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July - Dec 2010 KDN PP 4069


Malaysian Dental Journal Volume 31 Number 2

An investigation into the e ect of denture adhesives in limiting the food impaction Incidence of post-operative pain following single-visit endodontic therapy in single- and multi-rooted teeth Adenoid Cystic Carcinoma A Case Report And Review Of Literature Orthodontic Treatment Of A Unilateral Cleft Lip And Palate Patient With Secondary Bone Graft And Eruption Of Canine UKM undergraduates perception of Hand ProTaper System Regenerative endodontics: a review OZONE An Overview Abstracts : Poster and oral presentations from the 67th MDA/FDI World Dental Scienti c Convention and Trade Exhibition, 10-13 June 2010, Kuala Lumpur.

A Publication of the Malaysian Dental Association ISSN 0126-8023

Malaysian Dental Journal Editorial Team 2010/2011

Editor: Assistant Editor: Secretary: Treasurer: Ex-Officio:

Associate Professor Dr. Dalia Abdullah Dr. Shalini Kanagasingam Dr Nurul Asyikin Yahya Dr Mumtaj Nisah Abd Rahim Dr. Ng Woan tyng Dato' Dr. How Kim Chuan

The Editor of the Malaysian Dental Association wishes to acknowledge the tireless efforts of the following referees to ensure that the manuscripts submitted are of high standard. Prof. Dr. Toh Chooi Gait Prof. Dr. Lui Joo Loon Prof Dr Francesco Mannocci Dr. Zamros Yuzadi Dr. Elise Monorasinghe Dr. Lau Shin Hin Dr. Loke Shuet Toh Dr. Shahida Said Dr. Zamri Radzi Dr. Siti Adibah Othman Dr. Zeti Adura Che Abd. Aziz Prof. Dr. Ong Siew Tin Prof. Zubaidah Abdul Rahim Dr Philip Mitchell Dr. Siti Mazlipah Ismail Prof. Dr. Siar Chong Huat Assoc. Prof. Dr. Shanmuhasuntharam Dr. Fathilah Abdul Razak Dr. Lam Jac Meng Dr. Nor Himazian Mohamed Dr. Norliza Ibrahim Dr. Wey Mang Chek Dato Prof. Dr. Hashim b. Yaacob Prof. Dr. Phrabhakaran Nambiar Dr Omar Ikram Prof. Dr. Tara Bai Taiyeb Ali Prof. Dr. Rahimah Abdul Kadir Assoc. Prof. Dr. Datin Rashidah Esa Assoc. Prof. Dr. Tuti Ningseh Mohd Dom Assoc. Prof. Dr. Roszalina Ramli Assoc. Prof. Dr. Roslan Abdul Rahman Dr. Dalia Abdullah Dr. Wong Mei Ling

The Publisher The Malaysian Dental Journal is an official publication of the Malaysian Dental Association and is published half yearly (KDN PP4069/12/98). Malaysian Dental Association 54-2, (2nd Floor), Medan Setia 2, Plaza Damansara, Bukit Damansara, 50490 Kuala Lumpur Tel: 603-20951532, 20947606, Fax: 603-20944670 Website address: E-mail: /

Cover page: Pictures courtesy of Dr Sham Kishor K and co-authors

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 2010 The Malaysian Dental Association



Aim And Scope

The Malaysian Dental Journal covers all aspects relevant to the science and practice of Dentistry, interdisciplinary fields and supporting aspects of Medicine. Within the scope of the journal, the following articles will be published: Editorials - commentary by editors Clinical articles - in depth discussions on clinical procedures or treatment techniques Case reports - illustrating various aspects of clinical practice and management Materials, instruments and technical innovations - reports and research on new innovations and dental products Ask the Experts - questions posed to seek expert opinion and views on specific topics Book reviews - critical commentary on the latest printed publications Product reviews - critical opinion and feedback on newly introduced dental or dental-related products Letter to editor - comments and feedback from readers pertaining to journal articles Conference abstracts - proceedings of workshops, conferences and symposiums organized by the MDA Cover photographs Interesting photographs for the front cover of the journal The mission is to promote and elevate the quality of patient care and to encourage the advancement of practice, continuing education and scientific research in Malaysia. Publication The Malaysian Dental Journal is an official publication of the Malaysian Dental Association and is published half yearly (KDN PP4069/12/98) Instructions for submission Original articles, editorial, correspondence and suggestion for review articles should be sent to: Editor of Malaysian Dental Journal : Authors are requested to submit their typescript and illustrations via the email address provided. A paper is accepted for publication on the understanding that it has not been submitted simultaneously to another journal in the English Language. The editor reserves the right to make editorial and literary corrections in the interest of conciseness, clarity and consistency. Any opinion expressed or policies advocated do not necessarily reflect the opinion or policies of the editors. Copyright Authors submitting an article do so on the understanding that the work has not been published before. The submission of the manuscript by the authors means that the authors automatically agree to sign exclusive copyright to the Editor and the publication committee if and when the publication is accepted for publication. The copyright transfer agreement can be downloaded at the MDA webpage ( A copy of the agreement must be signed by the principal author before any paper can be published. There will be no limitation on your freedom to use material contained in the article (without having to request permission) provided that an acknowledgement is made to the journal as the original source of publication. Presentation of manuscript Please follow these instructions carefully as manuscripts which have not been prepared in the approved format will be rejected. Manuscripts should be submitted in journal style, in UK English with font should be Arial (size 12). Articles should be typed with double spacing. Papers should be set out as follows with each beginning in a separate page: title page, key words, abstract, text, acknowledgements, references, tables, caption to illustrations. Title page. The title page should give the following information: 1) title of the article; 2) full names and professional/ academic qualifications/positions of each author; 3) name, address, telephone, fax and e-mail address for the corresponding author, assumed to be the first listed author unless otherwise advised. If the paper was presented at an organised meeting, the name of the organization, location and date of the meeting should be included.
Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 2010 The Malaysian Dental Association 62

3 to 5 keywords Abstract. Summary of article, with a maximum of 250 words (structured as aim, materials and methods, results and conclusions). Text. Normally only two categories of heading should be used: major ones should be typed in capital in the centre of the page and underlined; minor ones (or subheadings) should be typed in lower case (with an initial capital letter) at the left hand margin and underlined. Please use clear and concise language. References. The accuracy of the references is the responsibility of the author. References should be entered consecutively by Arabic numerals in superscript in the text. The reference list should be in numerical order on a separate page in double spacing. Reference to journals should include the author's name and initials (list all authors when six or fewer; when seven or more list only the first three and add et al.), the title of paper, Journal name abbreviated, using index medicus abbreviations, year of publication, volume number, first and last page numbers (ie. Vancouver style). For example: Ellis A, Moos K, El-Attar. An analysis of 2067 cases of zygomatico-orbital fractures. J Oral Maxillofac Surg 1985;43:413417. Reference to books should be sent out as follows: Scully C, Cawson RA, Medical Problems in Dentistry 3rd edn. Wright 1993:175. Tables. These should be double spaced on separate page, apart from the main text. A short descriptive title should appear above each table and any footnotes, suitably identified below. Care must be taken to ensure that all units are included. Ensure that each table is cited in the text (e.g. Table 1, Table 2 etc) Illustrations. All illustrations should be submitted in high resolution JPEG or TIFF format, minimum of 300 dpi. Photomicrographs should have the magnification and details of the staining technique shown. Radiographs should be of good contrast. Captions should be typed, double spaced on separate sheets from the manuscript. Patient confidentiality. Where illustrations must include recognizable individuals living or dead and of whatever age, great care must be taken to ensure that consent for publication has been given. Otherwise, the patients eyes or any indentifiable anatomy should be masked. Permission to reproduce, borrowed illustration or table or identifiable clinical photographs. Written permission to reproduce, borrowed material (illustrations and tables) must be obtained form the original publisher and authors and submitted with the typescript. Borrowed material should be acknowledged in the caption in this style. 'Reproduced by the kind permission of...... (publishers) from /....(reference)'. Abbreviations and units. Avoid abbreviations in the title and abstract. All unusual abbreviations should be fully explained at their first occurrence in the text. All measurements should be expressed in SI units. Proprietary names. Proprietary names of drugs, instruments etc. should be indicated by the use of initial capital letters. Grant support. Any direct or indirect commercial involvement or interest must be declared. Ethical approval. For clinical studies, the approval of the relevant ethical committee must be obtained. Please include a photograph of the lead author. Reviewing of manuscripts All submissions will be peer-reviewed anonymously . Page Proofs Page proofs will be emailed to the author for checking. The proofs with any minor corrections must be returned via email to the editor within 48 hours of receipt.


Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 2010 The Malaysian Dental Association


An Investigation Into The Effect Of Denture Adhesives In Limiting The Food Impaction Marlynda Ahmad, Dayang Fadzlina Abang Ibrahim, Nur Hafizah Hazmi, Natasya Ahmad Tarib, Kamarul Hisham Kamarudin 65

Incidence Of Post-Operative Pain Following Single-Visit Endodontic Therapy In Single- And Multi-Rooted Teeth 71 Neeraj Malhotra, Kundabala Mala, Shilpa Reddy, Priyanak Singh, Shashirashmi Acharya, Ramya Shenoy Adenoid Cystic Carcinoma A Case Report And Review Of Literature Sham Kishor Kanneppady, Santosh B. Sakri, Laxmikanth Chatra, Prashanth Shenoy K Orthodontic Treatment Of A Unilateral Cleft Lip And Palate Patient With Secondary Bone Graft And Eruption Of Canine Thomas Mathew UKM Undergraduates Perception Of Hand Protaper System Wan Noorina Wan Ahmad, Assoc. Prof Dr Dalia Abdullah, Shalini Kanagasingam, Safura Anita Baharin, Jasmina Qamaruz zaman Regenerative Endodontics: A Review Kundabala M, Abhishek Parolia, Neeta Shetty OZONE An Overview Rizwan M Sanadi 67th MDA AGM/ FDI World Dental International Scientific Convention & Trade Exhibition, 10-13 June 2010 at Kuala Lumpur Convention Centre - Poster 67th MDA AGM/ FDI World Dental International Scientific Convention & Trade Exhibition, 10-13 June 2010 at Kuala Lumpur Convention Centre - Oral 79







Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 2010 The Malaysian Dental Association


An Investigation Into The Effect Of Denture Adhesives In Limiting The Food Impaction
Authors: Marlynda Ahmad Department of Prosthodontics, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Malaysia. Dayang Fadzlina Abang Ibrahim Dental Clinic, Community Polyclinic, Jalan Masjid, 93400 Kuching, Sarawak Nur Hafizah Hazmi Dental Clinic, Community Polyclinic, Jalan Masjid, 93400 Kuching, Sarawak Natasya Ahmad Tarib Department of Prosthodontics, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Malaysia. Kamarul Hisham Kamarudin Klinik Kesihatan Putrajaya, 1 Jalan P9E, Presint 9, 62250 Putrajaya.


Aim of the study: To compare the weight of retrieved food accumulated under the dentures base with and without adhesive treatment.

Materials and Method: Each subject was given 32 g of non-salted dry roasted peanuts to chew and swallow. After finishing all the peanuts, the subject was asked to brush their denture using toothbrush and toothpaste without removing the denture from the mouth and rinsed their mouth vigorously with water. The weight of the retrieved peanuts accumulated under the denture base collected, dried, and weighted. All procedures were repeated with denture adhesive. Results: On average, the mean weight of peanuts particles recovered beneath upper dentures without application of denture adhesive was 51.21 mg which is higher than the mean weight of upper denture with adhesive treatment (35.36 mg). The similar pattern was detected for the lower dentures but at higher mean weight. Conclusion: Application of denture adhesive significantly reduced the amount of retrieved peanut particles collected under the denture base compared to no-adhesive treatment (p< 0.005).

Key Words: Food occlusion, denture adhesive, satisfaction, quality of life.

This research has been presented at the 66TH MDA AGM/ FDI International Scientific Conference & Trade Exhibition (2nd Place for poster presentation)

The huge prevalence of tooth decay, periodontal disease and the gradual ageing of population in the developed world have combined to produce a steady increase in the need for complete denture treatment. Complete dentures are the most common treatment offered to the edentulous patient worldwide. Complete denture wearers exist in all communities and it has been suggested that the number in this group will continue to increase in the immediate future with the expected increase in life expectancy. The presence of dentures in edentulous patients creates yet another environment with its

own microflora. Several studies have shown that plaque from both on denture surface and underlying supporting tissues. This will result in oral halitosis and supporting tissue inflammation in denture wearers. These conditions are frequently associated with food impaction beneath the denture surface, which is due to voids occurring in the interfacial space in the absence of absolute adaptation between denture base and bearing tissue. Edentulous patients also suffer a marked functional disability when chewing and speaking. The chewing ability of an average person with complete denture is about 20% of that chewing ability of an average person with complete dentition. This may
Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 2010 The Malaysian Dental Association

An Investigation Into The Effect Of Denture Adhesives In Limiting The Food Impaction

cause impairment on dietary intake and nutritional health status. Apart from that, edentulous patient encountered in dental practice might have been wearing denture for decades. Significant atrophy of alveolar processes following the loss of natural teeth is an all too familiar consequence of long term edentulism. This oral condition complicates both dentist ability to construct good complete dentures and the patients ability to successfully manage their new prostheses. Therefore, successful denture therapy must involve both technical excellences during prostheses fabrication and effective patient management throughout the whole process. Satisfying the expectations of many patients for optimal denture retention and stability is often beyond the technical skills of even the most accomplished practitioners. Implementing the judicious use of denture adhesive may satisfy patients expectations and achieve intended treatment goals as well as to enhance the treatment outcome. This study is to investigate the effectiveness of denture adhesive to form a barrier that prevents food from entering the space between denture base and bearing tissue, satisfaction after application of denture adhesive and evaluate the quality of life with denture adhesive.

Table 1: Classification of maxillary and mandibulcomplete denture based of MKIS N 1 2 3 4 MODIFIED KAPUR INDEX SCALE (MKIS) Sum score of <6 Sum score of 6-9 Sum score of 10-14 Sum score of >14 INTERPRETATION Poor Fair Good Excellent

Table 2: Denture Bearing Tissues Score (DBTS) for ridge shape, tissue resiliency and location of border tissue attachment, for maxillary and mandibular arches
RIDGE SHAPE SCORE Maxillary and Mandibular Flat V-shaped Shaped between U and V U- shaped TISSUE RESILIENCY Maxillary and Mandibular Flabby Resilient Firm LOCATION OF BORDER TISSUE ATTACHMENT Maxillary Low Medium High Mandibular High Medium Low -

1 2 3 4


A total of 50 patients were randomly selected from the UKM Registration Office and Putrajaya Dental Clinic. Patients were offered to participate and inform Table 3: Classification of denture bearing tissue score (DBTS) consent was obtained from the patient. Ethics approval was obtained from the Ethics Committee of Dental N DENTURE BEARING INTERPRETATION Faculty, UKM prior to clinical examination. Subjects TISSUES SCORE (DBTS) selection was based on their dentures quality. It must be well made and fitting (Kapur, Olshan 1 Sum score of <14 Poor Modification, Retention and Stability Index Sum Score 10)59complete dentures (Table 1). Patient with 2 Sum score of 14-17 Satisfactory known allergy to peanut were excluded from the study. Soft tissue examination was completed to assess the 3 Sum score of >17 Good denture bearing tissue such as shape, tissue resiliency and location of border tissue attachment. Then the A 32 gram non-salted dry roasted peanut (Cap denture bearing tissues total score were calculated Tangan) were packed into plastic bag (6 X 9 cm). and recorded. (Table 2) In order to standardize the weight of the peanuts, a same electronic weighing device (METTLER TOLEDO) was used. The bags containing the peanuts were then labelled. Each subject was given 32 g of non-salted dry roasted peanuts (Cap Tangan) to chew and swallow. After finishing all the peanuts, each subject then brushed their denture using toothbrush and toothpaste without removing the denture from the mouth. Finally, the subject rinsed their mouth vigorously with water. This procedure aims to remove any peanut particles that did not retained under the dentures base.

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Kamarul / Natasy / Nur Hafizah / Dayang Fadzlina / Marlynda

The upper dentures was removed and placed on a small examination tray (Germany) with the denture teeth side down to ensure that peanut particles did not fall out from the denture base. Any residual peanut particles were removed from the subjects palate or denture bearing area using a piece of gauze. The gauze and denture were later placed in a 500 ml beaker (Kimax KG-33 Glass) coded with the subject reference number and capital U for upper denture. Similar procedures were carried out for the lower denture, as well as for the lower denture bearing area. The upper and lower denture of each subject placed in the coded beakers (U &L) with the gauze (upper and lower separately). A total of 100 ml of hot water (60 C) was added to U and L beakers and both beakers were then sonicated in Bransonic Ultrasonic Cleaner (SweepZone) for 30 minutes to loosen any adhering peanut particles. The solution mixture of water, saliva and peanut particles in beaker U and L was heated to boiling with frequent stirring, to dissolve any undissolved adhesive. The hot solution in each beaker was then strained through a standard testing sieve, (Sartorius Stedim Biotech, Germany). The residue remaining on the sieve was washed repeatedly with hot water to remove any saliva. Next, the dried peanut particles were later transferred to 50-ml beakers coded with subjects reference number, before having them sonicated for 15 minutes. Then the peanut particles were strained again through a standard testing sieve. The peanut particles will be air dried on the petri dish coded (subject reference number, U/L and date) for 1 hour. In addition, the collected peanut particles were again air-dried overnight. Final drying was done in an oven (Memmert) at 105 F for 5 hours. The dish was then cooled to room temperature and later weighed, to determine the weight of the particles collected from each denture (weight of the retrieved peanuts). All procedures were repeated with denture adhesive (GlaxoSmithKline). The weight of the particles collected from each denture (weight of the retrieved peanuts) was recorded and analyzed using Statistical Package for the Social Sciences (SPSS version 12.0).

Figure 1: Number of subjects according to the age

Dentures were assessed for its retention and stability and then were categorized using Modified Kapur Index Scale (MKIS). Only dentures which scored more than 10 will be included in the study. Twenty nine set of the dentures (90.6%) were score more than 10 of Modified Kapur Index Scale (MKIS) and qualified for the study. Unfortunately, 3 out of 32 (9.4%) dentures were rejected during the screening because total score of Modified Kapur Index Scale (MKIS) was less than 10. Most of the dentures score between 10 and 14 (59.4%), followed by score more than 14 (31.3%) and the least were score less than 6 (9.3%) as shown in Figure 2. Therefore, the overall subjects for this study were 29 (90.6%). Figure 2: Modified Kapur Index Scale (MKIS) assessment.

A total of 32 patients agreed to participate in this study. There were more females (69%) compared to male (31%) as shown in Table 4. Most of the subjects aged between 60-69 years old age (n=15) followed by 50-59 years old (n=11) as illustrated in Figure 1.

For soft tissue examination, most of the subjects which account for 15 subjects fall under total score between 14 and 17, 8 of them were scored less than 14 for DBTS while 9 of the subjects scored above 17 as demonstrated in Figure 3.


Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

An Investigation Into The Effect Of Denture Adhesives In Limiting The Food Impaction

Figure 3: Denture bearing tissues assessment

With the application of denture adhesives, most of the upper (44.83%) and lower dentures (34.48%) have accumulated the highest amount peanuts particles between 20-39 mg. Lower dentures accounted for higher in number for weight more than 100 mg. Without application of denture adhesive, most of the lower dentures fall into group weight of 80-99 mg (34.48%), followed by group 40-59 mg (n=5) and more than 100mg weight (n=5). Most of upper dentures fall into group 60-79 mg of weight (34.48%), followed by group of 20-39 mg (n=4) and 0-19 mg (n=3). There were higher number of lower dentures (n=5) accounted for weight more than 100 mg. On average, the mean weight of peanuts particles recovered beneath upper dentures without application of denture adhesive was 51.21 mg which is higher than the mean weight of upper denture with adhesive treatment (35.36 mg). The similar pattern was detected for the lower dentures but at higher mean weight as shown in Table 8.

Successful denture therapy is influenced by the biomechanical phe-nomena of support, stability and retention.1 Retention, or the resistance to movement of the denture away from the supporting tissues, is critical. Unfortunately, the physical, physiological, and mechanical factors associated with denture retention are not completely understood. Physical forces influencing denture retention are believed to include adhesion, cohesion, capillary attraction, surface tension, fluid viscosity, atmospheric pressure, and external forces originating from the oral-facial musculature.2 A total of 32 subjects agreed to participate in this study. They were 22 females and 10 males. The small number of male subjects could be due to the fact that they are less concerned about their edentulism, less likely to opt for restorations and are less likely to visit a dentist than a female.3 Most of the subjects were in the age range of 60-69 years old. This could be due to the likelihood of tooth loss increases with the age as a result of the cumulative effects of caries, periodontal disease, trauma and dental treatment. 2

One important finding of this study was that the MKIS sum score for maxillary denture was higher than mandibular dentures. Besides, a few numbers of mandibular dentures fall into poor category, with the score of 0. However, based on Modified Kapur Index Scale (MKIS), the sum score is more important than the individual score. MKIS classified dentures into 4 categories; excellent, good, fair and poor.4 This classification is based on the sum score of retention and stability of maxillary and mandibular complete dentures.4 A score of at least 10 of MKIS was selected as it falls under good and excellent categories and hence, three of the subjects were rejected due to its score less than 10. Most of the subjects which accounted for 15 subjects fall under total score denture bearing tissues between 14 and 17. Ridge exhibit v-shaped ridge with resilience tissue and medium tissue attachment may be favorable formation because well-developed ridge resist lateral and antero-posterior movement of the denture, the roomy tissue attachment allows for the development of a good peripheral seal and resilience tissue results in the force which are applied to the denture during clenching and mastication being transmitted evenly to supporting tissue.5 However, 8 subjects with total score denture bearing tissues below 14 were accepted in this study as long as MKIS is satisfactory. This can be explained by some of the ridge exhibit undercut areas to provide retention, although the tissue attachment being shallow, but the width of the denture periphery adequate to provide peripheral seal and flabby ridge may have a cushion effects which reduces trauma to the underlying bone. 6 This study demonstrated strong relationships between quality of residual alveolar ridges, denture quality and subjects perception with their denture. There is less food impaction underneath the denture base because of the improvement of denture retention when using denture adhesive. The results confirmed the hypothesis that denture adhesive can reduce amount of food impaction under the denture base. According to Ozcan, denture adhesive increased biting force denture dislodgement which indicates that increase retention and stability not only for preexisting, but also for the new denture.7 The retention as result from the saliva in which it increases the viscosity of the adhesive, thereby increasing the force required to separate the prosthesis from the oral mucosa. 8 There is statistically significance difference between amounts of peanuts particles in the presence of denture adhesive (p<0.05). This is because of the elimination of voids between the denture base and its basal seal. Denture adhesive or more accurately, the hydrated material that is formed when an adhesive comes into contact with saliva and stick to both mucosal surface and denture base.8 In addition, denture adhesive increases the viscosity of saliva with which it mixes, and the hydrated material swells in the presence of water, in

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2


Kamarul / Natasy / Nur Hafizah / Dayang Fadzlina / Marlynda

which means that voids between denture base and bearing tissues are therefore obliterated.8 This studys data also showed that there is similar effect of denture adhesive on upper and lower denture. The improvement of retention was more pronounced in the maxillary than in the mandibular denture.9 Therefore the effect of denture adhesive should be better on the upper denture than the lower denture. This can be explained from the time of denture adhesives application which might also influence the result. In this study, the time interval of 15 minutes is recorded, thus it is limited time for denture adhesive to flow under the denture base which may contribute to the less effect of adhesive on upper denture. From previous study, it indicates that the chewing rate increased with increasing time of application of adhesive.10 Food impactions were low in those subjects whose denture bearing tissues were judged to be satisfactory. Conversely, the subjects whose tissues were predicted by clinical assessment as not providing a good denture bearing tissue have much higher food impaction. This is similar with the findings obtained from Tarbet which indicate that the quality of the denture bearing tissues can have a significant influence on denture stability as reflected by reduced food impaction. 11 These data thus indicate that a clinical assessment of the denture bearing tissue will reliably predict the natural stability and retention of a well-adapted denture, insofar as is reflected by food occlusion values. This finding did not represent the lower denture as MKIS revealed that stability or retention of several lower dentures were unsatisfactory. Although this study provides valuable information on the positive effects of denture adhesive in terms of reducing food impaction, there are limitations that must be considered. A total 64 gram of peanuts were given to the each subjects for two phases of treatment. A few of the subjects encountered difficulty to finish all the peanuts given and therefore this particular procedure is time consuming for both examiner and the subjects. Some studies have shown that wearing dentures contributes to avoidance of difficult to chew foods such as peanuts. 12 The other limitation is difficult to remove the retrieved peanuts particles from the gauze as well as the particles within denture adhesive. Thus, there might be some of the particles which remain entrap together with the gauze and adhesive, therefore, inaccurate of the weight of peanuts retrieved will result. Furthermore, the time for the application of denture adhesive might also influence the result. In this study, the time interval of 15 minutes after application of denture adhesive is taken before subjects chew peanuts and this short or limited time might not enough for the adhesive to show its effect. Thus, it is not surprising that several findings in this study do not have reduction or unpredictable

retrieved food occlusion resulted after the application of denture adhesive.

Within the constraints of this study, application of denture adhesive significantly reduced the amount of retrieved peanut particles collected under the denture base compared to no-adhesive treatment (p< 0.005). Thus, there is less food impaction under the denture base in the presence of denture adhesive.

Swartz ML, Norman RD, Phillips RW. A method for measuring retention of denture adherents: an in vivo study. J Prosthet Dent 1967; 17: 456-463. 2. Kanapka JA. Bite force as a measure of denture adhesive efficacy. Compend Contin Educ Dent 1984; 5: 26-30. 3. Shay K. The retention of complete denture. J Dent 2001; 400: 1-28. 4. Roessler DM. Complete denture success for patient and dentist. Int Dent J 2003; 53: 340-345. 5. Oshlan AM, Ross NM. A modified Kapur scale for evaluating denture retention and stability: Methodology study. Am J Dent 1992; 5: 88-90. 6. Fenn K, Liddelow JG, Gimson S. Clinical Dental Prosthesis: Impression. 1990; 1; 10. 7. Ozcan M, Kulak W. The effect of a new denture adhesive on bite force until denture dislodgement. J Prosthodont 2005; 5: 122-126. 8. Psillakis JJ, Wright RF, Grbic JT, Lamster IB. In practice evaluation of a denture adhesive using a gnathometer. J Prosthodont 2004; 13: 24450. 9. Abdelmelak RG, Michael CG. The effect of denture adhesives on the palatal mucosa under complete dentures: a clinical and histological investigation. Egypt Dent J 1978; 24: 419-30. 10. Chew CL, Phillips RW, Boone ME, Swartz ML. Denture stabilization with adhesives: A kinesiographic study. Compend Contin Educ Dent 1984; 432-8. 11. Tarbet WJ, Silverman G, Schmidt NF. Maximum incisal biting force in denture wearers as influenced by adequacy denture bearing tissues and the use of an adhesive. J Dent Res 1981; 60(2): 115-119 12. Sheiham A, Steele JG, Marcenes W, Finch S, Walls AW. The impact of oral health on stated ability to eat certain foods; findings from the National Diet and Nutrition Survey of Older People in Great Britain. Gerodontology 1999; 16: 11-20. 1.


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An Investigation Into The Effect Of Denture Adhesives In Limiting The Food Impaction

Address for correspondence: Dr. Marlynda Ahmad Department of Prosthodontics, Faculty of Dentistry UKM, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur. Phone: 603-92897748 Fax: 603-92897798 Email:

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2


Incidence Of Post-Operative Pain Following Single-Visit Endodontic Therapy In Single- And Multi-Rooted Teeth

Authors: Neeraj Malhotra MDS, Assistant Professor, Dept. of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Manipal University. Kundabala Mala MDS, Professor, Dept. of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore,Manipal University. Shilpa Reddy Reader Dept. of Conservative Dentistry and Endodontics, SVS Institute of Dental Sciences, Andhra Pradesh Priyanak Singh Ex-Postgraduate Student Dept. of Conservative Dentistry and Endodontics Manipal College of Dental Sciences, Manipal, Manipal University. Shashirashmi Acharya MDS, Professor, Dept. of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal, Manipal University. Ramya Shenoy MDS, Reader Dept. of Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal University.

Aim of the study: The incidence of post-operative pain was compared following single-visit canal treatment in single- and multi-rooted teeth, with and without periapical radiolucency. The article also reviews the issues of postoperative pain and healing , following single-visit and multi-visit endodontic therapy. Single-visit endodontic therapy (SVE) was performed in 50 single-rooted teeth and 60 multiple-rooted teeth Materials and Method: Single-visit endodontic therapy (SVE) was performed in 50 single-rooted teeth and 60 multiple-rooted teeth. The subjects were divided as follows: Group I Single-rooted teeth with periapical radiolucency (n=25); Group IISingle-rooted teeth without periapical radiolucency (n=25); Group IIIMultiple-rooted teeth with periapical radiolucency (n=30); and Group IVMultiple-rooted teeth without periapical radiolucency (n=30). Assessment of postoperative pain was done at 24hrs, 3 days and 1 week using a self report questionnaire. The data was analyzed using non-parametric Kruskal Wallis test. Results: No statistically significant difference was observed in postoperative pain following SVE between the single-rooted and multiple-rooted teeth groups at 24hrs, 3 days and 1 week. The presence or absence of periapical radiolucency had no significant influence on the incidence of reported post-operative pain following SVE. Conclusion: There was no difference in incidence of pain in single rooted teeth and multi-rooted teeth with and without periapical radiolucencies following SVE. Thus, incidence of post-operative pain does not seem to be a valid comparison criterion between single- and multiple-visit endodontic therapies. Also, the literature suggests similar success rates with single-visit and multiple-visit root canal treatment.


Key Words: Evidence based practice, Multi-rooted teeth, Periapical radiolucency, Post-operative pain, Single-visit root canal treatment


Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 2010 The Malaysian Dental Association

Incidence Of Post-Operative Pain Following Single-Visit Endodontic Therapy In Single- And Multi-Rooted Teeth

A major goal of nonsurgical root canal treatment is the prevention or treatment of apical periodontitis, leading to the preservation of natural teeth. Since apical periodontitis originates from an infected or affected pulp, it is axiomatic that the root canal must be thoroughly, carefully debrided and obturated. Contemporary endodontic therapy is often completed in two or more appointments. The concept of singlevisit endodontic therapy (SVE) is not new. However, it is only within the last few years that beliefs and attitudes concerning the inclusion of this technique into practice of clinical endodontics appear to be undergoing a process of change. SVE is defined as the conservative nonsurgical treatment of an endodontically involved tooth consisting of complete biomechanical cleansing, shaping, and obturation of the root canal system during one visit1. With the introduction of better diagnostic aids (surgical microscopes), instrumentation systems (Ni-Ti rotary systems), disinfection protocols (ultrasonics), and obturation techniques (single cone and injectable obturation systems), it is now considered as an acceptable alternative treatment option that is faster, well accepted by patients and also prevents the recontamination of root canals. A number of research studies have observed clinical success with single visit protocol2,3,4,5, but still there is lack of evidence-based clinical studies to support the same 6,7. The major considerations in SVE therapy are incidence of postoperative pain and healing following the treatment. Though no significant differences in success rates have been observed between the two treatment protocols8, the literature to date has failed to establish a consensus concerning the relationship between post operative pain and number of treatment appointments 6 . Thus, we designed a study to bring the post operative sequelae of SVE into sharper focus. The purpose of our study was to evaluate and compare the incidence of post operative pain in single and multirooted teeth as well as with and without periapical radiolucency. The article also discusses the literature review to highlight the indications, contraindications, and guidelines for SVE in clinics. This will aid to design an evidence- based practice for clinical cases that can be treated with single- visit endodontic therapy.

periodontal complications. Thus, due to variability in the level of operators knowledge regarding the procedure (SVE) and diagnosis made for individual cases, differences in incidence are observed. Indications Teeth indicated to be treated in single-visit include13, vital teeth with pulp exposures caused by trauma, caries, or mechanical reasons; teeth with subgingival breakdown; teeth with multiple coronal walls missing; full coverage restorations with carious margins; fractured anterior or bicuspid teeth where temporary restoration is required; teeth to be used as over-denture abutments, full jacket crowns on mandibular anterior; physically disabled patients or patients who require sedation or operating room treatment Contraindications The main contraindications are the presence of any anatomic anomalies (receded pulp chambers, calcified canals, sharply curved canals, bifurcated canals, and dilacerations) or procedural difficulties (broken instruments, perforations, ledge formation), that may unnecessarily extend the treatment time. Other contraindications patients suffering from any physical (muscular dystrophy) or mental disability (neuro-muscular disorders), who require longer treatment appointments due to their medical problems. It is often difficult to obtain sufficient co-operation from these patients for one single appointment. Probably the most controversial condition in terms of whether or not to perform SVE is in non-vital teeth with apical periodontitis and in re-treatment cases. The highest numbers of failures are seen in endodontic re-treatment cases 14. Thus use of an antimicrobial dressing [Ca(OH)2] is considered to be an important factor in treatment of such cases. An inter-appointment dressing of calcium hydroxide have shown to eliminate and /or reduce the number of bacteria in root canals 15,16,17. Complete elimination of micro-organisms is not practically possible by any endodontic therapy, especially with SVE 18,19. But some recent studies have proposed the treatment of teeth with apical periodontitis with SVE 20,21. A mMetaanalysis done in one of the studies showed that sample size of earlier conducted studies was unjustifiably small to make any clinical decision and also there is no statistically significant difference in the healing rate of the two treatment regimens in cases of apical periodontitis. The reason for this could be due to the ineffectiveness of an inter-appointment antibacterial dressing21,22, introduction of more effective irrigants (MTAD)23 better and superior cleaning and shaping techniques (rotatory NiTi files and systems) and disinfection systems (ultrasonics, PAD) 24,25,26. But still there is paucity of in-vivo and research based studies and data to claim the efficacy of above mentioned

The exact percentage of dentists practicing SVE is not well documented. It has been reported that around 35-67% of vital case and approximately 9-35% of non-vital cases have been complete in a single-visit9,10,11,12. In around in one-third of cases with periapical lesions, a multiple-visit root canal treatment with an intracanal medicament is preferred10. The main determining factors to opt for SVE are the tooth type, time available, dentist's skills and anatomic or
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materials and techniques in SVE 13. Thus on the basis of evidence-based practice, it is better to use a multiple-visit regimen for treatment of teeth with apical periodontitis Guidelines An appropriate selection of cases for SVE should be made based on the operating dentist clinical skills and their understanding of endodontic principles. The proposed criteria for case selection include27,28: 1. Positive patient acceptance. 2. Sufficient available time. The dentist should be able complete the procedure properly within 60 minutes 3. Absence of acute symptoms (pain, swelling), anatomical obstacles (calcified canals, fine tortuous canals, bifurcated or accessory canals) and procedural difficulties (ledge formation, blockage, perforations, inadequate fills) Healing rates One among the two basic parameters used for the comparison between SVE and multiple-visit endodontic treatment are healing rates. Healing following SEV is dependent on criteria such as case selection, proper treatment protocol, and adequate time management. Most of the studies have shown that there is minor or no substantial difference in the healing rate of single- and multiple-visit endodontic therapy4,5,28,29,30,31. Very low failure rates are also reported with SVE14,32,33. No statistically significant differences are observed between the two treatment protocols based on gender, age, arch, pulp vitality status or provider28,35. But it has been proposed that a higher success rate is seen in anterior teeth as compared to posterior teeth30,35. This can be attributed to the anatomical complexities of posterior teeth that may require considerable treatment time. On the contrary few studies have observed a higher success rate36 and better radiographic healing with multiplevisit endodontic therapy37. This difference in opinion among the different studies could be due to difference in the definition of success as proposed by different researchers as well as due to shortage of good unbiased studies. Thus the literature review suggests that there is no difference in success rate between single-and multiplevisit endodontic therapy. However, an appropriate case selection and clinical diagnosis is essential before opting for SVE as the treatment option. Incidence of postoperative pain and flare-ups The other most commonly used basic parameter for comparison is the incidence of postoperative pain. Studies have reported a lower incidence of postoperative pain following SVE 38,39, at times as low as 1% 40. Data from studies showed that there is no statistically significant difference between the

two treatment groups in relation to postoperative pain and swelling3,28,41,42. It is observed that if an accurate diagnosis, proper case selection, and skill in technique are used, the incidence of postoperative pain and healing remained equivalent in both the treatment groups30. Similarly, no significant difference existed between the groups when compared by tooth morphology (anterior teeth, premolars, and molars), sex, diagnosis (vital pulps versus necrotic pulps) and filling terminus (filling short or within 0.5 mm of the radiographic apex)28. Few studies have even observed a higher frequency of postoperative pain with multivisit endodontic treatment in both vital and non-vital cases as compared to SVE2,43. As far incidence of flare-ups is concerned, data from studies have shown no difference between the two treatment protocols or it is higher in case of multiple-visit endodontic therapy44,45,46 . Due to the difference in inclusion criteria and variability of sample size in different studies, subjective nature of the pain evaluation, and difference in definition of flare-up quoted different by different authors; evidence based data are still lacking to prove that there is no significant difference in the incidence of post-operative pain between the two treatment protocols6,7.

The purpose of this study was to compare the incidence of post-operative pain following single-visit endodontic therapy in single- and multi-rooted teeth, with and without periapical radiolucency.

The sample comprised of adult patients in the age group of 20-40 years that require root canal treatment. A total of 110 teeth that needed to undergo root canal treatment were selected for the study. Out of this, 50 were single-rooted teeth and 60 were multiple-rooted teeth. At initial appointment the subjects were informed about the nature of the study, along with a through description of the procedure to be performed. Following this an informed consent was taken from the subjects to include them in the study. A thorough clinical examination including the case history was documented. Patients who were on analgesics pre-operatively were excluded from the study. A Pre-operative radiograph was taken to check for the number and anatomy of roots and root canals, condition of periodontal tissues and for the presence of any periradicular radiolucencies. Then the subjects were divided into 4 groups as follows;


Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

Incidence Of Post-Operative Pain Following Single-Visit Endodontic Therapy In Single- And Multi-Rooted Teeth

Single-rooted teeth with periapical radiolucency (n=25) Group II Single-rooted teeth without periapical radiolucency (n=25) Group III Multiple-rooted teeth with periapical radiolucency (n=30) Group IV Multiple-rooted teeth without periapical radiolucency (n=30) Root canal treatment The access cavity was prepared and coronal orifices were enlarged upto Gates Glidden no.3. Working length was determined by Ingles radiographic method and cross checked using ROOT-ZX (J. Morita Mfg. Corp., Japan). Chemomechanical preparation was done with modified step back technique using 2.5% NaOCl and Saline. Canals were obturated with guttapercha and AH plus sealer by lateral compaction technique. Access cavities were restored with composite resin. Follow-up Subjects were recalled after 24hrs, 3 days and 1 week. At each recall appointment they were instructed to fill a self report questionnaire (Figure.1) for the assessment of postoperative pain at 24hrs, 3 days and 1 week

Group I

Figure 1: Questionnaire for the Assessment of Postoperative Pain Name Hospital No. Address Date Rating for Pain 0 No Pain 1 Mild Pain* 2 Moderate pain** 3 Severe Pain*** Please tick the appropriate response as per rating for pain described above Pain after 24 hrs 0 ( ) 1 ( ) 2 ( ) 3 ( ) Pain after 3days 0 1 2 3 0 1 2 3 ( ( ( ( ( ( ( ( ) ) ) ) ) ) ) ) Signature * Mild pain Any discomfort that did not require medication or emergency treatment, no matter how long it lasted. ** Moderate pain Pain requiring medication. *** Severe pain pain that was not relieved by medication and required palliative treatment. Most people would have used a visual analogue scale here

Pain after 1 week

The association between pain-scores in singleand multiple-rooted teeth with and without periapical radiolucency are shown in Table III and table VI. Table I and Table II show the pain experience (no. of subjects reported with postoperative pain) in singleand multiple-rooted teeth after SVE at different time intervals (24hrs, 3 days and 1 week) along with the p-value.

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Neeraj / Kundabala / shilpa / Priyanak / Shashirashmi / Ramya

Table I:

Pain experience in Group I and II at different time intervals 24 hrs 2 4 0.035 3 days 6 6 0.970 1 week 3 0 0.228

SVE has certain inherited advantages that include; Reduction in number of appointments and treatment cost as well. Avoidance of inter-appointment contamination leading to reduction in incidence of flare-ups No need of tooth anatomy refamiliarization by the clinician. Reduced chances of immune reaction that may be caused by intracanal medicaments. Fear of postoperative pain is considered as a major deterrent factor for SVE for both the dentist and the patient. Though performing SVE on molars is quite a debatable issue, in this study there was no significant effect of tooth type (single- or multiplerooted) on the incidence of post-operative pain. Similar results were observed by Oliet 28 in a longterm study that observed no significant difference between the single-visit and multiple-visit groups when compared by tooth morphology (anterior teeth, premolars, and molars), sex, diagnosis (vital pulps versus necrotic pulps) and filling terminus (filling short or within 0.5 mm of the radiographic apex). This can be attributed to the meticulous instrumentation technique, thorough debridement and utmost care taken to obdurate the root canals completely without harming the periapical tissues. Also incorporation of newer scientific advancements in cleaning, shaping, debridement and obturation of root canals encourage dentists to practice SVE on everyday basis. Presence or absence of periapical radiolucency also had no significant difference on incidence of postoperative pain any of the tooth groups. Similar observations are made in other studies also28,42,47. Thus results of this study show that neither the tooth type nor the existing periapical condition has any influence on the incidence of postoperative pain. Apart from this using pain as an evaluation criterion has the following drawbacks: Owing to its subjective nature, pain experience can be influenced by factors like age, sex, patient psychology and past experiences. Stressful situation unrelated to treatment can influence the incidence of reported pain. Anxiety and ignorance of procedure can also alter the incidence. Lastly pre and post-operative suggestions concerning a procedure can influence the patients response.

Groups Group I (n=25) Group II (n=25) p-value* *p<0.05

Table II: Pain experience in Group III and VI at different time intervals Groups Group III (n=30) Group VI (n=30) p-value* *p<0.05 Table III. Association between the pain-scores in single and multi-rooted teeth with periapical radiolucency after SEV at different time intervals 24 hrs Chi-square d.f. p value 6.120 1 0.013 3 days 0.84 1 0.772 Groups 3.73 1 0.06 24 hrs 5 5 0.602 3 days 8 11 0.351 Groups 0 1 0.317

Table VI. Association between the pain-scores in single and multi-rooted teeth without periapical radiolucency after SEV at different time intervals 24 hrs Chi-square d.f. p value 0.04 1 0.84 3 days 1.13 1 0.287 Groups 0.83 1 0.361

A non-parametric Kruskal Wallis test was applied to test the association between the pain scores following SVE in the single- and multiple-rooted teeth with and without periapical radiolucency, after 24hrs, 3 days and 1 week. The chi-squared value obtained was used to see the overall difference between the groups. The level of significance was set at p<0.05. The results of the study showed no statistically significant difference in postoperative pain following SEV between the single-rooted and multiple-rooted teeth groups at any recall appointment. Also presence or absence of periapical radiolucency had no significant influence of the incidence of reported post-operative pain.

Thus post-operative pain should not be taken as an avoidance factor for SVE nor is it an effective clinical parameter to compare SVE with any other treatment protocol. This also does not indicate that SVE can be opted blindly for any tooth requiring root75 Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

Incidence Of Post-Operative Pain Following Single-Visit Endodontic Therapy In Single- And Multi-Rooted Teeth

canal treatment. Therefore, the following suggested preliminary considerations should be taken into account before selecting a case for SVE48: Operator Ability and Clinical Experience SVE should be performed only by experienced practitioners who practice it on routine basis as they can better assess the time required to thoroughly cleanse, shape, and fill the root canal of teeth. Time and Auxiliary Utilization Based on the clinician's operative skill and the difficulty of the case a realistic time limit should be set for the endodontic treatment. As per the guidelines SVE should be completed within 45-60 minutes (a little longer woul;d not be unreasonable). A well-trained and efficient dental assistant could help in achieving this objective. Clinical Techniques Adequate knowledge and competence in basic operative skills can reduce the incidence of failure in an endodontic procedure. Thus it is necessary for the dentist to develop the skills mandatory to perform SVE. Moreover, further clinical studies are required taking into consideration additional criteria, such as, periapical healing, reduction in tenderness to percussion or palpation, etc. to recommend SVE as a routine clinical procedure.







9. 10. 11. 12.

Overview of the literature and results from the present in-vivo study concluded that: 1. There is no statistically significant difference among the incidence of pain in single rooted teeth and multirooted with and without periapical radiolucencies teeth from 1st day to one week in SVE therapy. 2. Incidence of post-operative pain does not seem to be a valid comparison criterion between single- and multiple-visit endodontic therapies. 3. The literature suggests similar success rate for single-visit and multiple-visit endodontic therapy. In spite of this clinical trials are still required to recommend SVE in apical periodontitis cases. 4. The choice of treatment should be made on the basis of individuality of a case and the operators skill. Wherever and whenever in doubt multiplevisit endodontic therapy is still recommended.


13. 14. 15.


1. 2. Ashkenaz P J. One-visit endodontics. Dent Clin North Am 1984; 28:853-63. Albashaireh Z S, Alnegrish A S. Postobturation pain after single- and multiple-visit endodontic therapy. A prospective study. J Dent 1998; 26:22732.


Al-Negrish A R, Habahbeh R. Flare up rate related to root canal treatment of asymptomatic pulpally necrotic central incisor teeth in patients attending a military hospital. J Dent 2006; 34:635-40. Weiger R, Rosendahl R, Lst C. Influence of calcium hydroxide intracanal dressings on the prognosis of teeth with endodontically induced periapical lesions. Int Endod J 2000; 33:219-26. Peters L B, Wesselink P R. Periapical healing of endodontically treated teeth in one and two visits obturated in the presence or absence of detectable microorganisms. Int Endod J 2002; 35:660-7. Sathorn C, Parashos P, Messer H. The prevalence of postoperative pain and flare-up in single- and multiple-visit endodontic treatment: a systematic review. Int Endod J 2008; 41:91-9. Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple visits for endodontic treatment of permanent teeth. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005296. Field J W, Gutmann J L, Solomon E S, Rakusin H. A clinical radiographic retrospective assessment of the success rate of single-visit root canal treatment. Int Endod J 2004; 37:70-82. Calhoun R L, Landers R R. One-appointment endodontic therapy: a nationwide survey of endodontists. J Endod 1982; 8:35-40. Trope M, Grossman L I. Root canal culturing survey: single-visit endodontics. J Endod 1985; 11:511-3. Gatewood R S, Himel V T, Dorn S O. Treatment of the endodontic emergency: a decade later. J Endod 1990; 16:284-91. Inamoto K, Kojima K, Nagamatsu K, Hamaguchi A, Nakata K, Nakamura H. A survey of the incidence of single-visit endodontics. J Endod 2002; 28:3714. Yazd Z M, Isfahan A F, Yazd M T. One-visit versus multiple-visit endodontic therapy- a review. Int Dent J 2006; 56:289-93. Pekruhn R B. The incidence of failure following single-visit endodontic therapy. J Endod 1986; 12:68-72. Waltimo T M, Boiesen J, Eriksen H M, rstavik D. Clinical performance of 3 endodontic sealers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92:89-92. Sjgren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997; 30:297-306. Delano E O, Ludlow J B, rstavik D, Tyndall D, Trope M. Comparison between PAI and quantitative digital radiographic assessment of apical healing after endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92:108-15.

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18. Nair P, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after one-visit endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99:231-252. 19. Vivacqua-Gomes N, Gurgel-Filho E D, Gomes B P F A, Ferraz C C R, Zaia A A, Souza-Filho F J. Recovery of Enterococcus faecalis after single- or multiple-visit root canal treatments carried out in infected teeth ex vivo. Int Endod J 2005;38:697704. 20. Kvist T, Molander A, Dahln G, Reit C. Microbiological evaluation of one- and twovisit endodontic treatment of teeth with apical periodontitis: a randomized, clinical trial. J Endod 2004; 30:572-576. 21. Sathorn C, Parashos P, Messer H H. Effectiveness of single- versus multiple-visit endodontic treatment of teeth with apical periodontitis: a systematic review and meta-analysis. Int Endod J 2005; 38:347-55. 22. Trope M, Delano E O, rstavik D. Endodontic treatment of teeth with apical periodontitis: single vs. multivisit treatment. J Endod 1999; 25:345-350. 23. Krause T A, Liewehr F R, Chin-Lo Hahn C L. The antimicrobial effect of MTAD, sodium hypochlorite, doxycycline, and citric acid on Enterococcus faecalis. J Endod 2007; 33:28 30. 24. Bergmans L, Cleynenbreugel J V, Wevers M, Paul Lambrechts P. Mechanical root canal preparation with NiTi rotary instruments: Rationale, performance and safety. Am J Dent 2001; 14: 324-333. 25. Al-Madi E M, Balto H A. The effect of intermittent passive ultrasonic irrigation and rotary instruments on microbial colonies of infected root canals. Saudi Dent J 2008; 20:10-16. 26. Bonsor S J, Nichol R, Reid T M, Pearson G J. An alternative regimen for root canal disinfection. Br Dent J 2006; 201:101-5; discussion 98. 27. Dorn S O, Gartner A H. Case selection and treatment planning. In: Cohen S, Burns R C (eds). Pathways of pulp. St. Louis, Missouri: Mosby, 1994: 60-76. 28. Oliet S. Single-visit endodontics: a clinical study. J Endod 1983; 9:147-152. 29. Jurcak J J, Bellizzi R, Loushine R J. Successful single-visit endodontics during Operation Desert Shield. J Endod 1993; 19:412-3. 30. Rudner W L, Oliet S. Single-visit endodontics: a concept and a clinical study. Compend Contin Educ Dent 1981; 2:63-8. 31. Waltimo T, Trope M, Haapasalo M, rstavik D. Clinical efficacy of treatment procedures in endodontic infection control and one year followup of periapical healing. J Endod 2005; 31:863-6.

32. Soltanoff W. A comparative study of the singlevisit and the multiple-visit endodontic procedure. J Endod 1978; 4:278-81. 33. Ashkenaz P J. One-visit endodontics--a preliminary report. Dent Surv 1979; 55:62-7. 34. Boggia R. A single-visit treatment of septic root canals using periapically extruded endomethasone. Br Dent J 1983; 155:300-5. 35. Field J W, Gutmann J L, Solomon E S, Rakusin H. A clinical radiographic retrospective assessment of the success rate of single-visit root canal treatment. Int Endod J 2004; 37:70-82. 36. Silveira A M, Lopes H P, Siqueira J F Jr, Macedo S B, Consolaro A. Periradicular repair after twovisit endodontic treatment using two different intracanal medications compared to single-visit endodontic treatment. Braz Dent J 2007; 18:299304. 37. Katebzadeh N, Sigurdsson A, Trope M. Radiographic evaluation of periapical healing after obturation of infected root canals: an in vivo study. Int Endod J 2000; 33:60-66. 38. Fox J, Atkinson J S, Dinin A P, Greenfield E, Hechtman E, Reeman C A, Salkind M, Todaro C J. Incidence of pain following one-visit endodontic treatment. Oral Surg Oral Med Oral Pathol 1970; 30:123-30. 39. Ingle J I, Bakland L K, Beveridge E E. Modern endodontic therapy. In: Ingle J I, Bakland L K (eds). Endodntics. Canada: Decker, Inc., 2002: 1-24. 40. Wolch I. The one-appointment endodontic technique. J Can Dent Assoc 1975; 41:613. 41. O' Keefe, EM. Pain in endodontic therapy: preliminary study. J Endod. 1976; 2:31519. 42. Mulhern J M, Patterson S S, Newton C W, Ringel A M. Incidence of postoperative pain after one-appointment endodontic treatment of asymptomatic pulpal necroses in single-rooted teeth. J Endod 1982; 8:370-5. 43. Roane J B, Dryden J A, Grimes E W. Incidence of postoperative pain after single- and multiple-visit endodontic procedures. Oral Surg Oral Med Oral Pathol 1983; 55:68-72. 44. Pekruhn R B. Single-visit endodontic therapy: a preliminary clinical study. J Am Dent Assoc 1981; 103:875-877. 45. Imura N, Zuolo M L. Factors associated with endodontic flare-ups: a prospective study. Int Endod J 1995; 28:261-5. 46. Eleazer P D, Eleazer K R. Flare-up rate in pulpally necrotic molars in one-visit versus two-visit endodontic treatment. J Endod 1998; 24:614-6. 47. Harrison J W, Gaumgartner J C, Svec T A. Incidence of pain associated with clinical factors during and after root canal therapy. Part 1. Interappointment pain. J Endod 1983; 9:384-387.


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Incidence Of Post-Operative Pain Following Single-Visit Endodontic Therapy In Single- And Multi-Rooted Teeth

48. Spangberg L S. Evidence-based endodontics: the one-visit treatment idea. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 91:617-8.

Address for correspondence: Dr. Neeraj Malhotra Department of Conservative Dentistry and Endodontics, MCODS Mangalore - 575001 Karnataka, India Tel. (91 0824) 98445 79329, Fax. (91 0824) 2422653 E-Mail:

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2


Adenoid Cystic Carcinoma A Case Report And Review Of Literature

Authors: Sham Kishor Kanneppady MDS, Lecturer, Department of Oral Radiology, Faculty of Dentistry, AIMST University, Malaysia. Santosh B. Sakri MDS, MBA, Lecturer, Department of Community Dentistry, Faculty of Dentistry, AIMST University, Malaysia. Laxmikanth Chatra BSc, MDS, DPh, Senior Professor and Head, Department of Oral Medicine and Radiology, Yenepoya Dental College, Mangalore, India. Prashanth Shenoy K MDS, Professor and Postgraduate guide, Department of Oral Medicine and Radiology, Yenepoya Dental College, Mangalore, India.


Adenoid cystic carcinoma (ACC) is a rare malignant tumor that arises within secretary glands, most commonly the major and minor salivary glands. It has a tendency for a prolonged clinical course, perineural invasion, with local recurrences and distant metastases. The three recognized histopathologic pattern of ACC are cribriform, tubular, and solid with the cribriform being most common. Standard treatment for salivary gland ACC is surgery and postoperative radiotherapy. We report a case of ACC of palate in a 30-year-old female and review the literature.

Key Words: Adenoid cystic carcinoma, palate, salivary gland, head and neck neoplasm.

Adenoid cystic carcinoma (ACC) is an uncommon malignant neoplasm believed to arise from the epithelial cells of mucous-secreting glands. 1 It is slow growing, yet aggressive tumor with a propensity for perineural invasion. The tumor accounts for around 10% of all salivary gland neoplasms, 2-7 22% of all salivary gland malignancies,8 and about 1% of all head and neck malignancies. It most commonly occurs in the salivary glands; but has also been reported to exist in lacrimal gland of the eye, trachea, lung, brain, breast, bartholin gland, and the paranasal sinuses. ACC occurs predominantly among women between 5th and 6th decades of life, but it is by no means rare even in the 3rd decade.9,10 It is known for its prolonged clinical course, multiple recurrence and delayed onset of distant metastases. Considering its behavior, ACC was rightly described by Conley and Dingman as one of the most biologically destructive and unpredictable tumors of the head and neck.3 We present one such case of ACC of palate in a 30-year-old female and a brief literature review on its clinical, pathological and therapeutic aspects.

Case presentation A 30-year-old female reported to Department of Oral Medicine and Radiology, Yenepoya Dental College, Mangalore, India; with the complaint of moderately painful swelling in the right upper jaw of four months duration. The teeth associated with the swelling were mobile two months preceding the swelling. There was no history of fever, or trauma to the facial region and neither had she performed any deleterious habits in her lifetime. The patient had been to a dentist 3 months prior to presentation and was offered endodontic treatment in the right maxillary teeth. On physical examination, patient was medium build size and clinically appeared normal. All vital signs were within acceptable range on the day of presentation. Extra orally, the swelling was diffuse, measured 6 x 6 cm in diameter, causing obliteration of right nasolabial fold (Fig. 1). It was neither compressible, nor fluctuant. Except the firm, slightly tender swelling, all other extra oral findings (TMJ, Lymph nodes and Salivary glands) were normal. Intra orally, the lesion was extending from the region of 13 to 18 on the buccal and palatal aspects, measuring about 4 x 3.5 cm (Fig. 2). The overlying mucosa was firm, erythematous, irregular and elicited tenderness in premolar region. The crowns of 12, 13 and 14 showed evidence of sealed endodontic access openings. Probing revealed
79 Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 2010 The Malaysian Dental Association

Adenoid Cystic Carcinoma A Case Report And Review Of Literature

the presence of deep periodontal pocket in 14 up to 18. All these teeth were grade II mobile and tender on percussion. Based on patients history, clinical exams and the rapid growth of the observed lesion, diagnosis of malignant neoplasm; either mucoepidermoid carcinoma, adenoid cystic carcinoma or carcinoma of maxillary sinus was hypothesized. Radiographs and CT scan were done to determine the extensiveness of the lesion and to aid in the diagnosis. Occlusal radiograph revealed loss of the buccal cortical plate from 13 to 17 with displacement of 15 and 17 away from 16 (Fig. 3). Panoramic radiograph showed radiolucent area at the apices of 13 to 17 with ill-defined margins (Fig. 4). External root resorption was evident in all of the involved teeth. The lesion caused destruction of right palatal vault, lateral margin of the nasal cavity and anterior nasal spine, sparing the nasal septum. The floor of the maxillary sinus appeared to be completely eroded by the extension of the lesion into the sinus. PNS view showed opacification and expansion of the right maxillary sinus with destruction of lateral wall, roof being intact (Fig. 5). CT scan demonstrated heterogeneous soft tissue density mass involving the right nasal cavity, maxillary sinus and infra temporal fossa, with ill-defined margins medially and posteriorly. Areas of hyperdensity within the lesion were suggestive of calcification (Fig. 6 and 7). An incisional biopsy was carried out and histopathological analysis demonstrated rounded groups of small darklystained cells of almost uniform size, surrounding multiple small clear spaces, resembling a swiss cheese or honeycomb pattern, suggesting cribriform variant of adenoid cystic carcinoma of minor salivary gland (Fig. 8). Screening chest radiograph and abdominal ultrasound did not show any evidence of metastasis. Patient was referred to Regional Cancer Center for further treatment. Figure 1: Diffuse extra oral swelling causing obliteration of right nasolabial fold

Figure 2: Buccal and palatal expansion of palate due to ACC

Figure 3: Occlusal radiograph showing loss of the buccal cortical plate from 13 to 17

Figure 4: Orthopantomogram showing root resorption with destruction of right palatal vault, floor of maxillary sinus and lateral margin of nasal cavity

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Sham Kishor / Santosh / Laxmikanth / Prashanth

Figure 5: PNS view showing opacification and expansion of right maxillary sinus with destruction of lateral wall

Figure 8: Histopathological picture of cribriform variant of ACC

Figure 6: Coronal CT image showing the lesion involving right nasal cavity and maxillary sinus ACC of the salivary glands was first described in 1856 and at the time was referred to as cylindroma due to its distinctive histologic appearance. The parotid and submandibular glands are the two most common sites for ACC accounting for 55% of the cases. As seen in the present case, 50% of ACCs of intraoral origin occur on the palate, with other less frequent sites of involvement including floor of mouth, buccal mucosa, lower labial mucosa, retromolar-tonsillar pillar region and sublingual gland. 11,12 Generally, ACC of minor salivary glands develop in the middle age group (mean 54 years) with a female/male ratio of 1.6:113 Many of the patients exhibit clinical manifestations of a typical malignant salivary gland tumor: early local pain, facial nerve paralysis in the case of parotid tumors, fixation to deeper structures and local invasion. Some of the lesions, particularly the intraoral ones, may exhibit surface ulceration.9 ACC has a tendency for infiltrating surrounding tissues and for perineural spread particularly towards the skull base. 14 The present case showed its aggressive nature with resorption of roots and destruction of palatal vault, nasal cavity, anterior nasal spine, the floor and lateral wall of the maxillary sinus. Histologically, ACC can present three different variables: glandular (cribriform), tubular and solid with cribriform being the most common and easily recognized pattern and solid the least common. But most of the times, grading is difficult as a tumor may show evidence of more than one sub-type. 11,15-17 The cribriform subtype of ACC is thought to have the best prognosis and the solid subtype the worst with the tubular form possessing an intermediate prognosis. 18-23 The cribriform variety shows basaloid epithelial cell nests that form multiple cylindrical cyst like patterns resembling swiss cheese. The tubular pattern reveals tubular structures that are lined by stratified cuboidal epithelium. The solid variety contains solid groups of cuboidal cells with little tendency towards duct or cyst formation.9

Figure 7: Axial CT image showing the spread of the lesion into infra temporal fossa and areas of calcification within the lesion


Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

Adenoid Cystic Carcinoma A Case Report And Review Of Literature

ACC typically displays an apathetic, but constant and recurrent growth pattern, long clinical course, and late onset of metastasis. In contrast to other types of carcinomas, distant hematogenous metastases are far more frequent than regional lymph node metastasis. In 40-60% of cases, distant metastases develop and are most common in the lung, bone and soft tissues.13 In the present case, chest radiograph and abdominal ultrasound did not show any signs of metastases. Regional lymph nodes were also normal; but the patient was complaining of moderate pain at the site of lesion, which could be the sign of peripheral nerve invasion. The primary treatment objective in ACC patients is local control, normal functionality and distant metastasis prevention. 24 The treatment of choice is wide surgical excision and post operative radiotherapy for the best chance of long time survival.25-27 There is considerable uncertainty about the systemic management of recurrent or metastatic ACC.1 Chemotherapy with high-dose melphalan and cisplatin showed promising results in previous studies, however, statistically there was no difference observed in survival rates when compared to placebo.28-30 The cure rate for patients with this disease, though varying somewhat from series to series, is discouragingly low. Factors influencing prognosis are the site of occurrence and the histological pattern of the tumor.


9. 10.


12. 13.


1. 2. Dodd RL, Slevin NJ. Salivary gland adenoid cystic carcinoma: A review of chemotherapy and molecular therapies. Oral Oncol 2006; 42:759-69. Khan AJ, DiGiovanna MP, Ross DA, Sasaki CT, Carter D, Son YH et al. Adenoid cystic carcinoma: a retrospective clinical review. Int J Cancer 2001; 96(3):14958. Chummun S, McLean NR, Kelly CG, Dawes PJDK, Meikle D, Fellows S et al. Adenoid cystic carcinoma of the head and neck. Br J Plast Surg 2001; 54(6):47680. Wiseman SM, Popat SR, Rigual NR, Hicks WL, Orner JB, Wein RO et al. Adenoid cystic carcinoma of the paranasal sinuses or nasal cavity: a 40-year review of 35 cases. Ear Nose Throat J 2002; 81(8):5108. van der Wal JE, Becking AG, Snow GB, van der Waal I. Distant metastases of adenoid cystic carcinoma of the salivary glands and the value of diagnostic examinations during follow-up. Head Neck 2002; 24(8):77983. Spiro RH, Huvos AG, Strong EW. Adenoid cystic carcinoma: factors influencing survival. Am J Surg 1979; 138(4):57983. Bradley PJ. Adenoid cystic carcinoma of the head and neck: a review. Curr Opin Otolaryngol Head Neck Surg 2004; 12:12732.


16. 17. 18. 19. 20. 21.




6. 7.

22. 23.

Hotte SJ, Winquist EW, Lamont E, MacKenzie M, Vokes E, Chen EX et al. Imatinib mesylate in patients with adenoid cystic carcinoma of the salivary glands expressing c-kit: a Princess Margaret Hospital Phase II consortium study. J Clin Oncol 2005; 23(3):58590. Rajendran R, Sivapathasundaram B. Shafers Textbook of Oral Pathology. 5th edn. Elsevier, New Delhi 2006: 330-31. Waldron CA, El-Mofty SK, Gnepp DR. Tumors of the intraoral minor salivary glands: a demographic and histologic study of 426 cases. Oral Surg Oral Med Oral Pathol. 1988 Sep; 66(3):323-33. Giannini PJ, Shetty KV, Horan SL, Reid WD, Litchmore LL. Adenoid cystic carcinoma of the buccal vestibule: A case report and review of literature. Oral Oncol 2006; 42:1029-32. Seaver PR, Kuehn PG. Adenoid carcinoma of the salivary glands: a study of ninety-three cases. Am J Surg 1979; 137:44955. Ellis GL, Auclair PL. Atlas of tumor pathology: Tumors of the salivary glands. Third series fascicle 17. Washington, DC: Armed Forces Institute of Pathology; 1996, 203-16. Pfeffer MR, Talmi Y, Catane R, Symon Z, Yosepovitch A, Levitt M. A phase II study of Imatinib for advanced adenoid cystic carcinoma of head and neck salivary glands. Oral Oncol 2007; 43:33-36. Hashimoto S, Takahashi H, Okamoto M, Yao K, Nakayama M, Makoshi T, et al. Prognostic factors of head and neck adenoid cystic carcinoma: quantitative morphological analysis of 19 cases. Acta Otolaryngol 2002; 547(5):936. Perzin KH, Gullane P, Clairmont AC. Adenoid cystic carcinoma arising in salivary glands. Cancer 1978; 42:26582. Spiro RH, Huvos AG. Stage means more than grade in adenoid cystic carcinoma. Am J Surg 1992; 164(6):6238. Tarpley TM, Giansanti JS. Adenoid cystic carcinoma: Analysis of fifty oral cases. Oral Surg 1976; 41:434-97. Nochomovitz LE, Kahn LB. Adenoid cystic carcinoma of the salivary gland and its histologic variants. Oral Surg 1977; 44:394404. Grahne B, Lauren C, Holsti LR. Clinical and histological malignancy of adenois cystic carcinoma. J Laryngol Otol 1977; 91:7439. Chomette G, Auriol M, Tranbaloc P, Vaillant JM. Adenois cystic carcinoma of minor salivary glands: Analysis of 86 cases. Virchows Arch 1982; 395:289301. Gates GA. Malignant neoplasm of the minor salivary glands. N Engl J Med 1982; 306:71822. Goepfert H, Luna MA, Lindberg RD, White AK. Malignant salivary gland tumors of the paranasal sinuses and nasal cavity. Arch Otolaryngol 1983; 109:6628.

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

Sham Kishor / Santosh / Laxmikanth / Prashanth

24. Soares ECS, Carreiro Filho FP, Costa FWG, Vieira ACM, Alves APN. Adenoid cystic carcinoma of the tongue: Case report and literature review. Med Oral Patol Oral Cir Bucal. 2008 Aug 1; 13(8):E4758. 25. Dal Maso MD, Lippi L. Adenoid cystic carcinoma of the head and neck: a clinical study of 37 cases. Laryngoscope 1985; 95:17781. 26. Casler JD, Conley JJ. Surgical management of adenoid cystic carcinoma in the parotid gland. Otolaryngol Head Neck Surg 1992; 106:3328. 27. Stell PM, Cruikshank AH, Stoney PJ, Canter R, McCormick MS. Adenoid cystic carcinoma: the results of radical surgery. Clin Otolaryngol 1985; 10:2058. 28. Schramm Jr VL, Srodes C, Myers EN. Cisplatin therapy for adenoid cystic carcinoma. Arch Otolaryngol 1981; 107:73941. 29. Sessions RB, Lehane DE, Smith RJ, Bryan RN, Suen JY. Intraarterial cisplatin treatment of adenoid cystic carcinoma. Arch Otolaryngol 1982; 108:2214. 30. Slichenmyer WJ, LeMaistre CF, Von Hoff DD. Response of metastatic adenoid cystic carcinoma and Merkel cell tumor to high-dose melphalan with autologous bone marrow transplantation. Invest New Drugs 1992; 10:458.

Address for correspondence: Dr.Sham Kishor K. Lecturer, Department of Oral Radiology, Faculty of Dentistry, AIMST University, Semeling, 08100 Bedong, Kedah Darul Aman, Malaysia. Ph: 006-0103719885 Email:


Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

Orthodontic Treatment Of A Unilateral Cleft Lip And Palate Patient With Secondary Bone Graft And Eruption Of Canine

Authors: Thomas Mathew MDS Orthodontics. Lecturer, Faculty of Dentistry, Aimst University


The cleft lip and palate patients often have constricted maxillary arch, congenitally missing teeth, impacted teeth, and many kinds of malocclusion problems. Secondary bone grafting in cleft lip and palate patients is performed preferably before the eruption of permanent canine in order to provide adequate periodontal support for eruption and preservation of the teeth adjacent to the cleft. Secondary grafting with iliac marrow consistently produces trabecular bone to unify the maxilla and provide odontogenic support. Presented here is a case of unilateral cleft lip and palate, which was treated by expansion by quad helix and straight wire appliance for correction of dental malocclusion. Also discussed in detail the entire range of treatment procedures the boy underwent from 14 years of age, especially the role of secondary bone grafting with iliac marrow to facilitate the eruption of permanent impacted canine.

Key Words: Bone grafting, Cleft lip, Cleft palate

The main difference in the interdisciplinary treatment protocol in the management of cleft lip and palate is the timing of occurrence of bone grafting. Accordingly, the graft may be classified as primary, secondary and tertiary. When performed during early childhood, at the same time as the primary repair surgeries, bone graft is called as primary. Some authors believe that this early procedure can cause impairment of the maxillary growth. Because of its controversial and counterproductive aspect, most rehabilitation centers that used to perform it have abandoned this technique. Bone grafting is called as secondary when performed later at the end of the mixed dentition. It is the most accepted procedure and is performed preferably before eruption of the permanent canine in order to provide adequate periodontal support for eruption and preservation of the teeth adjacent to the cleft.1,2 When bone grafting is performed in the permanent dentition after the completion of orthodontic treatment, it is called a tertiary or late graft. Occasionally, tertiary grafts cause progressive root resorption on the cervical thirds of roots of teeth adjacent to the cleft, especially canines. Such root resorption is caused by the contact of the grafted bone to the exposed root surface. Studies shows that secondary bone grafting can repair the cleft alveolus without increasing the already known iatrogenic effects of primary surgery on the maxillary growth. Mostly the Oslo cleft team is based on sound biological and technical principles and has extensively reported secondary bone grafting in literature. Grafted cancellous bone fills in the residual alveolar cleft and is anatomically joined to the adjacent
Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 2010 The Malaysian Dental Association 84

bone, becoming indistinguishable in radiographic images after an average period of 3 months. From an orthodontic viewpoint, the most important benefit of secondary bone grafting is that the newly grafted bone acts as the alveolar bone, allowing the spontaneous migration of the adjacent canine towards the alveolar ridge. Therefore, bone grafting has become mandatory in the treatment protocols of cleft patients, establishing two well-defined stages for orthodontic mechanotherapy3(pre and post secondary bone grafting). During the prebone grafting orthodontic phase, the upper dental arch is prepared for the graft and the permanent incisors are aligned whenever necessary. The pregraft orthodontic treatment also results in better access for the surgeon at the time of the grafting procedure. The presurgical orthodontic preparation involves predominantly transverse mechanics with the use of orthodontic or preferable orthopedic expansion during the mixed dentition4 in order to reposition the palatal segments. Occasionally some patients are subjected to maxillary protraction in addition to expansion in order to correct maxillary antero-posterior deficiencies. Three months after the bone graft procedure, and depending on the radiographic image of the area, orthodontic treatment is restarted to correct the position of the permanent teeth. This phase involves movement of the teeth through the grafted area.5,6,7 Here a case of unilateral cleft lip and palate is described, which was followed up in our hospital from 14 years of age.8,9 The role of an orthodontist in the team approach for management of such anomalies is also discussed.

Thomas Mathew

A 14-year old boy reported to dental surgery department for management of facial deformity and irregular teeth. The boy was born with unilateral cleft lip and palate(primary palate). According to the records, the lip repair was done when the child was 2 months old and the palate repair was carried out when he was 24 months old. His parent gives a history of Consangious marriage. The patient was referred to a speech therapist for speech correction. When the patient reported to the orthodontic clinic for further management at 14 years of age, radiographic records like the lateral cephalogram, OPG and occlusal x-rays of the maxilla were evaluated, study models and photos were taken(fig 1 and 2). Figure 1: Pretreatment extra oral and intraoral views at 14 years of age.

Figure 2: Pretreatment Radiographs.


Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

Orthodontic Treatment Of A Unilateral Cleft Lip And Palate Patient With Secondary Bone Graft And Eruption Of Canine

The Summary Of Cephalometric Analysis for this case is skeletal class III with retrognathic anti inclined maxilla and prognathic mandible, retroclined lower incisors and horizontal growth pattern and final diagnosis as case of unilateral cleft lip and palate on right side and Skeletal Class III with Angles Class III malocclusion. The treatment objectives were Expansion of upper arch and Correction of cross bite, Closure of fistula by secondary bone graft, Opening of the bite, Correction of skeletal class III, Correction of crowding, Dis-impaction of impacted upper right canine, Correction of axial inclination of upper and lower anterior teeth, improving facial esthetics. The treatment plan was put forward as Pre surgical Stage 1 orthodontics, where expansion of upper arch by Quad helix and opening of bite by posterior bite plane was planned. In stage 2 orthodontics, Strap up with 0.022 Roth prescription straight wire appliance for correction of crowding and rotations. In surgical phase, secondary alveolar grafting for closure of cleft and for eruption of the impacted canine was decided. In stage 2 surgical, after the boy completes his growth, distraction osteogenesis for correction of skeletal class III was decided. The initial treatment comprised of expansion of maxillary arch for cross bite correction by quad helix and for opening the bite posterior bite plane was used (Fig 3). In three months, 11mm of expansion was achieved by quad helix (Fig 3). Post expansion the leveling and aligning of upper and lower arches was done (Fig 4). Later a secondary bone grafting in the cleft region to facilitate eruption of permanent canine was done. The bone was harvested from the iliac crest (Fig 5). After 3 months, full comprehensive orthodontic treatment was initiated (Fig 6). After the leveling and alignment the permanent canine was disimpacted using orthodontic traction(Fig 7). The facial photographs after the bone grafting, there was commendable change in malocclusion and facial deformity(Fig 8). The OPG of the patient 6 months after the grafting procedure showed an adequate bone in the cleft site(Fig 9). Thus with a team approach, an acceptable face and occlusion was given to this child. Figure 3: Quad helix at insertion, expansion, occlusal radiograph after expansion, 0.022 strap up.

Figure 4: After initial leveling and aligning.

Figure 5: Harvesting bone from iliac crest and grafting into the cleft site.

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2


Thomas Mathew

Figure 6: Post bone grafting photographs.

Figure 7: Canine disimpaction by orthodontic traction.

Figure 8: After canine disimpaction Intra oral and extra oral photos.

Figure 9: Radiographs after 6 months of bone grafting.


Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

Orthodontic Treatment Of A Unilateral Cleft Lip And Palate Patient With Secondary Bone Graft And Eruption Of Canine

The Surgical goals of alveolar bone grafting and reconstruction10,11 are Stabilization of the dental osteal segments, Oronasal fistula closure, Improvement in the alveolar ridge form, Prevention of tooth loss due to lack of periodontal bone support, Provision of the nasal alar base support, Stabilization of the dental arch and closure of the oronasal fistula. The greater segment has a tendency to collapse due to lack of alveolar continuity and palatal scarring. Early secondary bone grafting, between the age of 2 and 6 is done primarily to provide alveolar bone support for the eruption of the lateral incisor. The lateral incisor is often malformed, congenitally missing, or erupts ectopically. Radiographic evaluation of the lateral incisor and canine associated with the cleft defect will help to determine timing of the graft. 95% of the anteroposterior and transverse growth is completed by the age of 8 and therefore the most common time for alveolar cleft grafting is between the age of 9 and 11 (before the eruption of the canine when the root is 1/2 to 2/3 formed). Anteroposterior and transverse growth is completed by this age and only vertical growth remains. Grafting between the age of 9 and 11 does not have much effect on mid face growth and will provide bony support for the erupting canine.12 The anterior iliac crest is the most common donor site used today(gold standard). This site is preferred as the amount of bone, which can be mobilized in adequate amount and has high particulate cancellous bone content. Calvarium and mandibular bone has been advocated, as being a superior donor however there is inconsistent clinical results. However the bone is membranous, less particulate cancellous bone and quantity harvested is inadequate. Radiographic follow-up demonstrated adaptation of the cancellous bone of the iliac crest to the host area, making it impossible to distinguish the mesial and distal limits of the cleft. In addition, it was radiographically apparent that canines migrate towards the occlusal plane through the grafted bone and create good periodontal conditions. The findings of present case agree with other studies in which teeth erupted through the grafted bone. Cancellous bone graft is quickly incorporated and vascularized . In Secondary bone grafting in cleft lip and palate, presence of the tooth contributes to the preservation of the grafted bone and to the differentiation of the periodontal support. Pre-bone grafting orthodontic management is begun in the mixed dentition stage with the correction of cross bites and the alignment of the anterior teeth. Expansion appliances should be left in place for a minimum of 3 months following placement of the graft to prevent a relapse. Preoperatively the surgeon must evaluate soft tissue for adequate closure, must plan flap design to maintain adequate blood supply, periodontal support of dentition, oronasal communication, and support of the alar base and evaluate the donor site.
Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 88

Thus to conclude, secondary bone grafting was considered successful for this patient at the age of 14 years. The treatment achieved satisfactory overbite, overjet and good occlusal function. To date, stable condition has been maintained. Outcome of this case permit periodic review of an overall treatment regimen and may serve as useful baselines from which to develop critical treatment pathways for the care of children with cleft lip and palate at 14 years of age.

Omar Gabriel da Silva Filho; Silvana Ghilardi Teles; Secondary Bone Graft and Eruption of the Permanent Canine in Patients with Alveolar Clefts: Literature Review and Case Report. The Angle Orthodontist: Vol. 70, No. 2, pp. 174178. 2. Helm JA, Speidel TM, Denis KL. Effect of timing on long term clinical success of alveolar cleft bone grafts. Am J Orthod Dentofac Orthop 1987;92:232-240. 3. De Silva Filho OG, Okada HY, Capelozza Filho L, Suguimoto RM. Orthodontic traction of a permanent canine through a secondary bone graft in a unilateral cleft lip and palate patients. J Clin Orthod 1998;32:417-422. 4. Brattstrom V, McWillian J. The influence of bone grafting age on dental abnormalities and alveolar bone height inpatients with unilateral cleft lip and palate. Eur J Orthod 1989;11:351-358. 5. El Deeb M, Messer LB, Lehnert MW, Hebda TW, Waite DE.Canine eruption into grafted bone in maxillary alveolar cleft defects. Cleft Palate J 1982; 19:9-16. 6. Enemark H, Sindet-Pedersen S, Bundgaard M. Long term results after secondary bone grafting of alveolar clefts. J Oral Maxillofac Surg 1987;45:913- 919 7. Hinrichs JE, El Deeb ME, Waite DE, Bevis RR, Bandt CL. Periodontal evaluation of canines erupted through grafted alveolar cleft defects. J Oral Maxillofac Surg 1984;42:717-721. 8. Troxell JB, Fonseca RJ, Osbon DB. A retrospective study of alveolar cleft grafting. J Oral Maxillofac Surg 1982;40:721-725. 9. Epstein LI, Davis WB, Thompson LW. Delayed bone grafting in cleft palate patients. Plast Reconstr Surg 1970:46:363-367. 10. Johanson B, Ohlsson A, Friede H, Ahlgren J. A followup study of cleft lip and palate patients treated by orthodontics, secondary bone grafting and prosthetic rehabilitation.Scand J Plast Reconstr Surg 1974;8:121-135. 1.

Thomas Mathew

11. Bergland O, Semb G, Abyholm FE. Elimination of the residual alveolar cleft by secondary bone grafting and sub sequent orthodontic treatment. Cleft Plate J 1986;23:175- 205. 12. Semb G. Effects of alveolar bone grafting on maxillary growth in unilateral cleft lip and palate patients. Cleft Palate J 1988:25:288-295. Address for correspondence: Dr Thomas Mathew Lecturer, Faculty of Dentistry. Aimst University. Semeling, Malaysia.08100. Email:


Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

UKM Undergraduates Perception Of Hand Protaper System

Authors: Wan Noorina Wan Ahmad BDS (Adel), MClinDent (Endodontology)(Lond), MFDSRCS(Eng) Assoc. Prof Dr Dalia Abdullah BDS MClinDent in Endodontology, FDSRCSEd Shalini Kanagasingam BDS (Mal) MClinDent Endodontology (Lon),MFDS RCS (Eng) MRD RCS (Edin) Safura Anita Baharin DDS MClinDent in Endodontology MFDSRCSEng DipCDSc Jasmina Qamaruz zaman BDS MSc in Restorative Dentistry, MFDSRCSEng


This study aims to determine the prevalence of hand-held ProTaper files system among UKM final year dental undergraduates and to assess their perception in performing endodontic treatments.

Methods: 85 final year dental students from 2006/2007 academic session participated in the questionnaire survey. All students underwent didactic endodontic teaching of conventional stainless steel files throughout a 2-year course and a 2-day ProTaper hand files seminar on canal preparation. Each student had a total of 6 months clinical period before the survey was distributed to the subjects and returned for data analysis. Results: A 100% response rate was received. About 58.8% (n=50) used hand ProTaper routinely while 41.2% claimed themselves as non-users. Amongst the users, 52.5% were moderate users and about 33.6% were frequent users. Tooth type and size of canals were the selected criteria for file use. Majority of users used ProTaper hand for posterior teeth and regarded it as user friendly. Although almost all users expressed concern of instrument fracture during use, very few did break. Procedural errors were not experienced by 51.3% users. Conclusion: About 2/3rd majority of UKM undergraduate dental students use ProTaper hand-held system as an alternative for canal preparation. Procedural errors were perceived to occur much less when using the NiTi files. The system can be initiated to novice users and can be taught as part of endodontic curricula.

Key Words: Hand ProTaper files, nickle titanium (NiTi), undergraduate dental students.

Pulp space cleaning and shaping procedures have been the primary objective for predictable root canal treatment. The introduction of nickel titanium (NiTi) material in the late 1990s has greatly revolutionized endodontics and improved the quality of root canal instrumentations. The alloy contains roughly 55% nickel and 45% titanium, low modulus of elasticity, and is classified as a memory metal, one that retains its original shape. Its hyper elasticity offers increased flexibility therefore allowing faster

and efficient negotiation especially in curved canals. Consequently, cleaning, shaping and obturation of canals are much easier technical processes than the conventionally taught technique. It is now possible to clean and shape straight and curved canal faster with the use of NiTi instruments1. Nonetheless, one concern using NiTi files is fracture of instrument within the root canal during preparation. Metal fatigue and file distortion are difficult to be detected early due to its ability to retain its original shape. Incidentally fracture can also results from incorrect or overuse of an endodontic instrument, and occurs most commonly in the apical

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 2010 The Malaysian Dental Association

Wan Noorina / Dalia / Shalini / Safura / Jasmina

third of a root canal. Although the overall percentage of instrument fracture is relatively low (0.5-5%), in the hand on novice users, fracture occur significantly less frequently with hand instrumentation when compared to engine driven rotary NiTi files2. Fracture of enginedriven NiTi rotary instruments occurred because there was lack of tactile sensation when the file is rotating within the canal. Consequently, this has led to the introduction of hand NiTi systems which offer better tactile feedback and hand control during canal preparation stage. ProTaper hand-held system is one of NiTi systems introduced with multiple progressive taper concepts that come in two different files types. The first is the shaping files (Sx, S1 and S2) which are used to prepare the coronal and middle two thirds of the canal. The other is the finishing files (F1, F2 and F3) with 7-9% taper for finishing the apical one-third. This system offers fewer files to create a tapered shape canals. A root canal prepared to a taper of 8-10% is the ideal shape for irrigation and cleaning with sodium hypochlorite making it aseptic and rendering it easy for obturation3 There have been many reports on NiTi instruments and their properties but studies relating to teaching and experience of NiTi hand files users in dental school are relatively limited 4,5,6. An in-vivo study on molar teeth performed by undergraduate dental students showed significantly less incidence of procedural errors when compared using 2% taper NiTi hand files to 2% stainless steel files 5 with zipping and elbows occurred significantly less using NiTi rotary files4. The undergraduates impression on the use of NiTi rotary files showed that it was easier to learn, fast and effective for clinical use6. Thus, a relatively safe step in undergraduate training for endodontics would be to take full advantage of tactile feedback sensation using hand instruments and simultaneously gain the benefits of NiTi with wider taper files. Unfortunately, study using ProTaper hand-held files is limited in numbers when involving novice users. Original curvature of curved canal was maintained using the ProTaper hand files but no evaluation was conducted on the students experience of the instruments used7. This descriptive study aims to determine the prevalence of ProTaper for hand use files among Universiti Kebangsaan Malaysia (UKM) final year dental undergraduates and to assess their perceptive experience in performing endodontic treatments as well as benefits and problems that they encounter during clinical use.

a 2-year course including a 2-day seminar on ProTaper for hand use files after which a molar simulation exercise was carried out before they were permitted to start endodontic treatment on patients. At this point all students had been exposed to both conventional technique using manual stainless steel and ProTaper hand-held files. During their clinical sessions, the students were allowed to choose their preferred technique in preparing the canals for their respective patients. Each student had a total duration of 6 months clinical exposure to the newly introduced system before a questionnaire survey was distributed and returned on the same day. The questionnaire had been pre-tested, analysed and revised on a third of the samples (n25) prior to the distribution of the questionnaires to all the undergraduate dental students. The questionnaires were self-explanatory and consisted of closed ended questions concerning demographic data, number of completed root canal treatment cases, frequency and selection criteria of use, comfort and problems associated with the instruments during use. The data collected were analysed using software such as SPSS version 12.0.1 and then tabulated into table using Microsoft Excel.

A response rate of 100% was received and analysed. From this 82.4% were female and 17.6% were male. From the sample, about 65.9% had completed 2-4 of anterior and premolar teeth after having had both canal preparation systems used. About 22.9% of them had completed 5-7 teeth and only 1.2% of the samples had completed 8-10 teeth within the same period. About 58.8% (n=50) of the respondents stated that ProTaper files were used routinely in the clinic while 41.2% (n=35) claimed that they were non-users. One reason for not using was file was not available in the clinic. Reasons such as the system were difficult to learn and use was not selected. Amongst the users, minority were full-time users (use ProTaper files routinely all the time), while 33.6% claimed as frequent users (use ProTaper 80% of the time) and 52.5% used it moderately (use ProTaper 60% of the time). Tooth type was the most popular criterion (45.4%) followed by the size of canal (41.7%). A mere 3% chose to prepare all types of root canal with the system. Most users prepared both premolar and molar teeth with the system and almost all users regarded the files as user friendly with comfortable handle design, good working comfort and acceptable tactile feedback. A vast majority expressed concern about instrument fracture during use. In contrary, almost all (94%) never experience separation of instrument (Figure 1). 51.3% reported no procedural error while during instrumentation while the remainder reported 25.3% canal blockage, 17.4% ledging and 6% of strip perforation cases.
91 Malaysian Dental Journal July-Dec 2010 Vol 31 No 2


This cross-sectional study involved a total of 85 final year dental students from the 2006/2007 academic session who participated in the survey. All students underwent a series of didactic endodontic teaching of conventional stainless steel files throughout

UKM Undergraduates Perception Of Hand Protaper System

Figure 1: Overall experience of user of ProTaper files


% of ProTaper for hand users

100 80 60 40
33.6 82.3 14.8


94 79.5

Posterior premolar and molars

Anterior teeth only





41.7 12.9


Full time user

Not user friendly

Size of canal


User friendly


20 0


Tooth type

All types




Frequency of use

Selection criteria

Tooth type

Comfort during use

Concern about Actual experience fracture during of fractured le use

In an attempt to investigate the prevalence of hand ProTaper users, this study was carried out on the final year UKM undergraduate dental students. Response rate for this questionnaire survey was high due the timing of the questionnaires obtained which was held at the end of an assessment session. A majority of the students were able to complete between 2 to 4 teeth and 23% of them were able to finish 5-7 teeth despite limited clinical practice. Having given the liberty to choose the type of instrument for canal preparation, about a third of the subjects had not chose to use the ProTaper system. It would appear that ProTaper hand files is not the main choice of canal preparation technique. This could be attributed to the fact that the students had 2-year prior experience (Year 3 and Year 4) using the conventional stainless steel files, and felt much comfortable with the conventional files. The majority 2/3rd on the other hand, prefer the ProTaper hand technique even though it was recently introduced and was only taught on a 2-day seminar. It was plausible that the system was perceived as user friendly and a technique which is simple and easy to grasp in short period of time. Of the non-users in the clinic, none chose difficult to use or difficult to learn as their answers in the questionnaires but attributed unavailability of the system in the clinic as the main reason. In terms of knowledge, majority preferred to use hand NiTi files based on posterior tooth types which include both premolar and molar teeth with small apical diameter. This may be due to the fact that ProTaper system
Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 92

only offers up to F3/apical size .30 as the finishing file at the time of the study. The newer files of F4 and F5 were introduced later in 2008. Therefore, to the respondents canals with larger diameter such as upper incisors and canines would require a change in the routine ProTaper procedure in which majority of the students were not comfortable of, hence prefer not to use the system for these cases. The simplified routine sequence card provided by ProTaper set did not seemed to attract majority of the students to choose the instruments while treating patients. Students perceptions on the ProTaper hand system were easy to learn, user friendly, good handling property and reliable tactile feedback. This is in accordance with studies conducted by Chirani & Vulcain6 and Sonntag et al2,4. Although high number of students expressed their anxiety for instrument fracture during use, in reality only few did break a file. It would seem fair to assume that amongst novice users, fear of breaking any instrument persists regardless of file used. Future studies could be designed to compare whether concern regarding instrument fractures also affects skillful users. Procedural errors occurred in less than half of the subjects. Although blockage was the main error produced this has to be carefully interpreted because most canals need to be negotiated prior to the use of any instruments to maintain its patency. There was no means of knowing whether the canal was actually blocked prior to the use of the system or after patency has been established due to clinician incorrect use of the system. However a comforting note was that strip perforation was kept to minimum with regards to the use of the file.

Wan Noorina / Dalia / Shalini / Safura / Jasmina

Based on the results gathered from the survey, ProTaper hand-held files is an alternative option for canal preparation amongst the UKM dental students. Students prefer to use this type of files on posterior molar teeth with small apical diameter canals. It was regarded as easy to learn, user friendly and comfortable to work with. Although students fear for instrument fractures was high, only few did so. For those undergraduates that chose to use ProTaper hand files, procedural errors were perceived as much less when using NiTi ProTaper hand files. This type of nickel titanium file can be introduced to inexperienced users as part of endodontic curricula.

Address for correspondence: Dr Wan Noorina Wan Ahmad BDS (Adel), MClinDent (Endodontology)(Lond), MFDSRCS(Eng) Specialist in Endodontics, Department of Operative Dentistry Faculty of Dentistry Universiti Kebangsaan Malaysia Jalan Raja Muda Abdul Aziz 50300 Kuala Lumpur, MALAYSIA Telefon: +603-92897864/ Fax: +603-92897798

1. Rhodes JS, Pitt Ford TR, Lynch JA, Liepin PJ, and Curtis RV. Micro-computered tomography: a new tool for experimental endodontology. Int Endod J 1999; 32(3): 165-170 Sonntag D, Delschen S and Stachniss V. Root canal shaping with manual and rotary Ni-Ti files performed by students. Int Endod J 2003; 36: 715723 Ruddle CJ. The ProTaper technique: endodontics made easier. