relation DMFT Index were increased when the age
to duration of the disease, physician fellow up, increased with strong correlation this result agreed
and degree of diabetic control were shown in with many others who reported high caries
(Table 7). Statistically, the Z- test showed there prevalence among older diabetics (10,12), but
was an association between the diabetic patients disagreed with Arrieta-Blanco and others who
in relation to duration of disease, the physician found no significant differences in the number of
fellow up, and the degree of the diabetic control caries, missing teeth and fillings in different age
among the diabetic patients. groups of the diabetic population (6).
In the relation of the duration of the disease The result of the oral health behavior
with caries experience the results showed that the questionnaire showed better oral health habits
mean values of DMFT was lower in the group of regarding brushing frequency among the non
diabetes less than 5 years than those with duration diabetic group in comparison to the diabetic
from 5-10 years while the highest mean DMFT patients this result agreed with other study that
for the diabetes more than 10 years (Figure 3) but was showed the frequency of the tooth brushing
statistically, there was not significant correlation was high among the non diabetic patients (22),
between the DMFT and duration of the disease while the result showed there were no association
(Table 6). regarding to the cleaning methods and also for the

regular dental visits between the non diabetic and subjects with a longer duration (8). In the
diabetic group this results disagreed with other comparison of caries experiences among the
study which was found the use of dental floss and diabetic patients according to the degree of the
dental visits are better among the non diabetic control showed that there was non significant
group(23), other result showed the diabetics were difference between them this result agreed with
somewhat less likely to visit their dentists for several studies that found there were no
routine examination(24) the possible explanation, associations between the metabolic control of
apart from their medical status, was a lack of disease and dental caries in the studies groups
(6,8,11,12)
dental health education among the diabetic group. , and disagreed with other study that was
Regarding to the tobacco use the result showed found the risk of dental caries was increased
there was high difference in the distribution of among poorly controlled patients than well-
smoking in the diabetic group than control this controlled DM and non diabetic control subjects
(28)
result disagreed with Moore et al. study which .
was found that tobacco use in diabetic subjects The present study confirmed that the presence
and oral health behavior were similar to those of of dental caries was not significantly elevated in
non-diabetic subjects. (25). most diabetic patients, but suggested that it
Regarding to the blood glucose level the increased with age as well as with the increase of
values of FBGL and RBGL were higher among the blood glucose level. Furthermore the diabetic
diabetics than non-diabetic subjects. It is well- patients should be improving the general and oral
established that poor glycemic control among the health behaviors.
diabetic patient than non diabetic patients(22). In
this study, it was observed the severity of dental
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Table 1: The distibution of the diabetic and control subjects according to the age and gender
Patient Age
No. % Gender No. %
condition ( years)
40-50 60 33.3% Males 76 42.2%
Diabetic 51-60 60 33.3% Females 104 57.8%
patient 61-70 60 33.3%
Total 180 100% Total 180 100%
Non 40-50 60 33.3% Males 70 38.9%
diabetic 51-60 60 33.3% Females 110 61.1%
patients 61-70 60 33.3 %
(Control) Total 180 100 % Total 180 100%
Table 2: The mean value of the dental caries among diabetic and non-diabetic patients
Caries Patient
No. Min. Max. Mean SD t - test
experience condition
Diabetic 180 0 11 2.11 1.46
DT NS
Control 180 0 7 1.93 1.63
Diabetic 180 0 32 10.84 7.27
MT 2.32 *
Control 180 0 28 9.17 6.32
Diabetic 180 0 6 1.03 1.37
FT 2.843 *
Control 180 0 7 1.47 1.56
Diabetic 180 2 34 14.04 7.06
DMFT NS
Control 180 1 28 12.65 8.22
* Significant, P< 0.05
** Highly significant, P< 0.01
Table 3: Correlation between the DMFT and age among diabetic and control groups
Patient condition r-value P-value Significance
Diabetic 0.531 0.000 Highly significance
Control 0.482 0.000 Highly significance

Table 4: Oral health behavior among diabetic and non diabetic patients
Diabetic patients Non diabetic (control)
Variables P -value
No. % No. %
Tooth brushing frequency
NON 72 40 46 26
X = 14.79**
1/ day 43 24 48 27
P = 0.005
2/ day 23 13 44 24
df = 4
3/ day 6 3.3 2 1.1
irregular 36 20 40 22
Oral cleaning methods
X = 4.711
Brush 87 48 80 44
P = 0.09 NS
Brush + floss 21 12 36 20
df = 2
No 72 40 64 36
Regular dental visit
X = 0.93
Yes 15 8.3 20 11
P = 0.062 NS
No 79 44 80 44
df = 2
Sometimes 86 48 80 44
Smoking X = 12.33**
Yes 43 24 18 10 P = 0.000
No 137 76 162 90 df = 1
** Highly significant, P< 0.01
Table 5: Mean of the blood glucose level among diabetic and non diabetic patients
Blood glucose Patient
No. Mean SD t- test
level condition
FASTING BLOOD Diabetic 180 171.26 48.23
22.495**
GLUCOSE LEVEL Control 180 88.14 11.46
RANDOM BLOOD Diabetic 180 265.75 70.93 26.251**
GLUCOSE LEVEL Control 180 123.31 16.37
** Highly significant, P< 0.01, df = 358
Table 6: Correlation between the DMFT and fasting blood level, random blood glucose level,
duration of the disease among diabetic groups
Patient Variable r-value p-value Significance
Fasting blood glucose level 0.198 0.008 Highly significance
Random blood glucose level 0.186 0.024 Significance
Duration of the disease 0.079 0.293 Non significance
Table 7: Medical characteristic of the diabetic group

Diabetic patients
Variables z-test p-value
No. %
Disease duration ( years)
< 5 years 102 56.7 2.462 0.048*
5 10 years 56 31.1 2.147 0.049*
> 10 years 22 12.2
Physician follow up
< 3 month 78 43.3 4.985 0.028*
3 month- 1 year 28 15.6 4.023 0.031*
> 1 year 74 41.1
Degree of the control of the
diabetic state
Well controlled 119 66.1 3.024 0.044*
Poor controlled 61 33.9
* Significant, P< 0.05

Table 8: Comparison between the DMFT of the well diabetes control and poor diabetes control
Patient condition No. Min. Max. Mean SD t-test
Well Diabetic Control 119 2 34 13.92 7.74
NS
Poor Diabetic Control 61 6 28 14.28 5.59
DMFT of diabetic DMFT Non diabetic
18
16
14
12
DMFT
10
8
6
4
2
0
40-50 51-60 61-70
Age (years)
Figure 1: Distribution of the dental caries according to the age among diabetic and non diabetic
patients
FBGL RBGL
400
350
Blood glucose level
300
250
200
150
100
50
0
0-5 610 1115 16-20 21-25 26-30 31-35
DMFT
Figure 2: The relation between the blood glucose level ad dental caries among diabetic patient
18.73
20
18
14.36
16
14 11.61
12
10
DMFT 8
6
4
2
0
< 5 years 5-10 years > 10 years
duration of the disease
Figure 3: The relation between the dental caries and the duration of the diseases in diabetic
patient

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Dental knowledge
Dental knowledge and behavior among technical medical

institute students in Baghdad governorate
Jinan Mohammed Rashad B.D.S., M.Sc. (1)
ABSTRACT
Background: Oral health knowledge is important for promotion and maintenance of oral health. This study aims to
find out the difference in oral health knowledge and behavior of medical and dental students in technical medical
institute in Baghdad governorate.
Materials and Methods: A questionnaire survey was carried on 202 Iraqi students in technical medical institute of Bab
Al-Muadam quadrant in Baghdad governorate (92 dental students and 110 medical students). Students were invited
to complete a set of questionnaires on dental knowledge and behaviors that are related to oral hygiene and dental
visits.
Results: Highly significant differences were shown between medical and dental students related to dental
knowledge, dental students were found to have more dental knowledge than medical students. Concerning the
typical method for caries prevention, 90.2% of dental students compared to 35.5% of medical one were aware that
brushing regularly, minimizing sweets, visiting the dentist and the use of fluoride are all effective means of avoiding
caries. For oral hygiene behavior, dental students were practicing twice daily tooth brushing, flossing and rinsing in a
proportion greater than medical students. Irregular visits to the dentist were found to be common among both
medical and dental students and toothache was the major factor for dental visits in both groups. The lecturers were
found to be the most effective source of dental information for dental students, while the most effective source of
information for medical students was the family.
Conclusion: The results of this study indicate that knowledge and behavior toward oral health and dental care
especially for the medical students need to be improved and there is a need for inclusion of oral health education in
the medical curriculum.
Key words: Knowledge, behavior, dental visits. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):115-119).
INTRODUCTION Most researchers recommend tooth brushing

Oral diseases constitute a major public twice a day and agree that when performed with
problem (1), among common oral diseases; caries fluoride toothpaste, it could also reduce dental
is the foremost oral pathology that remains widely caries (8-10). However, a recent systematic review
prevalent and affects all populations throughout of the available evidence has shown that tooth
the life span. This disease not only causes damage brushing plays a limited role in caries prevention
(11)
to the tooth, but is also responsible for several , because brushing alone is not sufficient in
morbid conditions of the oral cavity and other cleaning the proximal surfaces of teeth. As such,
systems of the body (2). The prevalence of caries is using dental floss is therefore also recommended
declining in developed countries, increasing in to further help in preventing both dental caries
less developed countries and is an epidemic in and periodontal disease (12, 13). Limiting the
countries with emerging economies (3). Decline in consumption of sugar- containing foods is also
prevalence in developed countries has been important in preventing periodontal disease and
associated with improved oral hygiene practices tooth decay. Added sugar (two thirds of which
and several preventive programs unlike comes from confectionery, table sugar, and soft
developing countries where the focus is mostly on drinks) poses the greatest threat to dental health
(14)
curative care (4). Dental caries has been considered . Oral health knowledge is considered to be an
as a behavioral disease because adoption of essential prerequisite for health-related behavior,
healthy oral habits is crucial in controlling it. although only a weak association seems to exist
Traditionally, good oral health practice consists of between knowledge and behavior in cross-
continuous implementation of 2 broadly defined sectional studies (15, 16). Studies have shown that
sets of behavior: self-care habits (dental hygiene, there is an association between increased
restriction of sugar products, use of fluoride knowledge and better oral health (17, 18). To date,
products) and utilization of dental services information is limited regarding the publics
(regular dental examinations, oral health knowledge and attitude about dental caries and its
education, and professionally applied preventive prevention especially among college and institutes
measures) (5). Many methods are available for students. Therefore, this study aimed to
maintaining optimal oral hygiene, among which investigate the level of dental knowledge among
tooth brushing is the most widely accepted students of technical medical institute, and to
method for the prevention and control of determine their practices of oral care.
periodontal diseases (6, 7).

MATERIALS AND METHODS that dental students had a higher proportion of

This survey was carried out on 202 students correct answers than medical students, the
of technical medical institute in Bab Al- Muadam differences were highly significant P<0.001.
quadrant (92 dental students including 21 male The opinion of dental students on how to
(22.8%) and 71 female (77.2%) selected from prevent dental caries was very promising
preventive and prosthodontic departments with a compared to medical students as seen on Table
mean age of 19.9, and 110 medical students (2), 90.2% of dental students compared to 35.5%
including 55 male (50%), and 55 female (50%) of medical one were aware that brushing
selected from different medical departments in the regularly, minimizing sweets, visiting the dentist
institute with a mean age of 20.8. The survey was and the use of fluoride are all effective means of
based on collection of 16 item questionnaire. avoiding caries, a highly significant level was
Students from second class were invited to found concerning the typical method for caries
complete the questionnaire forms in their prevention.
classrooms after lectures. The questionnaire Table (3) illustrates dental behavior among
included the following aspects (first) general dental and medical students, significantly more
questions related to the name, age, sex, (second) dental students than medical one brush their teeth
information about knowledge and (third) at least twice a day (65.2% versus 50%
information regarding their oral heath behavior. respectively). 35.5% of medical students didnt
Knowledge was measured by asking questions know whether they used fluoridated or not
related to role of sugar, bacteria and soft drinks in fluoridated tooth paste compared to 7.6% of
dental caries, causes, prevention, and treatment of dental students, the difference was highly
dental caries and whether extraction of teeth is the significant P<0.001. greater proportion of dental
best treatment for painful teeth or not. Oral health students used tooth picks and mouth wash
behaviors were measured by asking questions (60.9%, 59.8% respectively), while only 25.5% of
about frequency of tooth brushing, and use of medical students used dental floss and 35.5% of
cleaning aids other than toothbrush (flossing, use them reported to use mouth wash, difference was
of mouthwash), use of fluoride toothpaste (yes, highly significant for dental floss use, while a
no, don't know), consumption of sugar-containing significant different was found for mouth wash
and sugar free products and behavior related to use. Both dental and medical students have visited
visits to the dental clinics (last dental visit and the dentist and treatment of dental caries being the
reason for last dental visit). The data were most common cause for the visit (67.4% and
analyzed using the SPSS. Differences were 78.2% respectively) P<0.05.
assessed by the chi-squared test. The significance Table (4) shows different sources of oral health
level (P-value) was set at 0.05. information, statistically highly significant
difference was found between medical and dental
students regarding different sources of
RESULTS information P<0.001 , for dental students it seems
Table (1) shows dental knowledge among that the most effective source of information was
dental and medical students in the institute, out of the lecturers as recommended by 60.9 %, while
92 dental students 77.2% knew that the main 15.2% recorded that the family was the second
causes of tooth decay were bacteria, sugar educating source. Teacher or newspapers were
consumption and weak enamel, the majority of indicated as sources of information by 2.2%. For
dental students (79.3%) believed that sugar free or medical students the most effective source of
diet drinks were harmful to teeth, and 89.2% of information was the family as mentioned by
them thought that extraction is not the only 28.2%, the dentist coming as the second source of
treatment for a painful tooth. Although, half of information (19.1%), while the lecturers were
medical students thought that sugar free or diet indicated as a source of information by only 8.2%.
drinks were harmful to teeth, only a small
proportion of them (5.5%) knew that the main
causes of tooth decay were bacteria, sugar DISCUSSION
consumption and weak enamel, and more than This is the first study to determine the
half of them (69.1%) believed that extraction is knowledge and behavior of dental health among
the only treatment for a painful tooth. Only few students at the technical medical institute in Bab
dental students (15.2%) didnt know whether Al-Muadam, so it forms a baseline description of
mouth wash benefit the mouth or not, while oral health behavior of medical and dental
(42.7%) of medical students didnt know whether students in the institute, in future these
mouth wash benefit the mouth or not. It is clear information might be benefit in the planning of
preventive programs among institute students. In

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Table 1: Knowledge of Dental Health among Dental and Medical Students.

Dental Medical Statistical
2-
Item description No (%) significant
No (%) value
level
Sugar consumption only 8(8.7) 59(53.6)
Causes
Sugars consumption and weak enamel 9(9.8) 22(20) HS
of 110.6
Bacteria and sugar consumption 4(4.3) 23(20.9) P<0.001
caries
Bacteria, sugar consumption and weak d.f=3
71(77.2) 6(5.5)
enamel
Does sugar free or Yes 73(79.3) 54(49.1) HS
diet drinks are 17.55 P<0.001
No 19(20.7) 56(50.9)
harmful to teeth d.f=1
Does extraction the Yes 10(10.8) 76(69.1) HS
only treatment for 11.81 P<0.001
No 82(89.2) 34(30.9)
painful teeth d.f=1
Yes 78(84.8) 57(51.8) HS
Does mouth wash
No 0(0) 6 (5.5) 25.71 P<0.001
benefit the mouth
Dont know 14(15.2) 47(42.7) d.f=1
HS: Highly significant
Table 2: The Number and Percentage of Dental and Medical Students Opinions in the Way to
Prevent Caries.
Dental Medical
No (%) No (%)
Brushing regularly 6 (6.5) 27 (24.5)
Typical
Visit dentist 1(1.1) 9 (8.2)
method
Use of fluoride 0(0) 7 (6.4)
for caries
prevention Minimize sweets 1(1.1) 9 (8.1)
All of the above 83 (90.2) 39 (35.5)
I dont know 1 (1.1) 19 (17.3)
2 = 108.7, P<0.001, d. f = 5
Table 3: Oral hygiene behaviors among dental and medical students
Dental Medical Statistical significant
Item description 2-value
No (%) No (%) level
Tooth Less than once a day 0 (0) 0 (0) S
brushing Once a day 32(34.8) 55(50) 4.73 P<0.05
frequency More than once a day 60(65.2) 55(50) d.f=1
Uses of Yes 75(81.5) 45 (40.9) HS
fluoride No 10 (10.9) 26 (23.6) 35.50 P<0.001
tooth paste Dont know 7 (7.6) 39(35.5) d.f=2
Yes 56 (60.9) 28 (25.5) HS
Use of dental
25.80 P<0.001
floss and tooth picks No 36 (39.1) 82 (74.5)
d.f=1
Yes 55 (59.8) 39 (35.5) S
Use of mouth wash 11.92 P<0.05
No 37(40.2) 71 (64.5)
d.f=1
Less than one year 54 (58.7) 34 (30.9) 24.97 HS
Last dental visit More than one year 11 (12) 19(17.3) P<0.001
Tow years and more 27 (29.3) 57 (51.8) d.f=2
Examination/ prevention 30 (32.6) 24 (21.8) S
Purpose of visit 8.02 P<0.05
Treatment 62 (67.4) 86(78.2)
d.f=1

Table 4: Number and Percentage of sources of oral health information

All the previous information known from
Family Dentist Doctor Teacher Lecturers T.v. And radio Newspapers Others
No. % No. % No. % No. % No. % No. % No. % % N No.% %
Dental 14 15.2 7 7.6 0 0 2 2.2 56 60.9 5 5.4 2 2.2 6 6.5
Medical 31 28.2 21 19.1 7 6.3 12 10.9 9 8.2 17 15.5 7 6.3 6 5.5
2 = 69.82, HS P<0.001, d. f = 7

J Bagh College Dentistry Vol. 24(special issue 1), 2012 A new calibration
A new calibration procedure for expectation of arch length

Mustafa M. Al-Khatieeb, B.D.S., M.Sc. (1)
Layth M. K. Nissan, B.D.S., M.Sc. (1)
Mushriq F. Al-Janabi, B.D.S., M.Sc. (2)
ABSTRACT
Background: The aim of the current study was to determine the relationship between arch length and different arch
widths, and the possibility of using different arch widths as predictors for expectation of arch length in upper and
lower dental arches and in both genders. The current study is a first attempt to select the patients on the basis of
gender in regard to different dental arch widths and length.
Subjects and method: The sampling procedure comprised 120 pairs of upper and lower dental casts of untreated
Iraqi adult subjects (60 male and 60 females) aged 17 -27 years old. The dental study casts of both upper and lower
dental arches were scanned and digitized by special procedure, six inter-arch widths and the arch length were
traced on images of upper and lower dental arches by the digitization procedure.
Results: Students t-test showed no marked gender differences for all measurements in both upper and lower dental
arches, regarding the inter-relation between upper and lower dental arches, there were significant correlation
coefficients at 0.01 level for the different arch widths and length, the predictability of the relationship between the
arch length and the inter-central incisor width in the upper arch was found to be very strong, while in the lower arch
the predictability of the relationship between the arch length and the inter-central incisor width was also found to
be very strong, but it was just found to be strong between the lower arch length and the lower inter-first premolar
width.
Conclusions: The manner of strong correlation between different arch widths and length may be due to that the
dental arch variables are acting together as a single biological unit, rather than a collection of discrete entities. From
the stepwise multiple linear regression analysis, it can be concluded that the upper inter-central incisor width plays an
important role in the prediction of the upper dental arch length, while in the lower arch, the lower inter-central
incisor and inter-first premolar widths play the same important role in the prediction of the lower dental arch length.
Keywords: Calibration procedure, Expectation, Different arch widths and length. (J Bagh Coll Dentistry 2012; 24(sp.
Issue 1):120-126).
, :
,
,
,
, ,

,

.
INTRODUCTION The attainability of an ideal arch length,

The knowledge of the standards of the dental anterior arch width, posterior arch width and other
arch measurements and analysis of different dental arch dimensions is influenced by many
relationships are the vital issue and the factors including the relationship between the
fundamental bases in orthodontic treatment total mesiodistal width of maxillary and
planning. Furthermore, the great value of mandibular teeth(2-3). During the comprehensive
understanding the dental arch measurements to orthodontic treatment, the inter-canine width can
clinicians in the different fields of dentistry be increased, but many authors (6-8) stated that any
besides orthodontics such as prosthodontics and change to the lower inter-canine width was
orthognathic surgery, and they are of great interest unstable; therefore, the original width has to be
to anthropologists in studying the dental arch in maintained to increase the long term stability,
relation to different genetic and physical factors nevertheless, it is preferred for reasons of stability
for different populations (1-2). The goal of every not to increase the inter-canine width more than 1
comprehensive orthodontic treatment is to obtain mm (9). Ricketts et al. found that for each one
optimal occlusion, overjet, overbite, esthetic and millimeter of arch width increase at the canines
function. and molars, arch length was increased by 1mm
and 0.25 mm respectively (10).
Expectation of the change in arch length in
relation to different arch widths could be helpful
in orthodontic treatment planning (11-15). Methods
(1) Lecturer, Department of Orthodontics, Dental College, to assess the arch length are abundant:
University of Baghdad. determination of a line drawn with devices such
(2) Assistant Professor, Department of Orthodontics, Dental as the dental pantograph (16), or the cubic
College, University of Baghdad.

craniophore (17), measurements with a caliper that The scanning procedure was done in a dark
involve subtraction of the amount of crowding, room during which the dental casts were
addition of the amount of spacing, or both to the surrounded with a millimetric ruler, hence when
sum of the mesiodistal crown diameters and the magnification of the millimetric ruler is
determination of the length of curves obtained by known; the dental casts magnification in the
mathematical functions such as expotential (8), image produced can be determined. The images
logarithmic (19), parabolic (20), cubic spline(21), and from the scanning process were then imported
polynomial(22) functions. While the relationship into AutoCAD software program 2011 on a laptop
between arch length and alterations in dental arch computer (HP); Pavilion DV6 2170ee, core I
width, the form of anterior teeth and the 7, 1.6 GHz (8CPUs), 6 GB RAM, and 1 GB video
remaining posterior teeth was studied by other card with DirectX 11 version, where the
authors (8,14,23). Studying the relation between digitization and calibration of the dental casts was
arch length and different arch widths and the use performed with the aid of the mouse as a user
of such different arch widths as predictors for interface for the digital method, so the AutoCAD
expectation of arch length have not been reported software can determine the magnification in the
previously, therefore, the goal of the current study scanned image from the millimetric ruler and
was to determine the relationship between arch specify the scale factor so that all the
length and different arch widths, and the measurements will be in millimeters and without
possibility of using different arch widths as any magnification.
predictors for expectation of arch length in upper
and lower dental arches and in both genders.

