1. health and fitness
2. dental care

Stomatološki vjesnik
Stomatological review
Stomatološki vjesnik 2014; 3(2)
ISSN 0350-5499
UDK 616.31
Izdavač / Publisher: Stomatološki fakultet Univerziteta u Sarajevu / Faculty of Dentistry, University of Sarajevo
Za izdavača / For publisher: Sead Redžepagić
ČLANOVI UREĐIVAČKOG ODBORA / EDITORIAL BOARD :
Glavni urednik / Editor in chief: Sadeta Šečić
Sekretar uređivačkog odbora / Secretary of editorial board: Selma Zukić
Članovi /Members: Sead Redžepagić, Samir Prohić, Muhamed Ajanović, Amira Dedić, Sedin Kobašlija, Tarik Mašić, Amra
Vuković, Enita Nakaš
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fakultet sa klinikama Univerziteta u Sarajevu.
Aim and Scope:
Stomatološki vijesnik / Stomatological review is a non-profit scientific journal that publishes original articles, case reports, letters to the
editors, current perspectives, editorials, fast-track articles in a field of dentistry and other bio-medical sciences. Papers are in Bosnian/
Croatian/Serbian language with at least title, abstract and key words bilingual in B/C/S and English language. All manuscripts undergo
the peer review process before can be accepted for publishing in Stomatološki vjesnik/ Stomatolgical review. Papers can be used for
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purposes is not permitted without prior written permission of the publisher. Copyright owns the publisher: Faculty of Dentistry with
Clinics, University of Sarajevo.
Časopis Stomatološki vjesnik je oslobođen poreza na promet prema Mišljenju Federalnog ministarstva obrazovanja, nauke, kulture i
sporta br: 04-15-661/2002.
Journal Stomatological review is tax exempt according to the opinion of the Federal Ministry of Education Science Culture and Sports no:
04-15-661/2002.
Indexed in: IIC (Index Copernicus International), DOAJ (Directory of Open Access Journal), EBSCO, HINARI, INFOBASE,
EZB (Electronishe Zeitschriftenbibliothek), SJIF (Scientific Journal Impact Factor Value 2.502), GOOGLE SCHOLAR
Stomatološki vjesnik
CONTENTS / SADRŽAJ
ORIGINAL SCIENTIFIC ARTICLES / ORIGINALNI NAUČNI RADOVI
DENTAL ASPECTS OF CHILD ABUSE AND NEGLECT - KNOWLEADGE AND ATTITUDES OF DENTISTS
IN BOSNIA AND HERZEGOVINA
Marković N, Arslanagić Muratbegović A, Kobašlija S, Bajrić E, Selimović-Dragaš M, Huseinbegović A,
Čuković-Bagić I
83
DEVELOPMENT STAGES OF THE THIRD MOLAR IN THE BOSNIAN AND HERZEGOVINIAN CHILDREN AND ADOLESCENTS
Selmanagić A, Vuković A, Brkić H , Galić I, Zukić S, Prohić S
91
EVALUATION OF ORAL HEALTH IN 12-YEAR OLD CHILDREN IN THE VOGOŠĆA MUNICIPALITY, THE SARAJEVO CANTON
97
Porović S, Koradžić-Zuban S, Spahić-Dizdarević M, BrkaniĆ B, Branković B, Cilović-Lagarija Š
COMPARISON OF INFLUENCE OF TWO DIFFERENT EPINEPHRINE CONCENTRATIONS IN LOCAL ANESTHESIA ON
HEMO-DYNAMIC PARAMETERS IN PATIENTS WITH HYPERTENSION
Trninić S, Šečić S, Trninić L
103
RELATIONSHIP BETWEEN PERIODONTAL STATUS AND OSTEOPOROSIS AMONG WOMEN IN MENOPAUSE
Gojkov Vukelić M, Hadžić S, Dedić A, Pašić E
111
REVIEW ARTICLE / PREGLEDNI ČLANAK
CURRENT PERSPECTIVES ON GLASS-IONOMER CEMENTS IN PAEDIATRIC DENTISTRY
Negovetić Vranić D, Majstorović M, Ferk P, Jurić H
117
STRUČNI RAD /PROFESSIONAL ARTICLE
LASER THERAPY IN BURNING MOUTH SYNDROME
Pavlić V, Adamović T, Gojkov-Vukelić M, Markovic Djuric LJ
123
CASE REPORT / PRIKAZ SLUČAJA
MAXILARY CANINE IMPACTION – EXTRACTION OR NOT?
Kapusevska B, Dereban N, Benedetti A
129
DENTICLES ( PULP STONES) – A CHALLENGE IN ENDODONTIC THERAPY- MULTIPLE CASE REVIEW
Konjhodžić- Prcić A, Korać S, Jakupović S, Vuković A
141
BOOK REVIEW / PRIKAZ KNJIGE
ORTHODONTIC AND SURGICAL MANAGEMENT OF IMPACTED TEETH
Kokich Vincent G , Mathews David P
147
Stomatološki vjesnik 2014; 3 (2)
EDITOR'S ADDRESS
Esteemed colleagues,
It is our pleasure to present to you the new issue of
"STOMATOLOŠKI VJESNIK". In this, sixth issue, we
prepared nine articles representing 6 scientific, 1
expert work and 2 case studies. As it is already our
practice, you may also find an overview of a book
intended not only for oral surgeons and orthodontists, but also for dentists of other specialties.
We sincerely hope to satisfy your expectations by
this issue as well.
With gratitude to the contributions you have given
so far through your numerous articles and works with
international characteristics, and extremely strict
reviews, we succeeded in indexing "STOMATOLOSKI
VJESNIK" into EBSCO, HINARI, INFOBASE and
GOOGLE SCHOLAR data bases.
Expecting your further support and active participation in the preparation of this journal, we wish you
lot of personal and professional success in the
forthcoming 2015.
Sadeta Šečić
Editor in chief
82
Stomatološki vjesnik 2014; 3 (2)
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
DENTAL ASPECTS OF CHILD ABUSE
AND NEGLECT - KNOWLEADGE AND
ATTITUDES OF DENTISTS IN BOSNIA
AND HERZEGOVINA
1
1
*Corresponding author
1
1
Marković N* , Arslanagić Muratbegović A , Kobašlija S , Bajrić E ,
Selimović-Dragaš M1, Huseinbegović A1, Čuković-Bagić I2
1
Department of Preventive and Pediatric Dentistry,
Faculty of Dentistry, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
2
Department of Paediatric and Preventive Dentistry,
School of Dental Medicine, University of Zagreb, Zagreb, Croatia
Nina Marković,
Assistant Professor, PhD
Department of Preventive
and Pediatric Dentistry
Faculty of Dentistry
University of Sarajevo,
Bolnicka 4a
71000 Sarajevo
Bosnia and Herzegovina
Phone: +387 33 214 249, ext. 107
e-mail: [email protected]
ABSTRACT
Dentists can play an important role in detecting and reporting
cases of CAN, particularly in cases of medical and dental neglect of
their young patients. The objective of this study was to assess the
current status of knowledge and attitudes of dentists in Bosnia
and Herzegovina regarding CAN, particularly in recognition of
signs and symptoms and reporting procedure of suspected cases.
Methods: Data were collected through a self-administrated
structured questionnaire offered to 300 dentists. The questionnaire consisted of twenty- seven questions adopted and modified
from previous studies. Final sample consisted of a total number of
210 questionnaires that were filled correctly and returned.
Questions were analyzed by means of descriptive statistics. Non
parametric statistical tests were used to analyze differences
among respondents in respect of age, gender, professional experience, specialty, and workplace. The level of significance was set
at (p<0.05).
Results: Only 7.6% of respondents indicated that they had
formal training about CAN, 66% of dentists had never suspected
CAN. In the section of social indicators respondents usually indicated correct answer (more then 60% ). If they suspect, only 9% of
them would report CAN. Prevailing reasons for not reporting
suspected case of CAN was lack of knowledge of the reporting
procedure (43%), never had a case and lack of knowledge about
the procedure (31%) and lack of adequate history (15%).
Conclusion: The study demonstrated a lack of overall understanding of the problem and also a lack of awareness of dentists'
responsibilities regarding this issue.
Key words: child abuse, child neglect, dental neglect, dentist,
Bosnia and Herzegovina.
Stomatološki vjesnik 2014; 3 (2)
83
DENTAL ASPECTS OF CHILD ABUSE AND NEGLECT - KNOWLEADGE AND ATTITUDES OF DENTISTS IN BOSNIA AND HERZEGOVINA
Introduction
Child abuse and neglect (CAN) are serious public
problem present worldwide in all countries and socioeconomic groups. Despite global awareness, data
on prevalence and incidence of CAN are lacking in
many countries. Prevention and management strategies are very diverse [1]. Dentists can play an important role in detecting and reporting cases of CAN,
particularly in cases of medical and dental neglect of
their young patients.
International studies emphasis the role of dentists
in detecting CAN [1, 2, 3, 4, 5, 6, 7]. Dental health care
providers are most likely the first who recognize the
evidence of physical abuse. Oro-facial trauma is present in approximately 50 to 75 percent of all reported
cases of physical child abuse [1, 6, 8]. The reason may
be in the fact that these areas are being exposed and
accessible or because it is considered to represent
the whole personality [1]. It is well documented that
parents and guardians avoid returning to the same
physician, but they repeat visits to the same dentists
[6]. Different nationwide studies reported low percentage of dentist's participation in reporting suspected cases of CAN [4,6,9,10]. Reasons could be
incomplete knowledge of reporting procedures of
signs and symptoms of CAN, or lack of awareness of
their roll in all important aspects of CAN. Therefore,
adequate education and training of dental practitioners is an important part for managing CAN in society. Properly trained dentists would be more confident in their ability to recognize child abuse, and
more cases would be diagnosed and reported by
dental profession. In Bosnia and Herzegovina (BH),
the protection of children from abuse is mostly regulated by the Criminal Law, but some aspects of CAN,
including dental neglect, are not legally regulated at
all [11]. Health workers and other BH citizens, have a
legal obligation to report suspected cases of CAN to
the relevant authorities [11]. Dentists do not diagnose CAN, but they do have legal, moral, ethical and professional obligation to report suspected cases [11].
Few studies in Bosnia and Herzegovina analyzed
the role of healthcare workers in detecting and reporting CAN [11]. Dentists' level of knowledge in important aspects of this issue has not been investigated so
far.
84
Objective
The objective of this study was to assess the current status of knowledge and attitudes of dentists in
Bosnia and Herzegovina regarding CAN, particularly
in recognition of signs and symptoms and reporting
procedure of suspected cases.
Methods
The survey was carried out between March and
June 2013 as a cross-sectional study. Data were collected through a self-administrated structured questionnaire offered to 300 dentists that were working
in 7 different towns in BH. General dentists and dental practitioners from all specialties who worked
with children on daily bases were included in the
study. A total number of 210 (70%) dentists agreed to
participate in the study and returned questionnaire
filled correctly.
The questionnaire was reviewed by two independent professionals with knowledge in this field.
The questionnaire consisted of twenty-seven
questions adopted and modified from previous studies [1,5,6,7]. The cover letter included information
about nature and the purpose of the study, consent of
the participation on voluntary bases, state on confidentiality of the information provided. The questionnaire was distributed to the dentists by hand
from an administrator. The average time to complete
the survey was approximately ten minutes.
The questionnaire was returned to the administrator in closed envelope.
The questionnaire included 27 questions in 5 sections regarding demographic characteristics of the
respondents, knowledge of social indicators, level of
education, knowledge and attitudes of physical abuse
and reporting procedure.
All questions about knowledge and attitudes were
formulated as a statement using multiple choice or
true/false formats. Data were coded and entered into
statistical program SPSS (Statistical Package for the
Social Sciences, v. 13) and analyzed by using descriptive analysis for responses to each question. Question
by question were tabulated and analyzed using frequencies and percentages from responses to each
Stomatološki vjesnik 2014; 3 (2)
Marković N, Arslanagić Muratbegović A, Kobašlija S, Bajrić E, Selimović-Dragaš M, Huseinbegović A, Čuković-Bagić I
questions to compile prevalence data. Non parametric statistical tests (The chi-square test and Kruzskal
Wallis H test) were used to analyze differences
among respondents in respect of age, gender, professional experience, specialty, and workplace. The
level of significance was set at p<0.05.
Results
All subjects (n=210) indicated to treat pediatric
patients on daily bases. Study sample was described
by distribution of frequencies and percentages and it
is presented in Table 1.
Education about CAN
Yes (%)
No (%)
Any kind of education
8
92
Provided with any kind of informations
16
84
Have had formal training
7.6
92.4
Table 2.
Level of educational training about CAN
The level of educational training and self education regarding CAN are presented in Table 2. Only
7.6% of respondents said that they had formal training on CAN.
Knowledge of social indicators related to CAN and
distribution of answers were presented in Table 3.
Percentage
Questions/social
indicators
64
30 %
146
70%
CAN is associated
with poverty and
low- income earners
Number
Gender
Male
Female
30-49 years
>50 years
36
17%
140
67%
34
16%
Years of working experience
101
48%
10-19
65
31%
20-30
25
12%
>30
19
9%
<10
145
69
No*
15
7
Don't know
50
24
Yes
36
17
No*
84
40
Don't know
90
46
Yes
41
19
No*
73
35
Don't know
96
46
Yes*
If a child readily states
that adult has caused
No
harm, the accusation
should be addressed. Don't know
137
65
14
7
59
28
Yes*
96
46
No
23
11
Don't know
50
24
Yes*
145
69
No
15
7
Don't know
50
24
Younger children
tell someone soon
after the abuse.
Elder children tell
someone soon after
the abuse.
Dental specialties
130
62%
80
38%
Public practice
147
70%
Private practice
63
30%
210
100 %
General dentists
Specialties working with children
Children are not
removed from
parents` homes
in cases of abuse.
Practice
Total
Table 1.
Description of participants in the study
Stomatološki vjesnik 2014; 3 (2)
Number Percentage
Yes
Age
<30 years
Answer
Parent delays
seeking medical
attention in child
abuse cases
* Correct answer is indicated with asterix.
Table 3.
Knowledge of social indicators of CAN among BH dentists
85
DENTAL ASPECTS OF CHILD ABUSE AND NEGLECT - KNOWLEADGE AND ATTITUDES OF DENTISTS IN BOSNIA AND HERZEGOVINA
In this section respondents usually indicated correct answer. However, the fact that the answer "don't
know" was frequently indicated revealed a lack of
knowledge related to social indicators of CAN. Statistically significant difference was found for the question: "CAN are usually associated with poverty and
low-income earners, and rarely occur among middleor high-income earners", between dentists from pri2
vate and public practice (c (2,n = 210) = 7.08 = p =
0.029, Cranmer`s V = 0,184), with correct answer
mostly prevailing among dentist in public practice.
More females selected "yes" in question: "Elder children who have been abused usually tell someone
soon after the abuse." (c2 (2,n = 210) = 7.39 = p =
0.025, Cranmer`s V=0,082). Significantly more general dentists answered correctly that: "Child abuse
may be indicated if a parent delays seeking medical
attention"(c2 (2,n = 210) = 7.28 = p = 0.026, Cranmer`s
V=0,082). Statistical significant differences between
other independent variables in this section were not
found Results of knowledge of physical indicators of
CAN were given in Table 4.
Respondents usually indicated correct answer
except for question number 6 and 7 were "don't
know" was the most prevalent answer. The last, tenth
question was different. Respondents were asked to
indicate what could be possible indicator of CAN.
Only 15 % gave correct answer indicated "all of the
above", 21% indicated psychosomatic complaints
and the most prevalent answer was "psychosomatic
complaints, unusual knowledge about sexual matters, untidy appearance"(46%).
Statistical differences were found only between
general dentists and specialists to the questions
regarding observed bite-marks as possible indicator
of CAN (Question 1) and bruises on cheeks and neck
as possible indicators of CAN (Question 6). Whereas
correct answer was more frequent among general
dentist. Question 1: (c2 (2,n = 210) = 10.91 = p = 0.004,
Cranmer`s V=0,228).
Question 6:(c2 (2,n = 210) = 8.45 = p = 0.009,
Cranmer`s V=0,201). Majority of BH dentists have
never suspected CAN (66%), and only 9% of them if
suspected, would report. Significant differences were
observed between dentists in private and public
practice (c2 (1,n = 210) = 8.83 = p = 0.03, fi = -0,216).
Results of knowledge and attitudes regarding legal
and ethical responsibilities should be omitted since
they can be seen in Table 5.
86
Questions
/possible
indicators
observed during
normal course
of a dental visit
1.
Observed
bite marks
2.
Bruises
on the cheek
3.
Additional bruises
in areas overlying
bony prominences
4.
Poor oral health
as a part of
physical neglect
5.
Repeated injury
to the dentition
6. Bruises on the
neck are usually
associated with
accidental trauma
7. Burns associated
with child abuse
cases have shapes
of hot objects
8.
Parent describes a
child injury as a
self-inflicted injury
9. Parent describes a
repeated child injury
as a injury made by
brothers or sisters
Answer
Number
Percentage
True*
128
61
False
26
12
Don't know
56
27
True*
163
78
False
22
10
Don't know
25
12
True*
102
49
False
59
28
Don't know
49
23
True*
148
70
False
43
21
Don't know
19
9
True*
41
19
False
73
35
Don't know
96
46
True
31
15
False*
136
65
Don't know
43
20
True*
101
48
False
25
12
Don't know
84
40
True*
162
77
False
12
6
Don't know
36
17
True*
129
61
False
22
11
Don't know
Psychosomatic
complaints
59
28
39
19
8
4
Untidy appearance,
untidy clothes
14
7
Psychosomatic
complaints,
unusual knowledge
about sexual matters,
untidy appearance
96
46
All of the above*
32
15
Don't know
21
9
Seductive behavior,
unusual knowledge
about sexual matters,
avoiding eye contact
10.
Possible indicators
of suspected CAN
* Correct answer is indicated with asterix.
Table 4.
Knowledge of signs of physical abuse among BH dentists
Stomatološki vjesnik 2014; 3 (2)
Marković N, Arslanagić Muratbegović A, Kobašlija S, Bajrić E, Selimović-Dragaš M, Huseinbegović A, Čuković-Bagić I
Questions
Did you ever
suspect CAN
If suspect did
you report
case of CAN
Were to report
suspected CAN
Reasons for
not reporting
suspicions
of CAN
Answer
Number
Percentage
Yes
71
34
No
139
66
Yes
18
9
No
107
51
No answer
85
40
Social service*
160
76
Police
24
11
Social service
and police
26
12
No*
121
58
No answer
21
11
Lack of adequate
history
31
15
Lack of knowledge
and the procedure
of reporting
90
43
Lack of confidence
that reports will
be correctly
investigated and
fear that it may
cause more harm
than good
11
5.1
Never have a case,
lack of knowledge
about procedure
of reporting
66
31
No answer
12
6
* Correct answer is indicated with asterix.
Table 5.
Knowledge and attitudes regarding legal and
ethical responsibilities among BH dentists
The most common reason for not reporting suspicions of CAN was lack of knowledge regarding the
subject including the reporting procedure (43%),
followed by lack of knowledge about procedure of
reporting together with "did not have a case of CAN"
(31%), lack of adequate history (15%), and lack of
Stomatološki vjesnik 2014; 3 (2)
confidence that report would be investigated
correctly along with fear that it could cause more
harm than good (5%). This question did not answer
6% of respondents.
The survey was approved by the Federal Ministry
of Education and Science of Federation of Bosnia and
Herzegovina and Faculty of Dentistry of University in
Sarajevo, Bosnia and Herzegovina.
Discussion
Child abuse and neglect (CAN) has been defined
by the World Health Organization (WHO,1999) as
"Every kind of physical, sexual, emotional abuse, neglect or negligent treatment, commercial or other exploitation resulting in actual or potential harm to the
child's health, survival, development or dignity in the
context of a relationship of responsibility, trust or
power."[12].
Abuse can be physical, sexual, psychological and
economic [11]. Neglect can be physical, psychological, medical (health) and educational [11].
Health neglect is defined as intentional failure to
provide necessary medical treatment and health protection [11]. American Academy of Pediatric Dentistry (AAPD) defined dental neglect, as willful failure of
a parent or guardian to seek and follow through with
whatever treatment is necessary to ensure a level of
oral health essential for adequate chewing function
and freedom from pain and infection [13].
WHO estimated that almost 53,000 children died
worldwide in 2002 from homicide [8]. In the United
States each year almost 2,000 infants and young
children die from being abused or neglected by caretakers [6]. A ten year study of 29 fatal cases of child
abuse found a high incidence of facial injuries, with
laceration of the mucosa of the upper lip that were
occurring in almost half of the cases [2]. These types
of injuries have been recognized in the literature as
pathogmonic of a child abuse [2].
The problem is more extended in low economic
countries associated with low incomes, poverty, high
rate of unemployment, increase level of stress and
unstable political situation [4, 8,12]. Bosnia and Herzegovina has all of the listed risk factors.
Child abuse and neglect are significant problems
worldwide. Numerous studies had showmen that oro
-facial region, head and neck are common sites of
87
DENTAL ASPECTS OF CHILD ABUSE AND NEGLECT - KNOWLEADGE AND ATTITUDES OF DENTISTS IN BOSNIA AND HERZEGOVINA
trauma of child abuse [2, 4,5,6,]. Statistics have
reported that 50% to 70% of all cases of child abuse
include trauma to the mouth, face and head [5]. The
lower number of intra-oral injuries recorded in comparison to high number of head and face injuries suggests that they may be overlooked due to the unfamiliarity of the medical practitioners with interior
examinations [1].
Dental professionals account for only small
percentage of reports of overall cases of CAN. In the
United States only 1% of all reported cases were
made by dentists [5,6]. Results of available studies
indicated that dentists failed to report suspected cases of CAN, mainly due to lack of knowledge and awareness of their ethical (and/or legal) responsibilities
[1,34,5,6,9,10].
There is a lack of epidemiological reports of CAN
for BH population. Few studies in BH have analyzed
the role of healthcare workers in recognizing and
reporting CAN [11]. Suspected evidence of child
abuse was found in 19% of children who underwent
regular medical checkups [11]. The findings of this
cross-sectional study present baseline survey of
knowledge and attitudes of dentists in BH towards
CAN. The findings of the present survey indicated a
national problem of lack of knowledge in many areas
related to the CAN issue. The most of dentists (92%)
had no education related to CAN, 84% stated that
they were not provided so far with any kind of related
information. Only 7.6% of respondents have been
trained on issues related to CAN. Having in mind that
education is very important in this issue, and that this
issue is very important for community, the lack of
education and training courses is serious problem for
all authorities involved. Subject of CAN has not been
included so far in curriculum for undergraduate and
postgraduate students in dental schools in BH. Findings of numerous studies emphasize the need for
mandated training related to recognition of CAN
through long-life learning courses [1, 4,5,7,8,14].
Obviously, many correct answers in the study
were drawn by logical conclusion rather than decision making based on knowledge.
Knowledge of social issues related to CAN was
evaluated in six questions were respondents indicated answers such as: yes, no or don't know. In this
section respondents usually indicated correct answer, but "don't know" as an option was selected frequently as well indicating a lack of knowledge related
to social indicators of CAN.
88
Many BH dentists recognized a bite –marks and
bruises in oro-facial region as a sign of a physical
abuse (61 % and 78%), but repeated injury to the
dentition were recognized by only 19% of them.
General knowledge of trauma may be the reason for
frequent indicating correct answers in section of
signs and symptoms of physical abuse. Several articles have documented evidence of cutaneous bitemarks and bruises in oro-facial region in patients
suspected to child abuse [2,5,6]. Bite- marks injuries
are rarely accidental and are good indicator of
physical abuse [2]. Principal injuries reported in
cases of suspected child abuse were fractures of
teeth, oral bruises, and oral lacerations, fractures of
maxilla and mandible and oral burns [2]. Dentists are
usually the first health care providers who see patients with dental trauma; therefore they have to be
aware of the importance of the issue and of their role
in recognizing and reporting suspected cases. This is
very important for prevention of further injuries and
maltreatment and for providing better treatment for
young domestic violence victims. Reporting suspicions of CAN on time can save life of young victim or
victims if more than one individual is involved.
Psychosomatic complaints, unusual knowledge
about sexual matters, untidy appearance were most
often indicated by respondents as indicators of CAN.
Seventy percents of BH dentist associated poor oral
health with physical neglect. Poor oral health could
be considered as a serious dental neglect. By the
definition of the American Academy of Pediatric
dentistry dental neglect is considered a form of CAN
when caregiver is aware of a child need for dental
care; bat willfully denies the children from dental
care [13]. It is considered that untreated caries,
periodontal diseases, and other conditions can cause
pain, infection and lost of function [4,11,15]. Dental
neglect affects nutrition, sleeping, learning, communication and other activities necessary for normal
growth and development of infants [4]. The most
frequent indicator of dental neglect is rampant early
childhood caries [11,16]. Epidemiological findings of
oral health status of children in BH, where dmft was
more then 6, suggests that dental neglect is widely
spread in the population [17,18]. However, it is necessary to reconsider weather poor oral health is due
to parent's ignorance. In countries with low socioeconomic status and many problems in health care
system, poor oral health of citizens is most likely due
to financial deprivation, inaccessibility to dental
Stomatološki vjesnik 2014; 3 (2)
Marković N, Arslanagić Muratbegović A, Kobašlija S, Bajrić E, Selimović-Dragaš M, Huseinbegović A, Čuković-Bagić I
health care or lack of prevention and public oral
health organization and promotion activities. Caries
and periodontal diseases are multi-factor diseases,
and many aspects may influence their development
and progression. Therefore, it is necessary to assess
patient's detailed history and to be well trained and
experienced to address poor oral health as neglect
exclusively.
Results of legal and ethical issues suggest that a
few respondents would act on the suspicion on CAN.
Only 9 % answered that they would report suspected
CAN. A total of 34% of them had suspicions on CAN in
their practice. The most common reasons for not
reporting was lack of knowledge of the reporting
procedure (43%), never had a case along with lack of
knowledge about the procedure (31%) and lack of
adequate history (15%). These findings are similar to
those in other studies [2, 4, 6, 19]. Dentists from other
surveyed studies indicated: lack of history (over
70%), uncertainty about diagnosis (over 70%),
possible consequences to a child (over 60%), and
effects of work litigation (over 50%) [2, 3, 4, 5, 6, 9, 10,
19]. Lack of awareness of the responsibility could be
significant reason for not paying attention and not
reporting CAN. According to results of the present
study, significant proportions of respondents are
aware of their responsibility to pay attention to CAN.
Social and psychological barriers can be one more
reason for under-reporting CAN. It is necessary to
emphasize that dental professionals are only responsible for reporting their suspicions to social service
that is in charge for further investigations and appropriate course action if necessary. High proportion of
BH dentists new where to report suspected CAN
(over 70%), and only half of respondents consider
that they have professional obligation to pay attention to CAN. Significant differences between general
dentists and specialists could be due to frequency of
patients on daily bases.
Dental professionals must become more aware of
their moral, professional, legal and ethical responsibilities in recognizing and reporting child abuse and
neglect. All health professionals including dental
teams must be aware of the seriousness of the
problem.
It has to be seriously understood that abuse and
neglect can lead to death as a result of maltreatment
and molestation.
Stomatološki vjesnik 2014; 3 (2)
Conclusion
The study revealed a lack of overall understanding
of the problem and a lack of awareness of the responsibilities of dentists regarding this issue.
In a view of the high likelihood of oro-dental
injuries occurring in association with child abuse,
there is a clear need for dentists to receive an adequate formal training at the levels of undergraduate
and postgraduate studies and during continuing
professional dental education trainings on topics
regarding the recognition and reporting of CAN.
Acknowledgments
The permission and financial support of the
Federal Ministry of Education and Science are
acknowledged. Technical and administrative supports of Faculty of Dentistry, University of Sarajevo,
Bosnia and Herzegovina are highly appreciated and
acknowledged.
Declaration of interests
All authors clearly state that there is no conflict of
interest for any person or institution included in this
research project.
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17. Arslanagić Muratbegović A, Marković N,
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Stomatološki vjesnik 2014; 3 (2)
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
DEVELOPMENT STAGES OF THE
THIRD MOLAR IN THE BOSNIAN
AND HERZEGOVINIAN CHILDREN
AND ADOLESCENTS
Selmanagić A*1, Vuković A1, Brkić H2 ,
Galić I3, Zukić S1, Prohić S4
1
Department of Tooth Morphology with Dental Anthropology and Forensics,
Faculty of Dentistry, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
2
Department of Dental Anthropology, Faculty of Dentistry,
University of Zagreb, Zagreb, Croatia
3
Study of Dental Medicine at the Faculty of Medicine,
University of Split, Split, Croatia
4
Department of Oral Surgery, Faculty of Dentistry, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
*Corresponding author
Aida Selmanagić, MSc
Department of Tooth Morphology,
Dental Anthropology and Forensics
University of Sarajevo
Faculty of Dentistry
Bolnička 4a
71000 Sarajevo
Bosnia and Herzegovina
Phone: +387 61 803 342
e-mail: [email protected]
ABSTRACT
The precision of age determination using third molars is
crucially important when there is a need to determine the juvenile
or adult status of an individual when no valid document is
available. Furthermore, this form of age estimation can be applied
to assess the age of patient suffering from amnesia and also
specimens of forensic or anthropological importance.
Aim: The aim of this study was to assess correlation of eruptive
stages of third molars between right and left side in upper and
lower jaws.
Material and methods: Sample of this study consisted of 529
individuals, whose OPGs have been analised- 264 (49,9%) male
and 265 (50,1%) female, aged 8 to 25 years, divided into six
groups, with known chronological age, by Olze method.
Results: There is a high Spearman's correlation coefficient
between eruptive stages of rigt and left lower and upper third
molars. Overall, no significant differences were found in the third
molar eruption between males and females.
Conclusion: We recommend the use of third molars in lower
jaws for assesing dental age by Olze method in the population of
Bosnian and Herzegovian, according to our results.
Key words: Third molar development, Age estimation by
teeth, Bosnian and Herzegovinian children and adolescents.
Stomatološki vjesnik 2014; 3 (2)
91
DEVELOPMENT STAGES OF THE THIRD MOLAR IN THE BOSNIAN AND HERZEGOVINIAN CHILDREN AND ADOLESCENTS
Introduction
Third molars, contrary to other permanent teeth,
show their variability in position, size, time of formation and time of eruption [1].
The third molar or "wisdom tooth" is unique in its
development and has the highest rate of agenesis [2].
The timing and sequence of its development are more
variable than for all other teeth. The relation of third
molar development and eruption to dental age, skeletal age, and level of maturity, as well as its effect on
malocclusion and the possibility of impaction are of
interest for planning therapy procedures [2].
The dental age can be assesed amongst children
with greater accuracy. This is because many teeth are
undergoing development and calcification simultaneously. However, this accuracy decreases with the
completion of dental development [3-6].
Age estimation is especially difficult after the age
of 14 years because all of the teeth, except unerupted
ones, are in the process of completing their apical formation [7]. Third molars teeth remain the most reliable biologic indicator available for estimation of age
during adolescent and early adult period , because
only this group of teeth continue to develop [1, 8] and
thereby is very important for dental age calculation
[1].
The precision of age determination using third
molars is crucially important when there is a need to
determine the juvenile or adult status of an individual
when no valid document is available [1]. Especcialy,
procedures of dental age estimation of living persons
are gaining frequency in Europe due to a high number
of illegal immigrants [1].
The Homeland War that took place in Bosnia and
Herzegovina from 1992 till 1995 urged the need for
dental identification in Bosnia and Herzegovina and
for dental age estimation as a part of it.
Furthermore, this form of age estimation can be
applied to assess the age of patient suffering from
amnesia and also specimens of forensic or anthropological importance [3].
The aim of this study was to show correlation of
eruptive developmental phases of third molars between the right and left side in the upper and lower
jaws.
Materials and Methods
Sample of this study consisted of 529 individuals,
whose OPGs have been analised- 264 (49,9%) male
and 265 (50,1%) female, aged 8 to 25 years, divided
into six groups, with known dates of birth.
Panoramic radiographs were collected during two
years (2011-2012) from the archive of the Faculty of
Dentistry, University of Sarajevo.
We used OPGs of Bosnian and Herzegovinian patients exclusively, being made according to strict specialist indications.This investigation used only OPGs
with present all of four third molars, with at least two
of them of normal shape. In total, 2116 third molars
were analyzed; there were 1058 upper and 1058
lower molars.
Numerous methods are currently used for dental
age estimation. Most of them are based on developmen phases of the third molars as seen on panoramic
radiographs (OPGs)[1].
Eruptive phases of third molars teeth (Figure 14) were classified into 4 stages, from A to D, and
Figure 1.
Mandibular third molar in Stage A.
The crown is completly formed
within the dental follicle. The root
has not yet begun to develop.
The occlusal plane is covered
with alveolar bone.
92
Stomatološki vjesnik 2014; 3 (2)
Selmanagić A, Vuković A, Brkić H , Galić I, Zukić S, Prohić S
Figure 2.
Mandibular third molar in Stage B.
The roots have started to develop
and there is complete resorption of
alveolar bone over occlusal plane
- Alveolar emergence.
Figure 3.
Mandibular third molar in Stage C.
The roots have developed to
two-thirds of their length and the
tooth has started to erupt, although
it has not yet reached the occlusal
plane of the adjacent second molar
- Gingival emergence.
Figure 4.
Mandibular third molar in stage D.
The roots have completly
developed, including closure of the
apices, and the tooth has reached
the level of the occlusal plane of
the adjacent second molar
- Complete emergence in occlusal
plane.
analized by Olze method. Stage A: Occlusal plane covered with alveolar bone. Stage B: Alveolar emergence; complete resorption of alveolar bone over occlusal plane. Stage C: Gingival emergence; penetration of
gingival by at least one dental cusp. Stage D: Complete
emergence in occlusal plane [1, 9-14].
Statistical analysis
Spearman's correlation coefficient were computed to assess correlation between eruptive stages of
Stomatološki vjesnik 2014; 3 (2)
left and right third molars in both jaws. Statistical
analysis was performed by SPSS program, 15 version.
Results
Distribution of chronological age of sample
individuals is shown in Figure 5. On a repeated
random sample of 53 OPGs identical findings were
observed, so kappa value (confirming intra-examiner
93
DEVELOPMENT STAGES OF THE THIRD MOLAR IN THE BOSNIAN AND HERZEGOVINIAN CHILDREN AND ADOLESCENTS
Discussion
Third molars development is important for dental
age estimation in adolescents and in early adult
period. Several studies showed that chronological
course of wisdom teeth mineralization varies slightly
between different populations and races [1,3].
We have found no significant difference in
eruptive phases of third molars between rigt and left
sides in both jaws in our investigation. Majority of
authors agree with this statement. Some of them
assess eruptive stages, but the others assess development of the third molars teeth. Sarnat et al. were
estimating dental age in Israeli children, aged 7-16 ,
using the method by Gat et al. They found very few
significant differences in the development of the
third molar between the right and left sides and the
upper and lower jaws [2]. Golovencu et al. estimated
dental age in Romanian population, aged 11-25, and
they concluded that there weren't significant
differences between development of wisdom teeth in
both sides of jaws [3]. Prieto et al. found in their
investigation regarding development of wisdom
teeth on Spanish population, aged 14 to 21, very high
correlation coefficient between rigt and left observed
third molars in both males and females. They concluded that the wisdom teeth reached the same
phases in Spanish population prior to Scandinavian,
American, German, Japanese and South African population, too (15). Kurita et al. didn't find statisticly
94
25
Male
Female
20
Frequency
reliability) was 1. Statistical analysis revealed high
Spearman's correlation coefficient between eruptive
developmental stages of rigt and left lower and upper
third molars (Table1). This coefficient showes the
highest value (ro=0,989) (Figure 6) of third molars
eruptive development phase between right side in
upper and left side in lower jaw. Follows ro=0,987
between righ side in lower and left side in upper jaw
(Figure 7); ro=0,966 between left sides in both jaws;
ro=0,964 between right side in lower and left side in
upper jaw. While Spearman's correlation coefficient
has the smallest value(ro=0,961) comparing rigt
sides in both jaws. And, it is same value (ro=0,961) for
third molars eruptive phases on right side in upper
and left side in lower jaw. The correlation between
chronological age and developmental stages are
shown in (Figure 8.).
15
10
5
0
5
10
15
20
25
30
5
10
15
20
25
30
Chronological age
Figure 5.
Distribution of chronologic age of participants according to their sex
Upper
(right)
Lower
(right)
Lower
(left)
0,989* 0,961*
0,961*
0,000
0,000
0,000
526
526
526
1,000
0,964*
0,966*
0,000
.
0,000
0,000
526
526
526
526
1,000
0,987*
Spear- Upper Correl. Coefficient 1,000
man's
(right) Sig. ( p )
.
rho
n
526
Upper Correl. Coefficient 0,989*
(left)
Sig. ( p )
n
Upper
(left)
Lower Correl. Coefficient 0,961* 0,964*
(right) Sig. ( p )
n
0,000
0,000
.
0,000
526
526
526
526
Lower Correl. Coefficient 0,961* 0,966* 0,987*
(left)
Sig. ( p )
n
1,000
0,000
0,000
0,000
.
526
526
526
526
* Statistically significant on p<0,01
Table 1.
Spearman rank correlation- Third molars' eruptive phases
on the right and left sides in the upper and lower jaw
significant difference in eruption stages of third molars teeth between right and left side, i.e. the wisdom
teeth were reached the same eruptive phases in the
same time approximatly in Brazilian children. (16)
Legović et al. didn't find significant difference between development of third molars on both sides in
jaws in their investigation of eruptive phases of these
teeth according to chronological age in Croatian
(Istra) population of children and adolescent. (17) Li
Guo et al. estimated dental age on Chinese children
and adolescent population. They didn't find significant difference between development on right and
left sides in jaws, too. (18) Orhan et al. concluded in
Stomatološki vjesnik 2014; 3 (2)
Selmanagić A, Vuković A, Brkić H , Galić I, Zukić S, Prohić S
200
ro = 0,989; p < 0,000
Count
150
100
50
0
A
B
C
D
Figure 6.
Correlation proportion of third molars eruptive
phases between rigt and left side in upper jaw
their age estimation on Turkish population of children and adolescents similar to previous authors.
(19) On the other side, Van Vlierberghe et al. found no
correlation in eruptive phases between rigt and left
sides of maxilla. In the upper jaws, the rigt side
seemed to have a higher score than the left side but
this difference was only significant for males. So,
scoring the upper molars is sometimes difficult when
the bootom of the maxillary sinus or the maxillary
tuberositas eclipse the roots. Authors recommend
using wisdom teeth in lower jaws for assesing dental
age to overcome this problem. (20) Knell (21) and
Mincer (22) have found right-left assimetry in
developing teeth roots in both jaws.
Conclusion
200
ro = 0,987; p < 0,000
Count
150
100
50
0
A
B
C
D
Figure 7.
Correlation proportion of third molars eruptive
phases between rigt and left side in lower jaw
Based on this study, we can recommend wisdom
teeth in lower jaws for assesing dental age by Olze
method on the Bosnian and Herzegovian population.
It is important to mention that forensic odontologist
must be warned of the fact that assimetry in
development and eruption are possible. Both sides
should be independently evaluated. Relation of third
molar development and eruption to dental age,
skeletal age, level of maturity as well as its effect on
malocclusion icluding the possibility of impaction,
are of interest for planning therapy procedures in
dental practice.
eta squared = 0,820 p < 0,000
Mean Chronological age
22
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Stomatološki vjesnik 2014; 3 (2)
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
EVALUATION OF ORAL HEALTH IN
12-YEAR-OLD CHILDREN IN THE VOGOŠĆA
MUNICIPALITY, THE SARAJEVO CANTON
Porović S*¹, Koradžić-Zuban S1, Spahić-Dizdarević M1,
Brkanic B1, Branković S2, Cilović-Lagarija Š3
1
Public Health Centre of the Sarajevo Canton, Sarajevo, Bosnia and Herzegovina
Faculty of Health Studies, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
3
Public Health Institute of the Federation of Bosnia and Herzegovina,
Sarajevo, Bosnia and Herzegovina
2
*Corresponding author
Porović Selma
Health Centre
of the Sarajevo Canton,
Infirmary Podhrastovi
Bardakčije 26
71000 Sarajevo
Bosnia and Herzegovina
Phone: + 38761282557
e-mail: [email protected]
ABSTRACT
Objective: The aim of this study was to present epidemiological parameters of caries prevalence and oral hygiene in 12 years
old municipality Vogošća, Sarajevo Canton.
Material and methods: The study was conducted during 2013
year for children aged 12. An oral helath survey was performed on
a total number of 269 children in line with World Health
Organisation methodology and criteria. Results for caries
prevalnce and oral hygiene index were presented and discussed
in this paper.
Results: Mean DMFT (decay, missing, filled teeth for
permanent dentition) for children aged twelve was 4,29 ± 2,62,
and average value of oral hygiene index was 2,72±2,079. SiC index
value was 7,2.
Conclusion: The present study provides some evidence of
relatively high caries prevalence and severity in comparison with
Western European countries. It is necessary to devote more
attention to the oral health of children and adolescents.
Key words: 12 years old, oral health.
Stomatološki vjesnik 2014; 3 (2)
97
EVALUATION OF ORAL HEALTH IN 12-YEAR-OLD CHILDREN IN THE VOGOŠĆA MUNICIPALITY, THE SARAJEVO CANTON
Introduction
Oral health is an important part of general health.
According to the WHO definition, oral health is defined as a quite normal status of teeth function and
supported tissue [1].
It is obvious that dental caries represents great
health problem today. Complications of dental caries,
as pain and other, have influence on psychical development, general health and quality of life, too. It is
especially important that caries is a disease of children and adolescents thus making these problems
more serious and greater [2].
The recent World Health Organization (WHO)
report and other studies suggest dental caries to be a
major public health problem in most of the developing countries, affecting 60-90% of the school children in spite of the declining trends in the most developed countries. Decline in dental caries among children in highly developed countries started to emerge
around 1970 and the percentages of caries free children in different age categories have increased since
then. This was mainly attributed to the increased use
of fluorides from all sources, especially toothpastes
[3]. This disparity between developed and developing countries has been attributed to preventive oral
health care programs adopted by the former and
changes in dietary habits coupled with inadequate
exposure to fluorides in developing countries. Most
European countries periodically conduct oral health
surveys for specific age defined population groups.
Recommended age groups in pediatric population to
evaluate oral health status are 5 to 6 years, 12 years
and 15 years of age [4]. Establishing baseline data on
children dental caries and other oral health issues
through regular national surveys is crucial for planning and developing intervention programs [5].
The aim of this study was to present oral health in
12-year-old school children from urban and rural
parts of the Vogošća Municipality, Sarajevo Canton,
capital city of Bosnia and Herzegovina.
Material and Methods
Municipality Vogošća is one of nine municipalities
of the Sarajevo Canton, capital city of Bosnia and Her98
zegovina. It covers 71,7 square km and is about 6 km
distant from the Sarajevo city centre. Municipality
Vogošća has population of 25.450 inhabitants, distributed in 21 places, according to the 1991 data [6].
The survey was conducted during October 2013, as a
cross-sectional study. The samples were 12-year-old
school children of five primary schools in Vogošća
municipality, attending 6th grade. Schools are
deployed in urban and rural areas of the Municipality.
The schools included in this research are: "Mirsad
Prnjavorac" and "Zahid Baručija" from urban site of
Municipality Vogošća, and "Porodice ef. Ramić" Semizovac, "Izet Šabić" Hotonj, and "Zajko Delić" Kobilja
Glava, belonging to rural site of Municipality Vogošća.
The study sample was 269, 12-year-old school
children. Written consent for the participation of the
children in the study was obtained from the principals of the concerned schools, and their parents. The
examinations were performed in the school-room
with children in a seated position on a school chair;
the examiner sat in front of them. Two calibrated
dentists performed the clinical examination under
adequate natural light using a plane mirror and CPI
ball-ended probe. Data were recorded into modified
WHO form for this kind of research. Dental findings
were recorded with DMFT index, recorded sealed
fissures and dental extractions due to orthodontic
reasons. Caries was measured using the DMFT index
according to WHO criteria [4]. It was detected at the
cavitation level only (detectable softened floor, undermined enamel or softened wall). Criteria of
"catching" or "retention" of the explorer was not used
to detect caries.
SiC Indeks was also calculated and presented in
results. 'Significant Caries Index' (SiC) was proposed
in the year 2000, in order to put attention to the individuals having the highest caries scores in each population. The SiC Index is the mean DMFT of the one
third of the study group with the highest caries score.
The index is used as a complement to the mean DMFT
value [7].
Oral hygiene was assessed using the Simplified
Oral Hygiene Index (OHI-S) of Green and Vermillon
(1964), including component Debris indeks. Score
was recorded from six index teeth (all first molars),
upper right and lower left central incisors per child.
Labial surfaces were examined for all teeth with the
exception of the lower molars, where the lingual
surfaces were examined. Codes for the Debris index
were as follows: 0= Absence of debris or extrinsic
Stomatološki vjesnik 2014; 3 (2)
Porović S, Koradžić-Zuban S, Spahić-Dizdarević M, Brkanic B, Branković S, Cilović-Lagarija Š
Good hygiene
< = 0,9 % (n)
Fair hygiene
1,0-1,9 % (n)
Poor hygiene
≥2 % (n)
OHI-S values
56,1 (151)
11,9 (32)
32,0 (86)
Males
55,3% (78)
12,1% (17)
32,6% (46)
Females
57,0% (73)
11,7% (15)
31,3% (40)
Urban
58,1% (68)
15,4% (18)
26,5% (31)
Rural
54,6% (83)
9,2% (14)
36,2% (55)
Table 1. OHI –S values by sex and by urban and rural areas
(This table describes OHI-s values divided by sex and by urban and rural areas of living)
stain, 1= debris covering not more than one third of
the tooth surface, 2= debris covering more than 1/3
but not more than 2/3 of the tooth surface regardless
of the presence of extrinsic stain, 3= Soft debris covering more than two thirds of the examined tooth
surface.
Oral hygiene of each child was recorded as good,
fair and poor. Results of OHI-S values were: poor (≥
2), fair (1, 0 – 1, 9) and good (≤ 0.9). Poor and fair
categories were used for "poor" oral hygiene [8].
Statistical analysis
The research results are presented in tables.
Descriptive statistical analysis was used, calculated
frequencies and percentages, arithmetical value and
standard deviation. Significances between variables
were calculated with nonparametric Pirsons hiquadrate test and Mann-Whitney test. Data analysis
was made by using Program R.
Results
The total number of examined was 269 students,
141 males (52, 4%) and 128 females (47, 6%). About
56, 5% (152) of the total sample was from rurally
located primary schools, and 43, 5% (117) from the
urban located schools.
Average DMFT value was 4, 29 (±2, 62). The most
part of DMFT were filled teeth in total - FT= 2, 32
(±2,035), than caries - DT=1, 81 (± 2, 21), while
Stomatološki vjesnik 2014; 3 (2)
component MT was 0, 16 (± 0.455). Mann-Whitney
test proved there was no significant differences of
DMFT index between males and females - (Z=-1,059,
p=0, 29). There was no significant differences of
DMFT index between urban and rural schools - (Z=0,197, p=0,843). Only 5, 2% (14) students had no
caries of the total number, while SiC index value was
7, 2.
Out of the total number, 87, 4% (235) students had
no sealed fissures, 5, 6% (15) had two sealed fissure,
and only one had 4, 8% (13) students.
Teeth extraction due to orthodontic reasons had 0,
4%, from 2-4 teeth.
Average value of oral hygiene index was 2, 72
(±2,079). According to OHI-S values, 32, 0% (86)
students had poor, 11,9% (32) fair and more than half
students had good oral hygiene 56,1% (151) (Table
1).
Hi2-test showed the next result – only 31,3%
examined females and 32,6 % males had poor oral
hygiene, while almost 55,3% male gender examined
persons and 57,0% female gender examined persons
had good oral hygiene, and there was no significant
differences between them (x2=0,081, df=2, p=0,960)
(Table 1).
According to the type of living places, greater
percent of examined persons living in urban parts
had good oral hygiene 58,1%, while 54,6% had the
same in rural parts. The differences were not
2
significant (x =4.205, df=2, p=0.122) (Table 1).
99
EVALUATION OF ORAL HEALTH IN 12-YEAR-OLD CHILDREN IN THE VOGOŠĆA MUNICIPALITY, THE SARAJEVO CANTON
Discussion
This research made the average analysis of oral
health of 12-year-old children of the Vogošća
municipality, part of the Sarajevo Canton, capital city
of Bosnia and Herzegovina, during the year 2013.
This research showed that DMFT index in 12-yearold children was 4, 29 ± 2, 62. This result does not
significantly differ from the results of similar
research realized during 2004 in Sarajevo, where
value of DMFT index was 3,9 ± 2,9 [9], and are also
comparable with another similar research provided
in Sarajevo Canton during 2003, when DMFT index in
12 year olds was 4,81 ± 3,24 [10].
Comparing with research results from 1999 in the
Sarajevo Canton, when DMFT index in 12 year olds
was 7, 18 [11], significant decrease of this value was
recorded 14 years after.
Possible explanation for this result could be the
fact that period 1995-2000 was the post-war period,
when faced with hard economic challenges, it was
likely that most people gave less priority to oral
health issues. People were occupied with basic
existential things, and there was not enough
information about oral health. It could be the reason
for such great DMFT index differences between 1999
and 2013. In spite of such index decrease, its value (4,
29) is very high, and it showed the lack of national
preventive programme, education, and small number
of paediatric dentists in Bosnia and Herzegovina. In
1979 WHO Council adopted important goal for
children's oral health – average DMFT index should
not be above 3, 0 and 50% of children at age of 6
should be without caries [12]. Main values of DMFT
index in majority of countries of North and West
Europe are under 3, 0, and in USA under 2, 0 [13]
respectively.
The value of SiC index of 7,2 and the fact that only
5,2% examined persons had no caries, showed that
Bosnia and Herzegovina has high caries prevalence
rate and bad education of population regarding the
significance of oral health.
By definition, SiC is a part of DMFT index
calculated on one third of examined persons with
highest values of calculated DMFT index [14].
Comparing SiC Index with neighbouring countries –
Croatia, where SiC was 7, 4 [15], and Montenegro 6,
100
35 [16], our values are not significantly different, but
in comparison with Germany in 12 year old persons,
where SiC value was 2.29 [17], we realised alarming
difference between the values. Surrounding
countries have DMFT index in 12 year olds as it
follows: Croatia 4,8 [15], Kosovo 5,8 [18],
Montenegro 3,43 [16], and these values does not
significantly differ from our results. Average value of
oral hygiene index in this research was 2, 72 ± 2,079,
belonging to poor oral hygiene. Finding of high DMFT
index is expected due to poor oral hygiene. Bad socioeconomic environment, population knowledge
regarding oral health and caries preventive measures
are possible reasons for such bad oral health in our
survey. Comparing with similar research provided in
Montenegro with the same methodology presenting
the value of Debris index in 12 year olds as 1,086 [16],
and another research provided in Sudan with the
OHI-S being 1, 3 ± 0, 9 [8], we can conclude that values
obtained by our research are significantly different
from mentioned results in these two countries in the
sense of poor oral hygiene.
Conclusion
This study demonstrated the significance of
epidemiological studies, which are rare in our
country. High DMFT index and very bad index of oral
hygiene estrange us decades away from the world
trends in oral health. Relevant oral health promotion
and treatment programs need to be established
urgently. Poor oral health is not only a health problem
but also a social one.
References
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Kobašlija S. Huseinbegović A. Selimović-Dragaš
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Kantonu Sarajevo; magistarski rad, Sarajevo:
Stomatološki fakultet, 2003.
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with a proposal for a new global oral helath for
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101
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
COMPARISON OF INFLUENCE
OF TWO DIFFERENT EPINEPHRINE
CONCENTRATIONS IN LOCAL ANESTHESIA
ON HEMO-DYNAMIC PARAMETERS
IN PATIENTS WITH HYPERTENSION
Trninić S*1, Šečić S1, Trninić L2
*Corresponding author
Slobodan Trninić, MSc
Department of Oral Surgery
Faculty of Dentistry
University of Sarajevo
Bolnička 4a
71000 Sarajevo
Bosnia and Herzegovina
Phone: +387 33 214 249
e-mail: [email protected]
1
Clinic for Oral Surgery, Faculty of Dentistry with Clinics,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
2
Private dental practice "dr. Vejsilovic", Sarajevo, Bosnia and Herzegovina
ABSTRACT
Introduction: "Divinum opus est sedare dolor" these are the
words of Hippocrates and means "It's divine to alleviate pain".
Chemical agents that accomplish this goal are called local
anesthetics. Adrenaline (epinephrine) is a vaso-constrictor, being
most commonly used in local anesthetics.
The aim of the study: Compare the effect of two different
concentrations of epinephrine (1:80.000 and 1: 160.000) of local
anesthesia (2% lidocaine) on hemodynamic parameters (heart
rate, systolic and diastolic pressure) in patients with hypertension.
Patients and Methods: This is a prospective, controlled,
clinical-experimental, single-blind study. The study includes a
total of 30 patients of both sexes and all age groups. After the first
dental examination, each patient extracted at least one tooth, and
we performed two applications of local anesthesia in two
different concentrations in two visits.
Results: Results of the Kruskal-Wallis test showed no
significant statistical difference between the value of systolic and
diastolic blood pressure and pulse rate after anesthesia in
hypertensive patients.
Conclusion: Based on these analyzes, we recommend using of
local anesthetic lidocaine 2% the concentration of adrenaline 1:
80.000 in oral surgery requiring more consistent hemostasis, but
in the routine work we recommend the use of local anesthesia
with adrenaline at concentration of 1: 160.000, because we can
control pain and bleeding successfully.
Key words: epinephrine, local anesthesia, hypertensia,
haemodynamic parameters
Stomatološki vjesnik 2014; 3 (2)
103
COMPARISON OF INFLUENCE OF TWO DIFFERENT EPINEPHRINE CONCENTRATIONS IN LOCAL ANESTHESIA ON HEMO-DYNAMIC PARAMETERS IN PATIENTS WITH HYPERTENSION
Introduction
"Divinum opus est sedare dolor" thes are the
words of Hippocrates and means "It's divine to
alleviate pain". Chemical agents that accomplish this
goal are called local anesthetics, local anesthetic
solutions or local analgesia. Perhaps the term local
analgesia is didactically more correct term to use
from the conventional local anesthesia [1], because
with this procedure the patient does not loose consciousness as in general anesthesia, than is achieved
by reversible absence of pain – analgesia of certain
regions. Local anesthetics are leading to inability to
cell depolarization and subsequent creation of a
nerve impulse by reducing the permeability of sodium channel [2]. Local anesthetic agents themselves
produce vasodilatation (except cocaine) during infiltration. Vasoconstrictors are added to local anesthetics due to the slowdown of absorption, prolonging
the anesthetic action, reducing the increase in the
concentration of anesthetic in plasma and blood flow
reduction in the operative field. Adrenaline (epinephrine) is a vasoconstrictor, which is most commonly
used in local anesthetics. It acts directly on alpha and
beta adrenergic receptors, but the effect of beta is
dominant. Among many systemic effects on heart,
adrenaline acts via beta 1 receptor positive inotropic
and chronotropic, increasing cardiac output and
heart rate, and causes vasodilation of the coronary
arteries thus increasing the blood flow. It affects the
cardiovascular dynamics by direct stimulation, increasing systolic and diastolic pressure, heart rate,
stroke volume, cardiac muscle contractions and
oxygen consumption.
Adrenaline is often used for local hemostasis due
to activation of alpha receptors. This effect is transient, because decreasing amounts of adrenaline
leads to a predominance of beta 2 receptors and consequent vasodilatation.
Peterson recommended that the maximum dose
of the local anesthetic in patients with compromised
cardiovascular status may not exceed 4 ml of the
anesthetic and adrenaline 0.04 for a period of 30 min.
[3, 4].
Hypertension (Greek hyper - over, over and fluent
- tension, weigh up, spread out), namely arterial hypertension (AH) is a disease of high blood pressure.
According to the agreed standards of the World
Health Organization (WHO), adults, ie. persons aged
104
20 years or more, are considered hypertensive if the
values ​of blood pressure are above 140/90 mmHg on
constant basis, when determined auscultatory by
using a mercury manometer, given diastolic pressure
is determined at the level of phase V Korotkovljev
noise [5].
Malamed [6] divides hypertensive patients into
groups of ASA (American Society of Anesthesiologists Physical Status Classification System) determining their indications and contraindications for
the use of local anesthesia with vasoconstrictor.
- ASA I patients - healthy patients without systemic
disease, normotensive
- ASA II patients - mild systemic disease, blood
pressure S (systolic) 140-159 mmHg, D (DBP) 9094 mmHg
- ASA III patients - severe systemic disease that
limits activity, blood pressure 160-199 mmHg, S, D
95-114 mmHg
- ASA IV patients - patients with severe systemic
diseases that threaten life, blood pressure S> 200
mmHg, D> 115 mm Hg
- ASA V patients - patients who are not expected to
survive 24 hours
In ASA III patients local anesthesia with vasoconstrictor is not contraindicated. In ASA IV patients local anesthesia and dental treatment are contraindicated until blood pressure is corrected.
The aim of the study
Compare the effect of two different concentrations of epinephrine (1:80.000 and 1: 160.000) of
local anesthesia (2% lidocaine) on hemodynamic
parameters (heart rate, systolic and diastolic
pressure) in patients with hypertension
Patients and Methods
This is a prospective, controlled, clinical-experimental, single-blind study. The study includes a total
of 30 patients of both sexes and all age groups. After
the first dental examination, each patient extracted at
least one tooth, ie. we performed two applications of
local anesthesia.
All patients have verified essential hypertension.
The study does not include patients with clinically
Stomatološki vjesnik 2014; 3 (2)
Trninic S, Šečić S, Trninić L
significant cardiac disease, pregnant women,
patients with impaired renal function, patients with
blood pressure S> 180 mmHg and / or D> 110 mm Hg,
patients with symptomatic hypertensive patients undergoing therapy with non-selective beta.
Tooth extractions and all measurements were
done at the Department of Oral Surgery, Faculty of
Dentistry in Sarajevo. All patients signed a voluntary
consent. Patients are administered local anesthetic, a
vasoconstrictor A or B with a dose of 2 ml, which does
not exceed the dose for patients at risk per visit, 0.04
mg / 2 ml [6, 4]. A local anesthetic - 2% lidocaine with
epinephrine concentration 1: 80,000, corresponding
to 40 mg / 0,025 mg (lidocaine / epinephrine) in 2 ml.
Local anesthetic B - 2% lidocaine with epinephrine
concentration 1: 160,000, corresponding to 40 mg /
mg 0.0125 (lidocaine / epinephrine) in 2 ml. The anesthetic is applied with plexus (terminal) anesthesia,
after negative aspiration. Patients were divided into 2
groups, each of which comprising of 30 patients who
are given anesthetic A or B.
At the first visit, each patient was given 2%
lidocaine with epinephrine at a concentration of 1:
160.000, and then at the second visit the same
anesthetic with increased levels of adrenaline 1:
80,000. Over all patients, whether they are in group A
or B group, we performed monitoring of blood pressure and pulse with the Norav Medical Company
machine NBP-24. Each patient goes through four
stages (F1, F2, F3, F4). F1 phase is preoperative
(stabilization of vegetative nervous system (VNS),
measured blood pressure and heart rate), F2 and F3
are operative (application of anesthesia and tooth
extraction, measured blood pressure and pulse), and
postoperative F4 (stabilization of the VNS, measured
blood pressure and heart rate).
The patient was scheduled for the next tooth extraction when he was given a local anesthetic with a
different concentration of adrenaline. The minimum
interval between tooth extractions at the same
patient was two days.
Female
50%
Male
50%
15
patients
15
patients
Figure 1.
The percentage of male and female patients
1,2
1,0
0,8
0,6
0,4
0,2
0,0
elevation of systole
pressure in mmHg
% of elevation
a - conc. 1:80.000
1,01
0,64
b - conc. 1:160.000
0,94
0,59
Figure 2.
Comparative values of systolic pressure after aplication
of anesthesia 2% lidocaine with concentration of epinephrine
1:80.000 and 1:160.000 (Phase 2)
Statistical analysis was done in Epi Info program.
Test results showed that systolic blood pressure
slightly increases after application of 2% lignocaine
with adrenaline concentration of 1: 80,000 in
relation to systolic pressure after application of 2%
lignocaine with adrenaline concentration of 1:
160,000 (F2 stage).
10
8
6
4
2
0
Results
The study included a total of 30 patients who
addressed to the Department of Oral Surgery for
tooth extraction. All patients had verified essential
hypertension.
Stomatološki vjesnik 2014; 3 (2)
decrease of systole
pressure in mmHg
% of decrease
a - conc. 1:80.000
9,49
6,01
b - conc. 1:160.000
5,54
3,49
Figure 3.
Comparative values of systolic pressure at the end of
dental treatment at hypertensive patients who recived
anesthetic 2% lidocaine with epinephrine concentration
1.80.000 and 1:160.000 (Phase 4)
105
COMPARISON OF INFLUENCE OF TWO DIFFERENT EPINEPHRINE CONCENTRATIONS IN LOCAL ANESTHESIA ON HEMO-DYNAMIC PARAMETERS IN PATIENTS WITH HYPERTENSION
Test results showed that on average the systolic
pressure is more reduced 20 minutes after tooth
extraction (F4 stage) when administered 2%
lidocaine at a concentration of adrenaline 1: 80,000,
but in the same individual with a concentration of
adrenaline 1: 160,000 compared to the F1 stage.
Results of the Kruskal-Wallis test showed no
significant statistical difference between the value of
systolic pressure after anesthesia (F2), after tooth
extraction (F3) and 20 minutes after tooth extraction
(F4) in hypertensive patients who at firt visit were
administered with solution of local anesthetic 2%
lidocaine with epinephrine concentration of 1:
80,000, and at the second visit a concentration of
adrenaline 1: 160 000, H = 3.429, p> 0.05 (p = 0.333).
This study showed that diastolic blood pressure
was slightly more reduced after administration of 2%
lidocaine with epinephrine concentration of 1:
80,000 compared to diastolic blood pressure after
anesthesia with lidocaine 2% concentration of 1:
160,000 (Phase 2).
The study showed that 20 minutes after tooth
extraction in hypertensive patients there was a
greater reduction in diastolic blood pressure after
2% lidocaine with epinephrine concentration of 1:
160,000 compared to patients who were applied 2%
lidocaine with epinephrine concentration of 1:
80,000 compared to F1 stage.
Results Kruskal-Wallis test showed no significant
difference between the values ​of diastolic blood
pressure after anesthesia (F2), after tooth extraction
(F3) and 20 minutes after tooth extraction (F4) in
hypertensive patients who were administered in the
first visit a solution of local anesthetic 2% lidocaine
with epinephrine concentration of 1: 80,000, and in
the second visit with the concentration of adrenaline
1: 160 000, H = 3.244, p> 0.05 (p = 0.476).
These studies have shown that the pulse slightly
increases after application of 2% lignocaine with
adrenaline concentration of 1: 160,000 in relation to
the pulse following the application of 2% lidocaine
with epinephrine concentration of 1: 80,000 (F2
stage).
Examination has shown that 20 minutes after
tooth extraction, hypertensive patients had a greater
decrease in heart rate after 2% lidocaine with epinephrine concentration of 1: 80,000 compared to patients who were applied 2% lidocaine with adrenaline at a concentration of 1: 160,000 compared to F1
stage.
106
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0,0
decrease of dyastole
pressure in mmHg
% of decrease
a - conc. 1:80.000
0,06
0,666
b - conc. 1:160.000
0,03
0,033
Figure 4.
Comparative values of dyastolic pressure after aplication of
anesthesia 2% lidocaine with concentration of epinephrine
1:80.000 and 1:160.000 (Phase 2)
5,0
4,5
4,0
3,5
3,0
2,5
2,0
1,5
1,0
0,5
0,0
decrease of dyastole
pressure in mmHg
% of decrease
a - conc. 1:80.000
1,77
1,94
b - conc. 1:160.000
4,37
4,82
Figure 5.
Comparative values of dyastolic pressure at the end of dental
treatment at hypertensive patients who recived anesthetic 2%
lidocaine with epinephrine concentration 1.80.000 and
1:160.000 (Phase 4)
1,2
1,0
0,8
0,6
0,4
0,2
0,0
elevation of pulse
in beats/min.
% of elevation
a - conc. 1:80.000
0,87
0,98
b - conc. 1:160.000
1,10
1,20
Figure 6.
Comparative values of pulse after aplication of anesthesia 2%
lidocaine with concentration of epinephrine 1:80.000 and
1:160.000 (Phase 2)
Stomatološki vjesnik 2014; 3 (2)
Trninic S, Šečić S, Trninić L
8
7
6
5
4
3
2
1
0
decrease of pulse
in beats/min.
% of decrease
a - conc. 1:80.000
5,89
7,88
b - conc. 1:160.000
2,28
2,56
Figure 7.
Comparative values of pulse at the end of dental treatment at
hypertensive patients who recived anesthetic 2% lidocaine
with epinephrine concentration 1.80.000 and 1:160.000 (Phase 4)
Results of the Kruskal-Wallis test showed no
significant statistical difference between the value of
pulse rate after anesthesia in hypertensive patients
(F2), after tooth extraction (F3) and 20 minutes after
tooth extraction (F4) in hypertensive patients who
were administered in the first visit a solution of local
anesthetic lidocaine 2% with epinephrine concentration of 1: 80,000, and in the second visit with the
concentration of adrenaline 1: 160 000, H = 4.098, p>
0.05 (p = 0.343).
Discussion
Patients with hypertension are frequent patients
in a dental office. Data NHANES 3 studies show that
20% of the population, one in five, have hypertension,
and only 21% of these patients have successfully
egulated blood pressure levels [7].
Modern dentistry is unimaginable without the use
of local anesthesia or analgesia and is one of the
criteria for quality dental services. Local anesthetics,
except cocaine, cause vasodilatation during the
infiltration, and don't have the necessary length and
depth of anesthesia [8, 9], thus vasoconstrictors are
added to the local anesthetic solutions, usually
epinephrine, to minimize systemic absorption and
consequently toxic effect of anesthetics, to prolong
the effect of [10] as well as the depth of anesthesia
[11], and to decrease bleeding in the operative field
[12]. In the case of fear and pain during dental
Stomatološki vjesnik 2014; 3 (2)
interventions these ​adrenaline values can increase
up to 40 times [13, 14]. The pain may occur during
dental interventions due to inadequate anesthesia
and it should be avoided. Therefore, the use of
anesthetics with minimal amounts of exogenous
entered adrenaline, extravasculary administered,
has its justification rather than to leave the patient to
suffer pain during dental treatment when endogenous catecholamines are released directly into the
circulation.
These catecholamines inevitably lead to changes
in hemodynamic parameters that can not be controlled, because the amounts released are different in
each patient, instead of the known quantities we
apply in the local anesthetic solution.
Therefore, pain control is imperative in dentistry
for all patients, especially to those who are medically
compromised. Most of the recommendations advise
caution in the use of epinephrine in local anesthesia
in hypertensive patients [15], while others are
against its use [16]. At the first visit, our patients are
always applied with 2% lidocaine with adrenaline at
a concentration of 1: 160,000, and then, at the second
visit, with the same anesthetic but with increased
levels of adrenaline 1: 80,000.
The study was conducted as a single-blind, so the
patient did not know what kind of anesthetic is
administered. This is done to exclude fear as a provoking factor that exists in the dental intervention,
particularly in oral surgery.
We tried to reduce the secretion of endogenous
catecholamines, especially norepinephrine, due to its
adverse effects to the cardiovascular dynamics. This
explains why the pulse rate and systolic blood pressure in some patients were higher after application of
anesthesia with a concentration of adrenaline 1:
160,000. Systolic blood pressure and pulse are slowly
increasing due to beta-1 receptors, and diastolic
blood pressure falls due to beta 2 receptors.
Drop in blood pressure and heart rate in relation
to the value after the application of anesthesia and
return to approximately the same value or less in the
patient before the intervention goes in favor of reducing the secretion of endogenous catecholamines
and stabilization of vegetative nervous system.
These results are consistent with results published by Petronijević, Sulejmanagić and colleagues
[17], who stated that the increase in blood pressure
and pulse rate after application of a local anesthetic
as well as an easy tend to decrease after the inter107
COMPARISON OF INFLUENCE OF TWO DIFFERENT EPINEPHRINE CONCENTRATIONS IN LOCAL ANESTHESIA ON HEMO-DYNAMIC PARAMETERS IN PATIENTS WITH HYPERTENSION
vention may be explained by neurovascular reactions, ie. psychogenic factors.
Bader and his associates in their work in 2002
[18] tried to answer the question: 'What are the
additional adverse cardiovascular risks caused by
local anesthesia with adrenaline in controlled and
uncontrolled hypertensive patients in need of dental
treatment? He browsed the Medline and Embase
database, then Cochran list of controlled studies and
referenced relevant studies authors, and came to 373
scientific papers that dealt with local anesthesia, out
of which only six were related to the issue raised by
the author.
In these 6 studies, 325 patients were included, of
which 177 hypertensive. Of the total number of hypertensive patients 14% were taking antihypertensive medication.
In all studies, the effects of 2% lidocaine with
epinephrine concentration of 1: 80,000 and 1:
100,000 have been examined. The total quantity of
anesthetic administered was 2 to 4.5 ml, and blood
pressure and pulse were measured.
Patients required tooth extraction in 5 out of these
6 studies. Blood pressure monitoring in three studies
was made 5 minutes after anesthesia, while in other
two studies half-minute and 2 minutes after injection
respectively. On the basis of these studies, the authors
come to the conclusion that the maximum change in
blood pressure from baseline in hypertensive patients for systolic pressure was 15.3 mmHg, diastolic
2.3 mm Hg and heart rate 9.3 beats / min. These
results are correlating to ours, except for diastolic
blood pressure, being shown as the total value with a
slight increase, possibly due to the amount of anesthetic administered and the time measurement of
blood pressure and pulse. It is because the biotransformation of adrenaline is relatively quick, it enters
into circulation, and takes place over kateholortometiltransferaze, so immediate effects may remain
undetected. Gangormus [19] 2003 conducted research to evaluate changes in blood pressure and
heart rate in hypertensive patients requiring dental
extractions. Blood pressure and heart rate were
measured by a digital pressure gauge immediately
after anesthesia, before extraction and five minutes
after extraction. The fluctuation of the average
systolic blood pressure in hypertensive was -5.21 at
the end of the test. The results are consistent with
ours, with minor variations at the end of the test. The
differences in the depth of anesthesia with 2%
108
lidocaine with adrenaline at a concentration of 1:
80,000 and 1: 160,000 don't exist, except for
differences in hemostasis [20]. The maximum dose
for patients with KVS problems is 0.04 mg per visit
[10], or one ampoule 2 ml of the anesthetic lidocaine
2% with epinephrine at a concentration of 1: 80,000.
In those patients, we should consider applying
anesthesia with reduced levels of adrenaline 1:
160,000, which will enable us good anesthesia of
pulpa, soft tissue anesthesis and solid hemostasis
comparing to the 2% lidocaine at a concentration of
adrenaline 1: 80,000.
This anesthesia gives us the possibility of applying
2 ampoules 2 ml to medically compromised patients
because it does not exceed the dose, and at the
anesthesia failure it gives us the ability to repeat the
anesthesia. Anesthesia 1: 160,000 is good considering its depth, but the effect of hemostasis is bad. It
could be of use in tooth extractions and minor oral
surgical interventions when we do not expect major
hemorrhage.
Conclusions
1. No significant statistical difference in blood
pressure and pulse rate after application of the local
anesthetic lidocaine 2% with adrenaline in
concentrations of 1: 80,000 and 1: 160,000, systolic
pressure H = 3.429, p> 0.05 (p = 0.333), diastolic
pressure H = 3.244, p> 0.05 (p = 0.476) and pulse H =
4.098, p> 0.05 (p = 0.343).
2. Based on these analyzes, and the fact that even
in these groups of patients with hypertension during
the administration of the local anesthetic lidocaine
2% with adrenaline at a concentration of 1: 80,000
and 1: 160,000 we found significant statistical
differences in clinical practice, we recommend the
use of local anesthetic lidocaine 2% the
concentration of adrenaline 1: 80,000 in oral surgery
requiring more consistent hemostasis. However, in
the routine work of a dental practitioner with tooth
extraction in these patients, we recommend the use
of local anesthesia of 2% lignocaine with adrenaline
at a concentration of 1: 160,000, because we may
control pain and bleeding successfully.
Stomatološki vjesnik 2014; 3 (2)
Trninic S, Šečić S, Trninić L
References
1.
Todorović Lj, et al. Anestezija u stomatologiji.
Beograd: Univerzitet u Beogradu; 1997.
2.
Hille B, et al. Rate and site of action of local anesthetics in myelinated nerve fibers. In Fink BR,
editor:Molecular mechanisms of anesthesia.
New York, Rven Press; 1975:13-20
3.
4.
Peterson L., Ellis E., Hupp J., Tucker M. Contemporary Oral and Maxillofacial Surgery, 4th edition.
St. Louis: Mosby; 2003.
Kućanski B, Sulejmanagić H, Mustagrudić D,
Gojkov T. Oralna hirurgija, I dio, II izdanje, urednik: Sulejmanagić H. Sarajevo: USBiH; 1998
5.
Vrhovac B, et al. Interna medicina. Zagreb: Naklada Ljevak; 2003:566-83
6.
Malamed FS. Sedation. 4th edition: Mosby; 2003
7.
Working group report on primary prevention of
hypertension: National high blood pressure education program. Bethesada MD, National institute of health, national heart lung and blood
institute. 1993:93.
8.
Kessling F, Hinds C. Optimal concentration of
epinefrin in lidocain solution.J Am Dent Assoc.
1993;66 :337-340.
9.
Cowan A. Minimum dosage techniqe in the clinical comparasion of representative modern local
anaestetic techniques.J Dent Res. 1964;43:12281249.
10. Jage J. Circulatory effects of vasoconstrictors
combined with local anesthetics. Anesth Pain
Cont Dent. 1993;2:81-86.
12. Syngcuk K, et al. Haemostasis in endodontic surgery. Dent Clin North Amer. 1997;41:499-511.
13. Selaković S. Naučna stomatološka misao u Vojvodini: Povodom 25 godina rada Klinike za stomatologiju u Novom Sadu. Novi Sad: Univerzitet u
Novom Sadu, Klinika za stomatologiju; 2003;326.
14. Glover J. Vasoconstrictors in dental anesthetics.
Contraindications-Fact or Fallacy? Aust Dent J.
1968;13(1):65-69.
15. Glick M, New guidelines for prevention, detection, evaluation and treatment of high blood
pressure. J Amer dent Assoc. 1998;129:1588-94.
16. Goulet JP, et al. Contraindications to vasocontrictors in dentistry. Part 3. Pharmacologic interactions. Oral Surg Oral Med Oral Pathol. 1992;
74:692-7.
17. Petronijević S, Sulejmanagić H, Beganović M,
Radičević N. Kliničko ispitivanje djelovanja lidokaina, prokaina i butanilkaina. Stomatološki
glasnik Srbije. 1981;28(3):159-64.
18. Bader JD, Bonito AJ, Shugars DA. A systematic
review of cardiovascular effects of epinephrine
on hypertensive dental patients. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2002;93(6):
647-53.
19. Gungormus M., Buyukkurt M.C. The evaluation of
the changes in blood pressure and puls rate of
hypertensive patients during tooth extraction.
Acta Med Austriaca. 2003;30(5):127-9.
20. Johman K. Lokalni anestetici u stomatološkoj
praksi: Smjernice u izboru odgovarajućeg anestetika. Medix. 1999;25/26(5):99-101.
11. Falaiye VO, et al. Influence of adrenalin on the
onset time of lignocaine anesthesia. J Dent.
1990;18:221-23.
Stomatološki vjesnik 2014; 3 (2)
109
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
RELATIONSHIP BETWEEN PERIODONTAL
STATUS AND OSTEOPOROSIS AMONG
WOMEN IN MENOPAUSE
Gojkov Vukelić M*¹, Hadžić S¹, Dedić A¹, Pašić E¹
1
Department of Oral Medicine and Periodontology, Faculty of Dentistry,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
*Corresponding author
Mirjana Gojkov Vukelić,
Assitant Professor, PhD
Department of Oral Medicine
and Periodontology
Faculty of Dentistry,
University of Sarajevo
Bolnička 4a
71000 Sarajevo
Bosnia and Herzegovina
Phone: +387 33 210 683
e-mail : [email protected]
ABSTRACT
Introduction: The periodontal disease and osteoporosis are
resorptive bone diseases. Periodontitis is an inflammatory
disease characterized by the resorption of the alveolar bone and
loss of the soft connective tissue around teeth and constitutes the
most frequent cause of loss of teeth in adults. Osteoporosis is a
metabolical disease that is characterized by a reduction of bone
tissue quantity per unit of volume of anatomic bone thus making
the bone mechanically less valuable and increasing the possibility
of break occurrence even with small trauma.
The objective: The aim of this study was to evaluate relationship between periodontal status and osteoporosis.
Material and methods: Our study included 76 women in
menopause. Based on densitometry results, they were divided
into three groups. All participants went through the anamnesis
protocol, clinical examination and an orthopantomogram was
made. Based on the orthopantomogram analysis, the type of
mandibular bones resorption was determined.
Results: All participants had an adequate oral hygiene with a
medium value of the plaque index and papilla bleeding index up to
1.69 participants of the analyzed sample (90.8%) have a
periodontal bone resorption. In 83% of patients, the horizontal
type of periodontal resorption dominates, 8% of participants
have the combined type of resorption, and in 9% of participants
there was no resorption of the alveolar bone. The combined type
of resorption was perceived at 5 participants with osteoporosis,
only 1 participant with osteopenia and there were no such cases
of healthy participants.
Conclusion: This study suggested that there was a significant
relationship between periodontal disease and bone mineral
density. Further well-controlled studies are needed for better
analysis of the correlation between the systematic and alveolar
bone loss.
Key words: periodontitis, alveolar bone loss, osteoporosis,
menopause.
Stomatološki vjesnik 2014; 3 (2)
111
RELATIONSHIP BETWEEN PERIODONTAL STATUS AND OSTEOPOROSIS AMONG WOMEN IN MENOPAUSE
Introduction
Periodontal disease and osteoporosis are resorptive bone diseases. Periodontitis is an inflammatory
disease characterized by the alveolar bone resorption and loss of the soft connective tissue around
teeth and it is the most frequent cause of teeth loss in
adults. The loss of the alveolar bone is the most critical moment in the pathogenesis of the periodontal
disease.
The loss of bone actually signals the irreversibility
of the pathological process. The alveolar bone resorption may be explained by means of different
mechanisms. The common denominator of all of
these is the activation of the osteoclasts that demineralize the bone and degrade the non-collagen matrix
[1,2]. Since the alveolar bone loss is the most pronounced characteristic of the periodontal disease,
more severe forms of osteoporosis/osteopenia might
be viewed as an aggravating condition in the case of
periodontal destruction [3].
Osteoporosis is a metabolical disease characterized by the reduction of bone tissue quantity per
unit of anatomic bone volume, making bone mechanically less valuable and increasing the possibility for
the break occurrence even with a small trauma [4].
The loss of bone mass in osteoporosis is produced by
the activity of osteoclasts being either stronger or
expanded, thus making the resorption great. Today,
the prevailing opinion is that osteoporosis is not a
single disease, but rather a heterogeneous disturbance with several different causes [5]. The disease
primarily occurs in women, and it is particularly pronounced in menopause. Over the past several years,
there has been an increase in the correlation between
the systematic osteoporosis, oral loss of bone mass,
loss of teeth and periodontal disease. The basic goal
of this research was to evaluate the correlation of
periodontal status and bone mineral density in postmenopausal women.
index and measurement of periodontal pocket
depth) and an orthopantomogram was made. The
plaque evaluation was conducted by means of the
plaque index (Silness and Loe, 1964), the existence of
inflammation and activity of pockets was examined
by applying the papilla bleeding index – PBI (Saxer
and Mullemann, 1975). Depth of periodontal pockets
was measured for every tooth from two sides (mesial
and distal) following the enamel and cement line to
the bottom of the pocket. Measurements were
conducted by applying the Williams periodontal
probe graduated by 2 mm. Based on the analysis of
the orthopantogram, the type of mandibular bone
resorption was determined: The horizontal type of
alveolar bone resorption represented a line drawn by
the resorptive bone surface that forms a right angle
with the longitudinal tooth axe – the supra-bone
pocket. The vertical type of alveolar bone resorption
represented a line drawn on the resorptive bone
surface that forms a sharp angle with the longitudinal
tooth axe – the infra-bone pocket. The combined type
of alveolar bone resorption on the orthopantogram
was visible as a combination of the horizontal and
vertical type of resorption (infra-bone and suprabone pockets). All relevant anamnesis data and
analyzed parameters were entered in the file that was
specifically prepared for this research.
In the process of statistical data processing were
used: descriptive statistics, chi-square (χ2) test,
Pearson correlation, T-test for independent samples
and ANOVA (analysis of variance).
Results
In the analyzed sample, 69 participants (90,8%)
have periodontal bone resorption, and only 7 participants (9,2%) do not have periodontal bone resorption (Figure 1). In 83% of patients, the horizontal
Material and methods
Our study included 76 patients in menopause.
Based on densitometry result, they were divided into
three groups (24 healthy women, 26 women with
osteopenia and 26 women with osteoporosis). All
participants went through the anamnesis protocol,
clinical examination (plaque index, papilla bleeding
112
9,2
90,8
bone resorption
no bone resorption
Figure 1. Percentual presentation of periodontal
resorption for the whole sample.
Stomatološki vjesnik 2014; 3 (2)
Gojkov Vukelić M, Hadžić S, Dedić A, Pašić E
Healthy patients
Presence of the
combined type of
bone resorption
Yes
No
Total
Groups
Patients with
osteopenia
Patients with
osteoporosis
Total
Frequency
0
1
5
6
% among groups
0.0%
16.7%
83.3%
100.0%
Frequency
24
25
21
70
% among groups
34.3%
35.7%
30.0%
100.0%
Frequency
24
26
26
76
% among groups
31.6%
34.2%
34.2%
100.0%
Table 1. Correlation between the presence of the combined type of periodontal resorption and groups.
type of periodontal resorption dominates, in 8% of
participatns' cases, there is a combined type of periodontal resorption, and in 9% of participants, there
is no alveolar bone resorption. In all three groups
there was a pronounced horizontal alveolar bone resorption. A combined type of resorption was identified in the case of 5 participants with osteoporosis, in
only 1 participant with osteopenia and there were no
healthy participants.
By analyzing the correlation between the presence of the combined type of periodontal resorption
and groups, we established that the presence of
combined type of bone resorption was more frequent
in case of patients suffering from osteoporosis (f = 5)
as compared to healthy patients (f = 0) and patients
suffering from osteopenia (f = 1) (Table 1). The
significance of the chi-square ( (χ2) = 7.24, p = 0.03.)
points to a correlation between the presence of the
combined type of bone resorption and occurrence of
osteoporosis (i.e. groups).
All participants had an adequate oral hygiene with
a medium value of plaque index and papilla bleeding
index up to 1.
Plaque
index
Clinically
measured
pocket depth
Pocket depth
on the
radiograph
Pearson's correlation
0.434
0.415
Significance
0.000
0.000
N
76
76
Table 2.
Correlation between the plaque index and
pocket depth (clinically measured pocket depths
and pocket depth on the radiograph).
Stomatološki vjesnik 2014; 3 (2)
By analyzing the correlation between the plaque
index and depth of the periodontal pocket, we
identified that the average values of the plaque index
were statistically significantly related (at a level with
a 99% certainty) to the average values of the clinically
measured pocket depth (r=0.43) and pocket depth
measured by a radiograph (r = 0.42) (Table 2).
By analyzing the correlation between the papilla
bleeding index and periodontal pocked depth, we
established that the average values of the papilla
bleeding index are statistically significantly related
(with a reliability of 99%) to the average values of the
clinically measured periodontal pocket depth (r =0
.46) and pocket depth measured by means of a
radiograph (r = 0.46) (Table 3).
The T-test for independent samples has shown
that the average value of papilla bleeding index regarding the presence of periodontal resorption (M =
0.94) is considerably higher (with a reliability of
96%) compared to cases with no bone resorption (M
= 0.47) (Table 4). The average value of the papilla
bleeding index increases with the alveolar bone
resorption.
Pearson's correlation
Papilla
bleeding Significance
index
N
Clinically
measured
pocket depth
Pocket depth
on the
radiograph
0.465
0.463
0.000
76
76
Table 3.
Correlation between the papilla bleeding index and
periodontal pocket depth (measured clinically and
by means of a radiograph).
113
RELATIONSHIP BETWEEN PERIODONTAL STATUS AND OSTEOPOROSIS AMONG WOMEN IN MENOPAUSE
By analyzing the correlation between periodontal
pocket depth with combined type of alveolar bone
resorption Levens's test of equality of variance ( A - F
(1.74) = 0.42,p=0.52. B- F (1.74) = 0.53, p = 0.47.)
showed no statistically significant indication that the
variance of the average values ​of pocket depth (clinically measured pocket depths and pocket depth on
the radiograph) is statistically different in relation to
the presence of the combined type of bone resorption
(Table 5).
A. The T-test established that the average value of
the pocket depth mesured cliniclly in the case of the
combined resorption of the alveolar bone presence
(M=5.32) is considerably higher ( at 99% significancy
level) in comparison to cases in which the combined
type of bone resorption was not recorded (M= 2.86)
B. The T-test established that the average value of
the pocket depth mesured on the radiograph in the
case of the presence of combined resorption of the
alveolar bone (M=4.22) is considerably higher ( at
99% significancy level) in comparison to cases in
which the combined type of bone resorption was not
recorded (M= 3.57) (Table 6).
T - test
T
2.136
df
74
Sig.
0.036
Mdiff
0.47
Se
0.22
95% Reliability
Interval
Lower
Upper
0.03
0.91
Table 4.
T-test for independent samples between
papilla bleeding index and periodontal resorption.
Combined type
of alveolar bone
resorption
N
M
SD
Se
A.
Clinically measured
pocket depth
Yes
6
4.22
0.73
0.29
No
70
2.86
0.56
0.07
B.
Pocket depth on
the radiograph
Yes
6
5.32
0.83
0.34
No
70
3.57
0.66
0.08
Table 5.
Relationship between periodontal pocket depth
with combined type of alveolar bone resorption.
T - test
Discussion
Only several studies reported on the statistically
relevant correlation between a decrease in BMD in
different locations and loss of teeth [6,7]. Recent studies have provided stronger evidence on the correlation between osteoporosis and loss of the epithelial
tissue as a characteristic of periodontitis [8,9,10].
Authors Guiglia et al., in addition to the presence of
common risk factors, also believe that there may be
common factors in the pathogenesis of both of these
diseases. In their research, they state that microorganisms can change the normal homeostasis of bone
tissue by increasing the osteoclastic activity and decreasing both the local and systematic bone density
through direct impact (release of toxins) and/or
indirect mechanisms (release of infection mediators)
[11]. In our clinical study, the results have shown that
periodontitis is characterized by the presence of a
combined type of alveolar bone resorption and in
case of mandibular bones is more frequent in patients suffering from osteoporosis as compared to
healthy patients and patients suffering from osteo114
T
df
Sig.
Mdiff
Se
95% Reliability
Interval
Lower
Upper
5.542
74
0.000
1.36
0.24
0.87
1.85
6.120
74
0.000
1.75
0.29
1.18
2.32
Table 6.
T–tests for independent samples between periodontal pocket
depth and combined type of alveolar bone resorption.
penia. The goal of the study conducted by Vishwanath
et al. was to assess the correlation between the periodontal status and bone mineral density (BMD) in
women in menopause, and the skeletal bone density
of BMD was measured by means of the quantitative
ultrasound technique. Based on the obtained results,
it was concluded that BMD is related to the loss of the
alveolar bone and it implies that the loss of BMD in
menopause may be a risk indicator for periodontitis
in women [12]. These results correspond to the
results of our research, although we used the
densitometry analysis for determining the skeletal
bone density (two-energy absorption measurement
of x-rays – DXA) due to the possibility of precise
Stomatološki vjesnik 2014; 3 (2)
Gojkov Vukelić M, Hadžić S, Dedić A, Pašić E
measurement of skeletal density in several locations
(spinal column, hip) and the least exposure of
patients to x-rays, as well as due to the research
conducted by Al Habashneh et al. They examined the
relation between the skeletal bone density (BMD),
radiographic finding of mandibular bones and clinical parameters of the periodontal status of women
in menopause in Jordan. The analysis of the obtained
results has shown that it is more probable that
women with osteoporosis will face a serious loss of
the alveolar crestal height (ACH) and periodontitis,
and they believe that osteoporosis is considerably
related to the loss of the alveolar crestal height and
prevalence of periodontitis in women in menopause
in Jordan [13]. A decreased BMD, together with an
increase in the clinical parameters of the periodontal
status, independently from the plaque index,
suggests that there is a correlation between BMD and
periodontal status, which is also in compliance with
the findings of Passos et al., Estrugo-Deves et al., and
Kim et al. [14,15,16] and findings of our research.
Moeintaghavi et al. analyzed the potential correlation
between osteoporosis and periodontal indices, such
as the plaque index, pocket depth, loss of connective
tissue, loss of alveolar bone and loss of teeth among
women in menopause in Iran in order to explain
some of the existing controversies. In conclusion,
within the parameters of this research, changes in the
analyzed periodontal indices were not related to the
decrease in BMD, so they share the opinion that
further studies with larger samples are needed in
order to support these conclusions [17]. These
findings do not correspond with our findings,
although we can agree with the conclusion that better
controlled studies with larger samples are needed in
order to obtain more precise results.
Aspalli et al. also believe that further studies are
needed in order to better understand the relationship between these two diseases, and we agree with
it. The authors believe that osteoporosis may be
considered as risk factor for periodontitis. An analysis of clinical findings suggests that patients suffering
from osteoporosis should be advised to pay more
attention to their oral health in order to prevent any
periodontal problems [18]. Due to the prevalence of
osteoporosis, understanding of its etiology and
actual treatment regime in case of patients suffering
from a low bone density is crucial for dentists. Millions of patients today are taking osteoporosis medication (e.g. biosphosphonates), and periodontology
Stomatološki vjesnik 2014; 3 (2)
specialists should be aware of the numerous
treatment possibilities of these drugs [19]. It is well
known that biosphosphonates are not indicated as
part of the periodontitis therapy, especially du to the
possible risk of osteonecrosis. Dentists should
closely cooperate with their physician colleagues
who prescribe a biophosphonates therapy in order to
ensure the best possible periodontal and teeth health
before patients start with a biophosphonates
therapy. Although our research did not include
patients using an osteoporosis therapy, we believe
that a good cooperation with physicians is crucial due
to the correlation between the loss of skeletal bone
density and alveolar bone resorption in case of
periodontitis.
Conclusion
This study suggested that there was a significant
relationship between periodontal disease and bone
mineral density. Further well-controlled studies are
needed for a better analysis of the correlation
between the systematic and alveolar bone loss.
References
1.
Topić, B. Parodontologija: biologija, imunopatogeneza, praksa. Sarajevo: Stomatološki
fakultet; Zagreb: Medicinska naklada; 2005.
2.
Lyons K. Dental Applications for Bone Morfogenetic Proteins. intranet.biolchem.ucla.edu
/bc205/lyons/04docs/pptpdfs2004/lec3bmp.
pdf - Supplemental
3.
Yoshihara A, Hanada N, Miyazaka HA. A longitudinal study of the relationship between periodontal disease and bone mineral density in community dwelling older adults. J Clin Periodontol.
2004;31:680-684
4.
Rumenjak V. Oksidacijski stres kao rizični čimbenik u nastanku osteoporoze, Bochemia Medica,
2005;15:1-2.
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Curtis WS, Whyte W, Lenrow D. Osteoporosis
(Secondary). EMedicine.com 2005.
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6.
Megson E, Kapellas K, Bartold PM Relationship
between periodontal disease and osteoporosis.
Int J Evid Based Healthc. 2010 Sep;8(3):129-39.
periodontal disease and osteoporosis in postmenopausal women in jordan. 2010;81(11):
1613-21.
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Kribbs PJ. Comparison of mandibular bone in
normal and osteoporotic women. J Prosthet Dent
1990;63:218-22.
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Otomo-Corgel J. Osteoporosis and osteopenia:
Implications for periodontal and implant therapy. Periodontol 2000 2012;59:111-39.
14. Passos JS, Vianna MI, Gomes-Filho IS, Cruz SS,
Barreto ML, Adan L, et al. Osteoporosis/osteopenia as an independent factor associated with
periodontitis in postmenopausal women: a casecontrol study. 2013;24(4):1275-83.
9.
Martínez-Maestre MÁ, González-Cejudo C, Machuca G, Torrejón R, Castelo-Branco C. Periodontitis and osteoporosis: A systematic review.
Climacteric 2010;13:523-9.
10. Shum I, Leung PC, Kwok A, Corbet EF, Orwoll ES,
Phipps KR, et al. Periodontal conditions in elderly men with and without osteoporosis or
osteopenia. J Periodontol 2010;81:1396-402.
11. Guiglia R, Di Fede O, Lo Russo L, Sprini D, Rini GB,
Campisi G. Osteoporosis, jawbones and periodontal disease. Med Oral Patol Oral Cir Bucal
2013;18:e93-9.
12. Vishwanath SB, Kumar V, Kumar S, Shashikumar
P, Shashikumar Y, Patel PV. Correlation of
periodontal status and bone mineral density in
postmenopausal women: a digital radiographic
and quantitative ultrasound study. 2011;22(2):
270-6.
15. Estrugo-Devesa A, Gómez-Vaquero C, LópezLópez J Osteoporosis and oral diseases. 2013;
140(4):169-74.
16. Kim JW, Kong KA, Kim HY, Lee HS, Kim SJ, Lee SH,
et al. The association between bone mineral
density and periodontitis in Korean adults
(KNHANES 2008-2010). 2013 Aug 26.
17. Moeintaghavi A, Pourjavad M, Dadgar S, Tabbakh
NS. Evaluation of the association between periodontal parameters, osteoporosis and osteopenia
in post menopausal women. J Dent (Tehran).
2013;10(5):443-8.
18. Aspalli SS, Shetty V S, Parab PG, Nagappa G,
Devnoorkar A, Devarathnamma M V. Osteoporosis and periodontitis: Is there a possible link?.
Indian J Dent Res 2014;25:316-20
19. Anil S, Preethanath RS, AlMoharib HS, Kamath
KP, Anand PS. Impact of osteoporosis and its
treatment on oral health. 2013;346(5):396-401.
13. Al Habashneh R, Alchalabi H, Khader YS, Hazza'a
AM, Odat Z, Johnson GK. Association between
116
Stomatološki vjesnik 2014; 3 (2)
REVIEW ARTICLE / PREGLEDNI ČLANAK
CURRENT PERSPECTIVES ON
GLASS-IONOMER CEMENTS
IN PAEDIATRIC DENTISTRY
Negovetic Vranić D*1, Majstorović M1, Ferk P, Jurić H1
1
Department of Paedodontics, Faculty of Dentistry,
University of Zagreb, Zagreb, Croatia
*Corresponding author
Dubravka Negovetić Vranić,
Professor, PhD
Department of Paedodontics
Faculty of Dentistry
University of Zagreb
Gundulićeva 5
10000 Zagreb
Croatia.
Phone: +38514802110
fax:+38514802159
e-mail: [email protected].
ABSTRACT
New formulations of glass-ionomer cements with higher
ability of fluoride release have high significance in secondary
caries prevention. Aim of this study was to evaluate improved
manipulating techniques as application of heat during cement
setting that are claimed to increase preventive efficacy of these
materials.
Despite the relatively inferior mechanical properties
compared to compomers and composites, the main advantage of
glass-ionomer cements is their strong preventive effect on
surrounding tissues produced by releasing fluoride ions.
Introduction of new formulations of glass-ionomers with
substantially higher level of fluoride release, makes their
preventive effect even more important. Apart from chemical
properties, new manipulating techniques, such as the application
of heat during setting process, are claimed to have improved
effects on mechanical and aesthetic material properties and their
efficacy in clinical work in paediatric dentistry.
Key words: Glass-ionomer cements, preventive effect, heat
application
Stomatološki vjesnik 2014; 3 (2)
117
CURRENT PERSPECTIVES ON GLASS-IONOMER CEMENTS IN PAEDIATRIC DENTISTRY
Introduction
Glass-ionomer cements (GIC) are very important
materials for primary teeth restorations and
treatment of patients with high caries risk in both
dentitions. A restoration in the primary is different
from a restoration in the permanent dentition due to
the limited lifespan of primary teeth and the lower
biting forces of small children. As early as 1977, it was
suggested that glass-ionomer cements (GIC) could
offer particular advantages as restorative materials
in the primary dentition because of their ability to
release fluoride and to adhere to dental hard tissues.
They also require a short time to fill the cavity, glassionomer cements present an additional advantage
when treating young children. GIC have a large
number of applications in dentistry. The preventive
effect of material is defined as prevention of marginal
leakage and formation of secondary caries. It also
includes prevention of bacterial penetration, pulp
infection as well as local demineralization of hard
dental tissues and systemic influence on surrounding
teeth [1, 2, 3]. (Figure 1.)
GIC is predominantly used as cements in dentistry; however, they have some disadvantages. Most
important disadvantage is lack of adequate strength
and toughness. In an attempt to improve the
mechanical properties of the conventional GIC, resinmodified glass-ionomers have been added, with
hydrophilic monomers, such as hydroxyethyl
methacrylated (HEMA). As filling material, glassionomer cement mimics tooth colour but not as good
as composites showing faster surface loss by wear,
but since it is less technically sensitive, it may serve in
many ways more successfully than resin-based
composites. One of the most important advantages of
GIC, compared to other restorative materials, is that
they would be placed in cavities without any need for
bonding agents. [3, 4]. Some studies showed that
RMGIs generally have much higher flexural strength
compared to conventional GIC (approximately, 71
MPa vs. 11 MPa) [5] – which show the historical
improvement of the material solidity. Despite
relatively inferior mechanical properties compared
to compomers and composites, the main advantage
of glass-ionomer cements is their strong preventive
effect on surrounding tissues produced by releasing
2+
3+
fluoride and other remineralisation ions like Sr , Al
and F ). With the introduction of new formulations of
glass-ionomers with substantially higher level of
fluoride release, their preventive effect became even
more important. Apart from chemical properties,
new manipulating techniques, such as the application of heat during setting process, are claimed to
have improved effects on material properties and
their efficacy [4, 5]. For direct restorative dentistry,
the slow setting of conventional glass-ionomers is
considered as an inconvenience. Apart from the
necessity of waiting for restoration completion, a
drawback of the slow setting is laying in fact that the
water content of the freshly placed cement can easily
be altered either by dehydration or water uptake
from the saliva. New technique was introduced, by
which the cements hardening is substantially accelerated with heat treatment thus giving a solution for
many problems related to the slow setting of glassionomers. GIC were heated with external heat source
or polymerisation lamp. Mechanical properties are
also significantly enhanced by heat treatment [4, 5].
(Figure 2a. - Figure 2d.)
Discussion
Figure 1.
Restoration after two years made by
Fuji IX® GP Extra, (GC Corp., Japan)
118
Since the introduction of GIC to the dental
profession almost 40 years ago, numerous steps in
their development have taken place. Early on, a major
breakthrough the setting characteristics came with
the addition of tartaric acid by Wilson and coworkers. Further improvements have been achieved
Stomatološki vjesnik 2014; 3 (2)
Negovetic Vranić D, Majstorović M, Ferk P, Jurić H
by the inclusion of more reactive polyacids (e.g.
copolymers of acrylic and maleic acid), through
pretreatment of the glass surfaces and with modifed
glass compositions. Addition of elements like
lanthanum or strontium to the glass formulation led
to the creation of radiopaque cements. Sintering the
glass together with metals (e.g. silver) resulted in the
so-called cermets, where the metal part can absorb
mechanical stress to a certain extent and
subsequently reduce the brittleness of the cement
system [6,7,8].
Figure 2a. Cavity preparation in dentin
Figure 2b. Removal of caries by minimaly invasive technique
Figure 2c. Placement of the GIC on the bottom of the restoration
Figure 2d. Restoration after 12 months
Stomatološki vjesnik 2014; 3 (2)
The evolution of the GICs over the last decade has
resulted in changes in both the glass powder
component and the polycarboxylic acid liquid. Very
recently, the acid base setting reaction between these
two components has been modified by introduction
of water-soluble polymers and polymerizable
monomers into the composition. The ultimate goal in
prevention of development of secondary caries
lesions is to prevent marginal leakage of fluids,
bacteria and chemical agents between tooth tissue
and the filling [6, 7]. Dionysopoulos et al. showed that
formation of cavity wall lesions is the direct result of
microleakage of acidic products from dental plaque
or acidified solution along the tooth-restoration
interface [8].
The preventive effect of glass-ionomer cements
can be attributed not only to their capacity to release
fluoride and other remineralisation ions but also to
their chemical adhesion to hard dental tissues (enamel, dentine and cement). Their biocompatibility
with dental structures and mechanical properties
enable achievement regarding acceptable abrasion
and fracture resistance [9, 10, 11, 12]. Papagiannoulis et al. showed in vitro preventive effect of GIC in
the cases without the presence of marginal gap. Cases
with marginal gasps presented the incidence of
caries lesions comparable to composite fillings [13].
The same study showed in vivo that there were no
lesions in gap free regions. To the contrary, regions
with marginal gaps along GIC fillings showed a higher
incidence of caries lesions. The lesion dimensions
were also greater compared to composite fillings
[11].
Contrary to resin bonding, the adhesion of glassionomer to tooth structure is not technically sensitive
and its quality increases with time. Good GIC adhesion to dental tissues and marginal imperviousness
119
CURRENT PERSPECTIVES ON GLASS-IONOMER CEMENTS IN PAEDIATRIC DENTISTRY
enable ion exchange and deposition of fluoride in
surrounding areas. Reductions of secondary caries in
contact with freshly placed fluoride releasing materials (GIC) were observed by Fontana et al. [14].
Similar results were found by Arai et al. They observed that two weeks of exposure to demineralising
plaque, fluoride released from glass ionomer cement
enhanced remineralization of neighbouring demineralised enamel in vivo [15]. Incorporation of fluoride
ions in mineralised tissue of enamel and cement make them more resistant to demineralization process.
The fluoride release depends on material chemical
composition and manipulating technique. Mechanism of fluoride release is related to the setting
reaction of GIC. It includes reaction of ion leachable
aluminosilicate glass with aqueous solution of polyalkenoic acid. During reaction, acid degrades glass
component and simultaneously release metal cations
that are chelated by carboxylate groups. As a result
cross linking of polyacid chains occur [16]. Such acid
base reaction is exothermic in nature, accompanied
with heat release [17, 18].
Available studies dealing with the effect of heat
with light-curing on setting reaction show increased
mechanical properties of material after such treatment during polymerisation reaction. As described
by Al-Khateeb et al. the addition of fluoride can
initially accelerate mineralization of enamel tissue
[19]. Besides the improvement of mechanical properties, application of heat during setting of GIC
should enable better preventive effect of material
through fluoride release. The influence of accelerating the setting rate with heat has showed better
clinical results. Clinical experience has resulted in
improved formulations of the material and more controlled techniques [20, 21]. (Figure 3a., Figure 3b.)
Conclusion
Studies so far have reached the conclusion that
application of heat while using polymerisation units
has effect on accelerating setting time of GIC. Also,
application of heat with light curing unit during
setting of GIC enables better preventive effect of
material through fluoride release. With these
improvements of combined properties of enhanced
strength and fluoride release, this material becomes
120
Figure 3a. Cavity adequate for preparation and GIC filling
Figure 3b. Varnish for protection of GIC restorations.
an attractive choice for most restorative procedures.
For the paediatric dentist, this material has special
value due to its preventive characteristics, ease of
placement and aesthetics.
References
1.
Kilpatrick NM, Murray JJ, McCabe JF. The use of a
reinforced glass-ionomer cermet for the
restoration of primary molars: a clinical trial. Br
Dent J 1995; 179: 175-9.
Stomatološki vjesnik 2014; 3 (2)
Negovetic Vranić D, Majstorović M, Ferk P, Jurić H
2.
Hickel R, Voss A. A comparison of glass cermet
cement and amalgam restorations in primary
molars. ASDC J Dent Child 1990; 57:184-8.
3.
Tyas MJ. Placement and replacement of
restorations by selected practitioners. Aust
Dental Journal 2005; 50 (2): 81-9.
4.
Salama F, Riad MI, Abdel Megid FY. Microleakage
and marginal gap formation of glass ionomer
resin restorations. J Clin Pediatr Dent 1995; 20:
31-6.
12. Ngo H, Mount GJ, Peters MCRB. A study of glassionomer cement and its interface with enamel
and dentin using low temperature, high-resolution scanning electron microscopic technique.
Quintes Int 1997; 28: 63-9.
13. Papagiannoulis L, Kakabura A, Eliades G. In vivo
vs. in vitro anticariogenic behaviour of glassionomer and resin composite restorative materials. Dent Mater 2002; 18: 561-69.
5.
Nicholson JW, Czarnecka B. The biocompatibility
of resin-modified glass-ionomer cements for
dentistry, Dent Mater (2008) doi: 10.1016/
j.dental. 2008.04.005
14. Fontana M, Gonzalez-Cabezas, Haider A, Wilson
ME, Sordelli A, Stookey GK. Inhibition of secondary caries around freshly placed, fluoride releasing dental materials. Caries Res 2000; 34:
340(Abs.93)
6.
Kleverlaan CJ, van Duinen RMB, Feilzer AJ.
Mechanical properties of glass ionomer cements
affected by curing methods. Dent Mater 2004;
20: 45-50.
15. Arai K, Kato K, Nakagaki H, Robinson C. Plaque
fluoride released from the glass ionomer cement
and remineralization of neighbouring enamel in
vivo. Caries Res 2000; 34: 340(Abs.92).
7.
Yap AUJ, Pek YS, Kumar RA, Cheang P, Khor KA.
Experimental studies on a new bioactive material: HAIonomer cements. Biomaterials 2002;
23: 955-62.
8.
Dionysopoulos P, Kotsanos N, Papadogiannis Y,
Konstantinidis A. Artificial secondary caries
around two new F containing restoratives. Oper
Dent1998; 23: 81-6.
16. Towler MR, Bushby AJ, Billington RW, Hill RG. A
preliminary comparison of the mechanical properties of chemically cured and ultrasonically
cured glass ionomer cements using nanoindentation techniques. Biomaterials 2001; 22:14016.
9.
Hicks MJ, Flaitz CM, Silverstone LM. Secondary
caries formation in vitro around glass ionomer
restorations. Quintes Int 1986; 17: 527-32.
10. Kidd EAM, Silverstone LM. Remineralisation in
vitro of artificial caries-like lesions produced in
relation to amalgam restorations. Caries
Research 1978; 12: 238-42
11. Mazzoui SA, Burrow MF, Tyas MJ. Fluoride
release from glass ionomer cements and resin
composites coated with dentin adhesive. Dent
Mater2000; 16: 166-71.
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17. Fleming GJ. Advances in dental materials. Prim
Dent J. 2014;3(2):54-61.
18. GC. Personal communication. 2005.
19. Al-Khateeb S, Exterkate R, Angmar-Mänsson B,
ten Cate B. Effect of acid-etching on remineralization of enamel white spot lesions. Acta Odontol
Scan 2000; 58: 31-6.
20. Prentice LH, Tyas MJ, Burrow MF. The effect of
particle size distribution on experimental glassionomer cement. Dent Mater 2005; 21: 505-10.
21. Nicholson JW, Czarnecka B. The biocompatibility
of resin-modified glass-ionomer cements for
dentistry. Dent Mater 2008;24:1702–8.
121
STRUČNI RAD /PROFESSIONAL ARTICLE
LASER THERAPY IN BURNING
MOUTH SYNDROME
*Corresponding author
Pavlić V*1, Adamović T1, Gojkov-Vukelić M²,
Markovic Djuric LJ ³
Verica Pavlic, DDS, PhD
Department of Periodontology
and Oral Medicine
Institute of Dentistry,
Zdrave Korde 4
78000 Banja Luka
Bosnia and Herzegovina
Phone/fax: +387 66 769-844
e-mail: [email protected]
1
Department of Periodontology and Oral Medicine,
Institute of Dentistry, Banja Luka, Bosnia and Herzegovina
2
Department of Oral Medicine and Periodontology, University of Sarajevo,
Faculty of Dentistry, Sarajevo, Bosnia and Herzegovina
3
Public Health Centre, Kneževo, Bosnia and Herzegovina
ABSTRACT
Burning mouth syndrome (BMS) is a distinct clinical condition
that causes burning and painful sensations of the mouth, in the
absence of significant mucosal abnormalities. Incomplete
understanding of the etiology and pathophysiology of BMS, lack of
appropriate diagnostic criteria and effective treatments are
making management of BMS very challenging. Recently, laser
therapy (low-level laser therapy- LLLT; photo-bio-stimulation)
has been described as an efficient therapy option for BMS, due to
possibility to reduce the pain/burning sensations related to the
BMS. Results of this study demonstrated significant reduction of
pain/burning sensations following LLLT. Even though majority of
the available literature demonstrated beneficial effects of LLLT in
treatment of BMS, these results should be interpreted with
caution, due to the possibility that beneficial outcome might be a
result of placebo response. Further, different design and sets of
laser irradiation parameters of a limited number of available
studies prevent us from making definite conclusion on the
efficiency of using LLLT in therapy of BMS.
Key words: “burning mouth syndrome”, “stomatodynia”,
“stomatopyrosis”, “laser therapy”, “low-level laser irradiation”.
Stomatološki vjesnik 2014; 3 (2)
123
LASER THERAPY IN BURNING MOUTH SYNDROME
Introduction
Burning mouth syndrome (BMS) is a distinct
clinical condition that causes burning and painful
sensations of the mouth, in the absence of significant
mucosal abnormalities or other clinical signs of organic disease [1]. Although BMS may appear in patients
of any age and gender, it is 7 times more frequent in
the postmenopausal middle aged women (mean age:
50-60 years) than men [1, 2]. Most commonly BMS
affects the tongue, especially in the anterior region,
followed by the lips, hard palate, buccal mucosa and
oropharynx. When burning sensation is limited to the
tongue, it is said that patients with BMS are having
glossodynia and/or glossopyrosis, and if present in
other oral regions, which can be multiple including
tongue, it is called stomatopyrosis, stomatodynia and
recently, oral dysesthesia [3]. BMS is typically characterized by a continuous, spontaneous and often
intense burning sensation as if the mouth or tongue
were scalded or on fire [4]. The patients also complain on xerostomia and loss or altered sense of taste
[5].
BMS may present an idiopathic condition (primary BMS type) distinct from the symptom of oral
burning that can potentially arise from various local
or systemic abnormalities (secondary BMS type),
including nutritional and vitamin deficiencies (iron,
folate, vitamin B complex), hormonal changes associated with menopause, local oral infections (candidiasis), denture-related lesions, oral habits (tongue
thrusting, bruxism), depression/anxiety, xerostomia,
hypersensitivity reactions, medication side effects
(topiramate, carbidopa/levodopa), systemic diseases (diabetes mellitus) and/or autoimmune type
connective tissue diseases, such as systemic lupus
erythematosus and Sjögren's syndrome [4]. Because
of its chronic nature and unknown etiology, BMS is
usually treated symptomatically with a combination
of several drugs, including anxiolytics, anticonvulsants, antidepressants, atypical antipsychotics, histamine receptor antagonist and/or dopamine agonists.
In addition, other therapies and treatments are being
considered, such as natural supplements catuama,
zinc, capsaicin, antioxidant alpha lipoic acid, sucralose and aloe vera [3, 6], tongue protectors, salivary
mechanical stimulation therapy, acupuncture, cognitive therapy, electroconvulsive therapy and lingual
124
nerve block [1, 3, 6, 7]. Recently, laser therapy (lowlevel laser therapy- LLLT; photo-bio-stimulation) has
been described as an efficient alternative or supplementary therapy option for many painful oral mucosal diseases, due to possibility to reduce the pain of
various etiologies [8]. Therefore, the aim of this study
was to demonstrate effects of laser therapy in
treatment of BMS.
Materials and Methods
The articles published until December 31st 2013,
were obtained from the Medline/PubMed online
database. A systematic summary of published
articles was carried out using following search terms
and key words: "burning mouth syndrome" AND
"laser therapy", "burning mouth syndrome" AND
"low-level laser irradiation", "stomatodynia" AND
"laser therapy", "stomatopyrosis" AND "laser therapy" and "burning mouth syndrome". Secondary sources included papers cited by articles retrieved from
the above mentioned studies.
Effects of laser therapy on BMS
According to author's knowledge only 7 studies
reported the effects of LLLT on BMS (Table 1). All
studies had the same main outcome measure:
pain/burning sensations, which were assessed by
visual analogue scale (VAS) before and immediately
after each laser session. Five out of seven studies
reported beneficial effects of LLLT on BMS [1, 2, 5, 9,
10], and remaining 2 studies suggested that beneficial effects of LLLT could be considered due to the
placebo [11, 12].
Yang et al. demonstrated effectiveness of diode
laser (wavelength: 800 nm; power 3W, frequency 10
Hz and irradiation time of 70 s) in the complete resolution of BMS symptoms [1]. Authors [1] reported an
average of 47.6% of pain reduction after LLLT
(average pain score before laser treatment was 6.7
compared to 3.5 following LLLT). Dos Santos et al. [2]
demonstrated significant pain reduction (up to
58.2% in the tenth laser session) following InGaAlP
diode laser (wavelength: 660 nm; power 40 mW,
2
fluence 20 J/cm and irradiation time of 10 s). PezeljRibaric et al. [5] demonstrated effects of low-level
GaAlAs laser irradiation (wavelength: 685 nm) on 40
Stomatološki vjesnik 2014; 3 (2)
Pavlić V, Adamović T, Gojkov-Vukelić M, Markovic Djuric LJ
patients (20 patients-laser group; 20 patientsplacebo group). 20 patients were irradiated with
laser (power: 30 mW, fluence: 3 J/cm2, irradiation
time: 10 min). Apart from significant reduction of the
pain/burning sensations, authors [5] also reported
statistically significant reduction in salivary levels of
proinflammatory cytokines (tumor necrosis factor
alpha; TNF-α and interleukin 6; IL-6). Similarly, Kato
et al. [9] reported significant reduction of the pain/
burning sensations (80.4% with three laser sessions)
after low-level diode laser (wavelength: 790 nm;
2
power 120 mW, fluence 6 J/cm and irradiation time
of 10 s). Cekić-Arambašin et al. [10] also reported a
significant decrease of the burning symptoms in patients with BMS using low-level Ga-As laser irradiation (wavelength: 904 nm; power: 20 W, irradiation
time: 3 min).
Placebo Effects
On the other side, Vukoja et al. [11] employed
pulsed diode laser (wavelength: 685 nm) on 40
patients (20 patients-laser; 20 patients-placebo) in
order to compare an effectiveness of laser to placebo.
Laser parameters used were: power 30 mW, frequen2
cy 4.56 Hz and irradiation dose 2 J/cm . Irradiation
was applied five times a week for 2 weeks. As a result,
Vukoja et al. demonstrated reduction of pain/burning sensation following LLLT, but they also reported
symptom reduction in placebo group [11]. Therefore,
they concluded that beneficial effects of LLLT could
be considered as placebo effect. These results were
similar to results obtained by Hansen et al. [12], who
investigated the effects of diode laser therapy (wavelength: 904 nm) in 28 patients with BMS out of 40
patients with different painful oral lesions enrolled.
Employed laser parameters were as follows: power
2
30 mW, fluency 4.7 J/cm and 60s of irradiation time,
in direct contact with irradiated tissue, two times in
four weeks. Authors [12] also demonstrated that
effects of LLLT were based on the placebo effect, as a
decrease in symptoms was also seen in patients who
were treated with inactive placebo laser probe.
Discussion
BMS is a multifactorial complex chronic disorder
of orofacial sensation that is distressing both for the
Stomatološki vjesnik 2014; 3 (2)
patient and clinician [1]. Incomplete understanding
of the etiology, pathophysiology and lack of
diagnostic criteria are always a big challenge in
selection of effective therapy for BMS [6]. To date,
selected therapy options are usually symptomatic,
therefore somewhat disappointing. Also, selected
pharmacological means (systemic and topic) are
known to have many side effects, especially during
long-term use. Therefore, new efficient therapy alternatives for BMS were constantly searched. Recently
introduced LLLT was described as non-destructive,
non-thermal and painless procedure with no thermal
damage effects visible in the oral mucosa [13]. It has
been widely used in oral medicine, especially in therapy of painful oral lesions, such as oral lichen planus,
oral mucositis, recurrent aphthous stomatitis, etc. [7,
13]. Therefore, it was reasonable to expect that it
would be efficient therapy approach for pain/burning sensations in BMS, too.
The results from this study demonstrated that
majority of the selected articles are confirming the
efficacy of LLLT in therapy of BMS, due to analgesic
effect [1, 2, 5, 9, 10]. LLLT was effective in reducing
symptoms caused by BMS, decreasing burning sensations. Also, LLLT is not associated with any side
effects contrary to pharmacological usually used for
BMS.
To date, several possible mechanisms responsible
for reduction of the BMS symptoms have been proposed. However, the exact underlying mechanism is
still unknown. There is wide range of reported
positive effects of LLLT in analgesia, mainly its ability
to improve peripheral and local blood circulation,
such as reported decrease in burning sensations in
BMS by increase in tongue blood flow following LLLT
[14]. It is known that LLLT inhibits secretion of
inflammatory mediators, such as prostaglandin E2
and interleukin 1-beta. Further, LLLT is claimed to
reduce the level and inhibit cyclooxygenase and
substance P activity and/or lymphocyte metabolism
that could lead to reducing of edema, and to further
reduction of inflammatory processes [15-17]. Also,
release of endogenous pain relievers - endorphins
and enkephalins [7], increase in production of serotonin and suppression of bradikinin activity [13] had
been suggested. However, it is believed that not just
one, but two or more co-existing mechanisms are
responsible for the beneficial outcome of LLLT in
analgesia [13].
125
LASER THERAPY IN BURNING MOUTH SYNDROME
Even though, results from our study supported the
statement that LLLT is promising tool in therapy of
BMS, these results should be interpreted with
caution, mainly due to a limited number of, so far,
published studies. Also, each and every study had its
own protocol, including number of patients enrolled,
female-male ratio and patients' main age (Table 2).
Further, employed laser devices used completely
different wavelengths and sets of irradiation
parameters, such as power, fluency, irradiation time
etc. (Table 1). Also, pain assessment, as the major
outcome compared, was evaluated by VAS. Even
though, VAS has been established as a valid and
reliable method in a range of clinical applications,
being strictly subjective and highly sensitive method.
Consideration of the VAS in terms of its physical
structure and the patient's behavior when confronted with the scale, casts doubt on its validity [18].
Wide range of positive effects of LLLT, or lasers generally, can be considered due to the placebo. Placebo
effect is mainly determined by the doctor-patient
relationship and further by beliefs and anticipation of
the patients [12]. Some authors are claiming that,
even though placebo-controlled studies are trying to
assure patients' blindness by using laser active and
inactive probe (sham laser irradiation), patients can
predict when and where active laser probe is applied,
due to mild warmth on targeted oral spot when using
laser. As a result, some of the authors are constantly
suggesting that patients are "favoring" the outcome
of laser application in clinical settings. Even so, placebo response represents a natural, safe and effective
method of treatment that can be successfully used in
therapy of pain/burning sensations [12].
Conclusion
Majority of available literature suggests that LLLT
can be efficiently used in treatment of pain/burning
sensations in patients with BMS. Since to date there is
no efficient approach to guide the treatment of BMS
with LLLT, it is difficult to support the effectiveness of
LLLT as superior to other known therapy options.
Author and the year of
the publication (reference)
Case study design
(number of patients)
Output measures
Laser device
(wavelenght, emission mode)
Yang HW. et al.
2010. (1)
Laser
(17 patients)
Pain assement
Diode laser/K-laser
(800 nm; pulsed waves)
dos Santos L de F. et al.
2011. (2)
Laser
(10 patients)
Pain assement
InGaAIP diode laser
(660 nm; continuous waves)
Pezelj-Ribaric S. et al.
2010. (5)
Laser vs. placebo
(40 patients)
Pain assement salivary flow rate,
salivary levels of TNF-α and IL-6
GaA1As diode laser
(685 nm; continuous waves)
Kato IT. et al.
2010. (10)
Laser
(11 patients)
Pain assement
Diode laser
(790 nm; continuous waves)
Cekic-Arambasin A. et al.
1990. (11)
Laser vs. medicaments
(40 patients)
Pain assement
Ga-As diode laser
904 nm; pulsed waves)
Vukoja D. et al.
2011. (12)
Laser vs. placebo
(40 patients)
Pain assement
GaA1As diode laser
(685 nm; continuous waves)
Hansen HJ. et al.
1990. (13)
Laser vs. placebo
(28 patients)
Pain assement
Ga-As diode laser
904 nm; pulsed waves)
Table 1. Effects of laser therapy in treatment of BMS (BMS - Burning mouth syndrome); TNF-α (Tumor necrosis factor alpha); IL-6 (Interleukin 6)
126
Stomatološki vjesnik 2014; 3 (2)
Pavlić V, Adamović T, Gojkov-Vukelić M, Markovic Djuric LJ
Author and the year of
the publication (reference)
Number of
patients
Gender
(Female/Male ratio)
Patients
main age
Yang HW. et al.
2010. (1)
17
13 F / 4 M
50,6
dos Santos L de F. et al.
2011. (2)
10
9F/1M
65.8
Pezelj-Ribaric S. et al.
2010. (5)
20
15 F / 5 M
61.2
Kato IT. et al.
2010. (10)
11
10 F / 1 M
64
Cekic-Arambasin A. et al.
1990. (11)
40
mainly F
(not specified)
46-77
Table 2. Study protocol/general information (F - female, M - male)
Also, these results should be interpreted with caution, due to the possibility that beneficial outcome
could be considered as a result of placebo response.
Therefore, further long-term randomized controlled
clinical studies are necessary to give any valid
suggestion regarding the use of LLLT in therapy of
BMS.
Laser parameters
Laser
application
Observation period/
Follow up
Findings
Power 3W
Fluence 105 J/cm2
Irradiation time 70 s
Once a week
Before-Immediately after
irradiation/ once every month
to once every 3 months
up to 12 months
Reduction of the pain
following LLLT (45.6%)
Power 40 mW
Fluence 20 J/cm2
Irradiation time 10 s
Once a week
for 10 weeks
Before-Immediately after
irradiation/ every day
up to 10 weeks
Reduction of the pain
following LLLT (in the 10th
session by up to 58%)
Power 30 mW
Fluence 3 J/cm2
Irradiation time 10 s
5 times a week
for 4 weeks
Before-Immediately
after irradiation/
up to 4 weeks
Reduction of the pain
Statisticaly significant reduction
of TNF-α and IL-6 following LLLT
Power 120 mW
Fluence 6 J/cm2
Irradiation time 10 s
Weekly for 3
consequitive weeks
Before-Immediately
after irradiation/
up to 6 weeks
Reduction of the pain
following LLLT (80.4%
with three LLLT sessions)
Power 20 W
Irradiation time 3 min
5 consequitive
weeks
Before-Immediately
after irradiation/
up to 5 days
Reduction of the pain
following LLLT
Power 30 mW
Fluence 2 J/cm2
Frequency 4.56 Hz
5 times a week
for 2 weeks
Before-Immediately
after irradiation/
up to 10 days
Reduction of the pain
is result of placebo
Power 30 mW
Fluence 4.7 J/cm2
Irradiation time 60 s
2 times a week
for 4 weeks
Before-Immediately
after irradiation/
up to 4 weeks
Reduction of the pain
is result of placebo
Stomatološki vjesnik 2014; 3 (2)
127
LASER THERAPY IN BURNING MOUTH SYNDROME
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Stomatološki vjesnik 2014; 3 (2)
CASE REPORT / PRIKAZ SLUČAJA
MAXILARY CANINE IMPACTION
– EXTRACTION OR NOT?
Kapusevska B*¹, Dereban N², Benedetti A³
1
Department of Prosthodontics, Faculty of Dentistry,
University "St. Cyril and Methodicus", Skopje, Republic of Macedonia.
2
P.H.I. Orto-gan, Struga, Republic of Macedonia.
3
Department of Maxillofacial Surgery, Faculty of Dentistry,
University "St. Cyril and Methodicus", Skopje, Republic of Macedonia.
*Corresponding author
Biljana Kapusevska, MD, PhD
Faculty of Dentistry
University "St. Cyril and Methodicus"
Majka Tereza PO BOX 17
Skopje 1000
Republic of Macedonia
Phone: ++ 389 (02) 3115-647
e-mail:
[email protected]
ABSTRACT
Introduction: The canine is a tooth rarely considered for
extraction, because it determines the physiognomy of the facial
profile. However, extraction is still imminent in secluded cases
with precisely specified indications. Orthodontic reasons for
extraction are attributed to severe canine malposition with high
risk of orthodontic treatment failure or situations with complete
loss of space for placing the canine and for ideal dental arch
arrangement.
Objective: The purpose of this paper is to simplify the eternal
dilemma ''maxillary canine impaction - extraction or not?'' and
thus help the clinicians to make a better distinction between cases
with extraction of impacted maxillary canine and cases with
orthodontic traction.
Methods: From our clinical material composed of 25 clinical
cases of patients with maxillary canine impaction, we selected
and exhibited 3 carefully chosen cases with specific etiology and
clinical expression: primary dental arch crowding, secondary
dental arch crowding and supplementary teeth. The patients
were diagnosed with maxillary canine impaction, then analysis
was performed with use of palpation, inspection, periapical and
orthopantomographic RTG scans.
Results: Summing up the results from the different analysis in
each of the 3 clinical cases, we determined the etiological cause,
the discrepancy between chronological and dental age and then
we made individual decisions to extract the maxillary canine or to
perform an orthodontic traction.
Conclusions: From this study we come to the conclusion that
for the majority of clinical cases, the extraction of the canine is
strictly contraindicated. The exceptions from this general rule
should be cases with severely mal-positioned canine analyzed in
tree special planes on the panoramic RTG.
Key words: impaction, maxillary canine, RTG diagnosis, RTG
prognosis, malposition, extraction, corticotomy, orthodontic
traction.
Stomatološki vjesnik 2014; 3 (2)
129
MAXILARY CANINE IMPACTION – EXTRACTION OR NOT?
Introduction
In the literature, the canines are also known as
pillars of the occlusion and this is why their position
in the dental arch is being used for classification of
the inter-arch relationships. They also represent a
boundary between the frontal and the lateral group
of teeth, thus determining the shape of the dental
arch. With their specific morphology they stand out
from the rest of the dentition, because they are the
only teeth without their own morphological substitute from the same group of teeth. Their massive root
causes prominence on the facial side of the maxilla
that touches and elevates the angles of the mouth and
contributes to better personal esthetic appearance
[1].
The long and massive root of this tooth makes it an
ideal abutment for fixed partial dentures and
together with its long eruptive path considerably
contributes to the initiation and stimulation of the
maxillary growth during the period of development
of the facial bones. The canines are one of the most
frequently impacted teeth in the dental arch. They are
third in frequency after the impaction of the maxillary and mandibular third molars. The reasons for
their impactions are multiple and vary from systematic to local and hereditary factors.
One of the most common local factors is the long
and painstaking eruptive path of the canine. The
biggest part from the root of the canine is created
before its eruption and therefore at the time of the
eruption there is no growth impulse from the
developing root. The eruption of the maxillary canine
overlaps with the eruption of the first permanent
premolar and therefore these two teeth often
compete for space in the dental arch. The mesiodistal
width of the deciduous canine is smaller in relation
with the permanent canine, which is contrary to the
morphology of the rest of the transcanine deciduous
teeth. The calcification of the crown of the permanent
upper canine begins between the 4th and the 5th
month. By the age of one year the unerupted permanent maxillary canine is high in the front-nasal
processus of the maxilla, beneath the floor of the
orbit and above the bifurcation of the first deciduous
molar. The canine crypt rapidly migrates forward in
the maxilla and by the age of three years, the crown is
130
mesial and lingual positioned above the apex of the
deciduous canine. Because of the bud of the canine
being placed exactly behind the root of the deciduous
predecessor, every peri-apical lesion caused by
trauma or deep caries, affects the position and the
angulation of the permanent canine [2]. As the root
moves downward towards the occlusal plane, the
crown lies in close proximity to the root of the
permanent erupted lateral incisor. It travels down the
distal aspect of the root from the lateral incisor until
the age of 11-12 years when emerges in the oral
cavity.
The local factors that are considered as a cause for
impaction could be the fibrous mucous of the alveolar ridge, prolonged retention and lack of resorption
of the roots from the deciduous teeth [3], small, missing or roots with reduced height of the permanent
lateral incisor [4], ankyloses of the permanent canine, crowding in the dental arch or lack of space for
permanent canine placement, supplementary teeth,
odontogenic cyst and odontoms [5]. The genetic
factors are the most important systematic factors for
canine impaction. These factors include patients with
family predisposition, malposition of the canine bud
[6], diminished length of the dental arch [7] and cleft
palate.
The systematic factors often include endocrine
deficiency with reduced secretion of the growth
hormone and infective diseases [8]. There are lot of
dilemmas concerning the clinical solutions for the
impaction of maxillary canine especially taking into
account their undisputed value. The general principle implied in this treatment is inter-clinical cooperation between an orthodontist and an oral surgeon for
placement of the canine in its appropriate position in
the dental arch, even in the cases when we are forced
to obtain the space necessary for its placement with
extraction of another proximal tooth [9]. However,
there are exceptions when the achievement of optimal arrangement of the teeth in the dental arch may
lead us to a decision for extraction of the canine despite the clinical value of this tooth [10]. The reasoning that makes some of the impacted canines suitable for treatment and others indicated for extraction was the primal focus of this study, in which we
closely considered the factors that affect the final decision making and prognostic evaluation for treatment.
Stomatološki vjesnik 2014; 3 (2)
Kapusevska B, Dereban N, Benedetti A
Objective
2 3
a.
3 2
3
Material and Methods
2
Displaced source of radiation
3 2
b.
The purpose of this paper is to simplify the eternal
dilemma ''maxillary canine impaction - extraction or
not?'' and thus help the clinicians to make better
distinction between cases with extraction of impacted maxillary canine and cases with orthodontic
traction.
2 3
2
3
Displaced source of radiation
Figure 1.1.
RTG prognosis on the favorability for orthodontic traction
– de termininig the position of the impacted tooth with the use
of parallax method a. mesially displaced source of radiation,
b. distally displaced source of radiation
As material for investigation in this study we used
25 clinical cases of patients with maxillary canine
impaction. In an effort to set up relevant clinical
guidelines for making a treatment decision between
orthodontic traction and surgical extraction of the
impacted canine, we reviewed 3 types of clinical
cases with impaction of the upper maxillary canine.
The patients from this study were divided into three
groups: cases with teeth/arch discrepancy (primary
dental crowding), missing space in the dental arch
due to mesial migration of the permanent teeth
(secondary dental arch crowding) and supplementary teeth. From the examined patients, we selected 3
clinical cases for presentation. The analysis of these
clinical cases included: detailed medical and dental
history, elaborate description of the teeth condition
and arrangement found after the evaluation of the
dental arch as well as estimated prognosis for success
of outcome from the possible treatment with
orthodontic traction.
The prognosis for favorable or unfavorable outcome from the orthodontic traction was based on the
position of the impacted canine in the patient's jaw.
This position was accepted as one of the most
relevant factors for the prognosis of the canine
placement in the dental arch and was estimated using
peri-apical and panoramic RTG scans.
From the beginning, in each of the clinical cases,
we determined the vestibule-oral placement of the
canine with the use of the parallax method (Figure
1.1.). This method requires development of two
subsequent retro-alveolar RTG scans in the area of
the impacted tooth. The initial retro-alveolar RTG
scan was taken according to the regulations for
Stomatološki vjesnik 2014; 3 (2)
131
MAXILARY CANINE IMPACTION – EXTRACTION OR NOT?
ortho-radial projection, meaning that the source of
the radiation was under a perpendicular angle to the
object that was being recorded and the film was
placed on the opposite side of the dental arch. The
second retro-alveolar RTG is always taken with a
change of the radiation angle for at least 20 degrees. If
the shadow of the impacted tooth from the first scan
moves in the same direction as the source of the
radiation in the second scan, this is a sign that the
impacted tooth is positioned at the oral side of the
dental arch. If the shadow of the impacted tooth in the
second RTG scan moves opposite to the direction of
the radiation source, it means that the impacted tooth
is vestibular placed.
More simplified method for determination of the
vestibule-oral position of the impacted canine in the
frontal plane is according to the RTG shadow of the
root from the nearest lateral incisor (Figure 1.2).
This method uses the localization of the tip from the
crown of the impacted canine on the RTG in relation
to the shadow of the root from the lateral incisor. The
position of the shadow of the tip from the canine can
be placed in front or behind the lateral incisor and
this is also the vestibule-oral position of the entire
canine. The oral position unlike the other locations
for the impacted canine is less favorable for
orthodontic traction than the vestibular placement.
However, the vestibule-oral position of the canine is
less significant than its angulation, upper-lower and
mesio-distal position for the estimation of the
prognosis of the orthodontic treatment.
The prognostic value for orthodontic traction
according to the position of the impacted canine in
the frontal plane is determined by using the
horizontal rule of thirds. In the frontal plane we
evaluate the mesio-distal relationships of the
impacted canine towards the lateral incisor. The
analysis begins with the drawing of 3 standard
straight lines on the panoramic RTG scan. The first
line is drawn by connecting two dots that are located
at the most distal contours of the crown and root of
the lateral incisor. The second line is constructed by
connecting the most mesial dots of the contours from
the crown and root of the lateral incisor. The third
line is constructed as a line of symmetry in the angle
created by the other two lines and represents the axis
of the lateral incisor. By drawing the 3 lines, we have
created three areas, where the crown of the impacted
132
Poor
Bad
Good
Figure 1.2.
RTG prognosis on the favorability for orthodontic traction
- based on the frontal position of the impacted canine
Bad
Poor
Good
Figure 1.3.
RTG prognosis on the favorability for orthodontic traction
– Vertical rule of thirds based on the vertical position
of the impacted canine
Stomatološki vjesnik 2014; 3 (2)
Kapusevska B, Dereban N, Benedetti A
Figure 1.4.
RTG prognosis on the favorability
for orthodontic traction
– Determination of the
angulations of the canine in
relation to the bicondilar line
canine can be placed in the frontal plane. In the first
area, distal to the axis of the lateral incisor, the tip of
the canine in the panoramic RTG scan is either barely
touching or is not even overlapping with the lateral
incisor and the prognosis for placement of the canine
in the dental arch with orthodontic mechanisms is
favorable. The second area is between the axis of the
lateral incisor and the line of its most mesial
contours. In the situations when the shadow of the tip
from the canine overlaps the shadow of the lateral
incisor, but doesn't go beyond the line of the most
mesial contours of the lateral incisor, the prognosis
for placement of the canine is uncertain. The third
area is when the position of the tip from the crown of
the impacted canine is mesial to the line of the most
mesial contours of the lateral incisor. In this position,
the tip from the crown of the canine completely
overlaps and goes beyond the crown of the lateral
incisor. When the canine is placed in this area, the
prognosis for successful orthodontic traction in the
correct position in the dental arch is poor.
The prognosis on the favorability of the canine
position in relation to the occlusal plane is determined by the vertical rule of thirds (Figure 1.3.). On a
panoramic RTG, we draw three parallel straight lines
in the area of the root from the lateral incisor. The first
line goes through the most mesial and the most distal
dot of the cement-enamel junction. The second line is
parallel to the first and goes through the center of the
root from the lateral incisor. The third line is also
parallel to the previous two, but touches the apex of
the lateral incisor. When the tip of the crown from the
impacted canine is positioned in the gingival third of
the lateral incisor in the RTG, the prognosis for orthoStomatološki vjesnik 2014; 3 (2)
dontic treatment is favorable. In situations when the
tip of the crown from the impacted canine is located
in the middle third of the lateral incisor in the RTG,
the outcome from the orthodontic traction of the
canine is uncertain. In the cases when the impacted
canine is positioned apically from the line touching
the apex of the lateral incisor, the prognosis for orthodontic placement of the impacted tooth is poor.
Some authors determine the angulation of the
canine according to linea mediana while others use
the occlusal plane or the bicondylar line (Figure 1.4).
In this study we evaluated the angulation of the
canine in the relation to the bicondylar line on the
panoramic RTG by connecting the most superior dots
from both condyles bilaterally. In each case we measured the internal angle that the bicondylar line
makes with the axis of canine (straight line that goes
through the tip of the crown and the apex of the
canine). If this angle is 45 degrees or overpasses 45
degrees, the prognosis for orthodontic traction is
favorable. When the angle of the canine with the
bicondylar line is between 40-45 degrees, the
prognosis for success of orthodontic treatment is
uncertain. In the cases when this angle is lower than
40 degrees, the prognosis for treatment with orthodontic traction is poor.
The final prognosis was made taking into account
all of the coordinates for the position of the maxillary
impacted canine in unison. This data were then
considered collectively and a final decision was made
towards the extraction or orthodontic traction of the
impacted maxillary canine.
The three clinical cases chosen for presentation in
this study are as they follow:
133
MAXILARY CANINE IMPACTION – EXTRACTION OR NOT?
a.
b.
c.
Figure 2.
Clinical case No. 1
Canine impaction due to teeth
- arch discrepancies
(primary crowding):
a. retroalveolar RTG of the impacted
canine,
b. intraoral view of the patient,
c. dental panoramic RTG
Clinical case No. 1
Clinical case No. 2
The patient was referred to us at the age of 12 by
the general practitioner because the presence of an
impacted left maxillary canine was observed. The
clinical examination confirmed the lack of the permanent maxilary canine as well as normoocclusion class
I according to Angle without presence of other
occlusal abnormalities (Figure 2).
The patient was referred to us at age of 17 with
purpose of esthetic reconstruction, when we
determined an impaction of the right maxillary
canine due to a delayed extraction of the deciduous
teeth and mesial migration of the permanent canine
(Figure 3).
a.
b.
Figure 3.
Clinical case No. 2. Canine impaction due to mesial migration of teeth buds (secondary crowding):
a. intraoral view of the patient, b. panoramic RTG
134
Stomatološki vjesnik 2014; 3 (2)
Kapusevska B, Dereban N, Benedetti A
a.
b.
c.
Figure 4.
Clinical case No. 3.
Canine impaction due to
supplementary tooth
(hyperdoncia):
a. intraoral view of the patient,
b. retroalveolar RTG,
c. panoramic RTG
Clinical case No.3
When the patient showed at the first appointment
being 12 years of age, the panoramic RTG revealed a
presence of supplementary tooth as a cause for
maxillary canine impaction (Figure 4).
Results
As shown in Table 1, the selected clinical cases for
presentation in this study were canine impaction
from different causes: teeth/arch discrepancies
(primary dental crowding), missing space in the
dental arch due to mesial migration of the permanent
teeth (secondary dental arch crowding) and
supplementary teeth (Table 1).
The collected data and results from our clinical
investigation in clinical case No. 1 were placed in
Table 1. The standard protocol in clinical cases when
the canine is naturally replaced with the first
premolar, without sufficient space in the dental arch
for its correct placement and an ideal contact point
between the lateral incisor and the first premolar,
when the patient refuses orthodontic treatment is to
Chronological
age
Dental age
Cause for impaction
Course of
treatment
Clinical case No.1
12
10-12
Primary dental arch crowding
(teeth/arch discrepancy)
Orthodontic
traction
Clinical case No.2
17
10-12
Secundary dental arch crowding
(mesial migration of permanent teeth buds)
Orthodontic
traction
Clinical case No.3
12
10-12
Supplementary tooth (hyperdoncia)
Orthodontic
traction
Table 1.
Etiology and treatment course of maxillary canine impaction
Stomatološki vjesnik 2014; 3 (2)
135
MAXILARY CANINE IMPACTION – EXTRACTION OR NOT?
perform an extraction. However after we performed
a retro-alveolar RTG, we observed that the first
premolar had a hypo-plastic root. This was why we
reconsidered our standpoint and decided to do a
premolar extraction. The position of the canine was
analyzed in horizontal and vertical direction and was
characterized as favorable for orthodontic extrusion.
In the clinical case No. 2, as shown in Table 1, we
preformed and elaborated an analysis on the position
of the permanent canine. After we estimated the
prognosis for orthodontic traction as favorable on the
basis of the position of the permanent impacted
maxillary canine, we preformed an extraction of the
deciduous canine and placed a fixed orthodontic
appliance.
In the clinical case No.3 as seen in Table 1., it was
determined that the patient is still in the mixed stage
of dentition. We observed that all of the deciduous
teeth in the maxillary dental arch were replaced with
their permanent successors other than the presence
of the deciduous left lateral incisor, left deciduous
canine and first deciduous molar on the right side of
the dental arch. The deciduous canines, first and
second molars were still not replaced in the
mandibular dental arch. A secondary retro-alveolar
RTG was performed with the purpose of confirming
the supplementary tooth in the maxilla. We made a
decision to extract the supplementary tooth and to
perform a serial extraction of the deciduous teeth.
The deciduous lateral incisor was extracted from the
upper right quadrant. In the upper left quadrant we
preformed an extraction of the deciduous canine and
first molar. Despite the interceptive actions, the
canine was retained and remained impacted. An
analysis was performed on the position of the canine
on the panoramic RTG in relation to the contours of
the lateral incisor and its position was estimated as
favorable for orthodontic traction.
Discussion
It is important to stress out that in all of the
situations that permit preservation and placement of
the impacted canine in its rightful place in the dental
arch, we should strive to accomplish this task. Only in
a few secluded cases, in which this is not possible, we
either close the empty space for the canine in the
136
dental arch, remodel the first premolar so as to mimic
the canine, or place implants when the patient
reaches the appropriate age. No matter to paradox,
the extraction of the labial erupted canine in a
situation of frontal crowding in the dental arch is
contraindicated. This intervention may temporarily
improve the esthetics, but it will complicate and even
endanger the results from the subsequent
orthodontic treatment [11]. Although the extraction
of the impacted canine is rarely considered, it may be
inevitable in situations in which the prognosis for the
orthodontic traction is poor (the canine is placed too
high, too mesial or horizontal with bad angulation)
[12]. Other reasons that can guide us towards
considering extraction are:
1.
The impacted canine is ankylosed and it
cannot be transplanted;
2.
The impacted canine suffered an internal or
external resorption of the root;
3.
There is an evidence for resorption on the
roots from the surrounding teeth produced
by the pressure from eruption of the canine;
4.
An acceptable occlusion is established with
the first premolar in the position of the
canine, where the contact between the first
premolar and the lateral incisor is good, with
exception of the impaction there is a
functional occlusion with good arrangement
of the teeth and the patient refuses
orthodontic intervention [13];
5.
There are pathological changes such as a
development of odontogenic cyst or infection
surrounding the impacted canine;
6.
Cases with delayed eruption of the
permanent canine (patients with un-erupted
canine over the age of 16). This cases are
risky for orthodontic traction because of the
unfavorable prognosis due to high rate of
ankyloses of the canines, long duration of
treatment and bad patient motivation and
cooperation. The age of a patient at the start
of treatment has been found to affect
treatment time and, since this may be lengthy,
older patients may find it unacceptable. The
upper age limits suggested for successful
alignment of an ectopic canine include 16
(McSherry, 1996) and 20 (Nordenram, 1987)
years of age. [14];
Stomatološki vjesnik 2014; 3 (2)
Kapusevska B, Dereban N, Benedetti A
7.
Patients that refuse orthodontic treatment
[15];
8.
Critical impaction with poor prognosis for
placement of the canine in the appropriate
place in the dental arch ( e.g. impacted canine
is placed between the roots of the lateral and
the central incisor and the orthodontic
movement may compromise the integrity of
these teeth) [16].
Many other parameters are also included in the
determination of the clinical prognosis of the
orthodontic treatment and the prognosis of the
severity of the impaction of the canine such as:
rotation, angulation in relation to the midline, the age
of the patient, vestibular or palatal placement of the
impacted canine, correspondence between the
midlines of the dental arches, the arrangement of the
teeth in the dental arch, the available space in the
upper labial segment between the lateral incisor and
the first premolar, vertical and horizontal position of
the permanent canine, the condition of the deciduous
canine and the presence of hypodontia of the lateral
incisor [17]. Some of these factors have decisive
significance for establishing the prognosis of the
orthodontic treatment, while others only confirm the
already established decision. The position of the
impacted canine is the most important determinant
for evaluating the prognosis of the orthodontic
treatment of the impacted canine. It is determined in
three directions, vertical, horizontal and labiapalatal. The labial position of the impacted canine is
considered as more favorable for orthodontic
treatment because the labial impacted canines may
erupt even without involving a surgical procedure
and be positioned ectopically in the dental arch. The
palatal impacted canines on the other hand rarely
erupt without surgical intervention. The hindered
eruption of the palatal impacted canine is a result of
the thickness in the palatal cortical bone as well as
the resilient palatal mucous. The palatal impacted
canines are often placed in a horizontal or inclined
position unfavorable for orthodontic treatment while
the labial impacted canines have more suitable
vertical position [18]. The main reason for vestibular
impaction is the frontal crowding in the dental arch
and the crowding itself complicates the orthodontic
treatment. The palatal impacted canines are less
accompanied by frontal crowding in the dental arch
and this is the only favorable feature for their
Stomatološki vjesnik 2014; 3 (2)
treatment. The favorability for orthodontic
treatment in the frontal plane i.e. horizontal direction
is determined by the degree of overlapping between
the lateral and central incisors from the crown of the
impacted canine. We determine the relationship
between the crown of the impacted canine and the
axis of the lateral incisor. The teeth placed distally
from this line have 91% probability for favorable
outcome from the orthodontic treatment. The
impacted canines whose crowns are placed mesial
from this line have poor prognosis and uncertain
outcome from the orthodontic treatment with 60 %
probability for their correct placement in the dental
arch. The impacted canine with a crown placed
mesial from the lateral incisor have generally poor
prognosis and unfavorable outcome from the
orthodontic treatment. In relation to the occlusal
spatial plane, the position of the impacted canine is
determined by partitioning the root of the nearest
lateral incisor in three thirds or levels. If the tip from
the crown of the impacted canine is placed in the first
level between the enamel-cement junction and the
middle of the root of the lateral incisor, the prognosis
for orthodontic treatment is favorable. Opposite to
this, if the position of the tip of the canine is in the
middle partition of the root from the lateral incisor,
the prognosis of the orthodontic treatment is with
uncertain outcome. The position of the tip from the
impacted canine in the apical third of the root from
the lateral incisor is considered as unfavorable for
orthodontic treatment. The next crucial parameter in
determining the prognosis for orthodontic traction of
the impacted canine is its angulation. Canines that
are horizontally inclined are more difficult for
orthodontic traction and have poor prognosis for
their placement in the dental arch. The more
inclination of the canine in relation to the midline
increases, the greater is the probability for extraction
instead of orthodontic traction. We can also estimate
the angulation of the canine from the angle formed by
its axis with the occlusal plane or the bi-condylar line.
Lesser important factors that also affect the
prognosis of the success from the orthodontic
treatment are the cooperation with the patient and
the oral hygienic habits. The chronological age of the
patients prolongs the treatment time and the older
patients may experience this as unacceptable. The
upper age limit for successful treatment of maxillary
ectopic canines according to some authors is 16 and
according to others is 20. The crowding in the frontal
137
MAXILARY CANINE IMPACTION – EXTRACTION OR NOT?
segment of the dental arch is unfavorable for
orthodontic treatment because of difficulty in
creating sufficient space for placement of the
impacted canine. The presence of ideally arranged
teeth in the frontal segment of the dental arch gives
uncertain prognosis for the orthodontic treatment of
impacted canines. On the other hand, the presence of
diastema (medial teeth gap) and teeth spacing is
considered as good prognostic sign. It is important to
determine the distance between the lateral incisor
and the first premolar. A distance of 4-7mm or more
than 7 mm is a sign for good prognosis, 2-4 mm
distance can prove difficult in obtaining space in the
dental arch, and 0-2 mm distance has poor prognosis.
The rotations in the frontal regions of the dental arch
can be potentially bad for prognosis of the
orthodontic treatment. A grater success from
orthodontic treatment is expected with patients
where the midlines from the maxillary and
mandibular arch coincide or when the midline is
displaced in direction of the impacted canine [19].
6.
7.
Acknowledgements
The institutions that helped with the preparation
of this scientific paper are as they follow:
1.
Faculty of Dentistry, University “St. Cyril and
Methodicus”, Skopje, Republic of Macedonia.
2.
Department of Prosthodontics, Public Health
Clinic ''St. Panteleimon, Skopje, Republic of
Macedonia
3.
Private Health Institution ”Orto-gan”, Struga,
Republic of Macedonia.
Conclusion
From the treatment, evaluation and management
of patients with impacted maxillary canines, we
made the following conclusions:
1. The orthodontic reasons and indications for
extraction of the impacted canine that refer
to the unsuitable and unfavorable position of
this tooth are rare;
2. The estimation of the position of the
impacted canine in the jaw bone is the most
relevant factor for the final prognosis of the
success rate of the orthodontic treatment;
3. The position of the canine is determined in
three directions: orally-vestibular, mesiodistal, corono-apical and by the angulation of
the impacted tooth;
4. The vertical rule of thirds dictates that the
prognosis of the orthodontic treatment is less
favorable when the impacted canine is placed
deeper in the patient's jaw;
5. The prognosis of the orthodontic treatment is
less favorable in the cases when the
angulation of the impacted canine
approaches the horizontal plane;
138
The horizontal rule of thirds is determined in
relation to the lateral incisor. The prognosis
of the orthodontic treatment is unfavorable
in the cases when the tip of the crown from
the impacted canine overlaps or goes beyond
the root of the lateral incisor;
The most accurate method for determining
the oral and vestibular position of the
impacted canine is with parallactic method.
The vestibular position is considered as more
favorable outcome from the orthodontic
treatment.
Declaration of Interests
None of the authors have any conflict of interest to
disclose.
References
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Chaushu S, Bongart M, Aksoy A, Ben Bassat Y.
Becker Buccal Ectopia of Maxillary Canines in the
Absence of Crowding. Am J Orthod Dentofacial
Orthop 2009; 136: 218–223.
2.
da Costa. O. O. The unerupted maxillary canine –
A review of literature, Nigerian Journal of Clinical
Practice Dec. 2002, 5 (2); 91-98
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Pinho T, Tavares P, Maciel P, Pollmann C. Developmental absence of maxillary lateral incisors in
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the Portuguese population. Eur J Orthod 2005;
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Ben Bassat Y, Brin I. Maxillary canines in patients
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severely resorbed maxillary incisors following
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Rutledge MS, Hartsfield, JK Jr., Genetic Factors in
the aetiology of Palatally Displaced Canines,
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Ely NJ, Sherriff M, Cobourne MT. Dental transposition as a disorder of genetic origin. Eur J
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Yan B., Sun Z.,Fields H., Wang L., Luo L. Etiologic
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Ferguson J W, Pitt S K J 2004 Management of
unerupted maxillary canines where no orthodontic treatment is planned; a survey of UK consultant opinion. Journal of Orthodontics 32:
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Dentofac Orthop 2009; 136: 657–665.
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11. Fink D F, Smith R J 1992 The duration of orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics 102: 45–51
12. Baccetti T. Risk indicators and interceptive
treatment alternatives for palatally displaced
canines. Semin Orthod 2010; 16: 182–192.
13. Stivaros N, Mandall N A 2000 Radiographic
factors affecting the management of impacted
upper permanent canines. Journal of Orthodontics 27: 169–173
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index for unerupted maxillary canines. European
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16. Becker A. Extreme tooth impaction and its resolution. Semin Orthod 2010; 16: 222–233.
17. Fleming PS, Scott P, Heidari N, di Biase AT. Influence of radiographic position of ectopic canines on the duration of orthodontic treatment.
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18. Daniels C, Richmond S 2000 The development of
the Index of Complexity, Outcome and Need
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205–211
139
CASE REPORT / PRIKAZ SLUČAJA
DENTICLES (PULP STONES)
- A CHALLENGE IN ENDODONTIC
THERAPY - MULTIPLE CASE REVIEW
Konjhodžić- Prcić A*1, Korać S1, Jakupović S1, Vuković A2
1
1Department of Restorative Dentistry and Endodontics, Faculty of Dentistry,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
2
Department of Dental Morphology, Dental Antropology and Forensics,
Faculty of Dentistry, University of Sarajevo, Sarajevo, Bosnia and Hercegovina
*Corresponding author
Konjhodžić Prcić Alma,
Assistant Professor, PhD
Department of Restorative
Dentistry and Endodontics
Faculty of Dentistry
University of Sarajevo
Bolnička 4a
71000 Sarajevo
Bosnia and Hercegovina
Phone: + 387 33 214 249
e-mail: [email protected]
ABSTRACT
Denticles are discrete calcified bodies in the pulp chamber.
Denticle prevalence varies from 8% to 95%. By their structure
they are classified as true and false, while by localization they can
be embedded (interstitium), adherent (fixed) and free. Its
etiology has not fully been cleared. Denticle represents a big
problem in the endodontic therapy, because they, partially or fully,
obliterate the pulp chamber or root canals, which aggravates or
fully disables any endodontic treatment. This paper describes
several cases of endodontic treatment with diagnosed denticles,
as well as specific therapeutic procedures used in clinical work for
each patient respectively.
Key words: Pulp calcifications, denticles, dental pulp stone,
pulp obliteration .
Stomatološki vjesnik 2014; 3 (2)
141
DENTICLES (PULP STONES)- A CHALLENGE IN ENDODONTIC THERAPY- MULTIPLE CASE REVIEW
Introduction
Calcified bodies located in the pulp chamber or
more rarely in the root canal are called denticles. The
literature also called them pulpolites, pulp stones,
corpora arenacea (grains of sand). They vary in size,
are found separately or as multiple stones. In some
cases they can be so large that they fill out the pulp
chamber or extend to the root canal [1]. They can be
diagnosed in all teeth, but most commonly in
permanent molars [2, 3].
Etiology of pulp stones is not clear, although the
literature mentions factors associated with the creation of pulp stones, such as: pulp degeneration, inductive interaction between the epithelium and pulp
tissue, age , circulatory disorders in the pulp, tooth
orthodontic movement, genetic predisposition, longterm irritation by caries, deep filling or chronic
inflammation and idiopathic factors [4]. Presence of
denticle in the pulp generally represents a local pulp
response to certain irritating factors [3, 4].
Denticle prevalence varies from 8% to 95% [3].
Since it is radiologically possible to diagnose only
bodies over 200 μm of size, the denticle prevalence
determined radiologically is much lower than when
confirmed histologically [5]. Certain studies indicate
an identical denticle prevalence at men and women
[4], while other studies showed much higher prevalence at women [3, 6].
Calcifications can be found in the pulp of people of
all ages. Although there are statements indicating
that the incidence of pulp calcifications increases
with the age of the patient [7] some authors do not
find a correlation between the age and occurrence of
calcification [3].
Generalized pulp calcifications might be associated with systemic and genetic disorders of the dentin
[2]. A generalized form of the denticle is found at
people with various pathological conditions such as:
tumoral calcinosis, dentine dysplasia Type II, Elfin
facies syndrome, familial expansile osteolysis [7].
Increased incidence of pulp calcification is found in
healthy pulps of patients with cardiovascular diseases [8], and significant correlation between coronary
arterial stenosis and pulp calcifications has been
established [9].
Structurally, they can be classified as true and false, while by localization, denticles can be embedded
(interstitium), adherent (fixed) and free. True pulp
142
stones are built of dentin, while the false ones were
made by calcification of degenerated pulp cells [7].
Since calcifications in the pulp usually do not cause
pulp disease nor do they give subjective symptoms, it
is still unclear whether they represent a pathology or
a biological variation [3].
From a clinical point of view, denticles represent a
problem because they partially or fully obliterate the
pulp chamber thus closing entrances to the root canals, which aggravates or fully disables any endodontic treatment.
This paper describes several cases of endodontic
treatment with diagnosed denticles, as well as specific therapeutic procedures used in clinical work for
each patient respectively.
Case review No.1 – embedded
(interstitium) denticle
Patient I.B. (37) was reffered to the Department of
Dental Pathology and Endodontics at Faculty of
Dentistry of the University in Sarajevo because of
strong pains of the tooth 27. Clinical examination and
appropriate diagnostics found a symptomatic
pulpitis of the tooth 27.
Analyzing radiograph (Figure 1), an obliteration
of the crown part of the pulp chamber was found
caused by a large embedded denticle, which was also
clinically diagnosed after opening the chamber. Since
the denticle was embedded to the bottom of the pulp
cavum (Figure 2), the morphological appearance of
the cavum was altered, and entrances to the root
canal blocked. The orientation of the therapist was
aggravated, and there was a possibility of a cavum
Figure 1.
Radiograph before the endodontic treatment of tooth 27
(visible obliteration of the pulp chamber).
Stomatološki vjesnik 2014; 3 (2)
Konjhodžić- Prcić A, Korać S, Jakupović S, Vuković A
Figure 5.
Endodontic treatment of tooth 27 completed.
Figure 2.
Interstitial denticle at the pulp chamber floor of
tooth 27 before identifying entrances to the roots canals.
Figure 3.
Treatment of the root canals entrances of
tooth 27 using a CAV1 ultrasonic tips.
Figure 4.
CAV1 ultrasonic tip used for the opening
of the root canals entrances.
Stomatološki vjesnik 2014; 3 (2)
perforation while looking for entrances in the root
canals. Entrances to the roots canals were unblocked
by CAV1 and a dentin removal tips (VDW Ultra),
embedded on a SCALER ultrasonic device incorporated within an Adeco unit chair (Figures 3, 4).
Advantages of this tips are shown through the posibility of a controlled, safe and efficient dentin removal by the means of discrete ultrasound vibrations,
without rotating movements. Usage of these long and
thin ultrasound extensions reduces working time
and allow a better manual control, especially during
an endodontic treatment of molars.
After unblocking the entrances of the root canals,
the endodontic treatment of the tooth is completed in
accordance to standard protocols (Figure 5).
Case No. 2 review – free denticle
Patient M.K. (33) was reffered to the Department
of Dental Pathology and Endodontics of the Faculty
for Dentistry of the University in Sarajevo because of
the pain occurred after the tooth preparation for
dental crown placement. The right upper second
molar was filed down some days ago. Since then
patient was feeling pain occurring spontaneously,
especially while lying on that side and disappearing
by changing the position. Radiography showed a
larger calcification in the crown part of the pulp
chamber (Figure 6). After a plexus anesthesia and
trepanation, the calcification of 4 mm in diameter
was easily removed using an excavator and a probe
143
DENTICLES (PULP STONES)- A CHALLENGE IN ENDODONTIC THERAPY- MULTIPLE CASE REVIEW
(Figure 7). Thus, root canal treatment was successfully performed (Figure 8).
By analyzing the aforementioned symptomatology, clinical tests and radio-visiography of the second upper molar, we concluded that denticle was
fixed to a layer of dentin, but not embedded into dentin. High-speed hand-peace vibrations, while preparing tooth for dental crown, led to the separation of
denticle from dentin causing moving of the denticle.
Odontalgia occurred specially in lying position
whenever the denticle compressed nerve endings on
that side of the pulp chamber.
Figure 6.
Visible calcification in the pulp chamber of tooth 17.
Figure 7.
Denticle found in pulp chamber of the tooh 17, dimeter 4 mm
Figure 8.
K - files in the root canals of tooth 17.
144
Case review No. 3 – adherent (fixed)
denticle
Patient F.B. (18) was reffered to the Department of
Dental Pathology and Endodontics for endodontic
treatment of tooth 16. X-rays revealed a denticle in
tooth 16, as well as in all adjacent teeth (Figure 9).
Denticle adherent to the bottom of the pulp chamber
was found, which was separated from the remaining
dentin by Gates-Gliden chisel and an excavator, and
endodontic treatment was completed (Figure 10). A
subsequent measuring found that a denticle 6 mm in
diameter (Figure 11). Pato-histological findings
colored by the HE technique demonstrated that the
denticle was made of several smaller irregularryshaped dentin islands, with segments of connective
and vascular pulp tissues. On a 250x magnafication,
scleroticized dentin tubuli were observed. A
morphological image of the sample corresponds to
real denticle, with several false denticles alongside its
edges (Figures 12, 13, 14, 15).
Figure 9.
Radiograph before the endodontic treatment of tooth 16.
Visible pulp calcifications in pulp chambers of all teeth.
Stomatološki vjesnik 2014; 3 (2)
Konjhodžić- Prcić A, Korać S, Jakupović S, Vuković A
Figure 10.
Radiograph after endodontic treatment of tooth 16.
Figure 14.
Several smaller dentin islands
Figure 11.
Denticle extracted from the tooth 16, 6 mm in diameter.
Figure 15.
Several false denticles are spotted alongside the edges of the true denticle
Discussion
Figure 12.
Denticle built of irregularry-shaped dentin, with segments
of connective and vascular tissues
Figure 13.
Sclerotized dentin tubuli
Stomatološki vjesnik 2014; 3 (2)
This paper presents successful endodontic treatments of permanent molars with denticles. Denticles
are created by calcification of the connective tissue,
as a result of degenerative changes in the pulp and
circulation reduction. Pulp calcifications can occur in
several forms. Real denticle has canalicular structure
similar to tertial dentin and on their periphery
odontoblasts can be found, while the structure of the
false denticle is amorphic. By localization, denticles
can be embedded (interstitium), adherent (fixed)
and free [7]. Free denticles are those found in the pulp
tissue of the coronary or radix pulp. Adherent denticles are connected to a layer of dentin, but not embedded into it, while interstitium denticles are completely embedded into dentin. Free denticles are easily
removed during extirpation whether they are in the
radix or crown pulp, while the adherent and embedded denticles can significantly aggravate the endodontic treatment [7].
Denticles in molars are the most common,
possibly because of the fact that they are the largest
teeth in both jaws, with the best blood supply to pulp
145
DENTICLES (PULP STONES)- A CHALLENGE IN ENDODONTIC THERAPY- MULTIPLE CASE REVIEW
tissues, which can result in calcium precipitation in
the chamber [3].
Denticles rarely cause symptoms. Symptoms
occur mostly when they are located by nerve fibers,
and pressing them, they cause pulpitic pains. The
character of the pain is neuralgiform, long-lasting
and can occur on the intact teeth. In the case of
odontalgia caused by denticle, endodontic therapy is
indicated. If they are discovered without the presence of symptoms or pathological changes the endodontic therapy is indicative.
Locating the entrances into the root canals, especially in the cases they are blocked by tertiary dentin
and calcifications represents a challenge. Although
denticles from the chamber can be removed by drill,
it is far easier to use appropriate ultrasound instruments [7]. Ultrasound in modern endodontics is widely used. It is primarily used to improve irrigation,
but can also be used for fine dentin treatment, which
alleviates visualization and access to the root canal.
It is important to mention that existence of individual or diffuse pulp calcification does not affect the
threshold of electric pulp-testing [7].
Newer studies point out that dental radiographic
determination of the presence or absence of pulp stones may have possibilities for use in cardiovascular
disease screening [8]. Pulp stones may provide useful
forensic information when examining dental records
to identified deceased persons [10].
Conclusion
Etiology of pulp calcification has not fully been
cleared. Calcified structures in human dental pulps
were usually found accidentally. Their presence in
pulp chamber aggravates and compromises the
endodontic treatment. Ultrasound proved to be useful addition to endodontic therapy. Using ultrasound,
for this purpose, it is possible to reduce the time of
operation and risks of root perforation during detection entrance of the root canals, as well as makes
operating more comfortable to both, the therapist
and the patient.
As we demonstrated in this paper, presence of
denticles in pulp chamber is not an insurmountable
barrier in the endodontic therapy, and with adequate
knowledge and tools, it is possible to complete the
endodontic treatment lege artis.
146
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in Australians. Aust Dent J. 2002;47(1):36-40.5.
5.
Tomczyk J, Komarnitki J, Zalewska M, Wiśniewska E, Szopiński K, Olczyk-Kowalczyk D. The prevalence of pulp stones in historical populations
from the middle euphrates valley (Syria). Am J
Phys Anthropol. 2014;153(1):103-115.6.
6.
Satheeshkumar PS, Mohan MP, Saji S, Sadanandan S, George G. Idiopathic dental pulp calcifications in a tertiary care setting in South India. J
Conserv Dent. 2013;16(1):50-55.7.
7.
Goga R, Chandler NP, Oginni AO. Pulp stones: a
review. Int Endod J. 2008; 41(6):457-68.8.
8.
Edds AC, Walden JE, Scheetz JP, Goldsmith LJ,
Drisko CL, Eleazer PD. Pilot study of correlation
of pulp stones with cardiovascular disease. J
Endod. 2005;31(7):504-506.9.
9.
Ezoddini-Ardakani F, Namayandeh SM, SadrBafghi SM, Fatehi F, Mohammadi Z, ShahrabiFarahani S, Hedayati AS, Rahmani-Baghemalek
MJ. Association of pulp stones with coronary artery stenosis. Community Dent Health. 2011;
28(4):305-307.
10. Sisman Y, Aktan AM, Tarim-Ertas E, Ciftçi ME,
Sekerci AE. The prevalence of pulp stones in a
Turkish population. A radiographic survey.Med
Oral Patol Oral Cir Bucal. 2012 Mar 1;17(2):212217.
Stomatološki vjesnik 2014; 3 (2)
BOOK REVIEW / PRIKAZ KNJIGE
TITLE: Orthodontic and Surgical
Management of Impacted Teeth
AUTHORS: Kokich, Vincent G. and
Mathews, David P.
PUBLISHER: Quintessence Publishing Co,
Inc; 4350 Chandler Drive,
Hanover Park, IL 60133
Media Ogled d.o.o.
Zagreb, Croatia
LANGUAGE: Croatian
FORMAT: 220 x 225
NUMBER OF PAGES: 188
NUMBER OF PHOTOGRAPHIES: 590
DATE OF ISSUE: 014
ISBN ISBN 978-953-7862-06-0
The advances in interdisciplinary clinical
management of impacted teeth have been made in
recent years. Impacted teeth are a commonplace
encounter in dental practice, yet currently there is not
a comprehensive book detailing the surgical
treatments and orthodontic therapy to erupt or
manage these teeth. You have in front of you the most
complete, organized and contemporary book concerning this topic. Written by undoubtly the best orthodontist in the world and his periodontist colleague of
almost 40 years, this text covers the various types of
impactions that an orthodontist and surgeon would
encounter. The most commonly impacted teeth have
been identified including maxillary central incisors,
maxillary canines (both labially and palatally
impacted), mandibular canines, premolars, and
mandibular molars. Second, the cause of impaction
has been discussed. In most situations, these
unerupted teeth have been diverted or are angulated
aberrantly during development. Once the root apex
has closed, they lose their potential to erupt. Each
chapter focuses on a specific impacted tooth and how
it can be surgically uncovered and orthodontically
moved. Careful coordination between the surgeon
and orthodontist is essential to ensure that the teeth
will fit correctly after the surgery. The various surgical
procedures to uncover these impacted teeth have
been described. Three different techniques (excision,
apically positioned flap, and closed eruption technique) may be used to uncover the impacted tooth.
The specific criteria used to select the proper surgical
technique were stated.
Stomatološki vjesnik 2014; 3 (2)
Last, the orthodontic mechanics and integration of
tooth movement and surgical procedures were delineated and illustrated for each of the various types of
impactions and uncovering techniques.The book also
presents a chapter on failed cases, explaining what
went wrong and how to prevent such negative outcomes when treating similar cases. All chapters were
enriched with photographs, as many as 590 giving the
specific value to this book. Ideal for any dental practitioner who treats impacted teeth, this comprehensive and up-to-date book is a fitting legacy for Dr
Kokich, whose impact within the field of orthodontics
will be felt for years to come.This is the perfect tool for
orthodontists, pediatric dentists, periodontics and
oral surgeons who treat these cases.
Finally, we can say this book will serve not only to
oral surgeons and orthodontists, but also to general
dental practitioners and students in order to better
understand the principles of impacted teeth
treatment.
Contents
1. Impacted Maxillary Central Incisors
2. Labially Impacted Maxillary Canines
3. Palatally Impacted Canines
4. Impacted Mandibular Canines
5. Impacted Premolars
6. Impacted Mandibular Molars
7. Complications and Adverse Sequelae
Sadeta Šečić
147
INSTRUCTIONS FOR THE AUTHORS
INSTRUCTIONS FOR THE AUTHORS
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Stomatološki vjesnik 2014; 3 (2)
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150
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Stomatološki vjesnik 2014; 3 (2)
INSTRUCTIONS FOR THE AUTHORS
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151
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Tashiro H, Shimokawa H, Sadamatu K, Yamamoto
K. Prognostic significance of plasma concentrations of transforming growth factor-ß. Coron
Artery Dis 2002; 13(3):139-143.
More than six authors:
Yetkin E, Senen K, Ileri M, Atak R, Tandogan I,
Yetkin Ö, et al. Comparison of low-dose dobutamine stress echocardiography and echocardiography during glucose-insulin-potassium infusion for detection of myocardial viability after
anterior myocardial infarction. Coron Artery Dis
2002; 13(3):145-149.
Books:
Heger JW, Niemann JT, Criley JM. Cardiology, 5th
ed. Philadelphia: Lippincott, Williams & Wilkins;
2003.
Chapter in a book:
Braunwald E, Perloff JK. Physical examination of
the heart and circulation. In; Braunwald E, Zipes
DP, Libby P (eds). Heart disease; a textbook of
cardiovascular medicine, 6th edn. Philadelphia:
WB Saunders; 2001, pp. 45-81.
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152
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