Sulaimani Dental Journal 2014 Volume 1 Issue 2

Scientific Journal Published by University of Sulaimani School of Dentistry

SULAIMANI DENTAL JOURNAL

ISSN: 2309-4656

SDJزان"""""كۆی س"""لێمان"""ی

Volume 1 Issue 2 December 2014

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Scientific Publication of the University of Sulaimani School of Dentistry

Sulaimani Dental Journal

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Editor'(in('Chief(Emeritus(Dr.!Falah!A.!Hawrami!

Editor('in('Chief(Dr.!Ibrahim!S.!Gataa!

Associate(Editor(Dr.!Abdulsalam!R.!Al7Zahawi!

Managing(Editor(Dr.!Faraedon!M.!Zardawi!

Editorial)Board)Professor'Sauza'A.'Faraj'Professor'Salam'Al2Qaisi'Professor'Balkees'T.'Garib'Professor'Shanaz'M.'Gaffor'Assist.'Professor'Saeed'A.'Lateef'Assist.'Professor'Fadil'A.'Kareem'Assist.'Professor'Aras'M.'Rauf'''Advisory)Editorial)Board))Professor'Richard'van'Noort''''(UK)''''''''''''''''''''Assist.'Professor'Adil'Al2kayat'''(Iraq)'Professor'Salem'Al2Samaray''''(Iraq)'''''''''''''''''''Assist.'Professor''Zeewar'Al2Qassab'''(Iraq)''Professor'Ali'Al2Zubaidi'''''''''(Iraq)''''''''''''''''''''''Assist.'Professor'Qais'H.'Musa'''('Iraq)'Professor'Anwar'Tappuni'''''(UK)'''''''''''''''''''''''''Assist.'Professor'Intesar'J.'Mohammed'(Iraq)'Professor'Hussain'F.'Al2Huwaizi'''(Iraq)'''''''''''''Assist.'Professor'Lamia'H.'Al2Nakib''(Iraq)'

'''Editorial)Of1ice))Dr.'Mohammed'Abdalla'Dr.'Tara'A.'Rasheed''Dr.'Arass'J.'Noori'Dr.'Dler'A.'Khursheed'Dr.'Ranjdar'M.'Talabani'

Journal)Secretory))Kaniaw'A.'Babala

SDJ

SULAIMANI DENTAL JOURNAL

Editorial!In the second issue of Sulaimani Dental journal we have taken another step in the march of issuing of the journal. The editorial board and editorial office of the journal made every efforts to bring out the second issue on predicted time on December 2014.

Readers may be noted that there are slight changes in the print style of the journal. Actually, the editorial board felt that we should add more details to the instructions of publishing in the journal within the approved regulations in medical journals. This will reflected on the process of quality of the journal academically while maintaining the privacy of Sulaimani Dental Journal.

On this occasion, we reiterate our welcome to any comments or notes from the readers which will serve and contribute to the development of the work of the journal. We would like also to inform the masters’ readers that they can read and follow the electronic version of Sulaimani Dental Journal, after the addition of the journal to the official website of the University of Sulaimani, through the following links;

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or

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Finally, as we are in the end of this year we hope new happy year and wish peace prevails for all people.

Editor in Chief

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Table of Contents

Contents Page

I Molar-incisor hypomineralisation (MIH) among Kurdish children in Sulaimani City, Iraq.

Arass Jalal Noori & Shokhan Ahmad Hussein

45

II Prevalence of cigarette smoking among Sulaimani University students. Zhian Salah Ramzi

51

III Priority in selection of treatment methods used for lymphatic malformations affecting maxillofacial region.

Qais H. Mussa

57

IV Prevalence of orofacial changes in patients with β-thalassemia major in Karbala City, Iraq.

Muhanned Salah Abulsattar & Ali Mihsen Al-Yassiri

64

V Assessment of calcium ions diffusion and pH measurements of three intracanal medicaments through dentinal tubules (in vitro comparative study).

Chrakhan A-Latif A-Qadir & Salam D. Al-Qaisi

68

VI Evaluation of some intracanal irrigants on push-out bond strength and mode of failure of resin and non resin cements to root canal centin (in vitro comparative study).

Rawa O. Ibrahim & Salam D. Al-Qaisi

74

VII Conservation of dentin thickness in the root canals orifice following two preparation techniques.

Ranjdar Mahmood Talabani, Shawbo Muhamad Ahmad & Arass Jalal Noori

80

VIII The prevalence and etiology of maxillary midline diastema among orthodontic patients attending Shorsh Dental Clinic in Sulaimani City.

Darwn Saeed Abdulateef, Azheen Jamil Ali & Nasih Fatih Othman

86

IX Angle’s classification of first molar occlusion among patients attending a private orthodontic clinic in Sulaimani City.

Anwar Ahmad Amin, Awder Nuree Arf & Zhwan Jamal Rashid

91

X A retrospective panoramic study for alveolar bone loss among young adults in Sulaimani City, Iraq.

Faraedon M. Zardawi, Alaa N. Aboud & Dler A. Khursheed

94

Sulaimani Dent. J. 2014; 1:45-50 Noori & Hussein

Introduction:Over the past two decades, a congenital defect of enamel mineralization commonly referred to as molar incisor hypomineralisation (MIH) has been of increasing concern to clinicians worldwide. The defect involves hypomineralisation of one to four permanent first molars and is associated frequently with similarly affected permanent incisors(1). Idiopathic enamel hypomineralisation was first noted in Sweden in the late 1970s(2). In view of the chronological distribution of enamel defects, Weerheijm et al. in 2001 defined MIH as a hypomin-eralisation of systemic origin of one to four first permanent molars frequently associated with affected incisors(3). This description emphasizes the fact that permanent first molars are always involved in those affected, and often there is a combination of molars with demarcated opacities of the incisors(1,3,4). On the other hand, opacities only on the permanent incisors may indicate defects from other origin such as traumatic injuries or periapical infection of the primary incisors, and these lesions should not be referred to as MIH(5).

Although the possibility of a genetic component in the development of MIH has not been excluded, it’s been postulated that MIH is a consequence of a variety of environmental factors acting systemically, which disturb the ameloblasts during their enamel production phase(1). Clinically, the defect presents as

opaque lesions varying in color from white to yellow or brown, with a sharp demarcation between the affected and sound enamel. In severe cases, post-eruptive enamel breakdown (PEB) can occur so rapidly that it appears clinically as if the enamel has been not formed at all. When PEB occurs because of chewing forces, it is more conspicuous in the first permanent molars than in the incisors(1).

Recent studies have emphasized that the presence of MIH can produce a number of problems for the patient including dental pain and hypersensitivity, disfigurement, encouragement of rapid plaque retention, and enhancement of caries development(6). The need for orthodontic treatment intervention as a consequence of tooth extraction caused by MIH has also been reported(7). Moreover, substantial challenges to dental care are caused by MIH, because of the lack of appropriate restorative management and difficulties with pain control(8).

A wide range of prevalence rate for MIH have been reported around the world ranging from 2.9 to 38%(2,6,9-12). Only one research study concerning prevalence and distribution of MIH is available in Iraq which focused on 7 to 9 year school children in Mosul City(13), mainly of Arabic ethnicity. This study aims to investigate the prevalence and distribution of MIH among Kurdish children in Sulaimani City, Iraq.

a Dep. of Pedodontics, Orthodontics, and Preventive Dentistry. School of Dentistry/ University of Sulaimani. ([email protected]) b Dep. of Oral Diagnosis. School of Dentistry/ University of Sulaimani.

Molar-incisor hypomineralisation (MIH) among

Kurdish children in Sulaimani City, Iraq


SDJArass Jalal Nooria Shokhan Ahmad Husseinb

Abstract Objectives: The aim of this study was to determine the prevalence and distribution of molar incisor hypomineralisation among Kurdish children in Sulaimani City, Iraq. Method: A cross-sectional survey was carried out on primary school students in Sulaimani City. A total of 2346 Kurdish children aged 7 to 9 years old were examined; 1194 (50.9%) males and 1152 (49.1%) females, enrolled in 20 primary public schools. The index teeth were evaluated using the European Academy of Paediatric Dentistry (EAPD) criteria for MIH. Results: The prevalence of MIH was found to be 18.2% where no statistically significant association was found with age or gender (P>0.05). Multiple teeth involvement (13.2%) was more common than a single molar involvement (5.1%). The mean number of the affected index teeth with MIH per affected child was (3.1). Mild defects were present in 64.1% of the affected teeth with demarcated creamy-white opacities were the most common finding (33.3%). Conclusions: It’s been found that MIH is a prevalent pathology among Kurdish children in Sulaimani City which could result in a large number of children continuously seeking professional dental treatment. Therefore, dental practitioners who deal with child patients could encounter such cases and should be aware of the treatment choices and management protocols for coping with this particular condition.

Keywords; Molar-incisor hypomineralisation, prevalence, index teeth, Kurdish children. Received: August 2014, Accepted: October 2014.


Method:

The research approval was obtained from the ethical committee for medical research in the Faculty of Medical Sciences/ University of Sulaimani and proper authorities and primary school administers at the city. The city was divided in to 20 geographical sections and a primary school was randomly selected from each section, then at each school level a class was selected randomly for the purpose of the study. A cross-sectional survey was carried out on 2346 Kurdish primary school students (1194 males and 1152 females) aged 7-9 years from 2nd, 3rd and 4th grade students.

The children were examined in their school sitting upright in an ordinary school chair in daylight classroom lighting conditions. Teeth were examined wet, as suggested by the FDI Working Group (14), using a mouth mirror and periodontal probe and cotton rolls were used to remove food debris, as necessary.

Examination of the twelve index teeth (Four first permanent molars and eight incisors) were carried out using an index developed by Sonmez et al.(15) in line with European Academy of Pediatric Dentistry (EAPD) criteria for MIH(4): Opacities (White-cream, 1; Yellow-brown, 2); Post-eruption structural loss (Enamel defects, 3a; Atypical small cavities with enamel and dentin loss, 3b; Atypical deep or large cavities extending to the pulp and covering one or more tubercle, 3c); Restored teeth, 4; Extracted teeth, 5. Lesion severity was recorded according to Alaluusua et al.(16) as either mild, moderate, or severe (Table 1).

Inclusion criteria for the study was children (aged 7-9 years old) of lifelong resident of Sulaimani City with at least one first permanent molar erupted or partially erupted (Any tooth with less than one third of the crown erupted were regarded as unerupted) and present on the day of examination, while, children undergoing orthodontic treatment at the time of

examination or having amelogenesis imperfecta or tetracycline staining and children with the crowns of the first permanent molars completely worn-out or lost and the cause cannot be assured to MIH were excluded from the study.

Data analysis was performed using the SPSS software program (Statistical Package for the Social Sciences, version 16.0, SSPS Inc, Chicago, Ill, USA). A descriptive analysis of the prevalence and distribution of the clinical finding was performed and the chi-square and Fisher’s Exact test was used for the data analysis. Statistical significance (P-value) equal or less than 0.05 was considered to be statistically significant.

Results:

The total number of examined children reached 2347 child; 1194 (50.9%) males and 1152 (49.1%) females, (Table 2).

The total number of children with enamel defects (All kinds of enamel defects: hypocalcifications, hypomineralizations, Turner’s teeth,…etc) were found to be 592 child (25.3%), while the total number of children with MIH only was 427 child (18.2%), (Figure 1).

46

Table 1: Criteria for diagnosing the severity of MIH among the indedx teeth, Alaluusua et al

Severity Code Description

Mild 1 Demarcated creamy-white opacity

2 Demarcated yellow-brown opacity

Moderate 3a Enamel loss

Severe 3b Enamel and dentin loss

3c Atypical large cavities extending to pulp and covering one or more tubercle

4 Atypical restoration

5 Extracted tooth

Table 2: Distribution of the sample by age and sex

AgeGender

BothMale Female

No. % No. % No. %

7 years 405 51.07 388 48.93 793 33.8

8 years 396 51.3 376 48.7 772 32.91

9 years 393 50.32 388 49.68 781 33.29

Total 1194 50.9 1152 49.1 2346 100

(16)


Younger age groups and males were slightly more affected by MIH. Although there was a small difference in the ratio of the affected children with MIH among different age groups and genders, these differences did not reach any statistically significant association, (Table 3) and (Table 4).

(Table 5) describes the distribution of the MIH affected children by the number and types of teeth affected. From the total 427 children affected, 119

(5.1%) child had only one molar affected and 163 (7%) child had more than one molar affected. The remaining 145 (6.2%) children had molars and incisors affected. The age and gender distribution of the affected children shows minor differences according to the type of teeth affected, and the majority of teeth affected were molars and multiple teeth involvement (13.2%) is more common than a single molar (5.1%) involved by the defect.

47

Figure 1: Prevalence of children with developmental enamel defects and MIH

Table 3: Prevalence and distribution of MIH by age

AgeMIH No MIH

X2No. % No. %

7 years 136 17.2 657 82.9X2= 1.12

df=2 P=0.5712

8 years 141 18.3 631 81.7

9 years 150 19.2 631 80.8

Total 427 18.2 1919 81.8

Table4: Prevalence and distribution of MIH by gender

Gender

MIH No MIH

X2

No. % No. %

Male 222 18.6 972 81.4 X2= 0.2

df=1

P=0.6547Female 205 17.8 947 82.2

Both 427 18.2 1919 81.8


Among the 1345 teeth affected, 887 teeth (65.9%) were molars and 458 teeth (34.1%) were incisors and the mean number of the affected Index teeth with MIH per affected child was (3.1). Mild defects were present in 64.1% of the affected teeth with demarcated creamy-white opacities were the most common finding (33.3%). Severe defects were found in about one-fifth (22.4%) of the total findings and moderate defects were present in the remaining 115.9%. It’s also worthy to note that more molar teeth were affected by severer forms of the defect than incisors, (Table 6).

Discussion:

Given the significant clinical consequences of MIH, it is clearly important to assess the impact of this condition when planning dental healthcare delivery,

and the first step in this process is to establish whether MIH is a significant dental public health issue or not in the community(17).

In this study, the overall prevalence of MIH in a sample of primary school children in Sulaimani City was found to be 18.2%. This prevalence figure was comparable to those reported by another study (18.6%) from Mosul City, Iraq(13) and with some other studies(6,18,19), but differ from prevalence rates reported from other studies(20-22). The differences in reported rates of MIH throughout the world have been attributed to differences in the age of study participants, geographic locations, environmental factors and evaluation criteria(15). Although the age for examination had been recommended at over 7 to 8 years were most of the index teeth had erupted (2,4,23-25), further standardization of the sampling model, examination criteria and indices used are needed to establish comparable results and to

48

Table 5: Prevalence and distribution of MIH in the permanent index teeth by age and gender

MIH affected teeth

Male Females 7 year 8 year 9 year Total

No. % No. % No. % No. % No. % No. %

Single molar 65 5.4 54 4.7 36 4.5 39 5.1 44 5.6 119 5.1

Two to four molars 81 6.8 82 7.1 52 6.6 54 7 57 7.3 163 7

Molars + Incisors 76 6.4 69 6 48 6.1 48 6.2 49 6.3 145 6.2

Total 222 18.6 205 17.8 136 17.2 141 18.3 150 19.2 427 18.2

Table 6: Severity distribution of MIH affected molars and incisors

Defects Molars IncisorsTotal by severity

codeTotal by severity

index

Severity Code No. % No. % No. % No. %

Mild 1 273 30.8 175 38.2 448 33.3852 64.1

2 248 28.0 166 36.2 414 30.8

Moderate 3a 132 14.9 82 17.9 214 15.9 214 15.9

Severe 3b 123 13.9 12 2.6 135 10.0

269 203c 76 8.6 8 1.7 84 6.2

4 20 2.3 15 3.3 35 2.6

5 15 1.7 0 0 15 1.1

Total 887 65.9 458 34.1 1345 100 1345 100


determine exact epidemiological nature of the condition.

No significant differences in the prevalence rates were found among males and females, which is comparable with the findings reported by other studies (6,11,13,20,21) and this may indicate that the condition is not a gender associated disease. As reported by some other studies(13,26) no significantly different prevalence figures were found among different age groups, but the prevalence in our study was slightly increased with age and this may be related to the dynamic nature of the defects(13) where some minor defects may be overlooked in younger teeth at younger ages and these defects possibly will develop to severer forms of the defect overtime, because of the inferior quality of the enamel(27,28), and their identification become easier when staining, enamel breakdown and/or caries develops. It’s been found that multiple teeth affected by MIH is more common than a single first permanent molar involvement and this result is in accordance with findings from other studies(12,13), and again emphasizing the systemic nature of the disease. These findings supports the theory that MIH is a developmental defect that occurs once the threshold level for the insult required to disturb enamel formation at a critical stage is reached(29).

The mean number of the affected index teeth with MIH per affected child was 3.1, of which about 2.1 were first permanent molars, which is near the figures found in other studies(5,9,10,20). Although the index teeth include only four molars with eight incisor teeth, it’s been found that the number of molar teeth affected by MIH is about twice the number of incisor teeth indicating the concentration of the defect mainly on the first permanent molars and incisor teeth are involved when the condition become more severe (12,13).

Mild defects were present in 64.1% of the affected teeth with demarcated creamy-white opacities were the most common finding (33.3%), and these are in agreement with other studies that mild forms of the defect are the most prevalent one(12,13,18). Sever defects were found to be also prevalent, about one-fifth of the affected cases and it was noted that molars can be affected more severely than incisors which is been found by other studies where more enamel breakdown occurs in molars due to the absence of masticatory forces on the incisors(10,13,15,18).

It should be noted that MIH defects, whether mild or severe, could become more and more symptomatic over time, which can influence the general health and quality of life of the affected child and its treatment is often challenging to both the patient and the clinician(30).

Conclusions:

It’s been found that MIH is a prevalent pathology among Kurdish children in Sulaimani City which could result in a large number of children continuously seeking professional dental treatment. Therefore; dental practitioners who deal with child patients could encounter such cases and should be aware of the treatment choices and management protocols for coping with this particular condition.

References:

1. Weerheijm KL. Molar incisor hypomineralization (MIH): clinical presentation, aetiology and management. Dent Update. 2004;3:9–12.

2. Koch G, Hallonsten AL, Ludvigsson N, Hansson BO, Holst A, Ullbro C. Epidemiologic study of idiopathic enamel hypomineralization in permanent teeth of Swedish children. Community Dent Oral Epidemiol. 1987;15:279–85.

3. Weerheijm KL, Jälevik B, Alaluusua S. Molar-incisor hypomineralisation. Caries Res. Karger Publishers; 200;35:390–1.

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13. Ghanim A, Morgan M, Mariño R, Bailey D, Manton D. Molar-incisor hypomineralisation: prevalence and defect characteristics in Iraqi children. Int J Paediatr Dent. 2011;21:413–21.

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Sulaimani Dent. J. 2014; 1:51-56 Ramzi

Introduction:Cigarette smoking is one of the major public health problems and its the leading preventable cause of morbidity and mortality. Currently, five million and four hundred thousand people die because of cigarette smoking every year in the world, and this number will rise to eight million per year by 2030(1). Moreover, more than 80% of deaths, caused by smoking, occurred mostly in developing countries(2). Half of the people start smoking cigarette since their teenage years and still goes on, will be died(3). Teenage smoking prevalence is around 15% in developing countries and around 26% in the United Kingdom and United States(4). According to the WHO, in the world, there are almost one billion smoking men and 250 million smoking women. In the year 2000, world inhabitants smoked about 5.5 trillion cigarettes(5). While cigarette consumption has been declining in high-income countries; it is rising in low-income and middle-income countries. By 2030, approximately 70% of deaths attributable to smoking worldwide are expected to occur in developing countries(6). The negative health consequences of smoking are considerable and have been well-documented(7). Epidemiological studies among different university student populations in Arab and Eastern Mediterranean countries demonstrated a marked variation in the prevalence of smoking(8-18).

Studies on smoking habits among university students in Sulaimani are scarce, which focus on a specific group of the university student population (19-21). The prevalence of smoking reflects the magnitude of the problem, and determining its importance since it provides a basis for the planning of public health actions. The present study was an epidemiological survey to determine the prevalence of smoking and its associated factors among Sulaimani University students in 2007.

Subjects and Methods:

Sulaimani University comprises many colleges. The total number of students at the academic year 2006-2007 was 15329 students distributed in 22 colleges. The researcher categorized colleges of the university in three groups; medical colleges, non medical scientific colleges, and non medical literary colleges. Nine colleges were selected by simple random sampling; three from each group, including college of medicine, dentistry, nursing, engineering, agriculture, fine arts, administration and economic, law and politics, and physical education. The total number of students among the selected nine colleges was 4215.

* Lecturer at Department of Community Medicine, School of Medicine/University of Sulaimani. ([email protected])

Prevalence of cigarette smoking among

Sulaimani University students


SDJZhian Salah Ramzi*

Abstract:Background: Tobacco smoking is a global behavior and it is a growing public health problem in the developing countries. Objectives: The study was carried out to determine the prevalence of cigarette smoking and find out the socio-demographic correlates of smoking among Sulaimani University students.Subjects and Methods: A cross-sectional study was conducted from October to November 2007 on 2750 students in Sulaimani University. A systematic stratified sampling technique was used. A self-administered questionnaire was used for data collection on age and gender of students, college, years of study, and age of starting smoking.Results: Out of 2722 respondents, 302 students were smokers giving a prevalence rate of 11.1%. The prevalence of smokers was significantly (P< 0.001) higher in males than females (19% and 1% respectively). The highest rate of smokers was among the age group 23-26 years in both sexes. About 10% of students started smoking at age less than 12 years, 8.2% at age 12-17 year, 50% at 18-22, and 31.7% at 23-26 years.Conclusions: The prevalence of smoking was moderate. More than half of students started smoking during their study years in the university. Males and students in third and fourth academic years were more likely to smoke. The results provide baseline data to develop an anti-smoking program to limit smoking in the university.Keywords: Prevalence, smoking, Sulaimani university, studentsReceived: May 2014, Accepted: August 2014


This cross-sectional survey was conducted from October to November 2007 in Sulaimani University. All students enrolled in the above 9 colleges (4215), were the population of this study. A self-administered questionnaire was designed by the researcher and pretested by a pilot study. The questions were grouped into categories related to socio-demographics, prevalence of smoking, reasons for smoking, not smoking and quitting attempts. Questionnaires were distributed during the classes by a well trained personnel. The students were informed that the results would be used for the stated research purposes only and their participation was voluntary. No identification was required and confidentiality was assured verbally.

Filled questionnaires were collected and checked for completeness before being entered into a personal computer and analyzed using SPSS version 17. Descriptive statistics and X2 test were used for studying association of smoking and categorical variables. A statistical level of ≤0.05 was considered significant. The outcome variable was smoking status, classified into three categories: current smokers, ex-smokers and non-smokers. Current smokers were defined as those who had smoked cigarettes on one or more days during the previous 30 days. Those who had been smokers before, but had stopped smoking at time of survey, were defined as ex-smokers. Those who had never smoked in his/her lifetime were defined as non-smokers.

Financial level was classified by the average annual income for single Iraqi subject according to the Ministry of Planning and Development, defined as low (<729$ ), moderate (729-4000$), good (4000-8000$), and very good (>8000$)(22).

Results:

A total of 2722 undergraduate students participated in the study, giving a response rate of 64.6%. The age of the respondents ranged from 17 to 28 years old with a mean ± SD of 21.2 ± 2.7 years. Males constituted 55.8% and females 44.2%.

A total of 302 students out of 2722 reported being current smokers, thus the prevalence of current smokers in this study was 11.1%. The prevalence of current smokers in males, 19.1% was significantly higher than prevalence among females, 1% (p<0.001). The ex-smoking rate was 4.5%. These rates, however, varied significantly between colleges. The male to female ratio among all respondents was 1.3:1; this ratio became 24.2:1 among current smokers. A significantly higher prevalence of current and ex-smoker was found among males (P=0.008) as shown in Table 1. The prevalence of smoking was higher among the age group 24-28 (17.4%) in all colleges in both males and females, followed by age group 21-23 (11.1%) and least prevalence was recorded among age group 18-20 (7.1%) with a statistical significant

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Table 1: Smoking status among male, female and total population

CategoryMales Females Total

Male: female ratioNo. (%) No. (%) No. (%)

Current smokers 290 96.02 12 3.97 302 11.1 24.2:1

Ex-smokers 109 89.34 13 0.5 12 4.5 8.4:2

Non- smokers 1120 48.74 1178 51.3 2298 84.4 0.9:1

Total 1519 55.80 1203 44.2 2722 1.3:1

Chi, P value X2= 6.99, P= 0.008

Table 2: Age and gender distribution of smokers

Age group (years)

Males Females Total

No. of participants

Smokers No. of participants

Smokers No. of participants

Smokers

No. % No. % No. %

18-20 550 70 12.7 471 2 0.4 1021 72 7.1

21-23 643 138 21.5 557 5 0.9 1200 143 11.1

24-28 326 82 25.2 175 5 2.9 501 87 17.4

Total 1519 290 19.1 1203 12 1.0 2722 302 11.1


variation in the prevalence among different age groups (Tables 2 and 3).

Table 3 shows the prevalence of current smoking by some socio-demographic and academic charact-eristics. Students of medical colleges recorded significant higher prevalence of 12%, compared to 10.1% in non-medical scientific colleges and 9.5% in non-medical and non medical literary colleges (P<0.001). The lowest prevalence was among students

of first year and the prevalence increased in second and third year with highest prevalence of 16.4% among fourth, fifth and sixth year students collectively (P<0.001). Married students showed a significantly lower prevalence of current smoking than single students (P<0.0001). No significant association was found between prevalence of smoking and family income.

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Table 3: Prevalence of current smoking among Sulaimani University students, by demographic and academic characteristics

Variable Total No.Smoking

P-valueNo. %

Sex

Male 1519 290 19.10.0001*

Female 1203 12 1.0

Age (years)

18-20 1021 72 7.1

0.0001 21-23 1200 143 11.1

24-28 501 87 17.4

Colleges (Faculty)

Medical colleges 1000 120 12

0.001 Non-medical scientific colleges 1122 113 10.1

Non-medical non scientific 600 57 9.5

Years of study

1st 700 60 8.6

0.0001 2nd 673 65 9.7

3rd 850 95 11.2

4th ** 499 82 16.4

Family income (ID/year)

< 958,000 549 61 20.2

0.997 958,000- 4,839,000 983 109 36.1

4,840,000- 9,679,000 714 79 26.2

≥9,680,000 476 53 17.5

Marital status

Single 2403 243 80.50.0001

Married 319 59 19.5

Total 2722 302

*X2 test;** 4th + 5th year dentistry and 6th year medical college


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Table 4: Some characteristics of smokers

Variable

Current smokers

No. %

Starting age of smoking(years)

9- 13 47 17.2

14-18 71 25.9

19-22 141 51.5

23-27 15 5.5

Total 274 100

When smoking?

During stress 166 55

After meal 64 21

At any time 42 14

With alcohol 15 5

Other causes 12 4

No response 3 1

Reason for starting smoking

Smoking of other member of family 73 24

Having a smoking friend 60 20

For pleasure 55 18

Social problems 33 11

Advertising 33 11

Other causes 48 16

Smoking status(cig/day)

Light ( 1-10) 52 17.5

Moderate (11-20) 147 48.5

Heavy (> 20) 103 34

Preference of place of smoking

Public 88 29

Smoking rooms 214 71

Intention to quit smoking

Yes 184 60.9

No 118 39.1

Total 302 100


The age of initiation of smoking ranged from 9 to 24 years with mean of 16.3± 3.3 years and was significantly higher in males than in females (16.3±2.8 compared to 14.0±4.4). More than half of current smokers smoked during stress, 21% after meals, 5% with alcohol and 14% liked to smoke at any time. Regarding reasons for starting smoking, 24% reported having another family smoker, 20% reported having a smoking friend and 18% for pleasure. Approximately half of smokers smoked 11-20 cig/day and 34% were heavy smokers. Eighty-eight of smokers preferred to smoke in public places (29%) compared to 214 (71%) in smoking rooms. Regarding quitting smoking, 60.6% had intention to quit smoking (Table 4).

Discussion:

The aim of this study was to evaluate the Sulaimani University students' smoking habits and the associated socio-demographic factors. The main finding of this study was that 11.1% of Sulaimani University students were current smokers.

Prevalence of smoking: This prevalence is lower than that reported previously in Sulaimani University 13.6% in 2005(19), and among students of Hawler Medical University in Erbil in 2007, 12.3%(20). A much lower prevalence of 9.3% was reported among students of Salahaadin University in Erbil in 2002(21). The prevalence of smoking in this study is also lower than that reported among participants of the Kurdistan-Iraq Global Youth Tobacco Survey in 2006, 15.3%(23). A much higher prevalence was reported in Duhok (24.5%) in a house hold survey among those aged 25-65 years in 2004(24).

In 2005 Mousawi reported a slightly lower prevalence among Karbala University Students (10.5%)(25), While another study in Karbala university reported a higher rate (19%) in 2009(27). Iraq Family Health Survey in 2006 reported a prevalence of 15.5%(26).

The smoking prevalence rate found in this study is consistent with those reported by other studies in Syria and Jordan(28-30). However, other studies in Jordan (30,13), Syria(32), Iran(33), and Saudi Arabia(34) reported higher rates. While other studies reported lower rates than this rate in Iran(35), Saudi Arabia(36), and Syria(37).

Variations in smoking prevalence in Iraq might be a real difference or may be related to a difference in the methodology, including the characteristics of the population surveyed, sampling, and methods of data collection. The large sample of this study might provide more confident outcomes or that the educational programs about smoking in Sulaimani might be more efficient.

Variations in the prevalence of smoking in neighboring countries may be related to differences in

use of different criteria for defining smoking, different age groups studied and different methodologies adopted.

Age of starting smoking: The finding that the most common age for starting smoking was between 19-22 years is consistent with the findings of other studies (11,13).

Years of university education: This study indicates that the prevalence of smoking increased significantly with higher number of years of university education. This may be due to longer exposure to other smokers (friends, teachers) within university environment who may influence their attitude and behavior. These findings are consistent with those of other studies (11,13).

Prevalence by gender: The finding of a significant difference in the prevalence of smoking by gender is in agreement with many studies conducted in Kurdistan, Iraq and Arab countries that reported much higher prevalence among males(19-21). However, the low prevalence among females might be under estimated due to reporting bias.

Causes of starting smoking: Friends, a smoking member of the family were considered the major causes for starting smoking, followed by stress and pleasure. Other studies had revealed similar results (20,25,31). This may be due to youth behavior of dealing with stress and the bad influence of friends and family members.

About 60% of smokers expressed a desire to quit smoking in the near future; a finding which is similar to other studies(19,20,32). This indicates that smokers may respond well to cessation programs.

Weakness and limitations of study include the general weakness of self-administered questionnaires with the possible underreporting among females and the low response rate. Also, as smoking behavior among students was self-reported there could have been a reporting bias. Verification of self-reported smoking behavior could not be verified biochemically.

Conclusions:

The prevalence of smoking among Sulaimani University students was moderate. More than half of students started smoking during their study years in the university. Males and students in advanced years of study were more likely to smoke. The results provide baseline data to develop an anti-smoking program to limit smoking in the university.

Acknowledgment:

I would like to extend my acknowledgment and gratitude to Dr. Ruzhgar Abid-Alla Saleem for her effort and precious help in distributing the questionnaires for different classes and colleges and recollecting them.

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Type to enter text

Sulaimani Dent. J. 2014; 1:57-63 Mussa

Introduction:The lymphatic system develops during the 6th week of embryonic life (1). Lymphatic malformation (LM) characterized by the size of the malformed channels which are microcystic, macrocystic, or combined. It's usually noted at birth or within the first 2 years of life. On occasion, LM first becomes evident in later childhood, adolescence, or even adulthood (2).

The Hamburg classification is currently the most accepted classification system. It is subject to continual improvement by the International Society for the Study of Vascular Anomalies (ISSVA)(3,4). LM is most commonly located on the head and neck; other common sites are the axilla, chest, and perineum. LM typically causes deformity and psychosocial issues, especially when it involves the head and neck.

The two most common complications associated with LM are bleeding and infection. Intralesional bleeding occurs in up to 35% of lesions causing ecchymotic discoloration, pain, or swelling (5). Oral lesions may lead to macroglossia, poor oral hygiene, and caries. Swelling due to bleeding, localized infection, or systemic illness may obstruct vital structures. Two-thirds of infants with cervicofacial LM require tracheostomy (6). Bony overgrowth is another complication; the mandible is most commonly involved resulting in an open bite and prognathism (7). These lesions are diagnosed by history and physical examination. Small, superficial or asymptomatic

lesions do not require further evaluation and intervention as they are benign lesions.

Large or deep LMs are assessed by MRI to: (1) confirm the diagnosis; (2) define the extent of the malformation; (3) plan the treatment. LM appears as either a macrocystic, microcystic or combined lesion with septations of variable thickness (8,9). Histological confirmation of LM is rarely necessary (10). An infected LM often cannot be controlled with oral antibiotics and needs intravenous antimicrobial therapy with hospital admission. Intervention for LM is reserved for symptomatic lesions that cause pain, significant deformity, or threaten vital structures (5).

Sclerotherapy is first-line management for large or problematic macrocystic/combined LM and its preferred due to lower complications rate than attempted resection (11). Several sclerosing agents are used to shrink LM likes doxycycline, sodium-tetradecyl sulfate (STS), ethanol, bleomycin, and OK-432 (9,12).

Excision of LM can cause significant morbidity: major blood loss, iatrogenic injury, and deformity (5,6). Usually excision is usually subtotal because LM involves multiple tissue planes and important structures so recurrence is common (35–64%) (13). In small, well-localized LM (microcystic or macrocystic) complete excision is recommended with preservation of the anatomy of the affected area. Subtotal excision

* Department of Oral & Maxillofacial Surgery/ College of Dentistry-University of Kerbala, Iraq. ([email protected])

Priority in selection of treatment methods used

for lymphatic malformations affecting

maxillofacial region


SDJ

Qais H. Mussa*

Abstract: Objectives: The purpose of this paper was to discuss and evaluate the treatment plan selection and the outcomes of 82 cases of lymphatic malformation in oral & maxillofacial region. Materials & methods: The analysis included of 82 cases of lymphatic malformation in oral & maxillofacial region during the period between January 2004 to November 2013 at maxillofacial department in Al-Hilla General Teaching Hospital. The treatment plans selection depend on details patient history, clinical examination & imaging investigations. Different techniques were used depended on age, extension, site & types of lymphatic malformation. The treatment methods were conservative treatment, surgery, use of sclerosing agents or combinations of them. Results: Total number of the patients were 82 complains from different types lymphatic malformation, 30 were males constituting 36.5% while 52 were females constituting 63.5% . The youngest patient was 5 days, while the oldest one was 45 years. Forty case treated by sclerotherapy and surgery (48.7%) . Surgery alone as primary treatment done for 27 patients (32.9%) other 10 cases treated by sclerotherapy alone ( 12.1%) & 5 cases ( 6% ) only needs observation . Conclusions: Careful treatment plan selection depends on age, extension, type of lesion & experience of surgeon associated with good prognosis. Conservative resection was the most effective method in treatment of lymphatic malformation. Keywords: Vascular malformation, lymphangioma, sclerosing agent. Received: April 2014, Accepted: September, 2014


of problematic areas, such as bleeding vesicles or a hyper-trophied lip should be carried out rather than an attempting “complete” resection that might result in a worse deformity than the malformation itself. Macroglossia may require reduction to return the tongue to the oral cavity or to correct an open-bite deformity (14). In order to assess different modalities of treatment of lymphatic malformations affecting the maxillofacial area this study was done.

Materials and Methods:

Eighty-two patient treated by the same surgeon during the period between January 2004 to November 2013 at maxillofacial department in Al-Hilla General Teaching Hospital.

Patient records, treatment modality used, response to treatment, the period of treatment & its complicati-ons were reviewed. The diagnosis depends on physical examination, ultrasound, computed tomography & magnetic resonance imaging (MRI) study. According to MRI examination, the patients grouped into macrocystic (45 cases), microcystic (22 cases) & unicystic (15 cases). The treatment plan divided the patients in 4 groups (Table 1) depend on the types, site of the lesion &age of the patients as follows:-

1- Patients underwent surgery as primary treatment. Indicated in all unicystic & localized macrocystic or microcystic cases

2- Patients underwent pre-surgical treatment by percutaneous sclerosing agent injection (Ethanol or bleomycin). Indicated in diffuse Microcystic & macrocystic lymphangioma that’s located in different tissues planes.

3- Patients underwent percutaneous sclerosing agent injection (Ethanol or bleomycin) alone. Indicated in cases of macrocystic & microcystic lymphan-giomas. Its safety as compared to surgery that’s may be at risk to damage important structures.

4- Patients need observation & follow-up without treatment. Indicated in small lesion that’s not affected the esthetic or function & without complication. Ethanol (95%) 1mL/kg was used in pre-surgery &

as primary sclerosing agent in the period from January 2004 till the end of 2009 while bleomycin was used between at the end of 2009 till November 2013.

The bleomycin diluted 1mg/1ml normal saline/kg after the fluid aspirated from the lesion the material injected into the lesion under deep sedation or general anesthesia. The procedure repeated each three weeks and in some cases the injection of sclerosing agent performed with ultrasonography guidance under deep sedation or GA.

Indications for treatment have based on tissue destruction or disfigurement (Fig.1) & obstruction of vital functions (Fig.6). The surgery in most of these cases represents the main modality of treatment as the first choice or follows different sclerosing agents treatment (Fig.5).

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Figure 1: Clinical view of neck lymphangioma extend to floor of mouth & raise the tongue due to infection

Figure 2: A : Clinical view of unicystic lymphangioma B: Post surgical excision (surgery primary treatment)

A B


Results:

Patients recorded in this study were 82 complains from different types lymphatic malformation 30 patients were males constituting 36.5% and 52 were females constituting 63.5% .

The youngest patient was 5 days while the oldest one was 45 years. Forty cases treated by sclerotherapy, followed by surgery (22 Ethanol & 18 bleomycin)

represented (48.7%). Primary surgical excision used for 27 cases (15 unicystic, 7 macrocystic & 5 microcystic) represented (32.9%), while 10 cases treated by sclerotherapy alone (7 Ethanol & 3 bleomycin) represented (12.1%) & 5 case only needs observation (6% ) as summarized by (Table 1).