The sampling procedure comprised 120 pairs of
upper and lower dental casts of untreated Iraqi
adult subjects (60 male and 60 females) aged 17 -
27 years old attending the Orthodontic
Department at the College of Dentistry,
University of Baghdad, and private clinics in
Baghdad city. The dental casts were selected from
385 subjects according to the following inclusion
criteria:
1. All the subjects were classified as Angle's Figure 1: Scanning of study models.
class I with minor crowding (less than 3 mm) (24).
2. All had permanent dentition from first molar
to first molar without gingival overlapping on the
surface of any tooth (no gingival enlargement).
3. The teeth had no evident loss of mesio-distal
crown width due to dental caries, crown fracture,
pathological wear, or congenital defects.
4. No previous history of orthopedic,
orthodontic, or orthognathic surgery.
5. No cross bite or open bite relationships.
Digitization:
Scanning the study models (Figure 1):
The dental study casts of both upper and lower
dental arches were placed approximately in the
middle of the scanning surface (flat-bed) of a Figure 2: landmarks were traced and
Hewlett Packard (HP) Scan Deskjet (F 2410) and verified in the images of upper and lower
scanned with the following scanner specifications: study models using the AutoCAD computer
- Scanner type Flat- bed (215 x 297 mm). program 2011.
- Scan resolution (optical) up to 1200 dots per
square inch.

4. Inter-first premolar width (R4L4): The

linear distance between the buccal cusp tip
points of the right and left first premolars in
the upper and lower dental arches (26, 27).
5. Inter-second premolar width (R5L5): The
linear distance between the buccal cusp tip
points of the right and left second premolars
in the upper and lower dental arches (26).
6. Inter-molar width (R6L6): The linear
distance between the mesiobuccal cusp tip
points of the right and left first permanent
molars in the upper and lower dental arches
(14, 26, 27)
.
Figure 3: Linear measurements for both 7. Arch length (AL): Ideal line between
arches every mesial and distal contact point of each
Landmarks identification (Figures 1 and 2): permanent tooth from the mesial of the first
The following landmarks were traced and molar to the mesial of the first molar of the
verified in the images of upper and lower study opposite side in the upper and lower dental
models using the AutoCAD computer program arches(14, 26).
2011: Statistical method
1. Mid-incisal points (R1, L1, R2 and L2) : The data obtained from digitization measuring
The midpoint of the incisal edges of the right procedure were subjected to computerized
and left central, and lateral incisors statistical analysis by using Statistical Package for
respectively, in the upper and lower dental Social Science (SPSS Inc.; version 17.0 ) to get
arches (25, 26). descriptive analysis (minimum, maximum, mean
2. Canine points (R3 and L3): The cusp tips and standard deviation) and to compare
of the right and left permanent canines in the measurements between the males and females
upper and lower dental arches (14, 25, 26). using independent sample t-test. Pearson's
3. First premolar cusp tips (R4 and L4): The correlation coefficient was used to show the
buccal cusp tips of the right and left first correlation between the arch length and the
premolars in the upper and lower dental different arch widths. Furthermore, the multiple
arches (26, 27). linear regression model was applied on the
4. Second premolar cusp tips (R5 and L5): variables to investigate if there was a valid
The buccal cusp tips of the right and left regression equation among these variables. The
second premolars in the upper and lower multiple linear regression equation based on the
dental arches (26, 27). following formula:
5. Mesiobuccal cusp tips of first permanent = + B1X1 + B2X2 + B3X3 + B4X4 + B5X5 + B6X6 + .
molar (R6 and L6): The mesiobuccal cusp : The value of dependent variable which is the
tips of the right and left first permanent arch length
molars in the upper and lower dental arches : The regression constant.
(14, 26, 27)
. B1, B2 - B6 : The regression coefficients of each
Linear measurements (figures 2 and 3): variable respectively.
The following linear dental arch measurements X1, X2 - X6 : The values of independent variables
were performed: (predictors) which are the different arch widths
1. Inter-central width (R1L1): The linear (inter- central, inter-lateral, inter-canine, inter-first
distance between the midincisal points of the premolar, inter-second premolar and inter-molar
right and left central incisors in the upper and widths respectively).
lower dental arches (26). Method errors: Ten pairs of dental casts
2. Inter-lateral width (R2L2): The linear (maxillary and mandibular) from the current study
distance between the midincisal points of the were randomly selected, the reproducibility of the
right and left lateral incisors in the upper and digitization measurements was analyzed by intra-
lower dental arches (26). and inter-examiner calibrations, the coefficient of
3. Inter-canine width (R3L3): The linear variation was used to determine the method errors
distance between the cusp tip points of the (coefficient of variance = standard deviation x
right and left permanent canines in the upper 100 /mean) (14,28,29). All coefficients of variation
and lower dental arches (14, 26). were very low (below 6.8 per cent) which were

1.01 to 6.11, and 1.3 to 6.7 for intra- examiner different dental arch widths and length.
and inter-examiner calibrations respectively. Subsequently, because there were no marked
gender differences for all measurements in both
RESULTS AND DISCUSSION upper and lower dental arches using students t-
The dental study casts have always been used as test, therefore Pearsons correlation coefficient
an important basic tool in orthodontic diagnosis was conducted on both dental arches not
and treatment planning, telling us about the assuming the gender as principle guideline for
patients occlusion in three planes of space, correlation between the variables. The Pearson
traditionally the casts have been held in the form correlation coefficients were found significant at
of physical plaster models, which are subjected to the 0.01 level (2- tailed) between the dental arch
loss, fracture and degradation. Digital storage length and the different arch widths (inter-central
eliminates inherent problems related to physical incisor, inter-lateral incisor, inter-canine, inter-
storage of models with up to 17 m3 of storage first premolar, inter-second premolar and inter-
space required for storage of traditional models molar widths) measured by the digitization
for one thousand patients (30). The current research process.
replaces the plaster models with virtual In the upper dental arch, the correlation
information, which has further potential merits coefficient (r) values obtained ranged from 0.423
including: to 0.810 and the p-values equal to 0.000, as shown
1- Virtual images may be transferred anywhere in in table 2, while in the lower dental arch, the
the world for instant referral or consultation. correlation coefficient (r) values ranged from
2- Instant accessibility of the information 0.370 to 0.731 and the p-values equal to 0.000, as
without the need for retrieval of plaster models shown in table 3. Regarding the inter-relation
from a storage area. between upper and lower dental arches, there
3- The ability to perform accurate and simple were significant correlation coefficients at 0.01
diagnostic setup. level (2-tailed) for the different arch widths and
There is no data related to expectation of dental length, the r values ranged between 0.246 to
arch length based on different dental arch widths. 0.696, and the p-values equal to 0.000 except for
The descriptive statistics and gender difference the upper inter-lateral incisor width and the lower
for all the linear measurements (different arch inter-molar width, the upper inter-second
widths and arch length) of upper and lower dental premolar width and lower inter-first premolar
arches were shown in table 1. It is obvious that width, and the upper inter-second premolar width
the mean values of all measurements confirmed and lower inter-molar width, there were
the accepted view that the maxillary dental arch is significant correlation coefficients at 0.05 level
larger in measurements than that in the (2-tailed), the r values were 0.193, 0.213 and
mandibular counterpart. This is in consistence 0.229, and the p-values equal to 0.035, 0.019, and
with the principle that the maxillary dental arch 0.012 respectively as shown in table 4.
overlaps the mandibular dental arch (31-34). This manner of strong correlation between
There were no significant gender differences for different arch widths and length within the same
all the measurements in both the upper and lower dental arch and between the upper and lower
dental arches using Students t-test as shown in dental arches may be due to their cross interaction
table 1, this may be due to the inclusion criteria of between each other, so the dental arch variables
the sample collected in which all the subjects are acting together as a single biological unit
were Angles class I with minor crowding, rather than a collection of discrete entities, thus
furthermore, the methodology of digitization indicating that changes in one magnitude may be
procedure by scanning of the study models may directly related to the other.
play another role in the non- significant difference The stepwise multiple linear regression analysis
which is considered as an accurate measuring of the inter-central incisor, inter-lateral incisor,
procedure (35, 36). Gender differences in tooth inter-canine, inter-first premolar, inter-second
dimension have been reported in literatures. premolar and inter-molar widths (the independent
Males generally have larger teeth than females (37, variables) which were used to predict the dental
38)
. However; there is a lack of agreement arch length (the dependent variable) represented
regarding sex differences in relation to tooth size by the following equation:
dimension. Although some studies described a = + B1X1 + B2X2 + B3X3 + B4X4 + B5X5 + B6X6 + .
difference (39,40), while others reported no
differences in dimension (41, 42). : The value of dependent variable which is the
The current study is a first attempt to select the arch length
patients on the basis of gender in regard to : The regression constant.

B1, B2 - B6 : The regression coefficients of each equal to 3.911 and 2.259, and p-values equal to
variable respectively. 0.000 and 0.026 respectively.
X1, X2 - X6 : The values of independent variables The current findings cannot be compared with
(predictors) which are the different arch widths other researches (14, 37, 38), since those authors used
(inter-central, inter- lateral, inter-canine, inter-first a completely different methodology for
premolar, inter-second premolar and inter-molar evaluation, and it was applied on non-orthodontic
widths respectively). treatment patients and not for patients who had
Upper dental arch equation: (Equation 1) undergone an orthodontic treatment.
(AL) = + B1(R1L1) + B2(R2L2) + B3(R3L3) + It is known that the establishment of regression
B4(R4L4) + B5(R5L5) + B6(R6L6)+ . equations is strongly dependent on a considerable
large sample size of population, while the current
(AL) = + 2.59(R1L1) + 0.18(R2L2) study has been done with a relatively not very
+0.03(R3L3) + 0.10(R4L4) + 0.003(R5L5) + large number of subjects due to the inclusion
0.10(R6L6)+ . criteria. Because of this, the employment of
T= 6.520 4.385 1.276 0.208 0.507 0.016 0.809
P= 0.000 0.000 0.205 0.836 0.613 0.987 0.420
regression analysis with future studies will be
F=14.032 P=0.000 R2=0.427 very helpful to the scientific community by too
The multiple correlation coefficients R- square much increasing the sample size, testing statistical
were equal to 0.427, and p-value was equal to tests dealing with uncertainties, and finally
0.000, explained a highly significant correlation responding to questions poorly clarified in the
between the different arch widths (independent current study, furthermore; it would be of interest
variables) and the arch length (dependent to test the current regression equation for
variable). The predictability of the relationship prediction of arch length using a group of young
between the arch length and the inter-central persons to further examine its validity.
incisor width in the upper arch was found to be
very strong (T= 4.385, and p = 0.000), as shown Clinical importance
above in equation 1. The present findings must be considered in the
The lower dental arch equation: (Equation 2) space analysis, general and individual characters
(AL) = + B1(R1L1) + B2(R2L2) + B3(R3L3) + of malocclusion treatment, and proper treatment
B4(R4L4) + B5(R5L5) + B6(R6L6)+ . planning in designing of the dental arch
expansion, furthermore, the knowledge of dental
(AL) = +4.19(R1L1) + 0.21(R2L2) arch length and different arch widths is mandatory
+0.05(R3L3) + 0.47(R4L4) + 0.23(R5L5) + to have a stable orthodontic end result.
0.10(R6L6)+ .
T=2.536 3.911 0.595 0.262 2.259 1.751 0.674
P= 0.013 0.000 0.553
2
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1987; 14: 293-7. 44. Germane N, Lindauer SJ, Rubenstein LK, Revere JH,
26. Taner T, Cigar S, Hakan EL, Germe D, Alphan ES. Isaacson RJ. Increase in arch perimeter due to
Evaluation of dental arch width and form changes orthodontic expansion. Am J Orthod Dentofac Orthop
after orthodontic treatment and retention with a new 1991; 100: 421-7.
computerized method. Am J Orthod Dentofac Orthop
2004; 126 (4): 464 75.

Table 1: Descriptive and comparative statistics for both genders in the upper and lower dental
arches.
Gender difference
Total (N=120) Males (N=60) Females (N=60)
(D.F.=118)
Variables
Min. Max. Mean Min. Max. Mean Min. Max. Mean
S.D S.D S.D t-test p-value
(mm) (mm) (mm) (mm) (mm) (mm) (mm) (mm) (mm)
R1L1 8 10.8 9 0.55 8.2 10.8 9.02 0.6 8 10.5 8.9 0.51 0.43 0.66(NS)
R2L2 17.5 27 21.9 0.97 18.5 27 22.05 0.07 17.5 26.8 21.8 1.87 0.53 0.59(NS)
Upper
Dental R3L3 28.8 39 33.4 2.2 30 39 33.47 2.39 30 38 33.33 2.01 0.33 0.73(NS)
Arch R4L4 35 47.5 41.41 2.02 38.2 47.4 41.41 2.04 35 47 41.4 2.02 0.03 0.97(NS)
R5L5 40 54 45.6 1.98 42 54 45.7 2.11 40 52 45.6 1.85 0.05 0.96(NS)
R6L6 44 57 51.3 2.29 44 57 51.2 2.48 48 56.8 51.4 2.09 0.6 0.55(NS)
AL 66 79 70.6 2.94 66 79 70.9 3.06 66 78.5 70.4 2.83 0.83 0.40(NS)
R1L1 4.5 6.5 5.28 0.43 4.7 6.5 5.29 0.43 4.5 6.5 5.27 0.43 0.35 0.72(NS)
R2L2 13.6 17.9 15.88 0.81 13.6 17.9 16.08 0.88 14.6 17.7 16.6 0.69 2.6 0.08(NS)
Lower
Dental R3L3 22 29.5 25.26 1.83 22 29.5 25.55 1.08 22 29.2 24.9 1.83 1.73 0.09(NS)
Arch R4L4 28.3 38.5 34.16 1.68 28.3 38.5 34.13 1.84 32 38.3 34.1 1.51 0.17 0.86(NS)
R5L5 34 46.7 39.9 2.71 34 46.7 39.9 2.94 35 46.7 39.8 2.48 0.17 0.85(NS)
R6L6 42 53 44.7 2.69 40 53 45.02 2.62 42 53 44.3 2.77 0.75 0.45(NS)
AL 53 74 62.56 3.91 53 74 62.55 4.52 57 73 62.5 3.23 0.04 0.96(NS)
R1L1:Inter-central width, R2L2: Inter-lateral width, R3L3: Inter-canine width, R4L4: Inter-first premolar width, R5L5: Inter- second premolar
width, R6L6: Inter-molar width, and AL: Arch length. NS: Non-significant (P>0.05).
Table 2: Correlation between the variables for total gender in the upper arch
Upper DentalArch AL R6L6 R5L5 R4L4 R3L3 R2L2
r=0.637** r=0.588** r=0.627** r=0.634** r=0.629** r=0.592**
R1L1
P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.000
r=0.468** r=0.454** r=0.488** r=0.503** r=0.520**
R2L2
P=0.000 P=0.000 P=0.000 P=0.000 P=0.000
r=0.423** r=0.472** r=0.513** r=0.534**
R3L3
P=0.000 P=0.000 P=0.000 P=0.000
r=0.475** r=0.605** r=0.810**
R4L4
P=0.000 P=0.000 P=0.000
r=0.428** r=0.612**
R5L5
P=0.000 P=0.000
** Correlation is significant at the 0.01 level (2-tailed)
r=0.452**
R6L6
P=0.000
Table 3: Correlation between the variables for total gender in the lower arch
Lower Dental Arch AL R6L6 R5L5 R4L4 R3L3 R2L2
r=0.731** r=0.467** r=0.700** r=0.716** r=0.685** r=0.501**
R1L1
P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.000
r=0.375** r=0.372** r=0.510** r=0.398** r=0.438**
R2L2
P=0.000 P=0.000 P=0.000 P=0.000 P=0.000
r=0.518** r=0.408** r=0.470** r=0.522**
R3L3
P=0.000 P=0.000 P=0.000 P=0.000
r=0.633** r=0.370** r=0.569**
R4L4
P=0.000 P=0.000 P=0.000
r=0.602** r=0.385**
R5L5
P=0.000 P=0.000
r=0.391**
R6L6 ** Correlation is significant at the 0.01 level (2-tailed)
P=0.000
Table 4: Correlation between variables of the upper and lower dental arches for total gender.
Lower Dental Arch
Variables
R1L1 R2L2 R3L3 R4L4 R5L5 R6L6 AL
r=0.629** r=0.687** r=0.508** r=0.408** r=0.509** r=0.336** r=0.462**
R1L1
P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.000
r=0.569** r=0.375** r=0.504** r=0.410** r=0.461** r=0.193* r=0.446**
R2L2
P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.035 P=0.000
r=0.492** r=0.475** r=0.413** r=0.316** r=0.395** r=0.354** r=0.390**
R3L3
Upper P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.000
Dental r=0.556** r=0.565** r=0.399** r=0.327** r=0.452** r=0.269** r=0.424**
Arch R4L4
P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.003 P=0.000
r=0.478** r=0.512** r=0.396** r=0.213* r=0.418** r=0.229* r=0.369**
R5L5
P=0.000 P=0.000 P=0.000 P=0.019 P=0.000 P=0.012 P=0.000
r=0.533** r=0.535** r=0.462** r=0.342** r=0.482** r=0.246** r=0.423**
R6L6
P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.000
r=0.696** r=0.509** r=0.502** r=0.464** r=0.617** r=0.338** r=0.582**
AL
P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.000 P=0.000
** Correlation is significant at the 0.01 level (2-tailed)
* Correlation is significant at the 0.05 level (2-tailed)

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Oral health status
Oral health status among children Downs syndrome in

Sumawa city, Iraq
Raya R. Al-Dafaai, B.D.S, M.Sc. (1)
ABSTRACT
Background: Down syndrome is a congenital autosomal anomaly characterized by generalized growth and mental
deficiency.This study was conducted to determine the oral health status of children with Down syndrome attending
special institute for mental retardation in Sumawa city at south region of Iraq in comparison with non syndromic
children.
Materials and methods: In the present study (35) children with Down syndrome (25 boys, 10 girls) were examined in Al-
rajaa institute of Sumawa city in the south region of Iraq for mentally retarded children. The same number of children,
matching the age and the gender of syndromic children, were chosen from school students in the same
geographical area. Caries severity, plaque, gingival and calculus indices were used for recording oral health status.
Results: This study revealed higher dmfs mean value among syndromic children at age (10-12) years old and higher
decayed surfaces of primary teeth at same age group with statistical significant differences. This study also showed
higher mean values of plaque and gingival index among children with Down syndrome than normal children with
highly significant differences.
Conclusion:It can be concluded from this study that children with Down syndrome have poorer oral health than
controls. They would benefit from frequent oral health assessment.
Key words:Down syndrome, mongolism, oral health. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):127-130).
It is common to find cases of periodontal disease

INTRODUCTION and lower incidence of caries in Down syndrome
Down syndrome is a genetic alteration in which patients (4). The higher prevalence of periodontal
the affected individuals carry an extra disease is probably related to the impaired host
chromosome 21. Children with Down syndrome response rather than to specific periodontal
have a smaller brain volume than other children pathogens (5). The low caries prevalence seems to
and improper neural development which might be be due to immune protection caused by the
responsible for the particular features of mental elevated salivary S. mutans specific IgA
retardation (1). The risk for this chromosomal concentrations (6). Previous Iraqi studies which
aberration is one out of 600-1000 live births. were conducted in the middle region of Iraq also
Down syndrome has also been referred to by the reported lower caries prevalence and poor oral
terms Trisomy 21, Trisomy G or Mongolism (2). hygiene among children with Down syndrome
Nine dental characteristics have been described in than normal non syndromic children (7,8).
children with Down syndrome. These are As there is no published data on the prevalence of
macroglossia (enlarged tongue), fissured tongue, the oral findings in Down syndrome children in
underdeveloped maxilla (upper jaw), tongue South Iraq, the present study will be carried out to
thrusting, congenitally missing teeth, determine the oral health status of a group of
malocclusion, high arch palate, increased children with Down syndrome attending special
salivation and microdontia (smaller than normal institute for mentally retarded children in Sumawa
teeth) (3). city at south region of Iraq.
Dental anomalies are very common, both in the
primary and permanent teeth, and in the patients
with Down syndrome, dental anomalies occur MATERIALS AND METHODS
with an incidence five times greater than in the The study is done after getting approval from
normal population(1). One of the most striking Ministry of Work and Social Affairs and Ministry
features of the facial characteristics of those with of Education for examining the children. All the
Down syndrome is the relative underdevelopment children with Down syndrome aged (6-12) years-
of the middle third of the face and the consequent old in Sumawa institute for mentally retarded
tendency to a Class III skeletal base relationship. children were examined. The sample of this study
(3)
. The teeth of these patients present complete was consisting of (35) child which considered the
mineralization, but with a great variation in the study group and including (25) boys and (10)
eruption pattern, although it maintains a certain girls. The comparative group was consisting of
similarity in the sequence and symmetry. normal non syndromic school students who were
randomly selected from nearby schools. They
were matching the number, age and the gender of
(1) Lecturer, department of preventive dentistry, College of study group and considered as control group. The
Dentistry, University of Baghdad. examination was done in the class room under

natural light using plane mouth mirror and sickle- found in schools children. Data analysis according
shaped explorer. Teachers were utilized for to gender could not be obtained due to small
communication and registration of information. number of females in the institute.
Decayed, missing and filled surfaces indices
(DMFS), (dmfs) were used for detection of caries DISCUSSION
in permanent and primary teeth according to The children with Down syndrome in this study
criteria described by WHO (9). Plaque (10), gingival had a higher incidence of dental caries than the
(11)
and calculus(12) indices were used for controls though not significantly so. The findings
recording dental plaque, gingival and calculus in this study contrasts previous studies that
conditions. Data analysis was conducted by reported a reduced rate of dental caries in children
application of (SPSS, version17). The Students t with Down syndrome (3,7,8)and agree with other
-test was applied and the probability was accepted study(3).This disagreement could be attributed to
at level of 5%. sample size, age range and different methods for
determining caries experience. Lower mean value
RESULTS of dmfs among children with Down syndrome at
Table (1) reveals the mean dmfs value for the age (6-9) years old and higher mean value at age
children with Down syndrome which was higher (10-12) years old could be explained by delayed
than normal children with no statistical significant primary teeth eruption and exfoliation among
difference (P 0.05). Also there was no children with Down syndrome. The differences in
statistically significant difference between the the eruption pattern were reported by many other
mean values of DMFS of the institution children studies(7,13,14) and could be responsible for the
and schools children. Higher mean value in dmfs higher decayed surfaces of primary teeth that had
of normal children than syndromic children were been reported in this study among syndromic
found at age (6-9) years old while the mean value children at age (10-12) years old than normal
of dmfs was lower in normal children at age(10- children. The higher missing surface of primary
12) years old with statistical significant teeth in controls at age (6-9) years old may be
differences(P 0.05). No statistical differences related to higher decayed surfaces at this age and
were found in DMFS mean values in different age neglect among even normal children as the child
groups. is receiving less dental care and dental treatment,
Table (2) shows that in both study and control if present, was directed towards extraction rather
groups, decayed fractions (ds/DS) contributing the than restoration. The higher mean values of
major component of (dmfs/DMFS) while the plaque and gingival indices with statistically
filled surfaces (fs/FS) were absence in both significant differences were observed in
groups. The mean values of decayed surfaces (ds) syndromic children. Other studies also showed
of primary teeth were higher in normal children at poor oral hygiene and gingival condition among
age (6-9) years old and lower at age (10-12) years Down syndrome children(7,15,16).The cause of the
old than syndromic children with statistically increased gingival inflammation in Down's
significant differences. The mean value of missing syndrome children is still unclear, secondary local
surfaces of primary teeth also was higher in factors such as malocclusion, crowding and lack
normal children than syndromic children at age of lip seal may be attributed to an increase of
(6-9) years old with statistically significant gingival inflammation among Down's
children. No significant differences were observed syndrome(17).This increase showed statistical
regarding the decayed and missing surfaces of differences at older age group due to obvious
permanent teeth malocclusion at this age as the permanent teeth
Table (3) shows higher mean values of plaque begin to erupt. The present study demonstrated
index and gingival index for study group than significant differences regarding caries and oral
controlswith statistically significant difference. cleanliness between children with Down
The significant difference was observed in mean syndrome and normal children which may
values of plaque and gingival index at (10-12) indicate that this type of disability may affect
years old where the syndromic group showed greatly the proper dental health and the ability to
higher values. Statistically no significant have better oral hygiene which could be due to the
difference was found between study and control local factors, or neglect among children with this
groups regarding calculus index. Calculus was not type of disability.
found in children with Down syndrome and fairly

Table 1: Caries severity of primary and permanent teeth in children with Down syndrome and
their controls (non syndromic children)
Down syndrome non syndromic
Age
Variables No. children children t-value
(years)
Mean SD Mean SD
6-9 14 8.14 6.78 17.21 13.90 -2.19*
dmfs
10-12 21 9.90 9.78 3.81 5.71 2.46*
Total 35 9.20 8.64 9.17 11.72 NS
6-9 14 3.00 5.42 1.71 2.75 NS
DMFS 10-12 21 3.05 1.65 3.33 2.63 NS
Total 35 3.03 3.58 2.69 2.76 NS
NS: not significantP 0.05, * significant P 0.05
Table 2: Decayed and missing surfacesof primaryand permanent teeth in children with Down
syndrome and their controls
Down
non syndromic
Age syndrome
Variables No. children t-value
(years) children
Mean SD Mean SD
6-9 14 7.43 6.28 9.86 6.13 NS
Ds 10-12 21 6.81 5.98 3.10 4.42 2.28*
Total 35 7.06 6.01 5.80 6.10 NS
6-9 14 0.71 2.67 7.36 10.11 -2.37*
Ms 10-12 21 3.29 7.01 0.71 2.39 NS
Total 35 2.26 5.77 3.37 7.30 NS
6-9 14 2.64 4.25 1.00 1.41 NS
DS 10-12 21 3.03 1.68 3.33 2.63 NS
Total 35 2.98 2.92 2.40 2.48 NS
6-9 14 0.36 1.33 0.71 2.67 NS
MS 10-12 21 0.00 0.00 0.00 0.00 ------
Total 35 0.14 0.84 0.29 1.69 NS
*P 0.05
Table 3: Means and standard deviations of plaque, gingival and calculus indices of children with
Down syndrome and their controls
Down
non syndromic
Age syndrome
Variables No. children t-value
(years) children
Mean SD Mean SD
6-9 14 1.30 0.27 1.24 0.25 NS
PLI 10-12 21 1.64 0.37 1.29 0.23 3.57**
Total 35 1.15 0.37 1.27 0.23 3.11**
6-9 14 0.99 0.15 1.03 0.38 NS
GI 10-12 21 1.47 0.35 1.03 0.21 4.88**
Total 35 1.28 0.37 1.03 0.28 3.13**
6-9 14 0.00 0.00 0.00 0.02 NS
CAlI 10-12 21 0.00 0.00 0.02 0.08 NS
Total 35 0.00 0.00 0.01 0.07 NS
**highly significant P 0.001
REFERENCES
1. de Morases M L, De Morases L C, Dotto G N, Dotto 3. Oredugba F. Oral health condition and treatment
P . Dental anomalies in patients with Down needs of a group of Nigerian individuals with Down
syndrome.Braz Dent J 2007; 18 (4): 103-8. syndrome. Research and Practice 2007; 12(1):72-6.
2. Asokan S, Muthu MS, Sivakumar N. Dental caries 4. Pilcher ES. Dental care for the patient with Down
prevalence and treatment needs of Down syndrome syndrome.J Down Syndr Res Pract 1998; 5:111-6.
children in Chennai, India. Indian J Dent Res 2008; 5. Reuland-Bosma W, Reijden WA, Winkelhoff AJ.
19(3): 224-9. Absence of a specific subgingival microflora in

adults with Down's syndrome. J Clin Periondontol 11. Loe H, Sinless J. Periodontal disease in
2001; 28:1004-119. pregnancy.Acta Odont Scand 1963; 21: 533-51.
6. Lee SR, Kwon HK, Song KB, Choi YH. Dental 12. Green JC, Vermillion JR. The simplified oral hygiene
caries and salivary immunoglobulin in Down index. J Am Dent Assoc 1964; 68(7):7-13.
syndrome children. J Paediatr Child Health 2004; 13. Regezi J, Sciubba J, Jordan R.: Oral pathology. 4th
40:530-3. ed. Saunders, USA. 2003, PP:358-3360.
7. Faris NJ. Caries experience and periodontal condition 14. Shapira J, haushu S, Becker A.: Prevalence of tooth
among Down syndrome population in Baghdad-Iraq. transposition, third molar agenesis, and maxillary
M. Sc. Thesis, College of Dentistry, University of canine impaction in individuals with Down
Baghdad, 1990. syndrome. Angle Orthod 2000; 70(4):290-6.
8. Al shakhRadhi NJ. Oral Health Status In Relation to 15. Morinushi T, Lopatin DE, Nakao R, Kinivo S.: A
Nutritional Analysis and Salivary Constituents comparison of gingival health of children with Down
among a Group of Children with Down's syndrome, syndrome to healthy children residing in an
In Comparison to Normal Children. PhD thesis institution. Spec Care Dentist 2006; 26(1):13-9.
submitted to the College of Dentistry, University of 16. AmaralLoureiro AC, Oliveira Costa F, Eustaquio de
Baghdad 2009. Costa J.: The impact of periodontal disease on the
9. World Health Organization. Oral health surveys: quality of life of individuals with Down syndrome.
basic methods. 3rd ed. Geneva; 1987. Down Syndr Res Pract 2007; 12(1):50-4.
10. Sinless J, Loe H. Periodontal disease in pregnancy 17. Reuland-Bosma W, Van Dijk J.: Periodontal disease
correlation between oral hygiene and periodontal in Down's syndrome: a review. J Clin Periodontol.
condition. Acta Odont Scand 1964; 22: 121-35. 1986, 1:64-73.

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Effects of Pimpinella
Effects of Pimpinella Anisum extract on salivary counts of

Streptococci and Mutans Streptococci in comparison to
Chlorhexidine in vivo
Sabreen S. Abd Al- Muhsen B.D.S. M.Sc (1)
Wesal A. Al-Qbaidi B.D.S. M.Sc (2)
ABSTRACT
Background: Pimpinella Anisum is one of the commonly utilized traditional medicines due to its pharmaceutical
properties such as anti-inflammatory, anti-viral, anti-fungal, and anti-bacterial effects. It is used to relieve coughs,
sore throats and contraction of epilepsy also used in refreshing mouth and against bad breath.
Aim of the study: To test the effects of Pimpinella Anisum extracts on the viability counts of salivary Streptococci and
Mutans Streptococci in comparison to chlorhexidine in vivo.
Materials and methods: Pimpinella Anisum was extracted using ethanol; Different concentrations of the extracts
were prepared in gm/100 ml of deionized water. Chlorhexidine used as control positive and deionized water as
control neutral. The volunteers were dental student divided into three groups each group rinse with one of the test
agent (Pimpinella Anisum extract, chlorhexidine and deionized water) for 1min. Counts of bacteria recorded at five
time interval (before rinsing, 1min., 15min., 30min. and 1hr). Mutans Streptococci were isolated from stimulated saliva
of the students, purified and diagnosed according to morphological characteristics and biochemical tests.
Results: Highly significant differences between the extract and both chlorhexidine and deionized water regarding
the count of bacteria. There were no significant differences between extract and chlorhexidine regarding pH, while
significant differences were found between the extract and deionized water at all time points except after 30
minutes it was highly significant difference.
Conclusion: Pimpinella Anisum ethanol extract was effective against Mutans Streptococci.
Key words: Streptococci, chlorhexidine, Pimpinella Anisum. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):131-134).
INTRODUCTION MATERIALS AND METHODS

Dental caries is a major chronic dental disease Pimpinella Anisum powder (250gm) was
affecting a large proportion of the inhabitant of dissolved in 1000 ml of ethanol (99%) mixed by
the world; it impairs the quality of life for people stirrer for five minutes, and then left closed at
causing pain and discomfort (1). In addition it room temperature for 24 hours. Then it was
places a heavy financial burden on public health filtered using filter paper, the filtered solution was
services, and its very high morbidity potential has left in the incubator at 37C for 48 hr to allow for
brought this disease into main focus of dental evaporation of ethanol. The powder was collected
health professionals. Dental plaque has been by scratching from petridishes, kept in closed
implicated as the principle etiological factor in glass container in refrigerator until use.
both dental caries and periodontal diseases (2). Sample is consist of 15 dental students were 20-
Which is highly specific variable structural entity 23years. All volunteers were healthy with no
formed by sequential colonization of medical history and did not take any antimicrobial
microorganisms on tooth surface (3, 4). Prevention agents during the last two weeks prior to the
of dental caries is directed to increase the study. All of them were dentate without any
resistance of teeth to acid attack by the multiple dental prosthesis or orthodontic appliance. They
fluoride therapy, diet modification involving were asked to suspend their usual oral hygiene
restriction of sugar intake, as well as dental practice at the day of experiment. The total
plaque control through individual and number of volunteers divided into study group
professional oral hygiene measures (5, 6, 7). and the two control groups. The procedure was
Recently, isolation of natural anti-plaque and anti- started at 9.00 am at least two hours after their
caries substances from plants has been reported (8, breakfast. First group used Pimpinella Anisum
9).
Pimpinella Anisum is one of these plants which extracts 6.5%, second group used chlorhexidine
have been used for wide variety of diseases and gluconate (CHX) 0.2% and third group used
health conditions and it has antibacterial, antiviral deionized water (DW). Each volunteer was given
and antifungal properties (10-12). a piece of Arabic gum and asked to chew it for
one minute only. Then the stimulated saliva was
collected in sterilized screw capped bottle. After
(1) M.Sc. student, Department of pedodontics and preventive two minutes only, each volunteer was asked to
dentistry.
(2) Professor, Department of pedodontics and preventive rinse with 10 ml of one of the above agents for
dentistry. one minute only then expectorated. Following

expectoration stimulated saliva was recollected in identification, colonies were counted by the use
the following time points: 1min., 15 min., 30min., of the colony counter.
and 1 hr. Through this time volunteers were asked
not to eat or drink any thing except water. RESULTS
Salivary samples were treated as the same method
For Pimpinella Anisum and deionized water
described earlier.
there is reduction in the viable counts of Salivary
Salivary samples immediately dispersed for 1
Streptococci and Mutans Streptococci after one
minute by vortex mixer, then 0.1 ml of saliva
min. and continue to decrease after 30 min. and
transferred to 0.9 ml of sterile normal saline (pH
then there was little increase after one hour, while
7.0), and the pH of saliva was measured. Ten-fold
for CHX there was decrease in the bacterial
dilutions were performed. From the dilutions 10-3,
counts after one min. continued till one hour. The
0.1ml was taken and spread induplicate on the
differences of Streptococcal counts among the
surface of MSB agar plates. Then incubated
three mouth washes were estimated by ANOVA
anaerobically for 48 hrs at 37C. Then incubated test, no significant difference was found among
aerobically for 24 hr. at room temperature. the three agents before rinsing, while highly
Streptococci were diagnosed according to their significant differences were found in the
morphological characteristic on the agar plates in Streptococcal counts for the rest time (Table 1and
addition to Gram's staining. Following 2).
Table1: Mean counts of salivary Streptococci and standard deviation of three mouth washes in
vivo.
Pimpinella Anisum Chlorhexidine Deionized water
Time F- test
Mean SD Mean SD Mean SD
After1min. 377.60 4.8 328.40 15.8 423.0 28.7 44.1**
After15min. 318.00 29.2 259.40 28.6 418.4 23.9 43.05**
After hr 287.00 40.5 229.40 38.6 428.0 25.2 41.44**
After 1 hr 306.00 33.6 168.40 38.9 434.6 20.3 86.9**
F-test 13.87** 30.91** NS
** Highly significant, *Significant
Table 2: Mean counts of Mutans Streptococci and standard deviation of three mouth washes in
vivo
Time F-test
After1min. 234.6 20.99 210.8 8.70 259.00 14.31 12.07**
After15min. 216.6 10.94 167.0 26.32 257.40 8.11 34.99**
After hr 193..4 17.40 132.6 25.86 254.80 20.81 39.68**
After 1 hr 217.6 21.41 67.8 13.66 257.40 47.78 51.18**
F-test 10.68** 96.28** NS
LSD test was performed to compare each two and after one hr. of rinsing, and Significant
mouth rinses (CHX and D.W, CHX and difference after 30 min. In comparison deionized
Pimpinella Anisum, Pimpinella Anisum and water with CHX and Pimpinella Anisum extract
D.W.) as in the (Table3), there was highly there were highly significant differences at all
Significant difference between CHX and time points.
Pimpinella Anisum extract after one min., 15 min.
Table 3: LSD between each two groups for salivary streptococci in vivo
CHX& DW D.W. & Pimpinella Anisum Pimpinella Anisum& CHX
Time
Mean differences P Mean differences P Mean differences P
After 1 min. - 94.60 0.000** - 45.40 0.000** - 49.20 0.000**
After15min. - 159.000 0.000** - 100.40 0.000** - 58.60 0.000**
After hr - 198.60 0.000** - 141.000 0.000** - 57.60 0.02*
After 1 hr - 266.20 0.000** - 128.60 0.000** -137.60 0.000**

To compare each two mouth rinses regarding significant differences were found between
MS counts LSD test was used (Table 4) Non each two groups except after one hour
significant difference in the counts of MS was between deionized water and Pimpinella
found between each two groups before Anisum extract it was found significant
rinsing, while for the rest time highly difference (P<0.05).
Table 4: LSD between each two groups for Mutans streptococci in vivo
CHX& DW D.W. & Pimpinella Anisum Pimpinella Anisum& CHX
Time
Mean differences P Mean differences P Mean differences P
After 1 min. -48.2 0.000** -24.4 0.02* -23.8 0.03*
After15min. -90.4 0.000** -40.8 0.003** -49.6 0.001**
After hr -122.2 0.000** -61.4 0.001** -60.8 0.001**
After 1 hr -189.6 0.000** -39.8 NS -149.8 0.000**
Salivary pH was measured for the three groups. after one minute, while there were significant
It was found that there was increase in the pH differences after 15 min. and 30 min. and there
value immediately after rinsing until 30 minutes was a highly significant difference after an hour.
after rinsing, and there was little decrease after Also ANOVA test used to compare different
one hour but it was higher than the baseline points of time for each one of the three mouth
value. The differences in pH among the three washes, significant differences were found
groups was estimated by ANOVA test, among the different points of time for the extract
statistically there were no significant differences and DW, while no significant difference for the
among the three mouth rinses at the base line and CHX. Table 5
Table 5: Salivary pH for the three mouth washes in vivo

Time F-test
After1min. 7.51 0.27 7.44 0.32 7.15 0.08 NS
After15min. 7.62 0.23 7.60 0.33 7.20 0.08 4.71*
After hr 7.74 0.19 7.72 0.32 7.27 0.10 6.70*
After 1 hr 7.47 0.17 7.60 0.29 7.10 0.09 7.94**
F-test 4.14* NS 3.44*
To compare between each two mouth rinses LSD highly significant difference, and there were no
test was used it revealed that there were no significant differences between CHX and
significant differences between Pimpinella deionized water at the baseline and one minute
Anisum extract and CHX at all time points, while after rinsing, while there were significant
there was significant difference between differences after 15 min, and highly significant
Pimpinella Anisum extract and deionized water differences after 30 min. and one hr. Table 6
for all time points except after 30 min. Which was
Table 6: LSD test between each two groups of mouth rinses for pH in vivo
CHX& DW D.W. & Pimpinella Anisum
Time
Mean differences P Mean differences P
After 1 min. - 0.29 NS 0.35 0.04*
After15min. - 0.39 0.02* - 0.42 0.01*
After hr - 0.44 0.000** - 0.46 0.007**
After 1 hr - 0.49 0.000** - 0.37 0.01*
DISCUSSION in comparison to DW after rinsing continue to

The results of this study indicate that Pimpinella decrease, but after an hour there was little
Anisum ethanol extract 6.5% had highly increase, but still CHX is more effective than the
significant antimicrobial activity against other agents in reduction the salivary counts of
Streptococci and Mutans Streptococci as it can the two types of bacteria with highly significant
reduce the viable count of the bacteria profoundly differences, this is coincident with some Iraqi

studies that test the effectiveness of CHX in REFERENCES

reduction the counts of salivary Mutans 1. Akhtar A, Deshmuk A, Kolekar M. In vitro
Streptococci in vivo (3) . The immediate slight antibacterial activity of Pimpinella Anisum fruit
reduction in the viable counts of both types of extracts against some pathogenic bacteria.
bacteria after rinsing with any of test or control Department of pharmacology and toxicology,
agents may be explained by mechanical removal College of Veterinary and Animal science, Animal
and fishery science University. Veterinary World
of different types of oral flora during rinsing (10) 2008. 1(9): 272-4.
while the reduction in the counts of the bacteria 2. Al-Bayati F. Synergistic antibacterial activity
after half an hour may be explained by the between Thymus vulgaris and Pimpinella Anisum
assumption that Streptococci and Mutans essential oils and methanol extracts. J Ethno
Streptococci were sensitive to the antibacterial pharmacology 2008; 116: 4036.
compound present in extract which is Anethole 3. AL-Nidawy A. Effect of Siwak extracts on mutans
streptococci, in comparison to selected antimicrobial
which continue to be released in the mouth after agents (an in vitro and in vivo study). M.Sc. Thesis,
rinsing (1). College of Dentistry, University of Baghdad,
The three mouth rinses produce immediate Preventive Dentistry Department, 2004.
increase in salivary pH which continue to increase 4. Bardow A, Hofer E, Nyvad B, Ten Cate JM, Kirkeby
after half an hour then began to drop down slowly S, Moe D, Nauntofte B. Effect of saliva composition
until it approximate the base line after an hour. on experimental root caries. Caries Res 2005; 39:
717.
this may be explained by that the taste of anethole 5. Burt B, Pai S. Is sugar consumption still a major
in pimpinella Anisum which stimulated the determinant of dental Caries, 2 consensus
salivary glands secretions, increase in salivary development conference on diagnosis and
flow rates lead to increase in salivary pH values management of dental caries through out life,
(10), Bethesda MD, U.S.A, 2001.
stimulation of salivary gland secretions by
mechanical rinsing causes increase in bicarbonate 6. Darby M, Walsh M. Procedures manual dental
hygiene, theory and practice. 3rd ed. Saunders
components which is the main buffering and Elsevier, 2010.
neutralizing constituents of saliva lead to increase 7. Devulapalle KS., Mooser G. Glucosyltransferase in
in pH value of saliva (11). Increasing flow rates of activation reduces dental caries. J Dent Res 2001.
saliva by mechanical rinsing lead to increasing 8. Duckworth R. The teeth and their environment
cleansing function of saliva which dilutes and physical, chemical and biochemical influences.
removes the acid components in dental plaque Kanger AG Switzerland 2006.
9. James A. The green pharmacy herbal hand book.
and saliva leading to increase pH values (12). Rodale Inc.2011.
Mouth rinse causes mechanical removal of oral 10. Peter S. Essentials of preventive and community
bacteria from mouth which may be acidogenic, dentistry, 2nd ed. Arya Publishing House. Darya
therefore reduce the acid production and elevate Ganj. New Delhi, 2004.
the pH (10). 11. Rodriges C, Shieham A. The relationship between
dietary guide lines, Sugar in take and caries in
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Alongitudinal study. Int J Paediatric Dent 2000;
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12. Sartos A. Evidence-bused control of plaque and
gingivitis, J Clin Periodontol 2003; (30): 5: 13-6.

J Bagh College Dentistry Vol. 24(special issue 1), 2012 The characteristics
The characteristics of profile facial types and its relation

with mandibular rotation in a sample of Iraqi adults with
different skeletal relations
Sara M. Al-Mashhadany, B.D.S., M.Sc. (1)
Nagham M.J. Al- Mothaffar, B.D.S., M.Sc. (2)
ABSTRACT
Background: Facial type plays an important role in the information of an orthodontic treatment plan and prognosis
that is whether an individual has long, short or average face and it is not possible to apply the same norms and
treatment objective to cases with different facial patterns. This study aims to determine the characteristics of Bimler's
facial types (dolichoprosopic, mesoprosopic, leptoprosopic) and their relationship with mandibular rotation in Iraqi
adults with different skeletal relations.
Materials and methods: The sample consisted of 230 digital true lateral cephalometric radiographs of age range
between 18-30years (104 males and 126 females), the sample was classified according to ANB angle into three
skeletal classes (class I, class II and class III) and each class was classified depended on PP-MP angle into three faces.
Thirteen cephalometric measurements (five angular, seven linear and one ratio) were measured for each individual
radiograph using AutoCAD program 2006.
Results: The mean values of all measurements for males were significantly higher than females, except for the GA,
UGA and LGA, The mean values of GA, LGA, AFH and LAFH were high in leptoprosopic face, while their values
decreased in dolichoprosopic face and the reversed were found with JR, PFH, RL and MAXL, moreover all these
measurements revealed a highly significant difference between the three facial types.
Conclusions: The mandibular rotation was not changed in all skeletal classes that belong to the same facial type as
it did not affected by the anteroposterior relation within the same profile
Keywords: Facial type, mandibular rotation, skeletal classes. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):135-139).
INTRODUCTION The possible association between facial

Facial type plays an important role in the morphology and growth direction is important for
information of an orthodontic treatment plan and two reasons: it would be possible to predict the
prognosis, of particular, is the vertical relationship direction of growth from a static analysis of facial
that is whether an individual has long face form, if a certain morphological pattern is
(leptoprosopic) or short face (dolichoprosopic) or typically associated with specific growth
average face (mesoprosopic) and it is not possible directions of facial landmarks; and the more
to apply the same norms and treatment objective important reason is the possibility of predicting
to cases with different facial patterns (1,2). morphological changes that will occur during
Dentofacial balance, harmony, and growth and growth which are associated with specific known
development have been studied by many growth directions (6).
investigations in four dimensions: height, depth, It is important for clinicians to be able to predict
breadth and time using lateral or profile the pattern of mandibular rotation at a relatively
radiograph (3). A balanced profile should be one of early stage of craniofacial growth, independent of
the key factors in deciding on the methods of whether malocclusion has already developed or
treatment for any form of malocclusion, as good not. This is explained by the fact that the more the
occlusion does not necessarily mean good facial mandible rotates during growth, the more serious
balance (4). the clinical problems that may arise, and this
The rotation of the mandible resulting from an should be seriously considered both at the initial
inharmony between vertical growth and diagnosis and the overall treatment planning (7).
anteroposterior or horizontal growth has important
implication in orthodontic treatment, orthodontist MATERIALS AND METHOD
must come to consider, understand and appreciate
Sample
the value of the vertical growth as it relates to an
The sample consists of 230 digital true lateral
anteroposterior growth. They must constantly
cephalometric radiograph (104 males and 126
seek a deeper understanding into how the total
females) for under and postgraduate students in
effect of growth in these two directions produces
the College of Dentistry, University of Baghdad,
different facial types (5).
and some patients attending the Orthodontic
(1) MSc student, dep. of Orthodontics, collage of dentistry,
university of Baghdad Department of the same college, that fulfill the
(2) Professor, dep. of Orthodontics, collage of dentistry, following criteria:
university of Baghdad 1. The age ranged between 18-30 years.

2. No history of previous orthodontic treatment. Skeletal Angular Measurements (Figure 1):

3. No craniofacial disorder, such as cleft palate. 1. Basal plane angle (PP-MP): This defines the
4. Full permanent dentition regardless the third angle of inclination of the mandible to the
molars. maxillary base, also serves to determine
5. No history of facial trauma. rotation of the mandible (8).
2. Gonial Angle (Ar-Go-Me): The angle between
Every lateral cephalometric radiograph was the posterior border of the ramus (Ar-Go) and
analyzed by AutoCAD program 2006 to calculate the mandibular plane (Go-Me). Gonial angle
angular and linear measurements. was measured to determine the mandibular
Sample classification: The radiographs were growth rotation (8).
classified depended on the sagittal skeletal 3. Upper gonial angle (UGA): The angle formed
relation according to Foster (1990) (16) into Table by the ascending ramus and the line joining
(1): nasion and gonion (8).
1. Skeletal Class I relation: 2 ANB 4. 4. Lower gonial angle (LGA): The angle formed
2. Skeletal Class II relation: ANB > 4. by the mandibular plane (Go-Me) and the line
3. Skeletal Class III relation: ANB < 2. joining nasion and gonion (8).
5. ANB angle: The angle between lines N-A and
Each skeletal relation was classified depended on N-B, it measured directly as the angle ANB
Bimlers facial analysis (17) according to palatal - (12)
.
mandibular plane angle into: Skeletal Linear Measurements (Figure 2):
1. Dolichoprosopic facial type: PP-MP angle 1. Total anterior facial height (AFH): It measured
ranged from 0-15. from N to Me (8).
2. Mesoprosopic facial type: PP-MP angle 2. Upper anterior facial height (UAFH): It is
ranged from 15-30. measured from N to ANS (13).
3. Leptoprosopic facial type: PP-MP angle 3. Lower anterior facial height (LAFH): It is
ranged from 30-45. measured from ANS to Me (5,14).
Cephalometric Bony Landmarks: Include the 4. Posterior facial height (PFH): It measured
following: from S to Go (8).
1. Point S (Sella): The midpoint of the 5. Jarabak ratio (JR) = (PFH / AFH) 100 (8).
hypophysial fossa (8). 6. Maxillary base length (Maxillary length): It
2. Point N (Nasion): The most anterior point on represents the distance from
the nasofrontal suture in the median plane (8). 7. Anterior Nasal Spine to Posterior Nasal Spine
(15)
3. Point ANS (Anterior Nasal Spine): It is the tip .
of the bony anterior nasal spine in the median 8. Mandibular body length (Mandibular length):
plane (8). It represents the distance from Gonion to
4. Point PNS (Posterior Nasal Spine): This is a Menton (15).
constructed radiological point, the intersection 9. Ramus length (RL): It measured from Ar to
of a continuation of the anterior wall of the Go (8).
pterygopalatine fossa and the floor of the nose. Statistical analysis
It marks the dorsal limit of the maxilla (8). All the data of the sample were subjected to
5. Point Me (Menton): The lowest point on the computerized statistical analysis using SPSS
symphyseal shadow of the mandible seen on a version 15 (2006) computer program. The
lateral cephalogram (9). statistical analysis included:
6. Point Go (Gonion): A point on the curvature of 1. Descriptive Statistics: Mean, Standard
the angle of the mandible located by bisecting deviation (SD)
the angle formed by the lines tangent to the 2. Inferential Statistics: Paired t-test,
posterior ramus and inferior border of the Independent samples t-test, One way analysis
mandible (9). of variance (ANOVA), Pearson's correlation
7. Point Ar (Articulare): The point of intersection coefficient
of the external dorsal contour of the
mandibular condyle and the temporal bone (10). In the statistical evaluation the following
8. Point A (Subspinale): The deepest midline levels of significance are used:
point on the premaxilla between the Anterior P > 0.05 NS Non-significant
Nasal Spine and Prosthion (11). 0.05 P > 0.01 * Significant
9. Point B (Supramentale): The deepest midline 0.01 P > 0.001 ** Highly significant
point on the mandible between Infradentale
and Pogonion (11).

RESULTS AND DISCUSSION posterior mandibular rotation in leptoprosopic

Balanced facial form and function are derived face in all skeletal classes. The correlation
from a harmonious integration of the various coefficient between the measurements expressed a
components of the craniofacial complex. These considerable amount of variations, some of them
components grow and develop throughout life in a showed positive correlation, while the others
sequential, predictable and orderly fashion, albeit showed negative correlation with varying degrees
with a wide range of variation in the amount and of significant, but the best correlation was found
timing of growth (18) in mesoprosopic facial type compared with
This study dealt with lateral view of the face by dolichoprosopic and leptoprosopic facial type,
using lateral cephalometric radiographs according Table 4 described the correlation coefficient in
to Bimler analysis, and study the relationship of mesoprosopic facial type. There was a highly
profile facial type with some mandibular rotation significant positive correlation almost between all
parameters in class I, class II and class III skeletal the different measurements, on the other hand GA
relation which was determined according to ANB and RL, GA and MANL, GA and JR, GA and
angle, Table 1 showed the Gender difference for PFH, UGA and RL, UGA and PFH, UGA and
different measurements in skeletal class I AFH, UGA and UAFH, UGA and LAFH, UGA
mesoprosopic facial type, it have been found that and LGA, LGA and MANL and between LGA
the mean values of all the measurements were and JR found to have a high significant negative
significantly higher in males than females except correlation with each other.
GA, UGA and LGA which were a non
significantly higher in females in all facial types REFERENCES
and all skeletal relations, this is due to the fact that 1. Christie TE. Cephalometric patterns of adults with
muscle traction exerts a considerable influence on normal occlusion. Angle Orthod 1977; 47(2): 128-35.
the bony structure, which is stronger and heavier 2. Collet AR, West VC. Terminology of facial
muscles mass in males than females. morphology in the vertical dimension. Aust Dent J
Table 2 showed the descriptive statistics and the 1993; 38(3); 204-9.
3. Downs WB. Analysis of the dentofacial profile. Angle
comparison between the three facial types in Orthod 1956; 26(4): 191-212.
skeletal class I. it have been found that There was 4. Bergman RT .Cephalometric soft tissue facial
a significant difference in all the measurements analysis. Am J Orthod 1999; 116: 373-89.
between the three facial types , except in UGA, 5. Schudy FF. Vertical growth versus anteroposterior
UAFH and MANL in which there was a non- growth as related to function and treatment. Angle
significant difference between the three facial Orthod 1964; 34(2): 75-93.
6. Bergersen EO. The direction of facial growth from
types infancy to adulthood. Angle Orthod 1966; 36: 18-43.
The mean values of GA, LGA, AFH and LAFH 7. Bjrk A. Prediction of mandibular growth rotation.
were high in leptoprosopic individuals, while their Am J Orthod 1969; 55(6): 585-99.
values decreased in dolichoprosopic individuals, 8. Rakosi T. An atlas and manual of cephalometric
and within normal limits in mesoprosopic ones, radiography. 2nd ed. London: Wolfe medical
while the mean values of Jaraback ratio, PFH, RL publications Ltd.; 1982. p. 7, 35, 40, 43, 45, 47-53, 61,
65, 85- 86, 135.
and MAXL decreased in leptoprosopic 9. Caufield PW. Tracing technique and identification of
individuals and increased in dolichoprosopic landmarks. In Jacobson A (ed). Radiographic
individuals. cephalometry from basics to videoimaging. 1st ed.
Table 3 showed the comparison between skeletal Chicago: Quintessence publishing Co.; 1995. p. 60.
class I, II and III for different measurements in 10. Bjrk A. The face in profile. An anthropological X-ray
mesoprosopic facial type, it have been found that investigation on Swedish children and conscripts.
Svensk tandlkare-Tidskrift. 40(5B), Suppl. 1947.
there was a non significant difference between the 11. Downs WB. Variations in facial relationship: their
three skeletal relations within the same facial type significance in treatment and prognosis. Am J Orthod
in all the measurements except in MAXL and 1948; 34(10): 812-40.
MANL in mesoprosopic face in which there was a 12. Steiner CC. Cephalometrics for you and me. Am J
significant difference between the three skeletal Orthod 1953; 39(10): 729-55.
relations. 13. Biggerstaff RH, Allen RC, Tuncay OC, Berkowitz J.
A vertical cephalometric analysis of the human
The mandibular rotation was not changed in all craniofacial complex. Am J Orthod 1977; 72(4): 397-
skeletal classes (class I, II and III) that belong to 405.
the same facial type giving a picture that the 14. Bjrk A, Skieller V. Normal and abnormal growth of
mandibular rotation did not affected by the the mandible. A synthesis of longitudinal
anteroposterior relation within the same profile cephalometric implant studies over period of 25 years.
facial type and there was anterior mandibular Eur J Orthod 1983; 5(1): 1-46.
rotation in dolichoprosopic face, while there was a

15. Dhopatkar A, Bhatia S, Rock P. An investigation into 17. Bimler HP. Bimler Therapy: Part 1 Bimler
the relationship between the cranial base angle and cephalometric analysis. J Clin Orthod. 1985; 19(7):
malocclusion. Angle Orthod. 2002; 72(5):456-63. 50123.
16. Foster TD. A textbook of orthodontics. 3rd ed. 18. Nanda RS. The contribution of craniofacial growth to
Oxford: Blackwell Scientific Publications; 1990. p. 12, clinical orthodontics. 2000.
95.
Table 1: Gender difference for different measurements in skeletal class I mesoprosopic facial
type.
Gender difference
Total (n=72) Male (n=30) Female (n=42)
variables d.f.=70
Mean SD Mean SD Mean SD t-value p-value
GA 123.97 4.47 123.6 4.84 124.23 4.23 -0.59 0.55
UGA 50.77 3.3 50.46 3.2 51 3.39 -0.67 0.5
LGA 73.16 4.02 72.96 4.08 73.3 4.02 -0.35 0.72
UAFH 51.55 3.23 53.51 2.97 50.14 2.63 5.06 0.000
LAFH 65.52 5.42 68.91 5.11 63.1 4.23 5.26 0.000
AFH 115.2 7.11 120.2 5.75 111.4 5.53 6.6 0.000
PFH 77.26 6.5 82.22 5.86 73.71 4.25 7.13 0.000
JR 67.01 3.38 68.26 3.52 66.12 3.02 2.76 0.007
MAXL 51.6 3.36 54.2 2.95 49.74 2.22 7.31 0.000
MANL 69.5 4.47 72.33 4.62 67.48 3.08 5.34 0.000
RL 47.18 4.87 50.29 4.51 44.96 3.82 5.408 0.000
Table 2: Comparison between the three facial types in skeletal class I.

ANOVA test
Dolicho (n=9) Meso (n=72) Lepto (n=10)
variables d.f.= 90
Mean SD Mean SD Mean SD F-value p-value
GA 117.33 3.31 123.97 4.47 132.4 4.22 28.95 0.000
UGA 50 2.82 50.77 3.3 50.4 2.59 0.27 0.76
LGA 67.22 2.16 73.16 4.02 82 3.46 36.79 0.000
UAFH 52.62 3.15 51.55 3.23 53.05 4.41 1.159 0.31
LAFH 61.28 4.86 65.52 5.42 73.24 5.91 12.57 0.000
AFH 113.16 8.36 115.24 7.11 124.06 9.02 6.87 0.002
PFH 82.57 7.54 77.26 6.5 74.04 4.65 4.26 0.02
JR 72.91 2.7 67.01 3.38 59.75 2.07 40.32 0.000
MAXL 54.92 3.02 51.6 3.36 51.53 2.3 4.26 0.02
MANL 72.7 4.24 69.5 4.47 69.07 4.02 2.24 0.11
RL 53.11 5.37 47.18 4.87 45.14 2.66 7.69 0.000
Table 3: Comparison between skeletal class I, II and III for different measurements in
mesoprosopic facial type.
ANOVA test
CL I (n=72) CL II (n=50) CL III (n=34)
variables d.f.= 155
Mean SD Mean SD Mean SD F-value p-value
GA 123.97 4.47 124.28 4.52 125.44 5.82 1.09 0.33
UGA 50.77 3.3 50.7 3.74 51.61 3.77 0.8 0.44
LGA 73.16 4.02 73.58 3.06 73.79 4.47 0.35 0.7
UAFH 51.55 3.23 51.24 3.35 51.53 3.26 0.14 0.86
LAFH 65.52 5.42 66.26 4.87 65.94 4.96 0.3 0.73
AFH 115.24 7.11 114.77 5.81 117.21 6.85 1.46 0.23
PFH 77.26 6.5 76.04 5.9 78.57 6.153 1.68 0.18
JR 67.01 3.38 66.22 3.45 67.05 3.87 0.89 0.41
MAXL 51.6 3.36 53.05 3.157 51.16 4.12 3.75 0.03
MANL 69.5 4.47 68.53 4.94 72.35 4.83 6.93 0.0013
RL 47.18 4.87 46.29 4.469 48 4.99 1.32 0.26

Table 4: Correlation between the different measurements in skeletal class I mesoprosopic facial
type.
Variables RL MANL MAXL JR PFH AFH LAFH UAFH LGA UGA
GA -0.3** -0.39** -0.12 -0.55** -0.35** -0.03 0.09 -0.14 0.7** 0.5**
UGA -0.32** -0.13 -0.04 -0.02 -0.39** -0.5** -0.41** -0.43** -0.24*
LGA -0.09 -0.35** -0.12 -0.61** -0.09 0.36** 0.43** 0.17
UAFH 0.57** 0.51** 0.53** 0.11 0.65** 0.8** 0.5**
LAFH 0.62** 0.21 0.56** 0.06 0.69** 0.88**
AFH 0.69** 0.45** 0.6** 0.1 0.8**
PFH 0.87** 0.51** 0.7** 0.67**
JR 0.6** 0.3** 0.42**
MAXL 0.59** 0.5**
MANL 0.39**
Figure 1: Cephalometric angular measurements Figure 2: Cephalometric linear measurements.

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Dental calculus in
Dental calculus in relation to idiopathic calcium renal

stone
Shaimaa Kh. Yaser, B.D.S., H.D.D., M.Sc. (1)
Mohammed S. Al-Casey, B.D.S., M.P.H., M.S.P.H. (2)
ABSTRACT
Background: Dental calculus is a form of calcification process that occur in the oral cavity and due to its similar
structural composition with calcium renal stone, so dental calculus formation may increase in those patients with
calcium renal stone. This study conducted to evaluate if there is a relation between dental calculus accumulation
with calcium renal stone formation by investigating the relations of oral hygiene and gingival health status with
urinary and salivary physical properties and constituents then comparing the results with healthy looking subjects.
Materials and Methods: Thirty patients with idiopathic calcium renal stone selected as study group with an age
range (25-30) years and 30 gender and age matched healthy looking persons selected as control. Plaque Index of
Silness and Loe and Calculus Index component of Simplified Oral Hygiene Index of Green and Vermillion recorded
oral cleanliness while Gingival Index of Loe and Silness recorded gingival health status. Urinary and stimulated
salivary samples collected and chemically analyzed to determine the concentrations of calcium, phosphorus,
magnesium and urinary creatinine. The pH and buffer capacity of saliva also estimated in this study.
Results: Higher mean values of Plaque, Calculus and Gingival Indices scores recorded among study group with high
significant differences compared control one, positive high significant correlation recorded between dental plaque
with calculus accumulations among study group, higher mean values of salivary pH and buffer capacity recorded
within study group with high significant difference compared control one, positive significant correlation recorded
between calculus accumulation with salivary pH among study group, high significant elevation in the concentration
of salivary phosphorus while high significant reduction in salivary magnesium concentration recorded within study
group compared control one, significant correlations recorded between calculus accumulation with urinary
constituents.
Conclusion: presence of significant correlations between dental calculus accumulations with calcium renal stone
formation, so special oral health preventive programs are needed for those patients.
Key Words: Dental calculus, dental plaque mineralization, idiopathic calcium renal stone, kidney stones, urolithiasis. (J
Bagh Coll Dentistry 2012; 24(sp. Issue 1):140-145).
INTRODUCTION
Renal stone which is a multifactorial disease Dental calculus is classified into supra and
is one of the most common problems of modern subgingival and always covered on its surface
society (1, 2) which may affect (12-15) % of the with an unmineralized layer of viable bacterial
population (3, 4) with observation of an increase in plaque that complicates its role in periodontal
its prevalence (5, 6). It is more common in males destruction (13).
and categorized into calcareous (calcium Saliva is important fluid that bathes the oral
containing) stones which make up 90% of all tissues, and is basic to maintain the integrity of
stones and non-calcareous stones. The probability the oral structures; it plays a major role in the
of its recurrence among calcium renal stone maintenance of health and in the production of
formers is approximately (10-50) % occurs within disease by inhibiting or permitting the formation
(1-5) years from the first stone formed (1, 6, 7, 8). of dental plaque, calculus, caries and the
Although many inherited and systemic diseases proliferation of selected microorganisms (14, 15, 16).
are associated with calcium renal stones, most of Yet, no previous Iraqi study could be found
such stones are idiopathic (9). Renal stone remain conducted among calcium renal stone patients to
the major source of morbidity in human (1), since evaluate the relations between dental plaque and
its formation may contribute to the development calculus accumulations with calcium renal stone
of chronic kidney disease (10) and increase the risk formation. Furthermore, there is no previous Iraqi
of hypertension in addition to bone disease (9). study could be found that investigate the effect of
Dental calculus represents a mineralized salivary physical properties and constituents'
dental plaque that form on the surfaces of natural changes among renal stone patients on dental
teeth and dental prosthesis in the oral cavity (11) plaque and calculus accumulations. For all these
and it has the same structural composition and explanations, this study was designed.
mineralization process that occur in all biological
system including renal stone (8, 12). MATERIALS AND METHODS
(1) MSc student, department of preventive dentistry, College of
In the present study, the study group
(2) Professor, department of preventive dentistry, College of composed of thirty patients (15 females and 15
Dentistry, University of Baghdad. males) with an age range (25- 30) years according

to the last birthday (17). They were diagnosed as electronic pH meter and for estimation the buffer
having calcium renal stone (in renal pelvis, the capacity of saliva (22), and other part was
ureter, or the bladder) based on new X-ray and centrifuged at 3000 r.p.m for 10 minutes then the
general urine examinations, they were attending clear supernatants was separated by micropipette
the Specialized Surgeries Hospital in Baghdad and then stored at (-20C) in a deep freeze till the
city for their treatment. The study group was time of biochemical analysis.
fulfilled the following criteria: Collection of Urinary Samples
No presence of another medical problem and Fasting second morning specimens were
the cases of pregnancy, bone fractures, collected in which all individuals that participated
immobilization, previous bowel resection and within this study were in fasting condition from 9
cases under calcium or vitamin D PM on the evening preceding the study. At
supplements were also excluded. By that the morning, the subject emptied his bladder (this
study group was with idiopathic type renal specimen being discarded) and fasting was
stone. continued until second morning specimen taken at
The size of renal stone is equal or less than 2 (9-12) AM. By using this technique, it can be
Cm (20 mm). assumed that the influence of recently ingested
The study group presents in fasting condition. food on the excretion is minimal (23). Also each
The study group practice teeth brushing and urinary sample was centrifuged at 3000 r.p.m for
not attending the dentist for calculus removal 10 minutes then the clear supernatant was
(scaling process) at least one year before. separated by micropipette and then stored at (-
Dose not wears any fixed or removable dental 20C) in a deep freeze till the time of biochemical
prosthesis or orthodontic appliance. analysis.
The control group also composed of thirty Biochemical Analysis
subjects and they were in healthy condition Frozen saliva and urine samples were allowed
(normally looking) according to their medical to thaw and come to room temperature. There
history matching with age and gender the study after, they were subjected to biochemical analysis.
group, they were subjects who working near and This was done by using colorimetric method for
at the same hospital where the study done; the determination of salivary and urinary (Calcium,
control group was fulfilled the following criteria: Inorganic phosphorus) and urinary Creatinine
No history of previous renal stone and concentrations while for salivary and urinary
without familial history from the first relative Magnesium ions concentration, it was determined
degree. by Flame Atomic Absorption Spectrophotometer
No presence of serious medical problems. using standardized procedure by air-acetylene gas.
Presence of a new ultrasound examination to Statistical Analysis
ensure that there is no renal stone. Data processing and analysis were carried out
The control group presents in fasting using SPSS version 18 (Statistical Package for
condition. Social Sciences) which provided the followings:
The control group practice teeth brushing and Calculation and presentation of statistical
not attending the dentist for calculus removal parameters, means and standard deviation of
(scaling process) at least one year before. the means for the clinical and biochemical
Dose not wears any fixed or removable dental variables examined in the study.
prosthesis or orthodontic appliance. The statistical tests that were used in this
Oral Hygiene and Gingival Health Status study:
Oral hygiene assessment done by using Student's t-test.
Plaque Index (PlI) (18) and Calculus Index (CI-S) Person's correlation coefficient.
component of the Simplified Oral Hygiene Index * The level of significance was accepted at P<
(19)
while gingival health status assessment done 0.05, and highly significance when P< 0.01.
by using Gingival Index (GI) (20). The four
surfaces of each tooth except the third molar were RESULTS
examined and scored in this study. The Table 1 represents the mean values in
assessment of plaque accumulation recorded addition to standard deviations of Plaque,
before salivary sample collection. Calculus and Gingival indices among the study
Collection of Salivary Samples and control groups. Clinical oral examination
Stimulated salivary samples (21) were revealed highest mean values of Plaque, Calculus
collected in this study at (9-12 AM). Each salivary and Gingival Indices among the study group
sample was separated in two parts, one for the compared to control group with statistically high
measurements of pH of saliva by using an significance difference (P<0.01). Concerning

gender differences in each group, the males within concentration, it was found higher in study group
study group recorded higher mean values of compared to control group but with no significant
Plaque and Calculus Indices with statistically high difference between them (P>0.05). Concerning
significant difference compared to females within gender differences, the inorganic salivary
the same group (t=3.21, P<0.01, df=28; t= 5.59, phosphorus concentration was recorded higher
P<0.01, df= 28, respectively). Among control within males than females among study group
group, also the males recorded higher mean with a significant difference between them (t=
values of Plaque and Calculus Indices than 2.35, P<0.05, df= 28) while among the control
females with statistically highly significant group the difference was statistically not
difference (t=3.53, P<0.01, df=28; t=4.26, P<0.01, significant (P>0.05) with higher concentration of
df= 28, respectively). Table 2 illustrates the inorganic salivary phosphorus within males also.
correlation coefficient of Calculus Index in Table 6 demonstrates the correlation coefficient of
relation to Plaque Index among study and control Plaque and Calculus Indices in relation to urinary
groups. In the study group there was a positive constituents among study and control groups. The
highly significant correlation (P<0.01) found statistical result revealed a positive significant
between them in contrast to control group which relation (P<0.05) found between dental plaque
was found to be with a positive not significant accumulations with the mean value of urinary
correlation (P>0.05). Salivary physical properties calcium/creatinine ratio among study and control
including pH and buffer capacity of saliva among groups. For dental calculus accumulation in
study and control groups with mean values in relation with the mean value of urinary
addition to standard deviations are presented in calcium/creatinine ratio, it is found to be a
Table 3. The results showed that presence of positive significant correlation (P<0.05) among
higher mean values for pH and buffer capacity of study group and a positive high significant
saliva among the study group compared with the correlation (P<0.01) among the control group. In
control group with statistically high significant the same table, one can notice presence of a
differences between them (P<0.01). Concerning positive highly significant correlation (P<0.01)
gender differences, among study group, males found between dental calculus accumulation and
found to have higher mean value of pH than the mean value of urinary phosphorous/creatinine
females with statistically significant difference ratio within the study group and a negative highly
between them (t= 2.44, P<0.05, df= 28) while significant correlation (P<0.01) within the control
among control group males also had higher mean group. For dental plaque accumulation, there is a
value of pH than females but with statistically no negative highly significant correlation (P<0.01)
significant difference (P>0.05). For buffer found with the mean value of urinary
capacity of saliva and among control group, it was phosphorous/creatinine ratio within the control
found that males had higher mean value than group while it is found to be a positive not
females with statistically significant difference (t= significant (P>0.05) within the study group.
2.15, P<0.05, df= 28) while among study group, Regarding the mean value of urinary
the males also had higher mean value of buffer magnesium/creatinine ratio, statistical results
capacity of saliva than females but with found a negative significant correlation (P<0.05)
statistically no significant difference (P>0.05). with dental calculus accumulation among the
Table 4 illustrates the correlation coefficient of study group while it is a positive not significant
Calculus Index in relation to salivary pH. Results (P>0.05) among the control group and also found
revealed presence of positive significant a negative not significant correlation (P>0.05)
correlation (P<0.05) between dental calculus with plaque accumulation among the study group
accumulation with salivary pH within study group while it is found to be a positive not significant
while it is positive not significant (P>0.05) within correlation (P>0.05) among the control group.
control group. Values of inorganic salivary
constituents (means and standard deviation) DISCUSSION
among study and control groups are presented in In present study, the higher mean values of
Table 5. The concentration of inorganic Gingival Index among study group may be
phosphorus ions was found higher in study group attributed to the higher mean values of Plaque
with statistically highly significant difference in Index scores that recorded among study group
comparing to control group ( P<0.01) while for with high significance difference compared to
concentration of magnesium ions, it was found control one, since dental plaque is the main
higher in control group in comparing to study etiological factor for gingival inflammation (24, 25,
group with also high significant difference 26)
. About dental calculus mean values, the oral
between them (P<0.01). For calcium ions examination of current study was recorded higher

dental calculus mean values among calcium stone between urinary magnesium/creatinine ratio
formers with high significant difference than the which is an inhibitor of calcium renal stone (1, 8, 31)
non stone formers, and this have many with dental calculus accumulation; second, a
explanations: The first may attribute to the higher positive highly significant relation between
plaque accumulation level that recorded in this urinary phosphorus/creatinine ratio which is one
study among the study group in compared to of calcium renal stone promoters (8, 23) with dental
control one as shown in Table 1, since dental calculus accumulation in addition to, Third, a
calculus is a mineralized dental plaque (11).This positive significant relation between urinary
explanation was supported by the result of this calcium/creatinine ratio which is also one of
study that revealed presence of a positive highly calcium renal stone promoters (23) with dental
significant correlation between dental calculus calculus accumulation, so present study revealed
accumulation with dental plaque accumulation presence of significant relations between calcium
among study group (Table 2). The second renal stone inhibitor and promoters with dental
explanation for higher level of dental calculus calculus accumulation; In other words, significant
among calcium stone formers may be due to other correlation reported among calcium renal stone
result that documented in current study which formers in this study between calcium renal stone
reported presence of higher values of salivary pH formation with dental calculus accumulation as
and buffer capacity among study group with high shown in Table 6.
significant difference compared to control one
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Table 1: Plaque, calculus and gingival indices (mean and standard deviation) among study and
control groups.
Study Control Statistical test
Parameter Gender
Mean SD Mean SD t-test P-value
M 1.60** 0.21 0.97** 0.36 5.90 0.000**
PlI F 1.33 0.24 0.59 0.22 8.86 0.000**
T 1.46 0.26 0.78 0.35 8.65 0.000**
M 0.43** 0.10 0.11** 0.05 10.65 0.000**
CI-S F 0.24 0.08 0.04 0.04 8.55 0.000**
T 0.34 0.13 0.08 0.06 9.78 0.000**
M 1.21 0.18 0.83 0.22 5.28 0.000**
GI F 1.12 0.12 0.63 0.31 5.71 0.000**
T 1.16 0.16 0.73 0.28 7.44 0.000**
** Highly significant P < 0.01
Table 2: Correlation coefficient between calculus index with plaque index among study and
control groups.
PlI
Groups Parameter
r P
Study CI-S 0.48** 0.007
Control CI-S 0.28 0.130
** Highly significant P < 0.01

Table 3: Salivary pH and buffer capacity (mean and standard deviation) among study and
control groups.
Salivary Study Control Statistical test
Gender
variables Mean SD Mean SD t-test P-value
M 7.43* 0.27 6.92 0.46 3.73 0.001**
F 7.20 0.24 6.87 0.37 2.87 0.008**
pH
T 7.32 0.28 6.90 0.41 4.64 0.000**
M 5.38 0.78 4.37* 0.91 3.26 0.003**
F 5.10 0.72 3.72 0.77 5.08 0.000**
Buffer capacity
T 5.24 0.75 4.04 0.89 5.61 0.000**
* Significant P<0.05 ** Highly significant P < 0.01
Table 4: Correlation coefficient between calculus index with salivary ph among study and
control groups.
pH
Groups Parameters r P
Study CI-S 0.43* 0.017
Control CI-S 0.31 0.092
* Significant P<0.05
Table 5: Inorganic salivary constituents (calcium, phosphorus and magnesium) (mean and
standard deviation) among study and control groups.
Study Control Statistical test
Elements (mmol/L) Gender
Mean SD Mean SD t-test P-value
M 1.37 0.69 0.71 0.36 3.23 0.003**
Calcium F 1.14 0.58 1.22 1.05 - 0.26 0.798
T 1.25 0.64 0.97 0.81 1.52 0.134
M 4.26* 0.63 3.15 1.17 3.25 0.003**
Phosphorus F 3.76 0.53 2.77 0.80 3.99 0.000**
T 4.01 0.63 2.96 1.00 4.87 0.000**
M 0.23 0.05 0.51 0.09 - 10.34 0.000**
Magnesium F 0.25 0.06 0.51 0.10 - 8.91 0.000**
T 0.24 0.06 0.51 0.09 - 13.71 0.000**
* Significant P<0.05 **Highly significant P<0.01
Table 6: Correlation coefficient between plaque and calculus indices with urinary constituents
among study and control groups.
Calcium Phosphorus Magnesium
Parameter /Creatinine (mmol/g) /Creatinine (mmol/g) /Creatinine (mmol/g)
Groups
r P r P r P
PlI 0.41* 0.024 0.22 0.242 -0.08 0.688
Study
CI-S 0.40* 0.029 0.53** 0.002 -0.39* 0.031
PlI 0.42* 0.022 -0.50** 0.005 0.13 0.510
Control
CI-S 0.49** 0.006 -0.54** 0.002 0.04 0.834
* Significant P<0.05 **Highly significant P<0.01

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Psychological impact
Psychological impact of dental aesthetics for Kurdish

young adults seeking orthodontic treatment
Trefa M. Ali Mahmood, B.D.S., M.Sc. (1)
Fadil A. Kareem, B.D.S., M.Sc., Ph.D. (1)
ABSTRACT
Background: The aim of this study is to investigate the relationship between Kurdish orthodontic patients severity of
malocclusion and their social and psychological impact.
Materials and method: The sample consists of 100 patients, 45 males and 55 females, aged 1322 years. A translated
pre-tested questionnaire [psychosocial impact of dental aesthetics questionnaire PIDAQ] was used to assess the
subjects social and psychological impact by their occlusal irregularities. The actual severity of malocclusion was
determined, using the dental aesthetic index (DAI) on 100 stone study models. Statistical analysis was carried out,
using chi-square test for assessing the associations, and person correlation coefficient was used for assessing
correlations. Analysis of co-variance (ANCOVA) and multiple regression tests were also carried out to complete the
statistical analysis.
Results: results of the multiple regression analysis showed that not only DAI score were significantly associated with
higher score of PIADQ scores, but other factors, like gender was a significant variable in predicting the psychosocial
impact of dental esthetics. However, age was not significantly associated with PIADQ scores. The value of R is equal
to 0 .226. Accordingly, there is a significant weak positive correlation between DAI score and PIADQ scale of the
study sample at p<0.005.
Key words: Psychology, severity of malocclusion, Kurdish young adult. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):146-
152).
INTRODUCTION systems, in which they live and in relation to their

Malocclusion represents an important health goals, expectations, standards, and concerns" [13],
problem worldwide [1]. Epidemiological surveys or, more simply, as "a sense of well-being that
of malocclusion in several countries have reported stems from satisfaction or dissatisfaction with
that this oral disorder is highly prevalent [2]. areas of life that are important" to the individual
[14]
Malocclusion affects not only oral function and . The more specific concept of "oral health-
appearance, but it has also economic, social, and related quality of life" has been defined as "a
psychological effects [3. 4]. Improvement of oral standard of health of oral and related issues,
health and enhancement of psychosocial well- which enables an individual to eat, speak, and
being are perceived benefits of orthodontic socialize without active disease, discomfort, and
treatment [3]. Patients' expectations from embarrassment" [15], or "The absence of negative
orthodontics are primarily improved in terms of impacts of oral conditions on social life and a
appearance, self-image and social functioning [5]. positive sense of dentofacial self-confidence." [16]
This is supported by research on general body Over the years, a variety of indices were
image, which shows that individuals' satisfactions developed to assist professionals in categorizing
with their own physical appearances tend to be malocclusion according to the level of treatment
more outgoing and successful in social contact [6]. needed: the Occlusal Index [17], the Handicapping
Orthodontists traditionally have considered oral Malocclusion Assessment record [18], and the
health and function as the principal goals of Treatment Priority Index [19]. These indices were
treatment [7,8]. However, there has been recently developed in the late 1960s and early 1970s,
growing acceptance of aesthetics and its primarily for epidemiological purposes, but they
psychosocial impact as an important treatment were also used to determine treatment
benefit [9,10] Some patients report markedly prioritization. Demand for orthodontic treatment
improved body image, and appearance-related is mainly motivated by personal concerns about
self-confidence after orthodontic treatment [11]. appearance and other psychosocial factors [20,21].
Good dental aesthetics and previous orthodontic However, traditional methods of estimating
treatment might have a beneficial influence on orthodontic need or evaluating treatment outcome
oral health-related attitudes and behavior of young are mainly based on assessment of normative need
adults [12]. The general construct of quality of life and use, with occlusal indices or cephalometric
originated in the field of general medicine and has measurements used to define need for or
been defined as "peoples perception of their success/failure of treatment [22,23]. These measures
position in life in the context of culture and value reflect only the viewpoint of professionals, rather
(1)Lecturer. Department of Prevention ,Orthodontics and than consumer expectations. This is a serious
Pedodontics / College of dentistry /University of Sulaimani shortcoming, because there are considerable

differences between professional and patient Dental Aesthetic Index: In spite of its reliability,
perceptions of dental appearance, and the need for validity and containing both esthetic and clinical
orthodontic intervention [22,24,25]. data, the unique aspect of the DAI is its linking of
Traditional occlusal indices such as the Dental people's perceptions of esthetics with anatomic
Aesthetic Index (DAI), and Index of Orthodontic trait measurements by regression analysis to
Treatment Need (IOTN) evaluate the esthetic and produce a single score [31]. The esthetic
anatomic components of malocclusion [26], but component of the DAI [32] includes 10 parameters
they do not give any information about how of dentofacial anomalies related to both clinical
malocclusion affects a patient's self-image and and esthetic aspects of the anterior teeth (Table 1).
quality of life in terms of subjective well-being, Four grades of malocclusion are given, with
and daily functioning [27]. Recently, there has been priorities and orthodontic treatment
increasing interest in the incorporation of recommendations assigned to each grade: grade 1
psychometric instruments that measure oral indicates normal or minor malocclusion/no
healthrelated quality-of-life (OHRQOL) treatment need or slight need (DAI 25); grade 2,
outcomes [27,28], and assess body image perception definite malocclusion/treatment is elective (26
[28]
during the orthodontic treatment planning DAI 30); grade 3, severe
process. The usefulness of OHRQOL measures malocclusion/treatment is highly desirable (31
alongside normative indices in predicting DAI 35); and grade 4, very severe
orthodontic concerns have been investigated by malocclusion/treatment is mandatory (DAI 36).
several researchers [21,24]. The data were collected by a single examiner
The use of sociodental indicators allow using periodontal probe with millimeter markings,
individuals with the greatest need to be a priority millimeter ruler, calipers, pencil, and eraser. Each
when financial resources are limited [23,29]. cast was examined and scored for the ten
Moreover, efficient clinical management of components of DAI [Table 1]. Each component
orthodontic patients would predict their behavior was then multiplied by its corresponding
and compliance during subsequent treatment, so regression coefficient using the rounded weights.
that individuals with minor or borderline The products were then added and summed with
treatment needs can be safeguarded from the the regression constant to give the DAI score.
potential risks of unnecessary treatment [21,23]. In
persons with minor dental malocclusion, there is Psychosocial Impact of Dental Aesthetics
insufficient evidence that orthodontic treatment Questionnaire - PIDAQ [33]: Some researches
enhances dental health and function. Treatment is conducted in Saudi Arabia, Egypt and Syria
often justified by the potential enhancement of confirmed reliability and validation of the use of
social and psychological well-being through Arabic version of previously used public health
improvements in appearance [30]. So the purpose questionnaires in UK and German. Thus, PIDAQ
of this study is to find out the psycho-social was chosen here to be applied on Kurdish people
[34,35]
impact of dental irregularities and malocclusion
on Kurdish adolescents seeking orthodontic PIDAQ is a 23-item psychometric instrument for
treatment. assessment of orthodontic-specific aspects of
quality of life, expressed in four domains: dental
MATERIALS AND METHODS self-confidence (six items), social impact (eight
items), psychological impact (six items), and
One hundred cases were selected from
esthetic concern (three items). The PIDAQ
patients attending orthodontic clinic (College of
instrument had been previously tested for its
Dentistry/ University of Sulaimani) after taking
validity, reliability, and factorial stability across
the participants` consent and agreement, with
samples [32]. The subjects were asked to rate how
different socio-economic status, aged 13-22 (45
much dental esthetics exerted a positive or
males and 55 females) with no prior orthodontic
negative impact using a five-point Likert scale
treatment asked to complete a translated form of
ranging from 0 to 4 (0 indicates not at all; 1, a
the 'Psychosocial Impact of Dental Aesthetics
little; 2, somewhat; 3, strongly; and 4, very
Questionnaire' (PIDAQ) and 100 stone study
strongly). An overall PIDAQ score was obtained
models (upper and lower) were obtained to assess
by summing all item scores.
the dental aesthetics by using the Dental Aesthetic
Statistical Analysis: Descriptive statistics of
Index (DAI, table 1). Patients with any mental or
clinical characteristics and scores were obtained.
behavioral disorders that might have reduced their
Chi-square test was used to reveal the association
ability for self-determination were excluded as
of DAI with age, gender and PIDAQ, furthermore
well as those who did not agree to participate.
Spearman and Pearson correlation coefficient and

Multiple linear regression analysis were used to patients perceptions into the index and it links the
test the influence of DAI scores, age and gender clinical and aesthetic components mathematically
on the PIDAQ scale. The significance level was to produce a single score that combines the
set at P < .05. SPSS 14.0 for Windows was used physical and aesthetic aspects of occlusion [37].
for statistical analysis. The DAI appears to be easy to use, although the
lack of assessment of traits such as buccal cross
RESULTS bite, open bite, centerline discrepancy and deep
Table 2 show age and gender distribution of the overbite is a limitation of this index [38]. On the
study sample, as it is clear that most of patients other hand PIDAQ appears to meet the criteria of
seeking orthodontic treatment between 19-22 a good instrument as manifested in factorial
years of age, which was about 43% of total stability across the samples, in consistency of
sample size and most of them were females scales, and in criterion-related validity. It may be
(55%). Table 3 explains the DAI scores, helpful in distinguishing between various patient
frequencies and percentages of the sample. Table and provider perspectives and values, and serve as
4 and 5 explain the non significant association of means of documenting the benefits of orthodontic
DAI score with gender and age group using chi treatment in health policy discussions [39].
square test (at P value = 0.328 and 0.372 Our study revealed that Subjects' perception
respectively), while table 6 reveals the significant scores of the PIDAQ scale were analyzed
association of DAI score with PIDAQ scale using according to the grades of malocclusion
Pearson chi-square( = 192.32 ). Thus, there is a determined by the DAI. Overall, scores on the
significant Correlation between DAI score and PIDAQ scale were higher with a greater DAI
PIDAQ at p<.005. Tables 7 and 8 explain the score (P < .001), so patients with higher DAI
significant Correlation of DAI score with PIADQ scores had greater esthetic impact scores, and
and gender at the 0.01 level (2-tailed) using those with less attractive dentitions may be
Pearson correlation and ANCOVA. Finally table psychosocially disadvantaged and have esthetic
9, shows the results of the multiple regression concerns. Mandall et al [40] found that children
analysis that not only DAI scores were with higher orthodontic treatment need perceived
significantly associated with higher score of more negative psychosocial impacts. Al-Sarheed
PIADQ scores, but the gender also play an et al [41] showed that 11- to 14-year-old
important role whereas other factors such as age individuals with malocclusion reported
was not significantly associated with PIADQ significantly more impact and hence a worse
scale.. quality of life compared to a group of individuals
with no or minimal malocclusion. Although
dissatisfaction with dental appearance is broadly
DISCUSSION related to the severity of irregularities, there are
The oral-facial region is usually an area of differences in the recognition and evaluation of
significant concern for the individual because it them. It is not uncommon to observe that some
draws the most attention of other people in patients with severe malocclusions are satisfied
interpersonal interactions and it is the primary with or indifferent to their dental esthetics, while
source of vocal, physical, and emotional others are very concerned about minor
communication. As a result, patients who seek irregularities [42].
orthodontic treatment are concerned with These results confirm the view that
improving their appearance and social acceptance, adolescents attribute high importance to an
often more than they concern with improving their attractive dental appearance [20, 25, 43]. Grzywacz
oral function or health. Enhancing these aspects of [43]
reported that 100% of 84 children aged 12
quality of life is an important motive for years judged that healthy and well arranged teeth
undergoing orthodontic treatment. Over the past were important in facial appearance. Van der Geld
decade, the impact of oral health and disease, et al [44] found that facial attractiveness was
dental appearance, malocclusion, and treatment correlated with personality traits and self-
for these conditions on psychological and confidence/ self-esteem and highlighted the need
functional well-being have drawn increasing for further study on the esthetic aspects of the oral
attention of clinicians and researchers. Indeed, a region within the whole scope of facial esthetics
recent issue of Seminars in Orthodontics was and within the context of acceptance of one's own
dedicated to the topic of quality of care and body. Phillips and Beal [42] showed that, in
quality of life associated with malocclusion and its adolescents, the self-perceived level of the
treatment [36]. attractiveness or positive feelings toward the
Unlike the Index of Orthodontic Treatment dentofacial region is a more important factor in
Need (IOTN), DAI attempts to incorporate

one's self-concept than the severity or perceived sociodental variables on perceived esthetic
severity of the malocclusion or the adolescent's impacts in adolescents, focusing on representative
perception of their malocclusion. In general, the samples of normal populations. The specific
impact of oral health conditions on quality of life, socio-demographic characteristics of this
especially in term of satisfaction with appearance, convenience sample may have resulted in
may result in feelings of shame in social contacts potential bias when clinical and epidemiologic
and those who are psychosocially disadvantaged inferences are considered. Finally, we think that
[25,29,42]
. Therefore, the expected benefits of the existence of an authorized program for
orthodontic treatment would include an treatment of malocclusion for adolescents in
enhancement of self-esteem and a reduction in schools by the Ministry of Health in our region
social anxiety [22,25]. will induce a great impact in this field. It deserves
Gender has a significant variable in predicting to flash that the highly cost of orthodontic
the psychosocial impact of dental esthetics, and treatment is one of the major causes of rejection
this come in accordance with other studies that of orthodontic treatment.
found, women are more critical of their perception
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Table 1: DAI components and rounded weight

Rounded
DAI
weight
1. Number of missing visible teeth (incisors, canines, and premolars in maxillary and mandibular
6
arch)
2. Crowding in incisal segment (0 = no segments crowded, 1 = 1 segment crowded, 2 = 2
1
segments crowded)
3. Spacing in incisal segment (0 = no spacing, 1 = 1 segment spaced, 2 = 2 segments spaced) 1
4. Midline diastema, in millimeters 3
5. Largest anterior maxillary irregularity, in millimeters 1
6. Largest anterior mandibular irregularity, in millimeters 1
milimetres Anterior maxillary overjet, in .7 2
8. Anterior mandibular overjet, in millimeters 4
9. Vertical anterior openbite, in millimetres 4
10. Anteroposterior molar relationship, largest deviation from normal either left or right (0 =
3
cusp mesial or distal, 2 = 1 full cusp or more mesial or distal) normal, 1 =
11. Constant 13
DAI
Total
score
Table 2: Age and gender distribution of the study sample
Frequency Percent
13-15 years 39 39
16-18 years 18 18
Age group
19-22 years 43 43
Total 100 100
Males 45 45
Gender Females 55 55
Total 100 100
Table 3: DAI score of the study sample

Frequency Percent
1 46 46
2 29 29
DAI scores 3 10 10
4 15 15
Total 100 100
Table 4: Association of DAI score and gender

Gender
DAI scores Total P- value
Males Females
18 28 46
25
39.1%3 60.86% 100%
15 14 29
26-30
51.72% 48.27% 100%
0.32
3 7 10 3.442824
30-36 NS
30% 70% 100%
9 6 15
36
60% 40% 100%
Total 45 55 100

Table 5: Association of DAI score and age group

Age group
DAI score Total P-value
13-15 years 16-18 years 19-22 years
22 7 17 46
25
47.82% 15.21% 36.95% 100%
9 5 15 29
26-30
31.03% 17.24% 51.72% 100%
3 4 3 10 0.37
30-36 6.468861
30% 40% 30% 100% NS
5 2 8 15
36
33.33% 13.33% 53.33% 100
39 18 43 100
Total
39 18 43 100
Table 6: Association of DAI score and PIDAQ

df P- value
Pearson Chi-Square 192.32 78 0.000
Likelihood Ratio 178.0 78 0.000
N of Cases 100
Table 7: Pearson correlation of DAI with PIADQ, Gender and Age

Correlations
DAI PIADQ Gender Age
DAI Pearson Correlation 1 0.403 -0.206 0.207
Sig. (2-tailed) 0.000** 0.039* 0.038
N 100 100 100 100
**Correlation is significant at the 0.01 level (2-tailed).
*Correlation is significant at the 0.05 level (2-tailed)
Table 8: Analysis of co-variance of PIADQ scores (as dependent variable) and several co
variants
Source Type III Sum of Squares df Mean Square F Sig.
Corrected Model 3294.11 a 5 658.82 5.49 0.00
Intercept 1465.2 1 1465.2 12.21 0.001
Gender 546.52 1 546.52 4.55 0.035
Age 6.09 1 6.097 0.05 0.822
DAI score 2816.99 3 938.99 7.82 0.000
Error 11276.8 94 119.96
Total 95625 100
Corrected Total 14570.91 99
Dependent Variable: PIADQ
a R = .226 (Adjusted R = .185)
Table 9: Multiple regression analysis of PIADQ scores (as a dependent variable) and several co-
variates (n=3)
Unstandardized Coefficients Standardized Coefficients t Sig.
B Std. Error Beta
(Constant) 5.422 6.754 0.802 0.42
DAI score 0.526 0.109 0.454 4.824 0.00
Age 0.000 0.313 0.000 0.000 1.00
Gender 5.999 2.23 0.24 2.681 0.008
a. Dependent Variable: PIADQ

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Antibacterial efficiency
Antibacterial efficiency of salvia officinalis extracts and their

effect on growth, adherence and acid production of oral
Mutans Streptococci
Hadi A. Hmeem Al-Lamy, B.Sc. (1)
Abbas S. Al-Mizraqchi, M.Sc., Ph.D. (2)
ABSTRACT
Background: The use of antimicrobial agent to control plaque and oral disease has been advocated for a number of
years. Different compounds have been delivered through mouth rinses or tooth pastes or by topical application. The
purpose of this research is to find out and to compare between the anticariogenic properties of aqueous and alcoholic
sage extract on the most causative cariogenic bacteria in the oral cavity (Mutans streptococci).
Materials and methods: In the present study Mutans streptococci were isolated from saliva often dental students (age
range between 21-23 yrs) .These bacteria were isolated, purified and diagnosed according to morphological
characteristic and biochemical tests.
Results: Agar diffusion technique showed that sage extracts (aqueous and alcoholic) were inhibited the growth of
Mutans Streptococci, and the diameter of inhibition zone increased as the concentration of sage extract increased, but
the effect of aqueous extract was less than the effect of alcoholic extract. The minimum bactericidal concentration of
aqueous and alcoholic sage extract were 50%, 20% respectively. Also the alcoholic extract was high significant inhibit
(P<0.01) the viable count of Mutans Streptococci in vitro in comparison to aqueous extract.
Conclusion: Alcoholic sage extract was interfered with acid production and adherence of Mutans Streptococci higher
than aqueous extract resultant in reducing of acid production and inhibition of the adherence of this cariogenic
bacteria; alcoholic sage extract have substantively phenomenon similar to those in chlorohexidine in comparison to
aqueous extract.
Key words: Sage leaves, extracts, oral mutans streptococci. (J Bagh Coll Dentistry 2012; 24(sp. Issue 1):153-157).
INTRODUCTION Salvia officinalis (Garden sage, Common sage)

Dental caries is a multifactorial disease, which is a small perennial evergreen subshrub. It is a
depends upon the inter-relation of four main groups member of the family Lamiaceae and is native to
of factors; dental plaque (microorganisms), the Mediterranean region, though it has naturalized
carbohydrates (substrates); susceptible teeth (host) in many places throughout the world. It has a long
and the time factor (1). The microorganisms history of medicinal and culinary use, and in
specifically adapted for life on teeth form a film modern times as an ornamental garden plant. It can
called dental plaque on the tooth surface which is a be applied to external wounds; the essential oil,
complex mass containing about 109 bacteria/g heated in a vaporizer, will disinfect sick-rooms. The
embedded in a polysaccharide matrix, they must phenolic acids in Salvia are particularly potent
have the ability to produce acid by fermentation of against Staphylococcus aureus. In vitro, sage oil has
carbohydrate and result in demineralization of the been shown to be effective against both gram-
mineral portion of teeth hard tissues followed by positive and Gram-negative bacteria including
disintegration of the organic matrix (2). Escherichia coli and Salmonella species, and
The use of antimicrobial agent to control plaque against filamentous fungi and yeasts such as
and oral disease has been advocated for a number of Candida albicans (4). Salvia also has an astringent
years. Different compounds have been delivered action due to its relatively high tannin content and
through mouth rinses or tooth pastes or by topical can be used in the treatment of infantile diarrhea; its
application. Some chemical agents have proven to antiseptic action is of value where there is intestinal
be helpful against plaque accumulation and thereby infection. Rosmarinic acid contributes to the herb's
to some extent also against caries (3). anti-inflammatory activity (5). Its bitter component
stimulates upper digestive secretions, intestinal
mobility, bile flow, and pancreatic function, while
the volatile oil has a carminative and stimulating
(1) MSc. student /College of Dentistry/ University of Baghdad effect on the digestion. The thujone has a vermifuge
(2) Professor, Department of Basic Science, College of Dentistry, action(6). It is effective in reducing milk production,
University of Baghdad. and can be used during the process of weaning an
Basic Sciences 153

infant off the breast; Salvia also deals effectively for the alcoholic extract; sage leaves extract
with throat infections, dental abscesses, infected concentrations were used as follows: 50mg%, 60%
gums and mouth ulcers (5). and 70%for aqueous extract and 20%, 30%, 40%
and 50% for alcoholic extract. Agar diffusion
MATERIALS AND METHODS technique was applied to study the antimicrobial
Stimulated saliva samples were collected under effects of both types of sage leaves extracts and
standard conditions to obtain 50 microbial samples. CHX against the isolates spreaded on Brain Heart
Dental students with no medical history aged 21-23 Infusion Agar (BHI-A); wells of equal sizes and
years were selected to participate in this study. Ten- depths were prepared in the agar using Kork porer.
fold serial dilutions were prepared using sterile Single control well filled with DMF to evaluate its
normal saline. Two dilutions were selected and antimicrobial effect alone was made in each plate.
inoculated on Mitis-Salivarius Bacitracin Agar Each well was filled with 50l of a concentration
(MSB Agar), then incubated anaerobically by using was prepared from the stocks of the extracts.
a gas pack supplied in an anaerobic jar for 48 hrs at Inhibition zones diameters were measured using a
37C followed by aerobic incubation for 24hrs at scientific ruler; resistance of the isolates to the
37C. tested agents was indicated when there were no
A single colony from MS, was transferred to 10 zones of inhibition. The diameter of inhibition zone
ml sterile BHI-B and then incubated for 24 hrs created by the DMF was zero mm. To determine the
aerobically at 37C to activate the inoculums. minimum bactericidal concentrations (MBC) for the
All the isolates were gram positive (Fig. 1). The extracts, final concentrations of 20, 25, 30, 40, 50,
motility of all types of microbial cells was 60 and 70%, and absolute DMF were prepared and
examined under microscope by direct smear and incorporate in the BHI-A from sage leaves extracts
without staining; the isolates were non- motile and to get 25ml of agar and sage extract then poured
catalase negative. Cystine Trypticase-mannitol into Petri dishes and allowed to harden and
media had been used to test the ability of MS to inoculated with 0.1ml from the activated isolates of
ferment the mannitol. MS(9).
All these Petri dishes were incubated for 24 hrs
at 37C including the control bottles (negative
control which contained BHI-A with microbial
inoculums without the addition of the extract and
the positive control plates which contained BHI-A
and different concentrations of aqueous and
alcoholic extracts of sage leaves separately without
microbial inoculums). Each petridishe was checked
Figure 1: MS colonies on MSB agar(20x and examined for microbial growth. The MBC was
magnification). determined as the lowest concentration of sage
leaves extract killed the microorganisms.
100gm of dried leaves of Sage was infused in The effect of MBC and 1/2MBC of Sage
500ml of boiling distilled water and left to cool to aqueous extract on the growth of M.S had been
room temperature to prepare the aqueous extract(7) tested in comparison to the control. thirty isolates of
and 100gm of dried leaves of Sage was infused in M.S were used in this experiment; after carrying out
500ml of 98% of ethanol alcohol to prepare the initial count for viable bacteria on MSA, 1 ml
alcoholic extract(8). Agitation of the infusions with bacterial suspension inoculated into their tubes
magnetic stirrer had been done alternatively; the which contained full concentration MBC, 1/2MBC
infusion was filtered by filter paper (Wattman No.1) and the third tube as a control contained bacteria
and the residue discarded. The extract left to dry in only. The three tubes already contain 10 ml of
a Petridish at room temperature, the resulted powder BHIB. After incubation for 18-24 hours at 37c.
kept in tightly closed glass container in refrigerator From the above tubes, a serial dilution of (10-1, 10-2,
until used to prepare different concentrations. 10-4) respectively prepared. 0.1 ml from dilution 10-
2
From aqueous and alcoholic extracts of sage & 10-4 to be cultivated onto the previously
leaves different concentrations were prepared by prepared MSB agar plates & incubated aerobically
using deionized sterile distilled water (for the for 48 hours at 37c.
aqueous extract) and Dimethyl formamide (DMF)
Basic Sciences 154

The adherence of M.S on the tooth surfaces was calculated by pH meter. pH was determined
tested in laboratory according to Balekjian et al.(10) , according to Al-Mizraqchi (12) as follows: pH = pH
in the presence of aqueous and alcoholic extracts of before incubation - pH after incubation.
Sage in sucrose broth media. Sound first premolars The ability of adsorption of Sage aqueous and
were collected, cleaned and polished using slow alcoholic extract to the tooth surface had been tested
speed hand piece and non fluoridated pumice then in comparison to CHX glucconate was according to
cleaned using deionized distilled water and Al-Mizraqchi (12).
autoclaved.
Final concentrations of 10%, 20% of Sage
alcoholic extract and 25%, 50% of Sage aqueous RESULTS
extract were obtained in the 5ml. of the sucrose Diameters of inhibition zones for aqueous and
broth; the sterilized teeth were placed in the screw alcoholic extracts of sage leaves were found to be
capped bottles, one tooth in each bottle, increased as the concentration of the extracts
Dry weight of dental plaque = weight of plaque increased. Figure 2 illustrates the mean diameters of
mass on the tooth the weight of the tooth alone. the inhibition zones in relation to the concentrations
Effects of Sage extracts (alcoholic and aqueous) of the aqueous extract and CHX. Students t-test
on acidogenicity of M.S isolated (in vitro) was showed highly significant differences among
tested according to Maltz-Turkienicz et al.(11) Sage different concentrations of sage extract and CHX
extracts: 10%, 20% alcoholic and 25%, 50% 0.2% . Figure 3 describes the antimicrobial effect of
aqueous in sterilized CTA media. Calculation of the the alcoholic extract against M.S..
pH: After incubation, the pH of all bottles were
Figure 2: Comparison between the mean diameters of inhibition zones of sage aqueous extract and
C
25
21.6
20
20
18.2
17.2
15
Mean
10
7 7.3
R
0
5 10 15 20 30 40 50
Figure 3: Comparison between the mean diameters of inhibition zones of Sage alcoholic extract.
The comparison between the anti-microbial significance in difference between different

effect of different concentrations of the aqueous and concentrations (Tab 1).
the alcoholic extract of sage showed the
Basic Sciences 155

Table 1: Statistical analysis (t-test) of the comparison between the Alcohol extract & Aqueous
extract.
t-test P-value Sig
1.950 0.049 Sig
P<0.05 Significant
MBC of sage aqueous extract of MS (Tab. 2) while about 85% of the isolates were inhibited by
was 25-50% where most isolates were inhibited by 20% alcoholic extract.
concentration equal to 50% of aqueous extract,
Table 2: Minimum Bactericidal Concentrations (MBC) of Sage aqueous and alcoholic extract for
Mutans Streptococci.
Concentration of sage extract (%)
Type of Sage extract
No. of isolates 10 20 25 30 35 40 45 50 60 70
Aqueous extract 30 2 2 3 3 4 16
Alcoholic extract 30 5 25
Table 3 express the compression of MS count in High significant difference between the two extracts
the presence of sage aqueous and alcoholic extracts. concentrations (P-value<0.01)
Table 3: Student's t-test for the Comparison between the Effect Alcoholic and Aqueous Extract of
Sage on the growth of MS (in vitro).
t-test P-value Sig
1/2MBC 31.4 P<0.01 HS
MBc 12.2 P<0.01 HS
Statistical analysis for the mean of dry weight of extract (in vitro) showed reduction in the plaque
plaque mass (mg) formed by Mutans streptococci mass accumulation (Table 4).
after treatment with sage alcoholic and aqueous
Table 4: Statistical analysis for the mean of dry weight of plaque mass (mg) formed by Mutans
streptococci after treatment with sage alcoholic and aqueous extract (in vitro).
Mean dry weight (mg) of plaque mass after treatment with Sage extract
MBC 1/2MBC t-test Pvalue
Aqueous 11 + 1.42 18 + 1.428 22.45 P<0.01 HS
Alcoholic 8 + 1.43 13 + 1.80 14.14 P<0.01 HS
Control 24 + 1.428 24 + 1.428 - -
t-test 10.64 16.36 - -
P-value P<0.01 HS P<0.01 HS - -
The experiment showed the effect of 1/2 MBC (Table5). The values of pH; p-value<0.01 Highly
and MBC (10-20%) alcoholic extract and (25-50%) Significant with control.
aqueous extract in reducing acid production
Basic Sciences 156

Table 5: Statistical analysis of the mean of pH from acid production by Mutans Streptococci
strains isolated after treatment with Sage Alcoholic and Aqueous extract.
Mean pH of Mutans streptococci after treatment with Sage extract
MBc 1/2MBc t-test P-value
P<0.01
Aqueous 1.0 + 0.132 1.4 + 0.141 77.71
HS
P<0.01
Alcoholic 0.5 + 0.135 1.2 + 0.127 26.57
HS
Control 2.5 + 0.129 2.5 + 0.129 - -
t-test 18.44 8.682 - -
P<0.01 P<0.01
P-value - -
HS HS
* initial pH=7.
The results of this experiment showed that ability to adsorbed on the tooth surface and release
alcoholic extract of Sage have ability adsorbed to from the retention sides (substantively).
tooth surface and then release from the retention site
(substantivity). This appear as inhibition zone
around the tooth treated with the extract due to the REFERENCES
1. Almeida A, Roseman, M M, Sheff, M, Huntington N,
release of the extract and diffused to agar media Hughes, C V. Future caries susceptibility in children
inoculated with MS, this phenomenon is similar to with early childhood caries following treatment under
ability of CHX adsorbed and released from general anesthesia. Pediatr Dent 2000; 22: 302-6.
retention site (Fig. 4). 2. Kidd E, Jouyston-Bechal S. Essentials of Dental Caries.
The Disease and Its Managements. Oxford 2002, pp 1-
20.
3. Thylstrup A, Fejerskov O. Textbook of Clinical
cariology, 2nd edn. Copenhagen: Munksgaard 1994.
4. Betsy C, Barner D. The New Book of Salvias. Timber
50 Press 2003, P 216.
aqueou 5. William T. Botanical Latin. Timber Press 2004, P 456.
s 6. John A. The Gardener's Guide to Growing Salvias.
Workman Publishing Company 2004, P 17.
0.2 7. Cowan M. Plant products as antimicrobial agents. Clin
%
50% Microbial Rev 1999; 12(4): 564-82.
Alcoholic 8. Matsumoto M, Minami T, Sasaki H, Sobue, S, Hamada
S, Ooshima T. Inhibitory Effects of Oolong Tea Extract
on Caries Inducing Properties of Mutans Streptococci.
Figure 4: Ability of CHX adsorption on the Caries Res 1999; 33: 441-5.
crown surfaces of the tooth in comparison to 9. Barry A L. The Antimicrobic Susceptibility Test:
the adsorption of Sage Alcoholic and Aqueous Principles and Practices. Lea and Febriger, Philadelphia.
1976.
extract. 10. Balekjian A Y, Cole J S, Guidry M S. Plaque formation
From the results shown above, it is quite obvious by S. mutans: An in vitro method for quantitative
that the aqueous and alcoholic extracts of sage determination. J Dent Res 1977; 56: 696.
leaves had exerted antimicrobial action against 11. Maltz-Turkienicz M I, Wyatt C, McBrid B C. Effect of
Mutans streptococci but the aqueous extract was chlorhexidine and iodine on in vitro plaque of
less effective than the alcoholic extract regarding Streptococcus mutans and Streptococcus sangius. Caries
Sp Suppl Microbiol 1980; 3:895-6.
the antibacterial effect against mutans streptococci 12. Al-Mizraqchi A. Microbiological and Biochemical
while the minimum bactericidal concentration Studies on Adherence of Mutans Streptococci on the
(MBC) of the aqueous extract was 50% and Tooth Surfaces. Ph D Thesis. Col Sci Univ Al-
alcoholic extract was 20%. Reduction in viable Mustansiriya, 1998.
count of MS requires higher concentration of
aqueous extract in comparison to concentration
alcoholic extract. Alcoholic and aqueous extracts
interfered with some metabolic activities of MS
including adherence on the smooth surface and acid
production; the alcoholic extract of sage have the
Basic Sciences 157

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Relationship between
Relationship between Herpes simplex Virus Type-1 and

Candida albicans in Pregnant Women with Aphthous
Stomatitis in the oral cavity
Mohammad T. Abdul Hussin B.Sc. (1)
Sana A. AL-Shaikhly, Ph.D. (2)
ABSTRACT
Background: This study was aimed to show the relationship between Herpes simplex virus type-1 (HSV-1) and
Candida albicans, and to determine HSV-1 antigen in saliva of aphthous stomatitis patients by immunoflourescent
(IF), as well as to determine HSV-1 antibodies immunoglobulin G (IgG) in saliva samples by enzyme linked
immunosorbent assay(ELISA)test ,in addition to study concentration of the total salivary protein.
Materials and methods: Sixty pregnant women with aphthae and thirty healthy control subjects were included in the
study. Saliva samples were taken from all the subjects and examined by direct IF and ELISA, and using the saliva
swab samples for isolation of Candida albicans .The isolated colonies were identified by germ tube formation,
growth at 45 oC, and measuring the total salivary protein.
Results: The results of the present study showed that aphthous were most prevalent at age group(26-30) years. The
most commonly affected mucosa are the labial mucosa, buccal mucosa, tongue, and rarely the soft palate and
floor of the mouth. Positive IF results were observed in 53.33% in patients and 6.67% in healthy control, while in ELISA,
the positive results were found to be 63.33% in patients and 6.67% in control subjects. There was significant difference
between anti HSV-1 IgG Abs and total salivary protein.
Conclusion: the present study show there was no difference between Candida albicans and HSV-1 .The present
study indicated that HSV-1 was detected serologically in saliva of patients by ELISA and IF method .The results
revealed positive association between HSV-1 and aphthous, and the virus may play a role in the occurrence of the
aphthous. Saliva is regarded as a transudate of the serum and it contains the same antibodies as serum, and a
similar range of IgG antibodies, but at a much lower concentration and it's easily available and simply examined.
The total salivary protein may play a role in the defense against the virus.
Key word:HSV-1,aphthous,ELISA,IF. (J Bagh Coll Dentistry 2012;24(sp. Issue 1):158-163).
INTRODUCTION
Viruses are the smallest infectious Herpes simplex virus -1 is a double stranded
microorganisms that can be observed by electron DNA (dsDNA) enveloped virus, the virion (virus
microscopy. They are composed of lipid envelop, particle) has 4 basic structures- the envelope,
protein coating and inner core of either RNA or tegument, nucleocapsid , and a DNA-containing
DNA. They depend in their own reproduction on core(6).It is incurable and persisted during the
hosts' cells (1). Herpes viruses comprise the largest lifetime of the host, often in latent form .Primarily
family of viruses with oral manifestations. Eight infect mucosal surfaces following exposure to
types of herpes viruses are known to be infected secretions, it causes a range of diseases
pathogenic in human, with varying significance from labialis and stomatitis to blinding keratitis
relative to oral diseases. HSV-1 is the most and rarely encephalitis (7).Their clinical
common virus cause oral and perioral viral manifestations are variable and influenced by the
infection (2).Herpes simplex virus is transmitted portal of viral entry, degree of host immune
during close contact with an infected person who competence as well as primary or secondary
is shedding virus from the skin, saliva or nature of the disease (8). Aphthous Stomatitis
secretions from the genitals(3).This horizontal caused by HSV-1 is a common disease that causes
transmission of the virus is more likely to occur the appearance of recurrent aphthous stomatitis in
when sores are present, although viral shedding, the oral mucosa, the incidence is of about 20% in
and therefore transmission, does occur in the the world population, and the disease is more
absence of visible sores (4).In addition, vertical frequent in females than males. Despite the high
transmission of HSV may occurs between mother incidence many studies dedicated to unveiling its
and child during childbirth, which can be fatal to causes, it still is very controversial regarding
the infant (5). etiology (9).This disease is currently defined as a
disease characterized by aphtha lesions in the oral
mucosa, in a recurrent fashion (every fortnight or
monthly), for a minimum period of one year, and
(1) MSc student, dep. of Basic Sciences, College Dentistry,
University of Baghdad its onset is usually without evidences of
(2) Assistant professor, dep. Of Basic Sciences, College associated systemic diseases(10).Incidence of
Dentistry, University of Baghdad. aphthous stomatitis is greater in the second
Basic Sciences 158

decade of life (11, 12). The aphthous stomatitis also Immunofluorescence for detection of HSV-1
caused by other pathogenic microbes including Ag:
Candida, many species of Candida cause aphthous ZEUS herpes simplex virus -1 IgG ( USA-
but Candida albicans is generally more virulent Products Series: 9051) was used for detection of
than any other species (13). There are several HSV-1 Ag by direct immunofluorescence assay
putative virulence factors of Candida albicans, according to manufacturer's protocol in the leaflet
including the ability to form germ tubes(14). of the kit. .
Adherence to host cells, and secretion of ELISA method for the detection of HSV-1Ab
proteinases (15,16,17).The ability to make the Enzyme immunoassay for the detection IgG
transition from budding to hyphal growth is antibodies to herpes simplex virus -1 by using
essential for virulence (18,19,20) .And the first stage HSV-1 IgG enzyme immunoassay, and its
in this transition is the formation of a germ tube procedure as in the leaflet of the kit.
(14)
. The ulcerations are not infected with the Laboratory identification of Candida albicans
virus. In these rare cases, HSV-1 may be Specimen collection: Specimen collection was
responsible for the initiation of the autoimmune done by using cotton tipped swab. The swab was
destruction; conversely, the immune taken from precipitation of saliva and inoculated
dysregulation that produces aphthae may have directly on Sabourauds dextrose agar. The
allowed the release of the virion (21).Saliva inoculated culture plates were incubated at 37C
samples for antibodies detection is being for 72 hours .and then kept at 4C for further
considered to be able to substitute for serum in investigation.
clinical diagnosis or screening purpose since Microbiogical identification:Each swab was
saliva is regarded as a transudate of plasma, streaked onto the surface of Sabourauds dextrose
containing a similar range of antibodies (22). agar, then incubated at 37C for 48hrs. The
isolated colonies were identified by:
Colony morphology: Colonies of Candida
MATERIAL AND METHODS aldicans appear smooth, creamy in color and
Ninety Iraqi pregnant women were included in typically medium sized 1.5 - 2 mm diameter
this study in the consultant clinic of Gynecology which later develop into high convex, off - white
in medical city ,and the working in teaching larger colonies after two days(23).
laboratories during the period from beginning of Microscopic examination: The slide was
November 2010 till the end of April 2011.The examined under light microscope, the rounded or
measurements included two groups: oval yeast cells were stained Gram positive (stain
1.Patients group : are sixty Pregnant women; age violet).
group range ,aged from(15- 45 years) suffered Germ tube formation:Germ tube are filamentous
from ulcers which were diagnosed clinically by out growth that arise from blastospores of
dentist as aphthous stomatitis. The patients were Candida albicans, this was carried through lightly
subjected to a questionnaire on the disease touching one representive colony with sterile
manifestations, family history and clinical platinum loop then it was suspended and
features, as shown in the .All the cases had incubated in one ml of human serum at 37C for 2
received no treatment with no complain history of hours after which it was examined under the light
chronic or systemic diseases. The ulcers of all the microscope to identify germ tube production of
sixty patients were of major aphthous stomatitis. Candida albicans (24).
2.Healthy group: are thirty Pregnant women age The growth at 37 oC and 45 o:This was done by
group range from(15-45 years), without any using cotton tipped swab. The swab was taken
history of oral mucosal lesions, and considered as precipitation of saliva and inoculated directly on
control group. Sabourauds dextrose agar (two plates).The
Saliva collection and preparation inoculated culture plates were incubated at 37C
Five ml of whole unstimulated saliva were and 45C for 24 hr after which it was examined to
collected using disposable test tubes. Subjects identify The growth in both degrees.
were asked to refrain from eating, drinking,
chewing and smoking one hour prior to collection
of saliva. Saliva then centrifuged at 1500 rpm for RESULTS
10 minutes; this was done within 1hour after Age
collection to eliminate debris and cellular matter, Table 1 shows the distribution of study group by
the supernatants were aspirated immediatelyinto age for both patients group suffered from
three pre labeled epndroof tube and stored frozen aphthous stomatitis and the control group without
at (-20 oC.) until assayed. any history of oral mucosal lesions. As seen in the
table the patients group and the healthy control
Basic Sciences 159

group were divided into six groups according to Candida albicans isolation
the age. Candida albicans were isolated from the saliva
Family history samples of 60 patients on Sabourauds dextrose
The distribution of study group according to the agar as following:
family history is seen in table 2. Concerning Colony morphology: Colonies of Candida
patients group, the positive family history aldicans appear smooth, creamy in color and
recorded was higher than negative family history typically medium sized 1.5 - 2 mm diameter
with statistically highly statistically significant which later develop into high convex, off - white
difference (P<0.01). While the control group , larger colonies after two days.
showed the positive family history lower than Microscopic examination: The slide was
negative family history with highly statistically examined under light microscope the rounded or
significant difference (P<0.01). oval yeast cells were stained Gram positive (stain
Type and Location of major ulcer violet) .
The ulcers of all the sixty patients were of major Germ tube formation: Germ tube are
aphthous stomatitis were diagnosis by dentist. The filamentous outgrowth that arise from
distribution of sample according to the location of blastospores of Candida albicans, this was carried
ulcer showed that the labial mucosa was the most through ,lightly touching one representive colony
common sites (33.33%) followed by buccal with a loop then was suspended and incubated in
mucosa (26.67%) then buccal vestibule (21.67%) one ml of human serum at 37C for 2 hours after
then the tongue (8.33) then soft palate (5%), while which it was examined under the light microscope
the less common sites were the floor of the mouth to identify germ tube production of Candida
(1.67%) as seen in table 3. albicans.
The age of aphthous stomatitis onset and The growth at 37 oC and 45 oC
number of ulcers All tested isolates showed growth at 37C while
Regarding the age of aphthous stomatitis onset, only Candida albicans isolates grow at 45 C (25)
all the patients group had the ulcer after the age of Thus, the test used to differentiate Candida
ten years, while for the number of ulcers, all the albicans and Candida dubliniensis because
patients got one or two ulcers per episode. Candida dubliniensis loss its ability to grow at 45
ELISA results C while Candida albicans grow due to its ability
Data of this study showing that the ELISA results to form germ tube formation .
(by using HSV-1 IgG enzyme immunoassay kit) Relation between HSV-1 Abs and Candida
As shown in table 4 the mean of anti HSV-1 IgG albicans
Abs in aphthous stomatitis patients was (0.329 In this study, there was no difference between
Hu/ml) which is higher than mean in healthy positive and negative results of Candida albicans
control group (0.128 Hu/ml).The results showed and anti HSV-1 IgG Abs in aphthous stomatitis
statistically significant differences. patients (mean = 0.343 0.022, mean = 0.329
Immunofluorescent results 0.029).table 6.
Results of direct immunofluorescent using the
ZEUS herpes simplex virus-1 for detection of
viral Antigen are summarized in table 5. Thirty
two (53.33%) patients with aphthous stomatitis
revealed positive reaction. While twenty eight
(46.67%) patients revealed a negative reaction.
The direct immunoflurescent method showed
cells producing HSV-1 specific antigen, which
was identified by the cytoplasmic apple-green
fluorescence which is considered as a positive
results figure 1 .These were taken from patients Figure 1: Positive Immunofluorescent picture in
patient with aphthous stomatitis showing large
having herpes labialis, while no specific
cells with ballooning degeneration.
fluorescence it will be considered as a negative
results figure 2. Regarding control group two
cases(6.67%) showed positive reaction as in
figure 3, while twenty eight (93.33%) cases show
a negative reaction figure 4.These results showed
a statistically significant differences.
Basic Sciences 160

Type and location of ulcers

The major aphthous stomatitis was the most
predominant type in this study. Regarding the
location of the ulcer, the study showed that labial
mucosa (33.33%) was the most common site for
aphthous stomatitis. This could be explained on
the basis that these sites were movable structures
and mostly affected by trauma which was the
most precipitating factor in developing the
Figure 2: Negative Immunofluorescent picture in aphthous stomatitis. This result confirmed the
patient with aphthous stomatitis. observation of (Al-Hijazi(28); Ship and Arbor(29).
The age of aphthous stomatitis onset and
number of ulcers
Most of the patients in the present study showed
that the onset after ten year of aphthous stomatitis
onset was after the age of ten year and were
numbered from one or two ulcers and this finding
confirmed the results observed by( Ali(26); Al-
Hijazi(28); Al-alttas(30).
ELISA
The finding analyzed apositive antibody IgG
Figure 3: Positive Immunofluorescent picture in against HSV-1 in the studied groups was detected
control group. in (63.33%) patients with RAS, while in control
group it appears positive in (6.67%).ELISA
results revealed that the mean values of anti HSV-
1 IgG in patients with RAS was (0.329 Hu/ml) in
comparison to among healthy control group
(0.128 Hu/ml). This may refer to direct
relationship between increased level of anti HSV-
1 IgG in saliva of RAS patients and prevalence of
the disease.
Immunofluorescent
The finding of Immunofluorescent results in this
Figure 4: Negative Immunofluorescent picture in study showed a positive result in 32 out of 60
control group. X 400 patients (63.33%) with aphthous stomatitis, in
which the cells swell to a large size leading to
DISCUSION ballooning degeneration and each field consist of
Age many cells more than 10 cells as shown in figure
Sixty pregnant women with aphthous stomatitis (1),while in control subjects showed positive in 2
were included in this study. The age of the out of 30 healthy individuals(6.67%), in which the
patients was ranged between 15-45 years, The cells appear smaller in size and their number less
high incidence of recurrent aphthous stomatitis than 10 per field as shown in figure (3).
was noticed among age of 26-30 years which can The positive results in control subjects could be
be due to that they were under stress (the main attributed to the shedding of HSV-1 in the oral
etiological factor for recurrent aphthous cavity which tends to be frequent and episodic.
stomatitis).The design of this study to deal with Relation between of HSV-1 and Candida
pregnancy women are due to the fast that female albicans
was more affected by recurrent aphthous In this study, there was no difference between
stomatitis than male Ali(26) and disagreement with positive and negative results of Candida albicans
Anuna, et al (27) and anti HSV-1 IgG Abs in aphthous stomatitis
Family history patients .The increasing of percentage of Candida
It had been found in this study that 53.33% of albicans in patient with HSV-1 may be due to the
RAS patients had family history of aphthae, in ability of HSV-1 to suppress of the body immune
which familial aggregation and concordant system lead to HSV-1 infection .Which leads to
disease support the involvement of genetic factors growth and then changing of non pathogenic
in the pathogenesis of the disease. Candida albicans to become pathogenic (Rinallo
and tropy(31).
Basic Sciences 161

18. Lo HJ, Kohler JR ,DiDomenico B, Loebenberg D,

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5. Kimberlin DW. Herpes simplex virus infections of the
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21. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral
6. Lee JH, Vittone V, Diefenbach E, Cunningham A.,
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Diefenbach RJ. Identification of structural protein-
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8. Brady R, Bernstein D. Treatment of herpes simplex
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Table 1: Age Distribution of patients and control healthy group.

Age group Patientsgroup Control group
(year) No. % No. %
15-20 5 8.33 2 6.67
21-25 16 26.67 8 26.67
26-30 18 30.0 10 33.33
31-35 11 18.33 8 26.67
36-40 9 15.0 2 6.67
>40 1 1.67 0 0
Total 60 100 % 30 100 %
2 value -- 6.03 ** -- 6.38 **
** (P<0.01).
Basic Sciences 162

Table 2: Distribution of study groups according to family history

Positive family Negative family
Subject Total 2 value P value
No. % No. %
Patients 32 53.33 28 46.67 60 3.283 * 0.025
Control 2 6.67 28 93.33 30 13.66** 0.0082
2 value -- 9.48 ** -- 11.63** -- 6.38 ** 0.0104
* (P<0.05) , ** (P<0.01).
Table 3: Distribution of ulcer according to their location among patients group .

Patients
Location
No. %
Tongue 5 8.33
Buccal mucosa 16 26.67
Labial mucosa 20 33.33
Buccal vestibule 13 21.67
Labial vestibule 2 3.33
Soft palate 3 5.00
Floor of the mouth 1 1.67
Total 60 100 %
2 value -- 6.49 **
** (P<0.01).
Table 4: Difference in mean of anti HSV-1 IgG Ab among study groups
Subject No. Mean SD of total protein
Patients 38 0.329 0.18
Control 30 0.128 0.13
LSD value - 0.051 *
* (P<0.05).
Table 5: Distribution of study groups in relation to result of IF.

Positive IF Negative IF
Subject Total 2 value
No. % No. %
60 3.283 *
Patients 32 53.33 28 46.67
Control 2 6.67 28 93.33 30 13.66 **
2 value -- 9.48** - 11.63** 90 --
* (P<0.05) , ** (P<0.01).
Table 6: Comparison between positive and negative of Candida albicans of patients according to
ELISA results (mean SD) .
Subject No. Mean SD of ELIZA results
Positive 28 0.343 1.164
Negative 10 0.329 9.169
LSD value --
NS: The difference is non-significant.
Basic Sciences 163

J Bagh College Dentistry Vol. 24(special issue 1), 2012 Study the role of
Study the role of proinflammatory and anti- inflammatory

cytokines in Iraqi chronic periodontitis patients
Zahraa F. Shaker M.Sc. (1)
Batool H.Hashem Ph.D. (2)
ABSTRACT
Background: Chronic periodontitis is a multifactorial polymicrobial infection characterized by an inflammatory
process that leads to destruction of teeth supporting tissues. There is a complex network of pro- and anti-
inflammatory cytokines acting in the inflamed periodontal tissues. This study was designed to detect the serum levels
of pro-and anti-inflammatory cytokines in chronic periodontitis patients and determine its correlation with different
clinical parameters of the periodontal status, as well as study the correlation among these cytokines and to evaluate
the ratio between pro-and anti-inflammatory cytokines.
Subjects and Methods: A total of 50 patients with chronic periodontitis were studied, their ages range from 23-60
years with a mean age of 40.17.6 years. Apparently healthy volunteers consisted of 25 individuals who were their
age range (21-50) years with a mean age of 33.49.1 years considered as control. Periodontal parameters used in
this study were plaque index, gingival index, probing pocket depth, clinical attachment level and bleeding on
probing. Blood samples were collected from CP patients and healthy control groups to assess serum concentrations
of IL-1, IL-2, IL-6, TNF- and IL-10 by means of enzyme-linked immune-sorbent assay.
Results: The current results revealed that median serum levels of pro-inflammatory cytokines (IL-1 and TNF-) were
significantly higher in CP patients than in healthy control groups (p<0.001), whereas the serum levels of IL-2and IL-6
were not observed any significant differences between two groups (p>0.05). In contrast serum levels of anti-
inflammatory cytokines (IL-10) was significantly low in patients when compared to control (p<0.001). On the other
hand, the ratios of IL-1\IL-10 and TNF-\IL-10 were significantly higher in patients when compared with the ratios in
control group.
Regarding correlation between serum cytokines and clinical periodontal parameters, serum IL-1 level was showed
significant positive correlation with each of plaque index, gingival index, probing pocket depth and clinical
attachment level. On the otherhand no association between serum IL-2 levels and clinical parameters of chronic
periodontitis were found. Moreover; IL-6 was showed significant positive correlation with probing pocket depth, while
TNF- revealed significant positive association with each of gingival index, probing pocket depth and clinical
attachment level. Conversely, serum IL-10 levels had negative significant correlation with plaque index, probing
pocket depth and bleeding on probing. Interestingly strong linear positive correlation was found among each of (IL-
1, IL-6 and TNF-,).While strong negative correlation was noticed between IL-10 and each of (IL-1 and TNF-).
Conclusion: The present results may provide direct evidence for the systemic activation of immune cells in
periodontitis, and suggests that cytokines may play an important role in pro-inflammatory response in serum of
patients with chronic periodontitis. Moreover imbalance between pro and anti-inflammatory cytokines could be
involved in the initiation and progression of chronic periodontitis and is indicative of a stronger systemic pro-
inflammatory state in disease.
Key words: Chronic Periodontitis, IL-, IL-2, IL-6, TNF-, IL-10. (J Bagh Coll Dentistry 2012;24(sp. Issue 1):164-169).
INTRODUCTION These host mediators directly or indirectly

Periodontitis is a multifactorial infection participate in periodontal tissue destruction and
characterized by a destructive inflammatory particularly in bone resorption (3).
process affecting tooth supporting tissues and Cytokines are biologically active molecules
resulting in periodontal pocket formation and released by specific cells that elicit a particular
alveolar bone resorption, which might eventually response from other cells on which they act (4).
lead to tooth loss (1). The chronic form of Interleukin -1 (IL-1), IL-2, IL-6, IL-8 and
periodontitis, termed chronic periodontitis (CP), is tumor necrosis factor- (TNF-) are generally
the most prevalent disease type (2). Although, classified as pro-inflammatory cytokines (5). Pro-
periodontal bacteria are the main causative agents inflammatory cytokines enhance the bactericidal
inducing the initiation of periodontitis, subsequent capacity of phagocytes, recruit additional innate
progression and disease severity are also cell populations to sites of infection, induce
determined by the host immune response. The dentritic cell maturation and direct the ensuing
continuous challenge of host immune and resident specific immune response to the invading
cells by periodontopathogens and their virulence microbes (6). While anti-inflammatory cytokines
factors results in a complex network of pro- and block this process or at least suppress the intensity
anti-inflammatory cytokines acting in the of the cascade, such as IL-4, IL-10 and IL-13 (6).
inflamed periodontal tissues. In periodontal disease, the balance between
(1)
Assistant Lecturer, Department of microbiology, college of pro- and anti-inflammation is directed towards
Dentistry, University of Al-Mustansiriya. pro-inflammatory activity (7). In periodontal
(2)
Assistant Professor, Department of microbiology, College of tissues IL-1 is known to stimulate the
proliferation of keratinocytes, fibroblasts, and
Basic Sciences 164

endothelial cells and to enhance fibroblast Correlation between the different parameters was
synthesis of collagenase, hyaluronate, fibronectin, calculated by the spearman test and P values of
and prostaglandin E2 PGE2. IL-1 upregulates P<0.01 and P<0.05 were considered significant
(15)
matrix metalloproteinases (MMP) and .
downregulates tissue inhibitor of
metalloproteinase production and it is also a RESULTS
potent stimulator of bone resorption (8). The results presented in this study are based
Interleukine 2 has primarily been associated as an on the analysis of 50 patients with CP, compared
autocrine factor for T cells, although some data with 25 apparently healthy individuals considered
indicate the ability of this factor to stimulate B as controls.
lymphocytes (9). Reports provided evidence for In the present study the age of CP patients
IL-2 in gingival crevicular fluid (GCF) ranged between 23-60 years with a mean age of
Interleukin 6 induces the enhancement of T-cell 40.17.6 years. Furthermore, there was males
proliferation and acceleration of bone resorption predominance among patients
by increasing osteoclast formation (10, 11). Local Regarding the differences in clinical periodontal
production of IL-6 also occurs in inflamed parameters in patients and healthy controls, the
periodontal tissues and has also been associated differences in clinical periodontal parameters in
with attachment loss in refractory periodontitis patients and healthy controls are summarized in
(12)
. table (1).
TNF- fuels tissue pathology towards I. Serum levels of IL-1, IL-2, IL-6, TNF- and
periodontal connective tissue destruction and IL-10 in CP patients and healthy control
bone loss (7). Accordingly, Tumor necrosis factor Table (2) revealed a significant elevation in
alpha is a multi-potential pro-inflammatory median serum IL-1 level among CP patients
cytokine produced as a result of bacterial (34.57pg /ml) in comparison to that of healthy
stimulation by monocytes/ macrophages, control (27.21 pg /ml) (p<0. 01,on the other hand
polymorphonuclear, leukocytes,fibroblasts, there is no significant differences (p>0.05) in
epithelial cells, endothelial cells and osteoblasts. serum median level of IL-2 between patients and
TNF- enhances connective tissue and bone healthy control groups (1.29pg\ml;1.19pg\ml)
destruction via enhanced osteoclast formation and respectively, Interestingly the level of IL-6 in
activity, induction of matrix-metalloproteinase sera of CP patients was significantly higher than
expression and stimulation of (PGE2) production. that in healthy control (4.567pg /ml; 1.261pg /ml)
In addition, apoptosis of fibroblasts is stimulated respectively, but statistically not significant (p>0.
by TNF-, resulting in limited repair of the 05). An anticipated, there are significant decrease
periodontal tissues (13). of median serum of IL-10 level in CP patients
In a complex network of pro- and anti- (0.039pg /ml) as compared to healthy control
inflammatory cytokines acting in the inflamed (0.095pg /ml), (p<0.01), revealed a significant
periodontal tissues, IL-10 is an example of a elevation in median serum level of TNF- among
cytokine with anti-inflammatory effects. IL-10 is CP patients (1.51 pg/ml) in comparison to that of
a regulatory a inflammatory cytokines (14). healthy control (0.52 pg/ml), (p<0.05)
II Correlation between Serum Cytokines and
SUBJECTS and METHODS Clinical Periodontal Parameters in CP patients
A total of 50 patients with chronic periodontitis Regarding correlation between serum
were studied, their ages range from 23-60 years cytokines and clinical Periodontal parameters,
with a mean age of 40.17.6 years. Apparently serum IL-1 level was showed significant positive
healthy volunteers consisted of 25 individuals correlation with each of PI, GI, PPD and CAL,
who were their age range (21-50) years with a (p<0.05), (p<0.001), as observed in table (3.9).
mean age of 33.49.1 years considered as control. On the other hand, there is no association between
Periodontal parameters used in this study were serum IL-2 levels and clinical parameters of
plaque index, gingival index, probing pocket periodontitis was found (p>0.05).
depth, clinical attachment level and bleeding on Moreover; IL-6 was showed significant positive
probing. Blood samples were collected from CP correlation with PPD, (p<0.05) according to table
patients and healthy control groups to assess (3.11), while TNF- revealed significant positive
serum concentrations of IL-1, IL-2, IL-6, TNF- association with each of GI, PPD and CAL
and IL-10 by means of enzyme-linked immune- (p<0.05), (p<0.001),
sorbent assay. Conversely, serum IL-10 levels had significant
Statistical analysis: It was assessed using P negative correlation with PLI, PPD and BOP,
(Mann-Whitney-test), P (Bonferroni-test). (p<0.05), (p<0. 01), table (3)
Basic Sciences 165

III Correlation between Serum Cytokines in CP inflammatory mediators like IL-1 and TNF- (31,
32).
patients
The present study revealed significant strong Interleukine-10 has a key role in
positive linear correlation among each of (TNF-, maintaining the health and stability of periodontal
IL-1 and IL-6) p<0.01.While strong negative tissues (33.34).Significant decreased of IL-10 in
correlation was noticed between IL-10 and each of serum CP patients in compared with healthy
(TNF-, IL-1) p<0.01. control this result was consistent with (23, 35,)
but at variance with Bodet and colleagues, who
DISCUSSION reported that there was no significant differences
the present study showed that the median serum in the level of serum IL-10 between CP patients
level of pro-inflammatory cytokine IL-1 was and healthy group (36).
significantly higher in patients with CP as Because of the interactions between cytokines,
compared with healthy control group, and these the ratios were studied in this work, and the
findings are consistent with other studies reported findings found out that the ratios were
by (16, 17). large number of studies observed significantly higher in the periodontitis group
significant positive correlation between the levels when compared with the ratio in the control
of IL-1 and periodontal parameters such as subjects, indicating a stronger systemic pro-
probing pocket depth and CAL (18,19), inducible inflammatory state in chronic periodontitis, this
metalloproteinases, which results in activation of result is consistent with (23).
osteoclasts and bone resorption and down- Based on data in this study the elevation of IL-1
regulation of type I collagen expression in bone (7) that accompanied by elevation, TNF-, IL-6,
that serum IL-1 may be a good marker of these observations agreement with (7,37) who
periodontal inflammation. the current findings observed that there was a synergism activity in
failed to show any significant differences in the biological activity of IL-1 with each of (TNF-
serum concentrations of IL-2 between CP patients and IL-6). Therefore, high level of TNF- noticed
and controls as well as neither correlation with in this study which has positive correlation with
clinical parameters of periodontitis was found IL-1 and IL-6 could be stimulates the production
these results are in agreement with other results of other pro-inflammatory cytokines including IL-
reported by (20). 1 and IL-6. Generally, IL-10 is a regulatory
This study the increase in the serum IL-6 level cytokine, which limits inflammatory responses by
was statistically not significant. Similarly to the inhibiting the expression of pro-inflammatory
present results (21, 22) observed that there were no cytokines (IL-1, IL-6, TNF-), also up-regulates
significant differences between CP patients and the recruitment and activation of B cells and it
controls (39)
down-regulates the Th1 response, .
High level of serum TNF- in CP patients Nevertheless, IL-10 lacked the competence to
observed in this study was comparable with suppress inflammation due to the elevation of
other studies reported by (23,.24) who observed inflammatory mediators e.g. IL-1, TNF-, IL-6
similar increase of this cytokine, another (40, 41).
Interestingly, this support the result of the
interesting finding in this study was the present study, regarding the presence of negative
significant positive association of serum TNF- correlation between IL-10 and each of (IL-1 and
with each of GI, PPD and CAL. TNF-), because one of the normal biological
In contrast these results were at variance with activities of IL-10 is down regulates of pro-
(25, 26)
who noticed that there was no significant inflammatory cytokines production by monocyte
difference in concentration of serum TNF- (42, 43)
. Finally, the balance between pro-
between the CP patients and healthy control. On inflammatory and anti-inflammatory cytokines in
the other hand other studies conducted by (,27,28) CP determines the degree and extent of
they used other different samples such as saliva, inflammation which can lead to major clinical
gingival tissues and GCF, they found also effects.
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Table 1: Demographic and Clinical Periodontal Parameters in CP Patients and healthy Control
groups
Healthy
CP Patients
Control P -Value
(n=50)
(n=25)
Demographic Parameters
Age Range (23-60) (21-50)
Age Mean SD 40.17.6 33.49.1 P=0.07[NS]
Male 40(80%) 18(72%) P=0.15[NS]
Female 10(20%) 7(28%) P=0.88[NS]
Clinical periodontal Parameters
Plaque Index 1.40.4 0.6 0.1 <0.001**
Gingival Index 1.60.3 0.50.1 <0.001**
Proping Pocket Depth (mm) 2.10.4 1.20.6 <0.001**
Clinical Attachment Loss (mm) 1.40.4 0 <0.001**
Bleeding on Probing (BOP) percentage of bleeding
21.829.2 2.61.5 =0.003**
surfaces
Table 2: CP patients-healthy control difference in serum median concentration of IL-1, IL-2,

IL-6, IL-10 TNF-, IL-1/IL-10.and TNF-/IL-10 (pg/ml)
Inter-quartile
Median Mean Rank P (Mann-
Range range
CP patients CP patients Whitney)
CP patients Healthy CP patients
Healthy Healthy median
N=50 N=25 Healthy
N=50 N=25 N=50 N=25
N=50 N=25
(0.013
(0.106 - (0.106 - (0.813 - (0.813 - (1.011 - (1.037 - (0.010
IL-1 - 0.003**
368.9) 117.8) 1.784) 1.918) 9.698) 6.50) - 0.82)
0.839)
IL-2 34.57 27.21 1.296 1.196 4.567 1.261 0.039 0.095 0.86[NS]
(0.027 (0.034
(13.046 - (9.691 - (0.959 - (0.959 - (1.261 - (1.347 -
IL-6 - - 0.12[NS]
86.817) 42.161) 1.479) 1.391) 4.567) 4.806)
0.051) 0.165)
IL-10 40.1 32.4 37.68 38.64 43.4 35.3 33.19 47.62 0.007**
(0.1 - (0.09 - (0.35 - (0.406 -
TNF- 1.51 0.52 45.2 36.8 0.012**
1.905) 0.81) 0.542) 0.577)
IL-
(3.12- (0.41 - (279.6 - (19.88 -
1/IL- 663.73 290.11 42 28.68 0.012*
40441.44) 2661.31) 1804.25) 853.74
10
TNF-
(0.35 - (0.55 - (7.69 - (1.87 -
/IL- 11.94 5.87 42.72 28.56 0.008**
53.9) 43.46) 16.16) 11.69)
10
Basic Sciences 168

Table 3: Correlation between serum level IL-1, IL-2, IL-6, IL-10, TNF-, IL-1/IL-10, TNF-
/IL-10 and clinical periodontal parameters in CP patients.
Clinical PLI GI PPD CAL BOP
Parameters Correlation P C P C P C P C P
IL (Mann- Whitney) (Mann- Whitney) (Mann- Whitney) (Mann- Whitney) (Mann- Whitney)
IL-1 0.329 0.329 -0.273 0.06[NS] 0.047 0.75[NS] 0.75[NS] 0.011* 0.149 0.31[NS]
IL-2 0.677 0.677 -0.151 0.3[NS] 0.001 1[NS] 1[NS] 0.97[NS] 0.363 0.009**
IL-6 0.332 0.332 -0.109 0.45[NS] 0.33 0.016* 0.016* 0.026* 0.299 0.035*
IL-10 0.491 0.491 -0.143 0.32[NS] 0.006 0.97[NS] 0.97[NS] 0.76[NS] 0.383 0.000**
TNF- 0.062 0.062 0.07 0.58[NS] -0.078 0.586[NS] 0.586[NS] 0.003* 0.171 0.235[NS]
IL-1/IL-10 -0.298 0.038* -0.05 0.73[NS] -0.316 0.006** -0.009 0.95[NS] 0.003 0.98[NS]
TNF-/IL-10 0.089 0.54[NS] -0.008 0.96[NS] 0.302 0.033* 0.008 0.95[NS] 0.109 0.45[NS]
Table 4: Correlation coefficient between serum Cytokines levels and ratios in CP patients
Serum Serum Serum Serum Serum Serum IL-1 Serum TNF-

Cytokines
IL-1 IL-2 IL-6 IL-10 TNF- \IL10 ratio \IL10 ratio
Serum IL-1 1 0.031 0.400** -0.60** 0.78** 0.745** 0.303*
Serum IL-2 0.031 1 0.183 0.276 0.089 0.106 0.287*
Serum IL-6 0.400** 0.183 1 0.064 0.65** 0.224 0.136

Serum IL-10 -0.60** 0.276 0.064 1 -0.54** 0.475* 0.712**
Serum TNF- 0.78** 0.089 0.65** -0.54* 1 0.336* 0.157
Serum IL-1
0.745** 0.106 0.224 0.475* 0.336* 1 0.188
\IL10 ratio
Serum TNF-
0.303* 0.287* 0.136 0.712** 0.157 0.188 1
\IL10 ratio
Basic Sciences 169

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Scientific Journal Published by the

College of Dentistry University of Baghdad

Vol. 24 No. Special Issue 1 2012

National Members International Members

v Instructions for the Authors

Oral and Maxillofacial Surgery and Periodontology

Orthodontics, Pedodontic, and Preventive Dentistry

Evidence for feasibility of aluminum potassium sulfate

INTRODUCTION which is used as an astringent and antisepsis in

Microleakage of class II packable resin composite lined

Restorative Procedure Sample grouping

Group-II (RMGIC): Resin modified glass RESULTS

to avoid polishing the cervical margin. (7) 0.2

based composite restorations. American J Dent.

A comparison between the arbitrary and kinematic

INTRODUCTION The importance of the ICD has been stressed

of producing a nonworking occlusal interference patients receiving multiple fixed restorations on

Figure 3. Marking the terminal hinge axis at

Table 1: Descriptive statistics of (AIFW) Table 5: ANOVA test results of (KICD).

Student's t-test results of the KIFW and the

Table 6: Group Statistics (Student's t-test)

Table 4: ANOVA test results of (KIFW).

A clinical comparison between maxillary and mandibular

INTRODUCTION occurs within the alveolar bone, which provides

used in this study was mains-operated unipolar Table 3: Percentages of solution

Table 7: Statistical comparisons of Table 10: Statistical comparisons of

Table 8: Statistical comparisons Table 11: Statistical comparisons of

Comparative study of wettability of different lining, tissue

1. Wooden stage with the dimensions of (69cm,

In a bulk of a solid or a liquid the molecules are

Evaluation of different techniques used in non surgical

INTRODUCTION A solvent can facilitate the removal of gutta-

Oral Med Oral Pathol Oral Radiol Endod 2003; 96:

Figure 1: Score 1 Figure 2: Score 2

Figure 3: Score 3 Figure 4: Score 4

The effect of addition of calcium hypochlorite disinfectant

INTRODUCTION Study by Abdelaziz et al.6 and Ivanoveski et

300 g of stone powder was added to 90 ml of Statistical analysis

Compressive strength test RESULTS AND DISCUSSION

Surface hardness test Setting expansion test

Reproduction of details test Consistency test

Table 17: LSD for the wet compressive

Table 18: one way analysis for variance for

Table 19: LSD for data of hardness test

Table 20: one way analysis of variance for

Figure 4: The compatibility of dental stone with alginate

Figure 5: The compatibility of dental stone with

Figure 6: The compatibility of dental stone with ZOE

Figure 7: Consistency of dental stone

Figure 8: Dry compressive strength of dental stone

Comparison the tensile strength of heat cure and visible

INTRODUCTION In 1984, visible light cured base resins

Curing and cooling

Preparation of test specimens of light cured

Table 1: showing the mean, standard

Finishing and polishing

Evaluation of the effect of Nigella sativa oil and powder on

Therefore the present study was designed to:

MATERIALS AND METHODS

Figure 5: Coronal portion of rabbit left

At Six Weeks postoperatively

Vitamin Biochemical function

Evaluation of topical versus systemic medications in the