Primary surgical excision was effective in 25 of 27 patients, most of them were unicystic and macrocystic. Ethanol pre-surgery was effective in 10 case, were

59

A B

C DFigure 3: A- Clinical view of macrocystic lymphangioma, B- Surgical excision through submandibular approach, C- Multiple cystic appearance of the specimen, D- Immediate post surgical with reduction of macroglossia

Table 1: Number of patient's distribution according treatment plan selection

Type Lymphangioma

No . of patients Surgery Ethanol pre-

surgeryBleomycin pre-surgery

Ethanol only as a sclerosing agent

Bleomycin only as a sclerosing agent

Observati-on only

Unicystic 15 15

Macrocystic 45 7 10 11 5 2

Microcystic 22 5 12 7 2 1

Total 82 27 22 18 7 3 5


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Figure 4: A- Clinical view of macrocystic lymphangioma, B- Surgical view of multicystic specimen, C- Post surgical view

B

C


61

Figure 5: Clinical view of huge macrocystic lymphangioma treated by bleomycin pre-surgical excision

Figure 6: A- Clinical view of macrocystic lymphangioma, B- Sclerosing agent used pre-surgical excision of the lesionA

B


completely cure other 7 case showed permanent shrinkage > 70% of their size & 5 cases had permanent shrinkage 50 - 70%.

The use of bleomycin pre-surgery was effective in 9 cases which were completely cure, other 5 cases had permanent shrinkage > 70% of their size & 4 cases showed permanent shrinkage 50 - 70% from their size.

Ethanol as a primary sclerosing agent was effective in 5 cases causing permanent shrinkage > 70% & 2 cases had permanent shrinkage 50 - 70% of the size of lesions.

Bleomycin as primary sclerosing agent was effective in 2 cases which had permanent shrinkage > 70% & 1 case show permanent shrinkage 50 - 70% of the size of lesion (Table 2).

Complication after primary surgical excision included lymphorrhea (3 cases), infection (2 cases) and unacceptable tissue scar (2 cases). The complic-ation after ethanol pre-surgical excision included lymphorrhea (8 cases), infection (4 cases), palsy of mandibular & cervical branches of facial nerve (2 cases), and tissue scar (4 cases). The complication after bleomycin pre-surgical excision included lymphorrhea (5 cases), infection (2 cases). The complication after ethanol as a primary treatment alone included infection (3 cases), palsy of mandibular branch of facial nerve (1 case) and tissue scar (2 cases). The complication after bleomycin as a primary treatment alone included skin scar in one case (Table 3). The ethanol has a greater incidence of adverse side-

effects than bleomycin. The major side-effect is skin necrosis & Severe pain that does not occur following the injection of bleomycin and there are fewer adverse reactions.

Discussion:

Based on the size of the lymphatic lumen, LMs (previously termed lymphangiomas) can be divided into microcystic lesions (previously termed lymphang-ioma circumscriptum), macrocystic lesions (previously termed cystic hygromas) (fig.4) and a combined form. Hence the term cystic hygroma has now been replaced by the term macrocystic. The most important diagnostic tool in lymphatic malformations is clinical examination and information from magnetic resonance scanning (MRI), which demonstrates the extent of the lesion and helps to differentiate between it and other vascular lesions.

Doppler ultrasound can confirm the flow of the lesion (15) and in this study the diagnosis depended on history , physical examination and MRI in majority of cases, but its cost and some time limited availability make the CT scan & ultrasonic used in diagnosis the lesions & classify them into macrocystic , microcystic & unicystic lesions.

Indications for treatment depend on the size, location and symptoms of the lesion. Cosmetic disability, presence of recurrent infection, oozing, crusting, ulceration and pain are the most frequent

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Table 3: Complications according to type of treatment plan

Type of complication Primary surgery 27 case

Ethanol pre-surgery 22 case

Bleomycin pre-surgery 18 case

Ethanol 7 case

Bleomycin 3 case

Total 82 case

Lymphorrhea 3 8 5 0 0 16Airway obstruction 0 0 0 0 0 0Infection 2 4 2 3 0 11

Tissue scar or ulceration 2 4 0 2 1 9

Facial nerve or any branch palsy 0 2 0 1 0 3

Total 7 18 7 6 1 39

Table 2: The effectiveness of primary treatment according to the treatment plan modalities

The cure or permanent shrinkage percentage

Primary surgery 27 case

Ethanol pre-surgery 22 case

Bleomycin pre-surgery 18 case

Ethanol 7 case

Bleomycin 3 case

100% cure 25 10 9 0 0

> 70% 2 7 5 5 2

50-70% 0 5 4 2 1<50% 0 0 0 0 0


indications for treatment. This indications supported by surgical excision is recommended for resectable lesions, there is a high recurrence rate (11).

Raveh et al reported a recurrence rate of 22% in 74 children treated with primary surgical excision, but in our study Cure rates were superior in the group having primary surgical excision in type with low compli-cation rates (16). The effectiveness of treatment were superior in the group having surgery with sclerotherapy (ethanol & bleomycin) similar result were observed by Kim et al. (17) & approximately similar result in ethanol & bleomycin pre-surgery but the complication with ethanol more than bleomycin were used presurgery.

Sclerotherapy is the first-line management for large or problematic macrocystic/combined LM (11). In this study the sclerotherapy (ethanol & bleomycin) used as a first line of treatment only in macrocystic 7 cases & 3 microcystic cases with similar acceptable outcome but the complication with ethanol is more than bleomycin. Five cases did not need treatment, just observation alone without any intervention; this fact supported by Dasgupta et al. that patients with asymptomatic macrocystic LMs of the head and neck, who underwent interventional procedures had a higher complication and recurrence rate compared to patients who were managed by observation alone (18). Priority should be placed on preservation of normal function and restoration of a normal appearance. Microcystic lymphangioma are diffuse, located in different tissues planes, and it is difficult to distinguish involved tissue from normal tissue. Macrocystic lesions on the other hand are more localized and are more easily excised this result supported by other study & surgical management in some cases associated with correction of macroglossia (14) .

Conclusions:

Careful treatment plan selection depends on age, extension, type of lesion and experience of surgeon associated with good prognosis. Conservative resection was the most effective method in treatment of lymphatic malformation and the macrocystic lesions are most easily excised. Diffuse microcystic lesions are more difficult and may require multiple operations. Care should be taken to identify and preserve important structures, because tissue planes are often damaged.

References:

1. Mulliken JB, Young A. Vascular birthmarks: hemangiomas and malformations. Philadelphia: WB Saunders; 1988.

2. Marler JJ, Fishman SJ, Upton J, Burrows PE, Paltiel HJ, Jennings RW, et al. Prenatal diagnosis of vascular anomalies. J Pediatr Surg. 2002; 37:318–26.

3. Lee BB, Laredo J, Lee TS, Huh S, Neville R. Terminology and classification of congenital vascular malformations. Phlebology. 2007; 22: 249-52.

4. Mattassi R, Loose DA, Vaghi M. Hemangiomas and Vascular Malformations, An Atlas of Diagnosis and Treatment. Springer Verlag. 2009.

5. Padwa BL, Hayward PG, Ferraro NF. Cervicofacial lymphatic malformation: clinical course, surgical intervention, and pathogenesis of skeletal hypertrophy. Plast Reconstr Surg. 1995;95:951–60.

6. Edwards PD, Rahbar R, Ferraro NF, et al. Lymphatic malformation of the lingual base and oral floor. Plast Reconstr Surg. 2005;115:1906–15.

7. Greene AK, Burrows PE, Smith L. Periorbital lymphatic malformation: clinical course and management in 42 patients. Plast Reconstr Surg. 2005;115:22–30.

8. Finn MC, Glowacki J, Mulliken JB. Congenital vascular lesions: clinical application of a new classification. J Pediatr Surg. 1983;18:894–900.

9. Choi DJ, Alomari AI, Chaudry G. Neurointerventional management of low-flow vascular malformations of the head and neck. Neuroimag Clin N Am. 2009;19:199–218.

10. Florez-Vargas A, Vargas SO, Debelenko LV. Comparative analysis of D2–40 and LYVE-1 immunostaining in lymphatic malformations. Lymphology. 2008;41:103–10.

11. Smith MC, Zimmerman B, Burke DK. Efficacy and safety of OK-432 immunotherapy of lymphatic malformations. Laryngoscope. 2009;119:107–15.

12. Burrows PE, Mitri RK, Alomari A. Percutaneous sclerotherapy of lymphatic malformations with doxycycline. Lymphat Res Biol. 2008;6:209–16.

13. Alqahtani A, Nguyen LT, Flageole H. 25 years’ experience with lymphangiomas in children. J Pediatr Surg. 1999;34:1164–8.

14. Grimmer JF, Mulliken JB, Burrows PE, Rahbar R. Radiofrequency ablation of microcystic lymphatic malformation in the oral cavity. Arch Otolaryngol Head Neck Surg. 2006;132:1251-6.

15. Marler JJ, Mulliken JB. Current management of hemangiomas and vascular malformations. Clin Plast Surg. 2005;32:99–116.

16. Raveh E, de Jong AL, Taylor GP, Forte V. Prognostic factors in the treatment of lymphatic malformations. Arch Otolaryngol Head Neck Surg. 1997;123:1061–5.

17. Kim KH, Sung MW, Roh JL, Han MH. Sclerotherapy for congenital lesions in the head and neck. Otolaryngol Head Neck Surg. 2004;131:307–16.

18. Dasgupta R, Adams D, Elluru R, Wentzel MS, Azizkhan RG. Non interventional treatment of selected head and neck lymphatic malformations. J Pediatr Surg. 2008;43:869–73.

63

Sulaimani Dent. J. 2014; 1:64-67 Abulsattar &Al-Yassiri

Introduction:The thalassemias are a group of congenital disorders characterized by a deficient synthesis of either the α or β chains of globin in the hemoglobin molecule. As a result, the red blood cells are microcytic and hypochromic with an aberrant morphology. The homozygous type that is known as β- thalassemia major or Cooley's anemia is the most common monogenic disorder in the Mediterranean basin, the Middle East, Asia and the South Pacific(1-3).

β-thalassemia major is the most severe congenital hemolytic anemia. At 4 to 6 months of life, with the change from fetal xx chain to adult xx chain hemoglobin production, the first clinical manifes-tations appear. The hematocrit decreases to less than 20, the degree of anemia can reach a hemoglobin level of 2 to 3 g/dl, and the hemolysis is extensive, as in the iron overload(1,4). Growth and development in children is slow. In adolescence, secondary sex characteristics are delayed. The skin color becomes ashen-gray due to the combination of pallor, jaundice, and hemosid-erosis. Patients also present cardiomegaly, hepatome-galy, and splenomegaly(5) .

Bimaxillary protrusion and other occlusal abnorm-alities are frequent in thalassemia major cases. Dental and facial abnormalities include spacing of teeth, open bite, prominent malor bones, and protrusion of maxilla and saddle nose. In addition, the pneumatization of the maxillary sinuses is delayed. Because of these skeletal changes, the upper lip is retracted, giving the person a" chipmunk" or "rodent face" (6).

In β-thalassemia major, there is no correlation between the chronologic, skeletal and dental age. The skeletal retardation increases with age due to hypoxia from severe anemia, endocrine hypodysfunction secondary to iron deposition, or the toxic action of iron enzyme systems leading to tissue injury.

The oral mucosa is pale or lemon yellow color due to anemia and deposition of billirubin pigment, then decrease lysis of red blood cells cause less deposition of billirubin(1,5).

Radiographic changes resulting from expansion of the marrow spaces in long bones include cortical

a Oral and Maxillofacial Surgery Department, College Of Dentistry, Karbala University. Iraq. Email: [email protected] b Oral Medicine, Oral and Maxillofacial Surgery Department, College Of Dentistry, Babylon University, Iraq. Email: [email protected]

Prevalence of orofacial changes in patients with

β-thalassemia major in Karbala City, Iraq


SDJMuhanned Salah Abulsattara Ali Mihsen Al-Yassirib

Abstract: Background: The thalassemias are a group of hemoglobinnopathies characterized by a reduced rate of production of one or more of these globin chains. The imbalance is due to disturbances in the control mechanisms of protein synthesis and results in altered function of the hemoglobin molecule and aberrant erythrocyte morphology. β- thalassemia major is the most severe congenital hemolytic anemia. The oral complications or manifestations are most common present in major thalassemic patients. The aim of this study was to investigate findings of oral abnormalities or changes in these patients, and compare it to healthy control subjects. Materials and Methods: Patients were selected from Thalassemia Center of Pediatric of Al Hussaini Teaching Hospital in Holy-Karbala during the period from March to September 2013. Forty (40) subjects were incorporated in this study. All these patients with age range (4-15) years, (22 males, and 18 females). All these patients were without any other systemic diseases. Results: The prevalence of orofacial complications in β-thalassemia major patients was: prominent maxilla (85%), bad oder (80%), oral ulcers (50%), angular stomatitis (40%), candidal infection (35%), changes in oral mucosa (30%), xerostomia (15%), and the last one was enlargements of salivary glands (zero). Discussion: Thalassemia is among the most widely distributed genetic disorders to cause a major public health problem. Β- thalassemia major is a life-threatening condition characterized by severe anemia, hepatoseplenomegaly, growth retardation, skeletal changes due to hypertrophy and expansion of erythroid marrow , susceptibility to infection, endocrine dysfunction and cardiac failure following iron deposition in the myocardium. Conclusions: Knowing the prevalence of complication can help the dentists to do properly for these patients to solve their problems and improve knowledge of the parents about their children's dental health.

Keywords: Orofacial changes , major β-thalassemia, prominent maxilla. Received: January 2014, Accepted: June 2014


erosions, subcortica lucencies, rarefaction, enlarged nutrients foramina, and "raindrop" spaces within the cortex(7,8). In the jaws, there is generalized rarefaction of alveolar bone, thinning of cortical bone, and a "chicken-wire" appearance of enlarged marrow spaces and coarse trabeculation. In some cases, the lamina dura may be thin, the roots of teeth short, and the premaxilla prominent(9). In the skull, proliferation of the marrow may completely erode the cortex, leaving only periosteum, and produce a hair-on-end Holy-Karbala radiographic appearance(6). In addition, pneumatization of the paranasal sinuses may be delayed, and the nasal cavity or the middle ear may be encroached upon to the point of occluding the anatomic spaces(7).

The common orofacial features among patients with severe β-thalassemia include: frontal bossing, skeletal changes, characteristic chipmunk facies, upper lip retraction(10-12), and various malocclusion stages due to bi-maxillary, alveolar bone expansion, skeletal and dental retardation. Marginal gingivitis which was mainly located at the level of lower frontal teeth due to malocclusion and poor oral hygiene(12,13 ), poor oral hygiene and high caries risk were reported in many studies(13) . Iron deposition (hemosiderosis) all over the body has been reported; face (ashen-gray color)(10), oral mucosa (bluish-black discoloration)(14), teeth (yellowish-brown)(10) and in parotid glands cause swelling and pain(15), iron overload from blood transfusion and increased iron absorption will lead to fatal complications(16).

There is higher tendency of glossitis (Depapillation) and candidiasis of the tongue due to chronic anemia, poor oral hygiene and other causes(17,18). There is susceptibility to recurrent infections, overwhelming and severe infections especially in splenectomized patients(18).


Patients were selected from Thalassemia Center of Pediatric of Al-Hussaini Teaching Hospital in Holy-Karbala during the period from March to September, 2013. Forty (40) subjects were incorporated in this study, Informed consent and ethical approval was obtained. For each individual a questionnaire case sheet was filled out. All these patients with age range (4-15) years, (22 males, and 18 females). All these patients were without any other systemic diseases.

All these Thalassemic patients were previously diagnosed by hematologist specialists, and were selected according to: clinical features, hematological examination (Hb<9.5 g/dl, RBC morphology), and Hemoglobin electrophoresis. Intra and extra-oral examination for these patients to record all the orofacial manifestations or findings (oral ulcerations, gingivitis, bad odor (halitosis), dry mouth or xerostomia, candidacies infections, prominent maxilla, enlargement of salivary glands, angular stomatitis, and changes in oral mucosa).

Results:

The total numbers of patients with β-thalassemia major were (40). The percentages of orofacial abnormalities in patients with β- thalassemia major was as fallow (Figure 1):

1. Prominent maxilla (85%), 34 out of 40 cases.

2. Oral ulcers (50%), 20 out of 40 cases.

3. Changes in oral mucosa (30%), 12 out of 40 cases.

4. Candidal infection (35%), 14 out of 40 cases.

5. Xerostomia (15%) 6 out of 40 cases.

6. Halitosis (80%), 32 out of 40 cases.

65

Figure 1: Distribution of orofacial abnormalities in patients with β- thalassemia major in the oral cavity


7. Angular stomatitis (40%), 16 out of 40 cases.

8. Enlargements of salivary glands (zero).

Discussion:

Thalassemia is among the most widely distributed genetic disorders to cause a major public health problem. β-thalassemia major is a life-threatening condition characterized by severe anemia, hepatosepl-enomegaly, growth retardation, skeletal changes due to hypertrophy and expansion of erythroid marrow, susceptibility to infection, endocrine dysfunction, and cardiac failure following iron deposition in the myocardium(19,20) . The clinical features of the disease are well documented(14,15,21-23).

Forty thalassemic patients were studied, (22) males and (18) females, the age range (4-15) years. The incidence of thalassemia were more in males than females, these results were matched with [Mattia et al., 1996 and Al- Kaysi, 2002].

In this study, the most common oral findings or manifestations among thalassemics maxillary promi-nence 85%, oral ulcers 50%, bad odors 80%, angular stomatitis 40%, change in oral mucosa 30%, candidial infection 35%, bad odors 10% and finally enlargement of salivary glands zero %.

Facial deformities such as maxillary prominence or expansion and protrusion of upper anterior teeth were observed 85% of the cases, as studies of [Caffey, 1957 and Baker, 1964]; we observe a close correlation between frequency and severity of bone changes and the severity of anemia. Patients with the mean low Hb. concentration have significantly higher and severe frontal bossing and facial deformities than those whose high or normal Hb concentration.

In our study, this was highly significant increase in maxillary prominence among beta-thalassemic major patients.

In this study, most of the patients with β- thalassemia major were in the first or second decodes of life, which indicates a lack of life expectancy.

Alveolar expansion that causes maxillary promi-nence were observed in this study, significantly increasing with age and duration of the illness, due to gradual bulging of alveolar buccal bone overlying the upper central incisors with increasing age, these results were matched with findings of [Johnson and Kragman, 1964].

The incidence of oral ulcers, changes of oral mucosa, and angular stomatitis among thalassemics were significantly higher than controls, the presence of these manifestations were multifactorial including: nutritional deficiency, folate, Vitamin-B complex

deficiencies. Rarely diabetes or staphylococcus, β. Hemolytic streptococcus. The majority of angular stomatitis cases were associated with candida albicans in thalassemics (27-29).

The incidence of candidial infection was significant among thalassemic patients compared to controls, because they were prone to infection particularly opportunistic candidiasis , other factors as iron overloaded, these findings were matched with [Abbott and Galloway, 1986].

The severity of oral findings or abnormalities among thalassemics of rural areas was higher than urban areas. This was because of: lower socioeco-monic status, difficult transplantation and difficulty of proper management in the rural areas unfortunately.

Dry mouth (Xerostomia) in thalassemics found to increase with age and severity of oral findings , due to iron deposition , pain and swelling in the parotid glands of patients with thalassemia major have been reported, possibly as a result of iron deposits in the serous cells, these findings were matched with [Hattab et al., 2001 and Goldfarb et al., 1983]. The presence of bad odors is due to bad oral hygiene.

Conclusions:

Thalassemia hemglobinopathies produce a wide variety of signs, symptoms, and complications in those patients who inherit the diseases. The orofacial changes and bone deformities were common finding among severe β-thalassemic patients.

Successful management of a patient with thalass-emia depends on a proper diagnosis and treatment plan that considers both the systemic and oral conditions. Regular and repeated blood-infusion preserving the hemoglobin amount in an appropriate level (at least 10g/dl), along with iron removal can prevent face and skull deformities. Therefore; skull and face deformities can be closely related to the patient's age, the intensity of anemia and the beginning time of treatment. Patients receiving inadequate blood transfusion in childhood will face more bone changes (expansion and deformity) in adolescence are cause of hyper activity of bone marrow to compensate anemia. Then early diagnosis and blood infusion cause less prevalence of complications.

References:

1. Braun wald, Antony S fuci, Kasper, Hauser, Longo, Jameson: Harrison's principle of internal medicine. 15th ed. New York, Mc-Grow Hill. pp, 2001;666-74.

2. Malcolm A, Martin S Greenberg: Burket's oral medicine. 9th ed. Philadeiphia, Lippincott. pp. 1994:534-9.

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3. Farhud D, Sadighi H. Investigation of prevalence of beta thalassemia in Iranian provinces. Iranian J Pub Health. 1997: 26:3-6.

4. Miller. Blood disease in infancy childhood. 3rd ed . London, Mosby. pp. 1989:280-340.

5. Gerrnberg M S. Burket's oral medicine. 10th ed. Philadelphia, Lippincott, pp. 2003: 430-6.

6. Margot L, Van Dis. Thalassemia. oral manifestations and complications. Oral Med, Oral Path, Oral Surg.1986; 62:229-33.

7. Modell B, Berdoukas V. The clinical approach to thalassemia. New York, Grune and Stratton,pp, 1984; 53-75.

8. Lawson JP, Ablow RC, Pearson HA. The ribs in thalassemia. I, The relasioship to therapy. Radiology.1981; 140:663-77.

9. Poynton HG. Oral radiology, Baltimore, Williams and Wilkins, pp, 1982; 230-2.

10. Martin S. Greenberg, Adi Garfukel. Hematologic Disease, Thalassemias, Diagnosis and Treatment, Burket's Oral Medicine 9th ed, 1994; 536-7.

11. Ernest Butler. Hemoglobinopathies, thalassemia syndromes, Harrison's Principles of Internal Medicine. McGraw-Hill. 15th ed, 2001; 106:668-74.

12. De Mattia D, Pettini PL, Sabato V, Rubini G, Laforgia A, Schettini F. Oromaxillofacial changes in thalassemia major. Minerva Pediatr. 1996;48:11-20.

13. Al-Kaysi GH. Dental and oral changes in a group of Iraqi thalassemia patients, the first scientific congress on thalassemia and hemoglobin pathies. Baghdad, 2002.

14. Duggal MS, Bedi R, Kinsey SE, Williams SA. The dental management of children with sickle cell disease and beta-thalassaemia: a review. Int J Paediatr Dent. 1996;6:227-34.

15. Goldfarb A, Nitzan DW, Marmary Y. Changes in the parotid salivary gland of beta-thalassemia patients due to hemosiderin deposits. Int J Oral Surg. 1983;12:115-9.

16. Olivieri NF. The beta-thalassemias. N Engl J Med. 1999 ;341:99-109.

17. Sonis, Fazio, Fang, Pigmented lesions. Hemochr-omatosis, Principles and Practice of Oral Medicine, 2nd ed, 1984;38;385.

18. Margot L. Van Dis, and Robert P. Langlais. The thalassemia: Oral manifestations and complications. Oral Surg. Oral Med, Oral Pathol. 1996;62:229-33.

19. Weatherall JD, Clegg JB. The thalassemia syndromes (3rd edn). Oxford: Blackwell, pp, 1981; 132-74.

20. Modell B. Management of thalassemia major. Br Med Bull. 1976; 32: 270-6.

21. Weel F, Jackson IT, Crookendale WA, McMichan J. A case of thalassemia major with gross dental and jaw deformities. Br J Oral Maxillofac Surg. 1987;25:348-52.

22. Kaplan RI, Werther R, Castano FA. Dental and oral findings in Cooley's anemia: a study of fifty cases. Ann NY Acad Sci. 1964; 119:664-6.

23. Van Dis ML, Langlais RP. The thalassemias: oral manifestations and complications. Oral Surg Oral Pathol. 1986; 62:229-33.

24. Caffey J. Cooley's anemia: a review of the rontgen-ographic finding in the skeleton. Am J Roentgenol Radium Ther Nucl Med. 1957; 78:381-91.

25. Baker D. H. Roentgen manifestations of Colley's anemia, Ann.N. Y. Acad of Sci. 1964;119:641-61.

26. Jonston FE, Kogman WM. Patterns of growth in children with thalassemia major. Ann N Y Acad Sci. 1964;119:667-79

27. Lynch M.A: Hematologic diseases, Diagnosis and treatment of Hematologic diseases, Burket's Oral Medicine, 7th ed, 1973; 203-409.

28. Sreebny LM, Valdini A. Xerostomia. Part I: Relationship to other oral symptoms and salivary gland hypofunction. Oral Surg Oral Med Oral Pathol. 1988;66:451-8.

29. Hattab FN, Hazza'a AM, Yassin OM, al-Rimawi HS. Caries risk in-patients with thalassemia major. Int Dent J. 2001; 51: 35-8.

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Sulaimani Dent. J. 2014; 1:68-73 A-Qadir & Al-Qaisi

Introduction:Cleaning and shaping of the root canal system are among the important phases in endodontic therapy. Nevertheless, it is recognized that chemo-mechanical instrumentation alone is unable to completely disinfect root canal systems. The remaining bacteria in the root canal after instrumentation have been shown to proliferate between appointments. Intra canal medicament is also well-established method for inhibition of external root resorption and stimulation of periapical healing in traumatized teeth(1).

Microorganisms are not only in the main root canal, but also disseminated throughout the root canal system therefore, the use of an intracanal dressing to eliminate the microorganisms is indicated(2).

The selection of intracanal medicament depends on the root canal microbiota and on the mechanism of action of the medication. Calcium hydroxide is the most used intracanal dressing due to its antimicrobial effect within root canal, its indirect and direct actions in the dentinal tubules(3).

Calcium hydroxide dissociate to hydroxyl ions and calcium ions & create an alkaline environment inside dentinal tubules, and as a result it shows antibacterial properties and stimulates hard tissue barrier formation in aqueous solution. Various biological properties have been attributed to this substance, such as inhibition of tooth resorption and induction of repair by hard tissue formation(4,5).

The new intracanal medicaments has been introduced like mineral trioxide aggregate (MTA) first introduced as a root end filling material and for repair of lateral root perforations since then it has been used for many clinical applications like pulp capping, pulpotomy & for treatment of root resorption & root filling material; similar to calcium hydroxide it has high alkaline pH & the same mechanism(6).

Recently calcium – silicate based material (Biodentine) has been introduced with the same clinical application as MTA but with a different chemical composition. It exhibits high alkaline pH and

a M.Sc. Department of Conservative Dentistry, School of Dentistry, Faculty of Medical Sciences, University of Sulaimani. b Professor. Department of Conservative Dentistry, School of Dentistry, Faculty of Medical Sciences, University of Sulaimani.

Assessment of calcium ions diffusion and pH measurements of three intracanal medicaments through dentinal tubules (in vitro comparative study)


SDJChrakhan A-Latif A-Qadira Salam D. Al-Qaisib

Abstract Objectives: The purpose of this study was to evaluate the release of Calcium ions from three intracanal medicaments [Ca(OH)2 , White Proroot MTA , Biodentine], and to measure the PH of these three materials.

Materials and Methods: Forty-two single rooted permanent teeth were prepared using crown down technique with Protaper rotary files to a master apical file size 40. The canals were irrigated by using 2 ml 5.25% NaOCl for 60 seconds after each instrument change, final irrigation of canals using 5 ml of 17% EDTA for 3 minutes and 5 ml of 5.25% NaOCl for 60 seconds and finally 10 ml of saline solution. The canals were dried and the intracanal medicaments were applied according to manufacturer instruction after setting of materials, both apical and coronal openings were sealed by Cavit and a layer of Epoxy resin on it. Each root was immersed in 30 ml of deionized water. The digital pH meter was used for measuring the pH values for each root 10 times per each studied period (1, 2, 7, 15, 30, 45, 60) days; The Calcium ions release measurements were taken for each studied periods using Atomic Absorption Spectrophotometer device. The results were analyzed statistically using ANOVA (F test), a p-value < 0.05 was considered as a significant.

Results: The pH values for Ca (OH)2 and PMTA groups were gradually increased and need more time for increasing than the Biodentine. The pH values for Biodentine were the highest at the first day then decreased in the 2nd and 7th days, then increased over time until sixty days. The calcium ions release values were gradually increase for three medicament and its values were highest for Biodentine followed by Ca(OH)2 and finally PMTA. The differences between groups were statistically highly significant.

Conclusions: Biodentine exhibited highest mean values in the calcium ions release and pH measurements than other groups and PMTA showed lowest mean values in the calcium ion release and pH measurement.

Keywords: Calcium hydroxide, Proroot MTA, Biodentine, deionized water

Received: March 2014, Accepted: October 2014.


release of calcium ions & also has good antimicrobial properties(7).

The pH measurement and calcium ions release measurement are determined by using digital pH meter and Atomic Absorption Spectrophotometer device respectively.


Forty-two extracted permanent maxillary central and maxillary second premolar human teeth with single and straight root were selected for present study. The soft tissues and hard deposits were removed using the ultrasonic scalar, the teeth were stored in 10% Formalin at room temperature for two weeks before instrumentation for sterilization, and then teeth were rinsed with distilled water to remove formalin and stored in normal saline until the time of instrum-entation.

The length of teeth was measured by a vernier, then the teeth were decoronated transversally with a water-cooled diamond disc with straight handpiece at the level of (12 mm) from the apex perpendicular to the long axis of the root to obtain a relatively standard root length. The pulp tissues removed by barbed broach, the root canals were measured by insertion of a K file #10 with a rubber stop. The root canals were prepared with a rubber dam in place; using a crown-down technique with Protaper rotary files to a master apical file size of 40. The canals were irrigated by using 2 ml of 5.25% sodium hypochlorite for 60 sec after each instrument changed, After finishing the instrumentation process, the canal was irrigated with 5 ml of (17% EDTA) for 3 minutes, followed by 5 ml of 5.25% NaOCl for 60 sec to remove smear layer, Finally, the canal was irrigated with 10 ml saline solution Then the canal dried with paper point size 40.

Sample grouping:

The prepared (42) roots were divided randomly in to three main groups of fourteen roots, which were calcium hydroxide, PMTA, and Biodentine as shown in figure1.

The powder of materials was mixed with distilled water according to manufacturer instruction. The calcium Hydroxide (Bio Dinamica Hydroyde Decalcium, France) and PMTA (Dentsply, Tulsa Dental, USA) were applied by lentulo spiral filler size 40 to 1 mm shorter than full working length using slow speed handpiece. While Biodentine (Septodent) was applied to the canal by amalgam carrier. Then materials condensed using finger plugger and endodontic condenser until 2 mm remain coronaly for sealing materials. Complete filling of the root canals for all three groups were checked by the over flow of material through the root canal opening and radiographic documentation through taking periapical radiograph for each root in buccolingual and mesiodistal aspects.

When the filling material set, both opening of roots were sealed by Cavit and when become hard, a layer of epoxy resin used on it for better sealing. After self drying of the epoxy resin, each root immersed in a separated plastic tubes containing 30 ml of Deionized water and transferred to an incubator at 37°C with humidify environment. The digital pH meter (pH meter 765 Calimatic, Knick, Germany) was used for measuring the pH values for each root 10 times per each studied period ( 1, 2, 7, 15, 30, 45, 60) days; The calcium ions release measurements were taken for each studied periods using Atomic Absorption Spectrophotometer device (PYE uniCAM Spg; Philips, England), figure 2. The results were analyzed statistically using ANOVA (F test), a P-value < 0.05 was considered as a significant.

Results:

The changes in pH and calcium ion release within the immersion medium are presented in table 1 and figure 3, table 2 and figure 4 respectively.

The pH values of the immersion media for three groups were approximately between 6.166 and 8.634.

Group1 which is Ca (OH)2 and Group2 (Pro root MTA) show positive increase of pH over time while Group3 (Biodentine) shows very high pH values in the first day then decreases in the 2nd and 7th days

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Figure 1: Sample grouping


70

Table 1: The Comparison between Mean and Standard Deviation of PH Measurement of Three Intra Canal Medicament at Different Studied Periods

Period of measurements

(Days)

Number of teeth

Group 1 calcium hydroxide

Ca(OH)2 Mean±S.D

Group 2 Mineral Trioxide

Aggregate (PMTA) Mean±S.D

Group 3 Biodentine Mean±S.D P- value Significant

degree

1st day 14 7.423±0.520 6.166±0.289 8.634±0.877 < 0.001 S

2nd day 14 8.190±0.513 7.097±0.256 8.461±0.513 < 0.001 S

7th day 14 8.163±0.500 7.432±0.195 8.134±0.458 < 0.001 S

15th day 14 8.314±0.172 7.718±0.221 8.274±0.212 < 0.001 S

30th day 14 8.334±0.208 7.960±0.196 8.248±0.153 < 0.001 S

45th day 14 8.464±0.231 8.034±0.213 8.418±0.207 < 0.001 S

60th day 14 8.482±0.180 8.054±0.177 8.400±0.176 < 0.001 S

Figure 3: The Comparison between Mean pH at Different Period of Measurements among Three Studied Groups

Figure 2: Atomic Absorption Spectrophotometer


`then increases over time from 15th day to the 60th day. The results show that Group2 (PMTA) exhibit lowest mean value in the pH measurement (6.166) in the first day than other groups while the highest mean value of pH measurement is observed in Group3 Biodentine (8.634) in the first day. The difference between the pH measurements of three intracanal medicaments groups for mean values is statistically highly significant (P value <0.001). The three groups of intracanal medicaments show positive increase of mean value of calcium ions release at different studied periods. The results showed that Group1 calcium hydroxide medicament exhibits the lowest mean value in the calcium ions release (0.698) in the first day while the highest mean value of calcium ions release measurement is observed in Group3 Biodentine (4.94) in the sixty days. The difference between the three intracanal medicament groups for mean values of

calcium ions release measurement is statistically highly significant (P value <0.001).

Discussion:

This study sheds light on the comparison of pH measurement & calcium ions release measurement of three intracanal medicaments Ca(OH)2, Proroot Mineral Trioxide Aggregate and Biodentine at different studied periods (1, 2, 7, 15, 30, 45 and 60) days.

1. pH measurement:

The diffusion through dentinal tubules, apical foramen, secondary and accessory canals allows the calcium hydroxide to reach regions contaminated by

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Figure 4: The Comparison between Mean Values of Calcium Ions Release at Different Period of Measurements among Three Studied Groups

Table2: The Comparison between Mean Values of Calcium ions Measurement of Three Studied Groups at Different Studied Periods

Periods of measurement

(days)

Number of teeth

G1: Ca(OH)2 (Control group)

Mean

G2: PMTA Mean

G3: Biodentine

MeanP-values Significant

degree

1st day 14 0.698 0.753 2.269 < 0.001 S

2nd day 14 0.962 0.94 3.027 < 0.001 S

7th day 14 1.489 1.17 3.456 < 0.001 S

15th day 14 1.83 1.313 3.994 < 0.001 S

30th day 14 2.214 1.478 4.368 < 0.001 S

45th day 14 2.511 1.654 4.632 < 0.001 S

60th day 14 2.907 1.742 4.94 < 0.001 S


microorganisms, areas of root resorption and surrounding tissues, promoting its antimicrobial and anti-resorptive action(7).

PH measurement method in immersion media applied in this study is to allow the measuring of pH at periods longer than the setting time, not representing the pH of material before setting, but rather its ability of alkanization(8).

The pH value of calcium hydroxide in this study came in agreement with the results of Mori et al(7). The pH values of calcium hydroxide obtained in 2nd, 7th, 15th days came in agreement with Sevimay et al(9), Barekatain et al(10) which could be due to irrigation materials, and pattern of hand instrum-entation which affects the amount of dentine removal and the diffusion of calcium ion by it's buffering effect.

This study showed that the pH values of PMTA were low in the 1st, 2nd, 7th days and close to the results of Ozdemir et al(11) who concluded that MTA didn’t produce enough alkaline shift in the immersion media during entire test period, which continued until 28th day, and this is due to inactivation of materials by dentin because of it's buffering capabilities.

The pH values of Biodentine in this study showed highest values in the first day, then decreased similar to the results of Khan et al(8) study during the 1st day, who found slightly higher pH values for Biodentine, but with the same pattern in that it obtained higher results in the first day then decrease.

The results of calcium hydroxide are not in line with studies of Zmener et al(12) since their results are higher than the results of this study, because of the use of saline solution which has higher pH than deionized water.

The results of PMTA disagree with Bortoluzzi et al(13) results which are higher, the reason behind this could be due the use of polyethylene tubes instead of natural roots.

2. Calcium ions measurement:

Intracanal medicaments should also release calcium ions in order to stimulate mineralization, the calcium ions react with tissue carbonic gas, forming calcium carbonate that favors mineralization(11).

In the present study there was remarkable amount of calcium ion released and it´s gradually increased with time and also came in agreement with Ghazvini et al14) study showed that all tested materials released remarkable amounts of calcium ions.

The results of calcium hydroxide in this study were close to the result of Uzunoğlu et al(15) who showed that calcium ion release from different calcium hydroxide pastes have continued up to 30

days; The results of PMTA were identical to the result of Ozdemir et al(11) especially in the 15 days which reached 1.3mg/dl.

Calcium ions release values of the present study are in agreement with Bortoluzzi et al(13) for PMTA and with Khan et al(8) for both PMTA and Biodentine which are as follows; in the first day calcium ions release values are nearly the same but with time the present study shows increase in values in contrast to both Bortoluzzi et al(13) and Khan et al(8) studies who showed decrease in the values and the reason behind this could be due to using poly ethylene tube instead of roots and changing deionized water with each measurements periods.

Also the result is not in line with Camargo et al(16) who showed higher values of calcium ions release from calcium hydroxide than in the present study the reason could be the type of atomic absorption Spectrophotometer device which was the UV type and the sample model which was the outer root surface cavity. The results of calcium hydroxide do not come in agreement with study of Fulzele et al(4) since their results were higher than the results of this study because of the use of polyethylene tubes and the use of smaller quantity of deionized water in the test tubes than present study leading to higher result in their study.

The results of PMTA in the first day calcium ions release values are nearly the same but with time the present study shows increase in values in contrast to the both Bortoluzzi et al(13) who showed decrease in the values and the reason behind this could be due to using poly ethylene tube instead of roots and changing deionized water with each measurements periods.

Conclusions:

The pH values for Ca (OH)2 and PMTA groups were gradually increased from first day to the sixty days. The pH values for Biodentine were the highest at the first day then decreased in the 2nd and 7th days, then increased over time until sixty days.

According to the results, the calcium hydroxide and PMTA need more time for increasing the pH values than the Biodentine. The calcium ions release values were gradually increase for three intracanal medicaments Ca(OH)2, PMTA, Biodentine. The calcium ions release values were highest for Biodentine followed by Ca(OH)2 and finally PMTA.

References:

1. Kazemipoor M, Tabrizizadeh M, Dastani M, Hakimian R. The effect of retreatment procedure on the pH changes at the surface of root dentin using two different calcium hydroxide pastes. J Conserv Dent. 2012;15:346-50.

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2. Andolfatto C, da Silva GF, Cornélio AL, Guerreiro-Tanomaru JM, Tanomaru-Filho M, Faria G, et al. Biocompatibility of intracanal medications based on calcium hydroxide. ISRN Dent. 2012;2012:904963.

3. Estrela C, Mamede Neto I, Lopes HP, Estrela CR, Pécora JD. Root canal filling with calcium hydroxide using different techniques. Braz Dent J. 2002;13:53-6.

4. Fulzele P, Baliga S, Thosar N, Pradhan D. Evaluation of calcium ion, hydroxyl ion release and pH levels in various calcium hydroxide based intracanal medicaments: An in vitro study. Contemp Clin Dent. 2011;2:291-5.

5. Sahebi S, Nabavizadeh M, Dolatkhah V, Jamshidi D. Short term effect of calcium hydroxide, mineral trioxide aggregate and calcium-enriched mixture cement on the strength of bovine root dentin. Iran Endod J. 2012;7:68-73.

6. Nunes AC, Rocha MJ. Hydroxyl and calcium ions diffusion from endodontic materials through roots of primary teeth - in vitro study. J Appl Oral Sci. 2005;13:187-92.

7. Mori GG, Ferreira FC, Batista FR, Godoy AM, Nunes DC. Evaluation of the diffusion capacity of calcium hydroxide pastes through the dentinal tubules. Braz Oral Res. 2009;23:113-8.

8. Khan SIR, Ramachandran A, Mohanavelu D, Kumar KS. Evaluation of pH and calcium ion release of mineral trioxide aggregate and a new root end filling material. e-Journal of Dentistry. 2012;2:166.

9. Sevimay S, Kalayci A, Yilmaz S. In vitro diffusion of hydroxyl ions through root dentine from various calcium hydroxide medicaments. J Oral Rehabil. 2003;30:1047 -51.

10. Barekatain B, Hasheminia SM, Shadmehr E, Attary Z. The effect of calcium hydroxide placement on pH and calcium concentration in periapical environment: an in vitro study. Indian J Dent Res. 2012;23:226-9.

11. Ozdemir HO, Ozçelik B, Karabucak B, Cehreli ZC. Calcium ion diffusion from mineral trioxide aggregate through simulated root resorption defects. Dent Traumatol. 2008;24:70-3.

12. Zmener O, Pameijer CH, Banegas G. An in vitro study of the pH of three calcium hydroxide dressing materials. Dent Traumatol. 2007;23:21-5.

13. Antunes Bortoluzzi E, Juárez Broon N, Antonio Hungaro Duarte M, de Oliveira Demarchi AC, Monteiro Bramante C. The use of a setting accelerator and its effect on pH and calcium ion release of mineral trioxide aggregate and white Portland cement. J Endod. 2006;32:1194-7.

14. Amini Ghazvini S, Abdo Tabrizi M, Kobarfard F, Akbarzadeh Baghban A, Asgary S. Ion release and pH of a new endodontic cement, MTA and Portland cement. Iranian Endodontic Journal. 2009;4:74-8.

15. Uzunoğlu E , Yılmaz Z, Evren Ülker A, Kalaycı S, Karahan S. Determination of pH and calcium ion release provided by different calcium hydroxide pastes. Clin Dent And Res. 2011;35:38-42.

16. Camargo CH, Bernardineli N, Valera MC, de Carvalho CA, de Oliveira LD, Menezes MM, Afonso SE, Mancini MN. Vehicle influence on calcium hydroxide pastes diffusion in human and bovine teeth. Dent Traumatol. 2006;22:302-6.

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Sulaimani Dent. J. 2014; 1:74-79 Ibrahim & Al-Qaisi

Introduction:Endodontic therapy comprises of two principal phases, the first phase include mechanical instrumen-tation to clean and shape root canals with irrigation and disinfection to prevent reinfection. The second phase is the filling phase which subsequently placed in the instrumented root canal(1).

Sodium hypochlorite (NaOCl) is the most common endodontic irrigant used with concentrations ranging from 0.5% to 5.25%. It presents strong antimicrobial activity and ability to dissolve necrotic pulp tissue, so it is usually chosen as suitable intra canal irrigant. However, it has been showed to be ineffective in removing the entire smear layer when used alone. Thus, the uses of chelating agents and acids have been suggested to remove the smear layer from the root canal(2).

Ozone is highly indicated in root canal therapy as an irrigant due to its strong disinfection property and

absence of cytotoxicity. Other interesting biological characteristics include: bactericidal action, debriding effect, angiogenesis stimulation capacity and high oxidizing power(3).

The use of ozonated water had showed that following ozone therapy there was high metabolic activity of the associated fibroblasts indicating an increase in the healing process.

Another study assessed the effect of an ozone application on the micromechanical properties of dentin and they concluded that the application of ozone does not affect the modulus of elasticity and the Vickers’s hardness(4).

Ozonated water has some potential in removing the smear layer, and it has certain ability for the smear layer removal in combination with 1% NaClO, especially without erosion on the root canal walls(5).

a M.Sc. Department of Conservative Dentistry, School of Dentistry, Faculty of Medical Sciences, University of Sulaimani. b Professor. Department of Conservative Dentistry, School of Dentistry, Faculty of Medical Sciences, University of Sulaimani.

Evaluation of some intracanal irrigants on push-out bond strength and mode of failure of resin and non resin cements to root canal dentin (in vitro comparative study)


SDJRawa O. Ibrahima Salam D. Al-Qaisib

Abstract Objectives: The purpose of this study was to evaluate the effects of five intracanal irrigants [distilled water, NaOCl, NaOCl + EDTA, ozonated water and NaOCl + ozonated water] on push-out bond strength of (zinc phosphate cement and Calibra® esthetic resin cement) and to determine the mode of failure.

Materials and methods: Seventy extracted single straight rooted teeth were selected. The crowns were sectioned at cemento-enamel junction. The sectioned roots were embedded vertically in clear acrylic resin. The root canals were prepared with K-files and Gates Glidden drills using step-back technique then the specimens were randomly assigned to five main groups according to the types of irrigant used and each main group were divided in to two subgroups and filled with zinc phosphate cement and Calibra® esthetic resin cement. The samples were sectioned horizontally to provide 4 millimeter dentin disc from coronal third of the roots. Each sectioned specimen was tested by using computerized universal testing machine. Finally each de-bonded specimens was examined under stereomicroscope to determine the mode of failure.

Results: Two-way ANOVA tests showed that there was statistical significance difference between the two type of cement used in this study, also there was statistical significance difference between the types of irrigant; while the interaction between types of cement with types of irrigant was not statistically significant. Considering the dentine surface treatment, Paired T-test showed that irrigation with 5.25% NaOCl produce statistically significant reduction in bond strength to root canal dentin in comparison to control group, while irrigation with distilled water, 5.25 NaOCl plus 17% EDTA, 5.25% NaOCl plus 5gm/L ozonated water, 5gm/L ozonated water alone had no statistical significant affect on bond strength to root canal dentin. Comparing the cements, zinc Phosphate cement showed higher bond strength in comparison to Calibra® esthetic resin cement.

Conclusions: NaOCl have negative effect on bond strength to root canal dentin, while distilled water, NaOCl plus EDTA, ozonated water alone or after NaOCl had no effect. Zinc phosphate cement had higher bond strength than Calibra® esthetic resin cement. The adhesive and mixed failures were higher than the cohesive failure for all groups in general.

Keywords: Ozonated water, push-out bond strength, resin cement. Received: April 2014, Accepted: September 2014.


With the evolution of adhesive systems, resin cements, and restorative materials, endodontically treated teeth began to be reconstructed conservatively, and many intra radicular systems have become available for this purpose(6).

Various types of cements are used for post retention. Zinc phosphate, zinc oxide eugenol and silicophosphate cements were used from the early twentieth century till 1970s when new cements were developed. At first polycarboxylate cement, next glass ionomer cements and within the last thirty years resin cements and resin modified glass ionomer cements were developed. Resin cements differ from restorative composites with lower filling structure and viscosity in their context (7).

Resin type luting cements provide high bond strength to restorative materials and hard dental tissue. Moreover, their useful properties of minimal solubility, biocompatibility, and stability greatly contribute to the formation of strong tooth restoration interfaces, with minimal removal of adjacent tooth tissue (8).


Seventy extracted human permanent teeth were selected. The teeth were mechanically cleaned with ultrasonic scaler to remove hard deposit and soft tissues. Then they were stored in distilled water at room temperature after that the teeth sterilized by using 20 ml of 10% formalin (Merch, Germany) for 5 days at 37cº. The coronal portion of each tooth was sectioned at the lowest point of cemento-enamel junction using a diamond double-faced disc in a slow-speed handpiece, cooled with air/water spray. The working length was established by the direct method by subtracting 1 mm from the remaining root length determined by introducing a no. 10 K-file. Each specimen was vertically positioned in the center of cylindrical containers of 15 mm length and 20 mm diameter using dental surveyor (Dentaurm poraline, Beograd Sirbija) for equalization of the parallelism. The root canals was prepared with K-files, using the step-back technique. The apical portion was enlarged

to a no. 45 master file. The coronal portion of each canal was shaped with sizes 2 to 4 Gates-Glidden drills. Then the canals were irrigated with different testing irrigants as shown in the figure 1.

Group 1(control group): The canals were irrigated by using 2 ml of distilled water (Al-Mansour Co., Iraq) for 60 seconds after each instrument. Group 2: The canals were irrigated with 2 ml of 5.25% NaOCl (Chlorox, commercial household, Iran) as in (Group1). Group 3: The canals were irrigated with 5.25% NaOCL with the same manner as in Group 1 then dried with paper point and rinsed with 1 ml of 17% EDTA (Dentaires SA Vevey, Switzerland) for 1 min and a final rinse with 3 ml of 5.25% NaOCl for 1 min. Group 4: The canals were irrigated with 2 ml of 5gm/L freshly prepared ozonated water with the same manner as (Group1). The ozonated water was prepared using ozone generator (A2z, USA) based on corona discharge which had the capacity to produce 600gm/hr of dissolved ozone according to the manufacturer instruction, and the bubbling stone of the device was immersed into 4 inch deep of 1L of distilled water for 30 seconds to produce 5gm/L of dissolved ozone according to manufacturing instru-ction as shown in figure 2. Chemical diagnostic test (Hanna ozone test kit, USA) was used to ensure the correct concentration of dissolved ozone in water. Group 5: The canals were irrigated with 2 ml of 5.25% NaOCL with the same manner as in Group 1, dried with paper point; then final rinse was done with 3 ml of 5gm/L freshly prepared ozonated water for 1min.

Each group (14) subdivided in to 2 subgroup and filled with zinc phosphate cement (Adhesor, Czech Republic) and Calibra® esthetic resin (Dentsply, Switzerland) according to the manufacturer’s instructions. The quality of filling for each filled specimens was examined by periapical radiograph then the filled specimens will be stored wet environment inside incubator for 24 hr at 37°C. The block was sectioned horizontally by linear precision saw (Isomat 5000, Germany) to provide 4 mm thick dentine discs from the coronal third of the roots. The sectioned specimen was tested by using universal testing machine (Wp310, Germany) for push-out test

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Figure 1: Sample grouping


which calibrated at a constant speed of (1 mm/min) with a 1mm-diameter stainless steel cylindrical tip. The force needed to dislodge the filling material was transformed into bond strength, and then the failure mode of each debonded specimen was assessed under stereomicroscope (NTB-3A, Philippines) with optical magnification (4X) using digital camera connected to the computer. The data was statistically analyzed by paired T-test and two-way ANOVA.

Results:

The means and standard deviations of push-out bond strength (in MPa) for displacement of the cement from the specimens after treatment of root canal dentine with different irrigants are given in Table 1.

Two-way ANOVA tests showed that there is statistical significance difference between the two type of cement used in this study, also there is statistical significance difference between the types of

irrigant; while the interaction between types of cement with types of irrigant is not statistically significant as shown in Table 2.

Comparing the cements, Zinc phosphate cement showed higher bond strength in comparison to Calibra® Esthetic resin cement. Considering the dentine surface treatment, showed that irrigation with 5.25% NaOCl produce statistically significant reduce in bond strength to root canal dentin in comparison to control group, while irrigation with distilled water, 5.25 NaOCl plus 17% EDTA, 5.25% NaOCl plus 5gm/L ozonated water, 5gm/L ozonated water alone had no statistically significant affect on bond strength to root canal dentin.

In the present study the adhesive and mixed failure were higher than the cohesive failure for all groups in general. For the control group the adhesive failure had the higher rate with no cohesive failure, also the adhesive failure was predominant for the group that irrigated with NaOCl; while mixed failure had the highest rate in both groups that irrigated with NaOCl+ ozonated water and ozonated water alone and cohesive failure was higher in group that irrigated with NaOCl+ EDTA in comparison to other groups as shown in Figure 3.

Discussion:

During irrigation, radicular and coronal dentin is exposed to the various solutions used to disinfect the endodontic space. This may cause alterations on the dentin surface and affect their interactions with materials used either for root canal obturation or for coronal restoration (8).

In this study irrigation with NaOCl showed the lowest bond strength, this result was supported by Morris et al.(9), Goldman et al.(10), Ari et al.(11); Santos et al.(12). The reasons could be its strong oxidizing agent caused degradation of organic dentin components mainly collagen, also reduces calcium and phosphorus levels and mechanical properties of dentin, such as elastic modulus, flexural strength, and

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Figure 2: Ozone generating machine with ozone testing kit

Table 1: The means and standard deviations bond strength in all studied groups

Distilled water 5.25% NaOCl5.25%NaOCL+

17% EDTA5gm/l ozonated

water

5.25%NaOCL +5gm/l ozonated

water

Calibra®ERC 9.0616±0.8423 4.8034±0.7512 9.0961±0.8698 9.1297±1.734 9.0294±1.5334

ZPhC 7.7326±0.6797 4.8714±0.5696 7.7009±1.3542 7.8304±1.1643 7.7663±1.0786


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Table 2: Two-way ANOVA represents effect of irrigants and type of cement on bond strength

Source of variation SS df MS F P-value F crit Degree of significances

Type of cements 18.82933 1 18.82933 14.7498 0.000298 4.001191 Significant

Type of irrigants 143.3191 4 35.82977 28.06695 0.0000 2.525215 Significant

Interaction between cement and irrigant 5.390785 4 1.347696 1.055707 0.386357 2.525215 Not significant

0

2

5

7

9

Gr1:Distilled water Gr2:NaOCl Gr3:NaOCl+EDTA Gr5:Ozonated water Gr4:NaOCl+Ozonated water

Adhesive Cohesive Mixed

Figure 3: The failure modes at different interfaces for the studied groups

Figure 4: Example of adhesive, cohesive, and mixed failure respectively (from left to right) of the sectioned samples under stereomicroscope


microhardness were reported after irrigation of root canals with sodium hypochlorite(13,12). Another reason may be the presence of a smear layer after treatment (14). Whereas Pelegrine et al(15) concluded that the different irrigant solutions did not affect the tensile bond strength of the fixation system used to cement the intraradicular glass fiber posts to dentin.

This study came in agreement with Cecchin et al (7), Nikaido et al(16); Barutcigil et al(17) who concluded that the use of EDTA as irrigating solution during endodontic treatment after NaOCl counteracts the deleterious effect of NaOCl. The use of EDTA counteracts the bad effect of NaOCl by its anti-oxidant power via redox reaction, allowing for free radicals polymerization without premature chains or failures. Moreover, it has the ability to remove the smear layer and the residual chlorine ions, what could benefit phosphoric acid etching and enhance resinous monomer penetration through dentinal tubules(18).

The ozonated water showed an increase in bond strength to root canal dentin which was statistically non-significant and the group that was irrigated with NaOCl and final irrigation with ozonated water as recommended by Lynch and Swift(19) doesn’t affect the bond strength to dentin by counteracting the bad effect of NaOCl. These results came in agreement with Garcia et al(20), Pithon and Santos(21). Whereas partially came in agreement with Ibraheem and Habeeb(22) who concluded that there was an increase in bond strength for ozonated water treated sample. The explanation of these results may be because Ozone is a powerful oxidizing agent but ozonated water becomes highly unstable and rapidly decomposes through a complex series of chain reactions eliminating this oxidizing effect(23). Other mechanisms of ozone are organic biodegradation and some potential in smear layer removal (22, 24).

Zinc Phosphate cement showed higher bond strength in comparison to Calibra® Esthetic resin cement, the results were support the results of Sadek et al(25), Habib et al(26), Yahya et al(27); Oliveira et al(28) this is may be due to stress generated during polymerization shrinkage of resin cement, which causes its displacement from the dentinal surface as well as incomplete bonding(29). Resin cements are more “technique sensitive” than most of the other luting cements. Other factor is insufficient adhesive resin infiltration/penetration into the demineralized dentine(30). While Chan et al(31) concluded in their study greater tensile strength of the dowels secured with resin cement to root canal dentin than those secured with zinc-phosphate cement. Possible reasons for this disagreement are the lack of standard methodology, using dowel inside the root canals and the use of extracted teeth without standardization in the investigations.

The results of the failure modes came in agreement with Barutcigil et al(17), Ari et al(11),

Chaharom et al(32), Morris et al(9); Sasafuchi et al(33) who showed that the failure mode of the samples treated with NaOCl mostly adhesive. For the group irrigated with NaOCl+EDTA, Barutcigil et al(17) showed that failure mode consists of cohesive, adhesive and mixed which was in agreement with the present study, while Vilanova et al(34) showed that failure mode consists of cohesive and mixed failure with no adhesive failure. The results of present study agree with the results of Ibraheem and Habeeb(22) since they concluded that ozonated water treated samples show the highest combination failures which represent the dominant type of failure.

Conclusions:

NaOCl have negative effect on bond strength to root canal dentin, while Distilled water, NaOCl plus EDTA, Ozonated water alone or after NaOCl had no effect. For the cements used in this study Zinc Phosphate cement had higher bond strength than Calibra® Esthetic resin cement. Regarding the failure modes the adhesive and mixed failures were higher than the cohesive failure for all groups in general.

References:

1. Bergenholtz G, Horsted-Bindslev P, Reit C. Textbook of Endodontology. 2nd edition.In: Wesselink P, Bergenholtz G.Treatment of the necrotic pulp. UK: Blackwell publishing Ltd; 2010.p.140-141.

2. Bidar M, Hooshiar S, Naderinasab M, Moazzami M, Orafaee H, Naghavi N, et al. Comparative study of the antimicrobial effect of three irrigant solutions (chlorhe-xidine, sodium hypochlorite and chlorhexidinated MUMS). J Contemp Dent Pract. 2012;13:436-9.

3. Thaman D, Sood P. Ozone therapy in conservative dentistry and endodontics: An overview. Indian J Stomatol. 2012; 3:165-9.

4. Magni E, Hickel R, Ilie N. Influence of gasiform ozone on the micromechanical properties of dentin. Int dent South Africa. 2009;11:16-21.

5. Bo D, Di Z, Jian-ping W. Scanning electron microscopic analysis of smear layer removal in root canals by ozonated Water. Shanghai Kou Qiang Yi Xue 2009; 6.

6. Bergenholtz G, Horsted-Bindslev P, Reit C. Textbook of Endodontology. 2nd edition. In: Wesselink P, Bergenholtz G ,editors.Treatment of the necrotic pulp.UK: Blackwell publishing Ltd; 2010.p.140-141

7. Sumer E, Deger Y. Contemporary permanent luting agents used in dentistry: A literature review. Int Dent Res. 2011;1:26-31.

8. Han L, Okamoto A, Fukushima M, Okiji T. Evaluation of physical properties and surface degradation of self-adhesive resin cements. Dent Mater J. 2007;26:906-14.

9. Morris MD, Lee KW, Agee KA, Bouillaguet S, Pashley DH. Effects of sodium hypochlorite and RC-prep on bond strengths of resin cement to endodontic surfaces. J Endod. 2001;27:753-7.

10. Goldman M, DeVitre R, Tenca J. Cement distribution and bond strength in cemented posts. J Dent Res. 1984;63:1392-5.

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11. Ari H, Yaşar E, Belli S. Effects of NaOCl on bond strengths of resin cements to root canal dentin. J Endod. 2003;29:248-51.

12. Santos JN, Carrilho MR, De Goes MF, Zaia AA, Gomes BP, Souza-Filho FJ, et al. Effect of chemical irrigants on the bond strength of a self-etching adhesive to pulp chamber dentin. J Endod. 2006;32:1088-90.

13. Schwartz RS. Adhesive dentistry and endodontics. Part 2: bonding in the root canal system-the promise and the problems: a review. J Endod. 2006;32:1125-34.

14. Oliveira SS, Pugach MK, Hilton JF, Watanabe LG, Marshall SJ, Marshall GW Jr. The influence of the dentin smear layer on adhesion: a self-etching primer vs. a total-etch system. Dent Mater. 2003;19:758-67.

15. Pelegrine RA, De Martin AS, Cunha RS, Pelegrine AA, da Silveira Bueno CE. Influence of chemical irrigants on the tensile bond strength of an adhesive system used to cement glass fiber posts to root dentin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110:e73-6.

16. Nikaido T, Takano Y, Sasafuchi Y, Burrow MF, Tagami J. Bond strengths to endodontically-treated teeth. Am J Dent. 1999;12:177-80.

17. Barutcigil CH, Harorh O, Ozcan E, ArslanH. Effects of ethylene diamine tetra acetic acid and sodium hypochlorite on the bond strength of bonding agents to pulp chamber lateral walls. J Dent Sci. In press 2013.

18. Lai SC, Mak YF, Cheung GS, Osorio R, Toledano M, Carvalho RM et al.. Reversal of decreased bonding to oxidize etched dentin. J Dent Res. 2001;80:1919-24.

19. Lynch E, Swift E J. Evidence-based efficacy of ozone for root canal irrigation. J compilation 2008;20: 287-93.

20. Garcia EJ, Serrano AP, Urruchi WI, Deboni MC, Reis A, Grande RH, Loguercio AD. Influence of ozone gas and ozonated water application to dentin and bonded interfaces on resin-dentin bond strength. J Adhes Dent. 2012;14:363-70.

21. Pithon MM, dos Santos RL. Does ozone water affect the bond strengths of orthodontic brackets? Aust Orthod J. 2010;26:73-7.

22. Ibraheem AF,Habeeb HM. Effect of ozonated water on dentin bond strength. J Bagh Collage Dentistry.2008:20:33-7.

23. Ibrahim NZ, Abdullah M. Antimicrobial evaluation of sodium hypochlorite and ozonated water on E. faecalis biofilm. Annal Dental University Malaya. 2008;15: 20-6.

24. Bo D, Di Z, Jian-ping W. Scanning electron microscopic analysis of smear layer removal in root canals by ozonated water. Shanghai Kou Qiang Yi Xue 2009; 6.

25. Sadek FT, Goracci C, Monticelli F, Grandini S, Cury AH, Tay F, Ferrari M. Immediate and 24-hour evaluation of the interfacial strengths of fiber posts. J Endod. 2006;32:1174-7.

26. Habib B, von Fraunhofer JA, Driscoll CF. Comparison of two luting agents used for the retention of cast dowel and cores. J Prosthodont. 2005;14:164-9.

27. Yahya NA, Lui JL,Chong KWA, Lim CM, AbuKasim NH, Radzi Z. Effect of luting cement to push-out bond strength of fiber reinforced post. Annal Dent Univ Malaya. 2008;15:11-9.

28. Oliveira I, Arsati Y, Basting R, Franca F. Waiting time for coronal preparation and the influence of different cements on tensile strength of metal posts. Int J Dent. 2012; 785427:1-6.

29. Bouillaguet S, Troesch S, Wataha JC, Krejci I, Meyer JM, Pashley DH. Microtensile bond strength between adhesive cements and root canal dentin. Dent Mater. 2003;19:199-205.

30. El-Badrawy W, Hafez RM, El Naga AI, Ahmed DR. Nanoleakage for self-adhesive resin cements used in bonding CAD/CAD ceramic material to dentin. Eur J Dent. 2011;5:281-90.

31. Chan FW, Harcourt JK, Brockhurst PJ. The effect of post adaptation in the root canal on retention of posts cemented with various cements. Aust Dent J. 1993;38:39-45.

32. Chaharom M, Kahnamoii M, Kimyai S, Moghaddam M. Effect of sodium hypochlorite on the shear bond strength of fifth- and seventh- generation adhesives to coronal dentin. J Biotechnol. 2011;10: 12697-701.

33. Sasafuchi Y,Nikaido T,Tagami J. The effect of chemical irrigant and medicament for endodontic treatment on dentin bonding. Int Chinease J Dent. 2003;3:7-12.

34. Vilanova WV, Carvalho-Junior JR, Alfredo E, Sousa-Neto MD, Silva-Sousa YT. Effect of intracanal irrigants on the bond strength of epoxy resin-based and methacrylate resin-based sealers to root canal walls. Int Endod J. 2012;45:42-8.

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Sulaimani Dent. J. 2014; 1:80-85 Talabani et al

Introduction:Coronal and root fracture teeth were the third most common cause of tooth loss in world after caries and periodontal disease(1). It is generally accepted that the amount of remaining dentine is directly related to the strength of the tooth and the thickness of the dentinal wall at the root circumference is critical, and there is a direct correlation between the root thickness and the ability of the tooth to resist lateral forces and avoid fracture(2), so the thinner the dentin, the more likely the tooth is to fracture(3).

Besides other factors, stresses and the forces generated during instrumentation have been linked to an increase risk of root fractures. It was reported that the root canal preparation alone significantly weakened roots and may have created apical root cracks and thus canal preparation techniques play a vital role in affecting the root fractures. Canal preparation involves dentin removal and may compromise the fracture strength of the roots that could at any stage induce fractures whether complete or incomplete(4).

Over preparation of the coronal third of canal is one of the aberrations that may occur during root canal preparation and it may weaken the tooth, and root perforation is a possible consequence of canal preparation that may result in treatment failure(5).

In the last decades, many new NiTi rotary instruments have been developed and introduced by various manufacturers. Most clinicians prefer these systems because of their advantages such as saving time and better cutting efficiency. Nevertheless, some functions of NiTi rotary systems such as cleaning ability, increased stress, and the inability to adequately prepare oval canals are still controversial. Additio-nally, a potential relationship between the design of NiTi instruments and the incidence of vertical root fractures have been found and file design affected apical stress and strain concentrations during root canal instrumentation(6).

The ProTaper system (Dentsply Maillefer, Ballaigues, Switzerland) consists of 8 rotating NiTi instruments with different tapers and a convex triangular cross-section. These files are classified as shaping files and finishing files with a different taper in the coronal and apical portion. The apical configuration closely resembles ISO files. The shaping files are Sx, S1, and S2, designed for coronal enlargement. The Sx shaping files are to be used in a brushing and milling action. The finishing files are F1, F2, F3, F4 and F5 have subsequently#20, #25, #30, #40 and #50 tip diameters(7).

Greater Taper™ nickel–titanium rotary files have been introduced ( Dentsply/Tulsa Dental, Tulsa, OK,

a Department of Conservative Dentistry. School of Dentistry/University of Sulaimani. ( [email protected]) b Department of Conservative Dentistry. School of Dentistry/University of Sulaimani. c Department of Pedodontics, Orthodontics, and Preventive Dentistry. School of Dentistry/University of Sulaimani.

Conservation of dentin thickness in the root canals

orifice following two preparation techniques


SDJRanjdar Mahmood Talabani a, Shawbo Muhamad Ahmad b & Arass Jalal Noori c

Abstract Objective: The aim of this study was to evaluate the amount of dentine removed after canal preparation using ProTaper (PT) and Greater Taper (GT) rotary instruments. Materials and methods: Twenty extracted human teeth with single roots were selected and sectioned at the level of CEJ. The roots were distributed in two groups (n= 20) using stratified randomization, and prepared under simulated clinical conditions with ProTaper (PT) and Greater Taper (GT) rotary NiTi system. The pre- and post-preparation photographs were traced and superimposed, dentin thickness was measured at the levels of canal periphery, canal area, tooth area, mesial dentin thickness, distal dentin thickness, buccal dentin thickness and lingual dentin thickness both before and after preparation. Results: The thickness of removed dentin was significantly different between the two preparation techniques (p<0.01) at the level of both tooth and canal area with more conservation for GT system while ProTaper system more conservative at buccolingual width than mesiodistal width, and GT system was more conservative at mesiodistal dimension than buccolingual dimension. Conclusion: GT rotary instrumentation prepares root canals has greater conservation of dentine structure on the overall dimensions of the root, while the ProTaper system is more conservative at buccolingual dimension.

Keywords: Dentine wall thickness, GT and ProTaper, Nickel Titanium rotary systems, root canal dimensions. Received: August 2014, Accepted: November 2014.


USA; Dentsply/Maillefer, Ballaigues, Switzerland). These files have maximum flute diameters of 1.0 mm and exhibit flute tapers that are three, four, five and six times the standardized ISO 0.02 taper(8), GT instruments are the only taper-centric shaping instruments available, meaning that they vary primarily by their tapers, rather than by their tip diameters, GT instruments are available in four basic categories of sizing, the 20 series, the 30 series, the 40 series, and the 0.12 accessory series. The 20, 30, and 40 series GT Files have the same range of tapers, 0.04, 0.06, 0.08, and 0.10 mm/mm in each file set but vary by their designated tip diameters(9).

The purpose of this study was to evaluate dentine thickness in the coronal portion of single rooted tooth both pre- and post-preparation using ProTaper and Greater Taper (GT) rotary canal instrumentation techniques.


The samples consisted of 20 single straight roots with well-formed and mature apices without visible apical resorption were kept in 10% formalin solution. The teeth were cut at CEJ using diamond disc mounted on straight hand piece to a level of approximately 15 mm length. The roots were embedded in cold cure acrylic resin using disposable syringe as a mounted mold, the specimens were marked by a soft pen from 1 to 10 as shown in figure 1 (A&B).

The roots were divided into two groups according to the instrumentation technique:

Group (A): 10 roots were instrumented using Greater Taper (GT) rotary system.

Group (B): 10 roots were instrumented using Protaper Taper rotary system.

A photograph of each specimen was taken, under stereomicroscope at 100x using Sony digital camera (14 MP) at 2X of magnification before and after instrumentation.

For group (A) all root-canal preparations were performed in a crown-down fashion using GT Greater Taper NiTi rotary system until size 40 (ISO 0.06)

taper while group (B) all roots prepared using ProTaper NiTi rotary system until size (F4) resemble to size 40 (ISO 0.06 taper). All samples were frequently irrigated with 2.5% sodium hypochlorite. Canals were dried with paper points.

All preparation photographs were analyzed by using AutoCAD 2013 software program as shown in figures 2 & 3, measuring the following variables were taken:

1. Canal Periphery (mm).

2. Canal Area (mm2).

3. Tooth Area (mm2).

4. Mesial dentin thickness.

5. Distal dentin thickness.

6. Buccal dentin thickness.

7. Lingual dentin thickness. (1)

To compare the root thicknesses before and after preparation in each of the groups and in each measurement (reading, variable), paired t-test was used. t-test (Student’s t-test) was used to compare the amount of dentinal substance removed from each dimensions by the two techniques. The data were analyzed with SPSS software version 16.0 (SPSS Inc., Chicago, IL). The significance level was set at 5%.

81

B

Figure 1: A: Sample distribution, B: Specimen mounted on acrylic resin block

A


The relative percentage of dentin removal in each dimension was calculated by dividing the amount of dentin removed to the initial dimension multiplied by 100(10).

Results:

The mean and standard deviation before and after instrumentation techniques for each group are presented in Table 1.

The remaining root dentin thicknesses were evaluated and significant differences were found for all dimensions and measurements before and after instrumentation (p<0.05). In the mesial and distal dimensions the ProTaper system reduced the length more than the GT system, while the GT system removed slightly more dentine from the buccal and lingual dimensions. The canal periphery was increased by about 10% by both systems.

In Table 2 which shows the mean and statics of removed dentine after instrumentation for both groups at all variables, both rotary instrumentation techniques had effect on coronal dentin thickness while there was significant removing of dentin thickness for ProTaper system at canal area and highly significant dentin reduction at the level of tooth area compared with GT rotary system.

Discussion:

The aim of all dental treatment should be to prevent and treat disease without inflicting iatrogenic damage to tooth structure. Non-surgical root canal therapy involves instrumentation that results in removal of dentin. Post-endodontic rehabilitation of teeth frequently requires post placement to reinforce a coronal restoration. Both root canal treatment and post placement remove dentinal tissue and have been implicated as a cause of vertical root fractures (VRFs) (11).

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Figure 2: A: Photomicrograph of root canal prepared with GT rotary NiTi system; pre-preparation. B: Same image post-preparation

BA

Figure 3: A: Photomicrograph of root canal prepared with Protaper rotary NiTi system; pre-preparation. B: Same image post-preparation

A B


This study analyzed the dentin thickness remaining in the coronal portion of single rooted tooth after instrumentation with two types of root canal rotary instruments.

It should be noted that the findings of this study are restricted by variables such as age and properties of dentin. Moreover, it may be more appropriate to conduct such measurements using more accurate techniques such as the micro-computed tomography (µCT) and with a greater number of cross-sections.

Lateral forces result in high stress concentrations in radicular dentine at the coronal one third of the root, the rotational axis of the tooth is located at the crest of the alveolar bone, and most of the applied force is concentrated around the circumference of the tooth where the crown diameter is the smallest, corresponding to the cervical region of the tooth at the cemento-enamel junction (CEJ), whereas the concentration of the forces is the lowest within the root canal. The center of the root canal, representing

the central axis of the tooth, is a neutral area with regard to force concentration. This force distribution may explain the susceptibility of teeth to fracture at the CEJ area when lateral forces are exerted on the coronal portion of the tooth during occlusal loading. From the point of view of stress concentration, the thickness of the dentinal wall between the root canal and its external circumference assumes great significance. There is a direct correlation between the root thickness and the ability of the tooth to resist lateral forces and avoid fracture(2,12).

The design of this study was such that an analysis of areas and dentine thickness before and after the root canal preparation would furnish data concerning the quantity of dentine being removed at the cervical level of the tooth.

In the present study the significant and more important results are shown by the difference effect of both systems on the canal and tooth area. Although both systems had a significant effect on the size of the

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Table 1: Mean values and SD of each of the measured groups pre- and post-preparation

Variable (mm) Prep. TechPre -preparation Post-preparation

% Variation T-test Sig.

Mean SD Mean SD

Canal Periphery (mm)

GT 5.84 1.34 6.39 1.29 9.48% 3.891 H.S*

PT 6.12 1.12 6.70 1.40 9.43% 6.503 H.S*

Canal Area (mm2) GT 1.80 0.72 2.25 0.75 25.17% 5.065 H.S*

PT 2.12 0.85 2.97 1.24 40.20% 2.867 H.S*

Tooth Area (mm2) GT 26.40 9.44 26.07 9.38 -1.25% 3.836 H.S*

PT 32.28 10.37 29.56 9.40 -8.41% 2.35 H.S*

Mesial Width (mm) GT 1.97 0.47 1.83 0.46 -7.21% 4.707 S**

PT 2.08 0.20 1.92 0.25 -7.47% 3.823 S**

Distal Width (mm) GT 1.96 0.50 1.83 0.45 -6.78% 5.611 H.S*

PT 2.08 0.42 1.81 0.40 -12.67% 7.558 H.S*

Buccal Width (mm) GT 2.27 0.40 2.19 0.40 -3.49% 3.1 S**

PT 2.41 0.46 2.34 0.47 -3.15% 5.061 S**

Lingual Width (mm) GT 2.42 0.60 2.23 0.55 -8.05% 2.72 H.S*

PT 2.72 0.41 2.58 0.37 -4.97% 2.548 H.S*

*H.S: Highly significant (P<0.001), **S: Significant (P<0.05)


canal area and tooth area. The canal area was increased by both systems highly significantly (p<0.01) about 40% for ProTaper and 25% for GT system as shown in table 1 and the findings of the present study is in agreement with study reported by Dong Choi et al (2004)(5) which reported that ProTaper cut more dentin than ProFile, GT Rotary file and Quantec file tested in mesiobuccal and mesiolingual canals of 40 mesial roots of extracted human lower molars were instrumented using the crown-down technique using muffle system, and this may explained by that the taper of the ProTaper files is bigger than the other files at the same level of the root canal, which may result in greatest reduction in the thickness of root canal dentin.

The present findings reveal that there is no significant difference between the ProTaper and GT group for the amount of the dentine removed at buccal, lingual, mesial and distal width, the ProTaper system removed more dentine mesially and distally while the GT system removed more dentine buccally and lingually and these result coincide with studies that were reported by El Hilaly Eid & Amin (2011)(13)

showing that ProTaper did not seem to touch the canal

wall buccolingually , whereas it removed dentin as much as manual H-files ; this could be attributed to both the circumferential motion used with ProTaper in a trial to access the buccolingual recesses, and study done by Grande et al (2007)(7) explained that the metallurgic properties of the alloy and the small tip of the instrument may have contributed to an ineffective action on the buccolingual dentinal walls.

According to the present study ProTaper system mostly remove dentin in mesiodistal dimension and more conservative in buccolingual direction while GT system which was less conservative in buccolingual dimension and this support the evidence that clinically its better to prepare the canal by ProTaper rotary system because clinical and experimental studies have shown that root fractures occur predominantly in a buccolingual direction, root cross-sections are usually ovoid in shape, especially in roots that are more prone to fracture such as mandibular incisors and mesiobuccal roots of molars and dentin thickness in the buccolingual direction, particularly in mandibular incisors, is often double that of proximal dentin, yet fracture usually runs through this thick region(3,5).

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Table 2: statistical differences between the effects of both systems on each variable

Variables Group Minimum Maximum Mean SD T-test df Sig.

Canal Periphery (mm) GT 0.06 1.57 0.5530 0.44947 0.116 18 N.S*

PT 0.09 1.59 0.5770 0.47726

Canal Area (mm2) GT 0.17 0.92 0.4520 0.21979 2.391 18 S**

PT 0.44 2.07 0.8510 0.47964

Tooth Area (mm2) GT 0.10 0.81 0.3291 0.20549 6.535 18 H.S***

PT 1.85 5.84 2.7130 1.13512

Mesial Width (mm) GT 0 0.50 0.1420 0.15662 0.185 18 N.S

PT 0 0.50 0.1550 0.15813

Distal Width (mm) GT 0 0.38 0.1330 0.10965 2.081 18 N.S

PT 0.03 0.55 0.2630 0.16432

Buccal Width (mm) GT 0 0.34 0.0790 0.10630 0.069 18 N.S

PT 0 0.29 0.0760 0.08834

Lingual Width (mm) GT 0 0.45 0.1950 0.13100 0.892 18 N.S

PT 0 0.58 0.1350 0.16755

*N.S: Not significant’ **S: Significant (P<0.05), ***H.S: Highly significant (P<0.001)


Conclussions:

Under the conditions of this in vitro study the follow-ing conclusions can be obtained:

1. The use of GT rotary file system and ProTaper system to prepare canals resulted in decreasing root dentin thickness at overall parameters and variables.

2. GT system was more conservative at tooth canal and canal area compared with ProTaper system which had taken significantly more dentin at these two levels.

3. ProTaper system had taken less dentin at the level of buccolingual dimension and much dentin removed at mesiodistal dimension while GT system are more conservative at mesio-distal than buccolingual dimension.

Acknowledgment:

The authors wish to thanks Professor “Dr. Balkees Taha Garib" head of oral diagnosis department for her kind cooperation. This work was done at the School of Dentistry, Faculty of Medical Sciences/ University of Sulaimani.

References:

1. Lammertyn PA and Sierra LG. Dentine thickness in buccal roots of maxillary first premolars following preparation with three techniques. International magazine of endodontology. 2012; 8 (3): 30-5.

2. Plotino G, Grande NM, Falanga A, Di Giuseppe IL, Lamorgese V and Somma F. Dentine removal in the coronal portion of root canals following two preparation techniques. Int Endod J. 2007; 40: 852-8.

3. Sathorn C, Palamara JEA, Palamara D and Messer. Effect of root canal size and external root surface morphology on fracture susceptibility and pattern: A Finite Element Analysis. JOE. 2005; 31: 288-92.

4. Vats A, Punja A, Hegde P, Hegde MN, Bains R and Loomba K. Evaluation of effect of root canal preparation techniques on inducing root fractures: An in vitro study. Asian J Oral Health Allied Sci. 2011; 1: 17-21.

5. Dong Choi S, Uk Jin M, Ok Kim K and Kyo Kim S. Shaping ability of four rotary nickel-titanium instruments to prepare root canal at danger zone. J Kor Acad Cons Dent. 2004; 29:446-53.

6. Yoldas O, Yilmaz S, Atakan G, Kuden Cand Kasan Z. Dentinal microcrack formation during root canal preparations by different NiTi rotary instruments and the self-adjusting file. J Endod. 2012; 38 (2): 232-35.

7. Grande NM, Plotino G, Butti A, Messina F, Pameijer CH and Somma F. Cross-sectional analysis of root canals prepared with NiTi rotary instruments and stainless steel reciprocating files. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 103:120-6.

8. Gluskin AH, Brown DC and Buchanan LS. A reconstructed computerized tomographic comparison of Ni–Ti rotary GT™ files versus traditional instruments in canals shaped by novice operators. Int Endod J. 2001; 34: 476–484.

9. Buchanan LS. ProSystem GT: design, technique and advantages. Endod Topics. 2005; 10: 168–75.

10. Akhlaghi NM, Kahali R, Abtahi A, Tabatabaee S, Mehrvarzfar P and Parirokh M. Comparison of dentine removal using V-taper and K-Flexofile instruments. Int Endod J. 2010; 43:1029-36.

11. Saeed MH, Bardestani Z, El Sadek DA and Ismail AI. Influnces of hands stainless steel and NiTi rotary file on the resistance to fracture of endodontic treated roots. IJRSR. 2014; 5: 660 -4.

12. El Hilaly Eid and Amin SA. Changes in diameter, cross-sectional area, and extent of canal-wall touching on using 3 instrumentation techniques in long-oval canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 112:688-95.

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Sulaimani Dent. J. 2014; 1:86-90 Abdulateef et al

Introduction:Spacing greater than 0.5 mm between the proximal surfaces of adjacent teeth is described as a “diastema” and if it is in the anterior maxilla in the midline it is known as a “midline diastema”, which is a common aesthetic complaint of people, seeking orthodontic treatment(1). Maxillary midline diastema (MMD) is a common aesthetic problem in mixed and early permanent dentitions. It may be considered normal for many children during the eruption of the permanent maxillary central incisors(2). However, if the midline diastema is present after eruption of canines or is more than 2-4mm, there is always an underlying cause(1).

No definite etiology for midline diastema has been identified. Midline diastema can be physiological, dentoalveolar, due to a missing tooth, due to peg shaped lateral, midline supernumerary teeth, procl-ination of the upper labial segment, prominent frenum and due to a self-inflicted pathology by tongue piercing(1). Angle’s suggestion of abnormal frenum as the cause of midline diastema has been supported by other researches(3-5).

Tooth size discrepancy can be considered as one of the main causes for maxillary midline diastema. The most common discrepancy concerning tooth size is the presence of peg shaped lateral incisors(6).

According to oral habits, any habit such as tongue-thrust, thumb sucking, finger bite and biting the lower lip that results in a long-term force leading to upper

anterior teeth separation should be considered as a possible etiological factor(6).

An accurate diagnosis is necessary before treatment can be initiated. No treatment should be initiated if the diastema is physiological and usually if the canines have not erupted(7).

The objectives of this study was to determine the prevalence of maxillary midline diastema among Shorish dental clinic`s patients seeking orthodontic treatment, and to determine the factors associated with maxillary midline Diastema.


Five hundred and seven patients attending Shorish Dental Clinic, seeking orthodontic treatment during 6 months (October,1 2013 – April,1 2014) were screened randomly to determine the prevalence and etiology of maxillary midline diastema. The age range was between 13 – 40 years to exclude diastema caused by ugly duckling stage or periodontal condition. Patients were excluded if they had previous history of previous orthodontic treatment, any artificial crown or proximal restoration in central incisors, without periapical and/or periodontal involvement to exclude any factors that may create or change the width of midline diastema.

a School of Dentistry, Faculty of Medical Sciences, University of Sulaimani, Kurdistan Region, Iraq. ([email protected]) b School of Dentistry, Faculty of Medical Sciences, University of Sulaimani, Kurdistan Region, Iraq . c Sulaimani Polytechnic University, Kurdistan Region, Iraq

The prevalence and etiology of maxillary midline

diastema among orthodontic patients attending

Shorsh Dental Clinic in Sulaimani City


SDJ

Darwn Saeed Abdulateefa, Azheen Jamil Alib & Nasih Fatih Othmanc

Abstract Maxillary midline diastema (MMD) is a common aesthetic problem of people seeking orthodontic problem, which means spacing greater than 0.5 mm between the proximal surfaces of maxillary central incisors. The causes for MMD may be: high frenum attachment; microdontia; macrognathia; supernumerary teeth; peg laterals; missing lateral incisors; midline cysts and unhealthy oral habits. Objectives: The purposes of this study were to determine the prevalence of MMD among Shorish dental clinic`s patients seeking orthodontic treatment and to find the factors associated with this anomaly. Materials and Methods: During 6 months, 507 patients with age (13 – 40) years old attending Shorish Dental Clinic, seeking orthodontic treatment were screened to find the prevalence and etiology of MMD. Result: The MMD was present in 110 patients (21.7%). The frequency of MMD was the same in males and females. It is highest in the young age group and lowest in the older age group (29% vs. 4%). Conclusion: The most frequent factor among the observed etiological factors was oral unhealthy habit which was found in 40% of MMD patients and 8.7% of all cases.

Keywords: Maxillary midline diastema, frequency, etiology. Received: May 2014, Accepted: October 2014.


After obtaining informed consent, Patients with visible space between maxillary central incisors were examined clinically by measuring the width at the incisal third of the maxillary central incisors. The existence of a 0.5 mm or more space between the maxillary central incisors was considered as a diastema and the patient as positive patient. The measurements were carried out using a Williams’s graduated periodontal probe. Photographs of the patients are taken after getting an informed consent.

The causative factors were identified via intraoral examination of labial frenum, generalized spacing, peg shaped maxillary lateral incisors, missing maxillary

lateral incisors and oral habits (Figures 1, 2 & 3). Findings of clinical examination of the patients that fulfilled the study criteria were recorded. Panoramic radiographs were taken to correlate the clinical findings. The statistical analysis was done by using STATA software version 12.

Results:

Total of 507 persons were examined during the study of whom 110 persons (21.7%) had diastema. The age ranged from 13 to 40 years with a mean age of 22.9

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Figure 1: A patient with maxillary median diastema due to generalized spacing

Figure 2: A patient with maxillary median diastema due to missing lateral incisors

Figure 3: A patient with maxillary median diastema due to oral unhealthy habit


years (SD=5.1 years). There were 347 males (68.5%) and 160 males (31.5%). The majority of persons (59%) were aged between 20-29 years. In terms of presence of potential risk factors, 6 persons (1.2%) had high frenum, 11 persons (4.3%) had missing lateral incisors, 22 persons (4.3%) had generalized dental spacing, and 44 (8.7%) had unhealthy oral habits (Table 1).

Table 2 compares males and females in relation to potential risk factors. Age group were similarly distributed between males and females. Although high frenum attachment was more common in females than males (1.4% vs. 0.6%), but this difference was not statistically significant (P=0.7). Similarly congenital missing lateral incisors was twice as common in females compared to males (2.6% vs. 1.3%), but the difference was not statistically significant (P=0.3). Additionally unhealthy oral habits were more common in females than males (10.1% vs. 5.6%) without being significant (p=0.1). Generalized spacing and presence of peg-shaped incisors were more common in males than females, but these differences were also not statistically significant (p=0.2) (Table 2).

Table 3 shows presence of diastema according to potential risk factors. Prevalence of diastema was

similar in males and females (21.2% vs. 21.9%). In relation to age group, prevalence of diastema was highest in the young age group of 11-19 years and lowest in the older age group of 30-39 (29% vs. 4%) and this difference was statistically significant (P<=0.001). Other statistically significant risk factors include presence of high frenum, presence of missing lateral incisors, presence of oral habits, presence of generalized spacing, and presence of peg-shaped lateral incisors.

Discussion:

Frequency of MMD in the current study was found to be 110 (21.7%). This frequency is considerably lower than 23% which is the prevalence of MMD in Aseer region of Saudi Arabia (8) and it is higher in our sample as compared to prevalence of MMD in orthodontic patients attending Armed Forces Institute of Dentistry

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Table 1: Main characteristics of the sample

Characteristic Number %

Total 507 100

Diastema

Yes 110 21.7

No 397 78.3

Gender

Male 160 31.5

Female 347 68.5

Age

13- 19 years 137 27.0

20-29 years 300 59.2

30-39 years 70 13.8

High frenum 6 1.2%

Missing lateral incisors 11 2.2

Generalized dental spacing 22 4.3

(Unhealthy) Oral habits 44 8.7

Presence of peg-shaped lateral incisors 27 5.3

Table 2: Comparisons of males and females in relation to potential risk factors

Potential risk factor Male

Number (%)

Female Number (%)

P-value

Age group

13-19 39 (24.4) 98 (28.2)

χ2 =0.8 P<=0.7

20-29 98 (61.3) 202 (58.2)

30-39 23 (14.4) 47 (13.5)

High frenum attachment

Yes 1 (0.6) 5 (1.4) χ2 =0.6 P=0.4No 159 (99.4) 342 (98.6)

Congenital missing lateral incisors

Yes 2 (1.3) 9 (2.6) χ2 =0.9 P=0.3No 158 (98.7) 338 (97.4)

Presence of generalized spacing

Yes 10 (6.3) 12 (3.5) χ2 =2.1 P=0.2No 150 (93.7) 335 (96.5)

Presence of oral unhealthy habits

Yes 9 (5.6) 35(10.1) χ2 =2.8 P=0.1No 151(91.3) 312 (89.9)

Presence of peg-shaped incisors

Yes 12 (7.5) 15 (4.3) χ2 =2.2. P=0.2No 148 (92.5) 332 (95.7)


in Pakistan 12.59%(9), prevalence in United Kingdom 3.4% of Caucasians(10) and 1.6% of South Indians(11). This difference may be related to the differences in methodology, sampling technique, the dissimilarity in chronological stratification of the population groups or genetic predisposition perhaps because of a higher ratio of consanguineous marriages in our country.

In relation to age group, there is a significant difference in the prevalence of diastema with highest in the young age group of 11-19 years and lowest in the older age group of 30-39 (29% vs. 4%). This may be due to the unaesthetic appearance of MMD that might make the young age group to seek the treatment more than the old age group due to the aesthetic purpose.

Regarding the gender, the frequency of MMD is nearly the same in both genders with 21.9% in females and 21.2% in males. Also in relation to the potential risk factors, the frequency of MMD in males and females are not significant statistically. This finding is in agreement with the result of the study done by Dissanayake et al (2003)(1) in which there is no signif-icant difference of MMD between males and females. While the study done by Luqman et al (2011)(8), in contrast to the current findings, shows higher prevalence of MMD in males than in females.

Differences in epidemiological study findings may be attributed to the increased number of factors contributing to midline diastema, to the definitions used to explain its presence and to gender and race

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Table 3: Presence of diastema according to potential risk factors

Potential risk factorDiastema Number (%)

No diastema Number (%) P-value

Gender

Male 34 (21.2) 126 (78.8) χ2 =0.3 P=0.9 Female 76 (21.9) 271 (78.1)

Age group

13-19 40 (29.2) 97 (70.8)

χ2 =17.2 P<=0.001

20-29 67 (22.3) 233 (77.7)

30-39 3 (4.3) 67 (95.7)

High frenum attachment

Yes 6 (100.0) 0 (0.0) χ2 =21.9 P<0.001 No 104 (20.8) 397 (79.2)

Congenital missing lateral incisors

Yes 11 (100.0) 0 (0.0) χ2 =40.6 P<0.001 No 99 (20.0) 397 (80.0)

Generalized spacing

Yes 22 (100.0) 0 (0.0) χ2 =83.0 P<0.001 No 88 (18.1) 397 (81.7)

Oral unhealthy habits

Yes 44 (100.0) 0 (0.0) χ2 =173.9 P<0.001 No 66 (14.3) 397 (85.2)

Peg-shaped incisors

Yes 27 (100.0) 0 (0.0) χ2 =102.90 P<0.001 No 83 (17.3) 397 (82.7)


differences in the distribution of the hereditary feature in question(6).

In the current findings, among the potential risk factors, oral unhealthy habit was the most frequent factor as it included 44 patients ((8.7% of all 507 cases) and (40% of 110 MMD patients)), while in some references as (McCoy JD, 1946)(4) generalized spacing was the most common factor. Deep bite was found significantly associated with MMD in study done by Oesterle and Shellhart (1999)(12), and in other study the most frequent etiological factor was found to be excessive over-jet in other study(9). This may be also due to the presence of more than single etiological factor that may be attributed to MMD in many cases.

The study could not focus on the precise etiology of MMD. Individual frequency of an observed etiological factor could be one of the reasons for this. Furthermore spacing in anterior region, Bolton’s discrepancy, impacted canines, extractions, variable size of pre-maxilla and periodontal problems must be taken into consideration. Future studies should focus on correlation of MMD with a single etiological factor with a more purified sampling technique(9).

Conclusions:

The frequency of MMD was 21.7% in the sample and the frequency were the same in males and females. Whereas the relation to the potential risk factors is not significantly different between males and females, the frequency of MMD is highest in the young age group and lowest in the older age group.

References:

1. Upul Dissanayake, MS Chandrasekara, ER Wikraman-ayake. The prevalence and mode of inheritance of median diastema in the Sinhalese. The Ceylon J Med Sci 2003;46:01-06

2. Vivek Govila, Smita Govila. Cosmotic creation-through diastema closure. Indian J Dent Sci. 2012;3:74-7

3. Tallents RH. Artificial gingival replacement. Oral Health. 1983;73:37-40.

4. McCoy JD. Applied Orthodontia. 2nd ed. Lea Febiger: Philadelphia; 1946. p. 72, 96-7.

5. Stones HH. Oral and dental diseases. Second edition. E. & S. Living stone Ltd., Edinburgh; 1951. p. 19-21, 211.

6. Alexandros T, Moullas. Maxillary midline diastema: A contemporary review. Hellenic Orthodontic Review. 2005;8:93-103.

7. Vivek Govila, Smita Govila. Cosmetic creations - through diastema closure. Indian J Dent Sci. 2012; 4:74-77.

8. Master Luqman, Syed Sadatullah, Mohammad Yunis Saleem, Mohammed Ajmal, Yahya Kariri, Mushabab Jhair. The prevalence and etiology of maxillary midline diastema in a Saudi population in Aseer region of Saudi Arabia. Int. J of Clinical Dent Sci. 2011;2:81-5.

9. Hameedullah Jan, Sadia Naureen, Ayesha Anwar. Frequency and etiology of medline diastema in orthodontic patients reporting to armed force institute of dentistry Rawalpindi. Pakistan Armed Forces Med J. 2010;60:126-8.

10. Lavelle CLB. The distribution of diastemas in different human ponpulation samples. Scand J Dent Res. 1970: 78:530-4

11. Nainar SM, Gnanasundaram N. Incidence and etiology of midline diastema in a population in south India (Madras). Angle Orthod. 1989;59:277- 82.

12. Oesterle LJ, Shellhart WC. Maxillary midline diastemas: a look at the causes. J Am. Dent. Assoc. 1999;130: 85-93.

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Sulaimani Dent. J. 2014; 1:91-93 Amin et al

Introduction:The epidemiological data on prevalence of malocc-lusion is an important determinant in planning appropriate levels of orthodontic treatment(1).

Enormous epidemiological studies have been conducted to find the prevalence of malocclusion in different racial and ethnic groups. There are growing consensus that the incidence varies from one to another populations(2). The Angle’s classification method has been widely used as a qualitative epidem-iological tool for malocclusion assessment(3).

To best of our knowledge, this is the first study looking for the prevalence of Angle’s classification among patients attending private orthodontic clinic in Sulaimani City.

Method:

This retrospective study conducted on orthodontic patients who attended a private orthodontic clinic in Sulaimani City (January, 2013 to May, 2014). The study enrolled 200 patients. However 29 patients were excluded as permanent 1st molars were absent.

Patients were between 6-35 years of age and they were classified into three age groups (6-11, 12-17 and 18-35)(4).

Pre-treatment orthodontic records of 171 patients (fulfilled selection criteria) were obtained and used in

this study. The inclusion criteria included patients with complete pre-treatment records, presence of permanent 1st molars (because Angle’s classification depends on 1st molars) and no previous orthodontic treatment.

Case sheets and dental casts were used to collect the data. A quantitative analysis with Angle’s classification was used to describe the anteroposterior relationship of the maxillary and mandibular permanent 1st molars during maximum intercuspation.

Results:

In the present study, data from stone dental models of 171 patients seeking orthodontic treatment including 60 males (35%) and 111 females (65%) were analyzed (Figure 1). The participants’ age ranged from 6 to 35 years with mean age of 17.44 years.

About half of patients [88 patients (51%)] were belonged to the 12-17 years age group. Whereas, the age groups 18-35 and 6-11 years were consisted of 54 patients (32%) and 29 patients (17%) respectively (Table 1).

According to Angle’s classification; the patients’ malocclusion statuses were as follow; 56 patients were Class I (33%), 83 patients were class II (48%) and 32 patients were Class III (19%) (Figure 2).

a Department of Pedodontics, Orthodontics, and Preventive Dentistry. School of Dentistry/ University of Sulaimani. ([email protected]) b Department of Pedodontics, Orthodontics, and Preventive Dentistry. School of Dentistry/ University of Sulaimani.

Angle’s classification of first molar occlusion among patients attending a private orthodontic clinic in Sulaimani City


SDJAnwar Ahmad Amina, Awder Nuree Arfb & Zhwan Jamal Rashidb

Abstract Objectives: The aim of this study were to find the prevalence of Angle’s classification and distribution of malocclusion amongst patients attending a private orthodontic clinic in Sulaimani City. Method: Pre-treatment orthodontic records of 171 patients of both genders and different age groups fulfilled selection criteria were obtained for the study. The data from case sheets and dental casts were analyzed to determine the prevalence of angles class I, class II, and class III malocclusion. Results: Malocclusion was found to be higher in females than males. Patient’s malocclusions were as follow: 56 (33%) Class I, 83 (48%) Class II, and 32 (19%) Class III. Patients of 12-17 years age group were found to be more interested in orthodontic treatment than other age groups. Conclusions: Class II malocclusion created almost half of the patients seeking orthodontic treatment in private clinic in Sulaimani City. Furthermore majority of orthodontic cases were young patients (12-17 age group) with females showing a higher percentage than males.

Keywords: Dental malocclusion, Angle’s classification, Orthodontic patient. Received: September 2014, Accepted: November 2014.


Discussion:

In current study, only those patients seeking orthodontic treatment were included.

The majority of patients looking for orthodontic treatment were females (65%), which is in agreement with the studies carried out by Piya et al (2013)(4), they showed among 131 patients enrolled in their study, 59.5% were females and 40.5% were males. In Gul-e-Erum and Mubassar Fida (2008)(5) study, out of 156 patients, 98 (62.8%) were females and Vibhute et al (2013)(6) studied sample group comprised 98 males (44.5%) and 122 females (55.5%).

According to the present study, Angle’s classifi-cation status was as follow; 56 patients were Class I (33%), 83 patients were Class II (48%), and 32 patients were Class III ( 19%), which is coincided to the study done by Gul-e-Erum and Mubassar Fida (2008)(5) which showed 18.6% were class I, 70.5%

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Table 2 : Angle’s classification status in different studies

Studies Class I Class II Class III

Wada et al (1999)(7) 89% 7.6% 3.4%

Bhattarai & Shrestha (2008)(8) 54.5% 37.5% 8%

Sharma (2009)(9) 72.3% 19.4% 5.9%

Shrestha (2011)(10) 44% 30% 16.1%

Shrestha (2012)(11) 59% 25% 16%

Shrestha (2013)(12) 54% 36.9% 8.4%

Durgesh et al (2012)(3) 66.3% 29.2% 4.5%

Piya et al ( 2013)(4) 59.5% 26.7% 13.7%

Table 1: Distribution of malocclusio ccording to age groups

Age Number Percentage

6-11 29 17

12-17 88 51

18-35 54 32

Total 171 100

Figure1: Distribution of malocclusion according togender

Figure2: Distribution of malocclusion according toclass of occlusion


were class II and 10.9% were class III. However, this is not in agreement with the studies shown in Table 2. Patients seeking orthodontic treatment mostly belonged to 12-17 years age group which is similar to what was found by (Piya et al, 2013)(4).

Further work needs to be done on larger scale such as conducting this study on population bases or all private orthodontic clinics.

Conclusions:

Class II malocclusion created almost half of the patients seeking orthodontic treatment in private clinic in Sulaimani City. Furthermore majority of orthodontic cases were young patients (12-17 age group) with females showing a higher percentage than males.

References:

1. Sidlauskas and K. Lopatiene. The prevalence of malocclusion among 7–15-year-old Lithuanian schoolchildren. Medicina. 2009;45:147-52.

2. Thilander, L. Pena, C. Infante, S. S. Parada, and C. De Mayorga. Prevalence of malocclusion and orthodontic treatment need in children and adolescents in Bogota, Colombia. An epidemiological study related to different stages of dental Development. Eur J Orthod. 2001;23: 153–67.

3. Durgesh BH, Prakash P, Ramakrishnaiah R, Phulari BS, Al Kheraif AAA. Malocclusion pattern (Angle’s) in

Mauritian orthodontic patients. ISRN Dentistry. 2012; Article ID 210306, 3 pages.

4. Piya A , Shrestha V B , Acharya J , Khanal S and Bhattarai P. Pattern of distribution of malocclusion among patients seeking orthodontic treatment at dental college- Nepal medical college. 2013;13:36-41.

5. Gul-e-Erum, Fida M. Pattern of malocclusion in orthodontic patients: a hospital based study. J Ayub Med Coll Abbottabad. 2008;20:43-7.

6. Vibhute Aniket H., Nupura A. Vibhute1, Rajendra Daule. An epidemiological study. Journal of Orthodontic. 2013;1:66-9.

7. Wada T, Mizutani S, Tatsuta U, Shrestha RM. The oral health status of the Kathmandu valley, Nepal: Report of the oral health survey 1997-1999. Osaka University Graduate School of Dentistry. Phect-Nepal. Unpublished Report; 1999.

8. Bhattarai P, Shrestha RM. Prevalence of malocclusion among Nepalese orthodontic patients according to Angle’s classification. J Nep Dent Asso .2008;9:29-35.

9. Sharma JN. Epidemiology of malocclusion and assessment of orthodontic treatment need for the population of eastern Nepal. World J Orthod. 2009; 10:311-6.

10. Shrestha BK, Yadav R, Gyawali R, Gupta S. Prevalence of malocclusion among medical students in Institute of medicine, Nepal; a preliminary report. Orthod J Nep.2011;1:24-7.

11. Shrestha BK, Yadav R, Basel P. Prevalence of malocclusion among high school students in Kathmandu valley. Orthod J Nep. 2012;2:4-8.

12. Shrestha S, Shrestha RM. An analysis of malocclusion and occlusal characteristics in Nepalese orthodontic patients. Orthod J Nep. 2013;3:19-25.

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Sulaimani Dent. J. 2014; 1:94-98 Zardawi et al

Introduction:Periodontitis is usually asymptomatic chronic inflam-matory condition caused by bacterial aggregation which affects the crest of the alveolar process by reducing the normal height in a vertical and/or a horizontal manner; furthermore, bone loss might be presented in a localized or a generalized form(1). Bone destruction can be detected using several radiogra-phical techniques that evaluate the quantity of the remaining bone and subsequently estimating the amount of bone loss on a radiograph. Panoramic radiography has a little diagnostic value in the identification of periodontal disease. It is useful as a general survey, but may not show precise details(2). However, it can be used as a valuable adjunct to conventional diagnostic procedures. It can be recommended as a part of routine dental and periodontal assessment which captures the entire maxilla-mandibular radiographic image on a single film(3,4). However, panoramic radiograph should not be used to replace other intraoral radiographies. Semenoff et al. (2011)(5) assessed variations between different dental radiographs for assessment of the interseptal bone crest loss on conventional and

digitized periapical, bitewing, and panoramic radiographs. Comparison among them showed that a small reduction in height of interseptal bone crest observed in panoramic radiographs should be carefully evaluated for over estimation(5). Moreover, several studies proposed that panoramic radiography might serve as a diagnostic aid in dental health evaluation programs(4,6). Epidemiological studies from many countries employing different methods of criteria showed great variation in prevalence of early periodontitis in life(7). It is acknowledged that early radiographic bone loss could be used as a screening method to identify subjects particularly susceptible to periodontitis(8).

Searching online databases showed no radio-graphic screening records on the prevalence of bone loss among young and adult people in Kurdistan region. Therefore, the aim of this study was to conduct a radiographic screening in order to determine the prevalence of alveolar bone loss on digital panoramic records for patients their ages ranged between 17-30 years.

a Department of Periodontology, School of Dentistry, University of Sulaimani, Iraq. *Corresponding author: [email protected] b Department of Radiology, Shikh Omar Specialised Dental Center – Baghdad., Iraq.

A retrospective panoramic study for alveolar bone loss among young adults in Sulaimani City, Iraq


SDJFaraedon M. Zardawia*, Alaa N. Aboudb, Dler A. Khursheeda

Abstract Objective: to determine the prevalence of alveolar bone crest loss among a selected sample of archival orthopantomography (OPG) in relation to number of sites affected and gender in Sulaimani City. Materials and methods: A retrospective study was conducted with an inclusive period running from March to December 2007 to determine the prevalence of alveolar bone loss among 1072 subjects on panoramic radiographs. Panoramic images were sampled at the radiological archive of Dental School Hospital–University of Sulaimani for a selected age class ranged from 17 to 30 years. Bone loss was estimated by measuring the distance from cementoenamel junction (CEJ) minus 2 mm (physiologic high of interseptal alveolar crest) to the crest of the alveolar bone at sites with reduced normal level of interseptal bone. Total bone loss was divided into two groups according to number of sites affected; group one (1-3) sites showing bone loss per panoramic radiograph, and group 2 showing bone loss at more than 3 sites. Samples were also divided into two age groups; group one from 17 to 23 years and group two from 24 to 30 years. Moreover, bone loss was determined according to gender into male and female and number of sites affected for each gender. Results: results showed that 347 images – 30.2% of the total images showed bone loss at one site or more. 14.6% of the images revealed bone loss at 1-3 sites, whereas, 15.6% demonstrated bone loss at more than 3 sites. Percentage of bone loss was significantly higher (P=0.001) among group two (24-30 years old group) than group one (17-23 years old group) 38% against 25% respectively. Female’s radiographs recorded a non-significantly higher (P>0.05) bone loss than male’s radiographs 31.7% against 28.7% respectively. Conclusion: prevalence of bone loss among young adults in Sulaimani City was relatively high compared to other published reports. There was a predilection for female. Bone loss was more prevalent at (24-30 years old group) compared to (17-23 years old group).

Keywords: Orthopantomography, alveolar bone loss, aggressive periodontitis. Received: September 2014, Accepted: November 2014.


Materials and methods:

Orthopantomography of 1072 subjects aged between 15 to 30 years were recruited from the records of the Department of Radiology at Dental School Hospital – University of Sulaimani from March to December 2007 in order to evaluate the interproximal alveolar bone loss and potential explanatory variables including age, gender and number of sites. Panoramic views were obtained using Planmeca 2002 CC Proline with Dimax3, Panoramic digital X-ray unit (60 KV and 20 mA), 1.2 magnification ratios. A digital method of estimating alveolar bone height on panoramic radiographs using 3X magnification was employed using constant anatomic landmarks as reference points - CEJ and alveolar crest. Bone loss considered when the distance from the CEJ to the alveolar crest exceeded 2 mm. Radiographic images were interpreted by one examiner - a dental radiologist in the department of radiology. Distorted, overlapped, unclear images particularly at the maxillary and mandibular anterior region or patients with orthodontic appliances were excluded in the study. Bone loss estimated digitally by measuring the distance between CEJ and alveolar crest at the interproximal areas minus 2 mm (physiologic high of interseptal alveolar crest) at sites with reduced normal level of interseptal bone(9,10) as shown in Figure 1.

The sample was divided into the following groups:

a- According to number of sites demarcated bone loss

Group one; radiographs revealing bone loss at 1- 3 sites

Group two; radiographs revealing bone loss at more than 3 sites

b- According to age groups

Group one; 17-23 years old group

Group two: 24-30 years old group

c- According to gender – male and female.

Ethical approval has been obtained from the University Research Ethics Committee, School of Dentistry – University of Sulaimani for the employing the panoramic radiography for conducting this study.

Descriptive statistics – tables, figures and percentages beside inferential statistics. Chi-square was used to present the results of the current study.

Results:

Table 1 demonstrates all recruited data including number of images showed bone loss and prevalence of bone loss according to age groups, number of sites affected per radiographic image and according to gender.

The height of interseptal bone was inspected on 1073 OPG images, 324 images (150 male and174 female) revealed evidence of bone loss at one or more than one site, this record constitutes 30.2% of the total OPG images examined in this study, whereas, 748 images – 69.8% showed intact alveolar crests. 157 images showed bone loss at 1-3 sites per image, and 167 images showed bone loss at more than 3 sites per image statistically the difference between the two groups was non significant (P>0.05).

Data analysed according to gender - male and female, 174 images (31.7%) panoramic images out of 549 for female showed bone loss at one or more sites, whereas 150 (28.7%) panoramic images out of 523 for male showed bone loss. Chi-square test revealed no significant (P>0.05) difference between the two groups (Table 1).

In the current study OPG images were also interpreted according to age groups as shown in Table 1, the total OPG images included 633 images for age group one (17-23 years old), 158 images (25%) showed bone loss, whereas group two (24-30 years old) included 439 images, 166 images (37.8%) showed bone loss. Statistically the difference between the two age groups was highly significant (P<0.05).

Table 2 shows that in age group one, 77 images (12.2%) had bone loss at 1-3 sites, whereas, 81images (12.8%) revealed bone loss at more than 3 sites. The statistical analysis using chi square test shows non-significant difference of the prevalence of bone loss (p>0.05) within the two different age groups in 1-3 sites.

Table 2 also shows that in age group two, 80 images (18.2%) had bone loss at 1-3 sites, whereas, 86 images (19.6%) showed more generalized pattern of bone loss (bone loss at more than 3 sites). The statistical analysis using chi square test showed non-significant difference of the prevalence of bone loss (p>0.05) within the two different age groups in more than 3 sites.

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Figure 1: Estimation of the amount of bone loss digitally on the OPG image


Discussion:

This retrospective study screened electronic radio-graphic images taken from the electronic archive of Department of Radiology at Teaching Hospital - School of Dentistry for presence or absence of interseptal bone loss exclusively and regardless of a thorough clinical examination for inspection of any local irritating factors, presence or absence of clinical signs of periodontitis and level of oral hygiene. Moreover, anatomical limitation(11) for interpreting OPG images i.e. lack of clarity for interpreting the interseptal bone at the maxillary and mandibular anterior regions and crowding teeth have an influence on the overall reliability and sensitivity of the method employed in this survey. Furthermore, this survey based on presence or absence of bone loss at one site and more as a diagnostic criterion. Therefore, the method used to interpret bone loss in this survey not necessarily indicates presence or absence of aggressive or chronic form of periodontitis since bone loss at 1-3 sites on a radiograph reveals intact interseptal bone

otherwise could be incidental to presence of a local factor at these sites such as calculus, open contacts or defective margins of restorations.

A consensus report of the 1999 workshop stated that an incidental attachment loss is an epidemiologic descriptor used for situations in which the clinical attachment loss cannot be attributed to the periodontal diseases such as aggressive or chronic periodontitis(12). These cases usually referred to as incidental periodontitis rather than aggressive periodontitis(13). However, such a lesion could be an initial stage or yet unrecognized stage of aggressive periodontitis especially when these initial lesions are detected at an early age of life. This study focused on the prevalence of bone loss in a limited population rather than focusing on the amount and extension of interproximal bone loss, furthermore the magnification ratio(14) of a panoramic radiography may in turn constrain the interpreter to a wrong decision while estimating an early or a tiny lesion at the crest of the interseptal bone(11). Epidemiological investigations have reported

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Table 1: Prevalence of bone loss according to age and number of sites

Total Affected Not affected

1072 324 30.2 % 748 69.8%

Group Total Affected Chi square P-value

Gender male 523 150 28.7%

X2=0.62 P=0.43 NS female 549 174 31.7%

Site

1-3 1072 157 14.6%

X2=0.27 P=0.6 NSmore than3 1072 167 15.6%

Age 17 – 23 y 633 158 25%

X2=10.7 P=0.001 HS24-30 y 439 166 37.8%

HS= high significant, NS= not significant

Table 2: Prevalence of bone loss according to age groups and number of sites affected

Age group No. of site Affected Chi square P-value

Age 17-23 y 1-3 sites 77 (12.2%)X2=0.09

P=0.76 NS

More than 3 sites 81 (12.8%)

Age 24-30 y1-3 sites 80 (18.2%)

X2=0.18P=0.67

NSMore than 3 sites 86 (19.6%)


high prevalence of attachment and bone loss in adolescents and young adults does not fit the characteristic of recognized early onset periodontitis, such occurrence have been termed incidental attachment and bone loss, which has been reported to occur in 1.6-26% of subjects(15).

Data obtained from the current panoramic survey showed high percentage of bone loss at the crest of the interseptal bone which involves 30% of the total radiographs examined, although half of the record comprises bone loss at less than 3 sites. However, the other half (15%) of the images examined showed bone loss at more than three sites, it is most likely that the majority of these cases are aggressive form of periodontitis presented in either localized or generalized form. Furthermore, results of the current study indicated a high prevalence of periodontitis among the sample examined. Higher incidence of bone loss in adult patients (24-30 years old) is a fact, that periodontitis is an age dependent disease the incidence and severity of bone loss and attachment loss increase with age(16) as a result of longer exposure to local factors as age grows older. The present study revealed non significantly higher prevalence of bone loss among female than male, the outcome of this study is consistent with other studies stated a higher prevalence of aggressive periodontitis among females rather than males. Van der Veiden (1989) reported a female/male ratio of 1.3:1, the study conducted to determine the prevalence and clinical appearance of destructive periodontal disease in a school population of 15– to 16–year old adolescents in Amsterdam(17). A higher prevalence of juvenile periodotitis in female against male was also reported by Høsrmand and Frandsen (1979)(18). However, Susin and Albander (2005) recorded an equal distribution of aggressive periodontitis among male and female in an urban population in Southern Brazil(19), whereas Albander et al 2002 reported a significantly higher prevalence of the disease in males than in females in school attendees in Uganda, aged between 15-25years(20). Variation in the prevalence of aggressive periodontitis and gender is attributed to the geographical and racial factors, furthermore, studies suggest differences between geographically and racially distinct populations in the prevalence of periodontopathic bacteria as well as greater periodontal destruction associated with infection by highly leucotoxic Actinobacillus actinomycetemcomitans (Aggregati-bacter)(16).

Radiographic images recruited in this study were not achieved exclusively for periodontal examination and diagnosis; they were achieved for different purposes in field of dentistry. Therefore, the significant of the current study is that a high prevalence of bone loss among young and adult has been recorded for our sample, which is considered as an alert sign for providing a suitable preventive and screening program among secondary students and graduated persons for early detection and prevention of primary periodontal

lesions. A screening program is required among our young and adults to identify subjects particularly susceptible to early periodontitis in life, hence involving the affected subjects into an early treatment schedule.

Conclusions:

Prevalence of bone loss among young persons in Sulaimani City was relatively high compared to other published reports with a predilection for female. Bone loss was significantly prevalent among adults compared to younger ages.

References:

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Health & Medicine

Sulaimani Dental Journal 2014 Volume 1 Issue 2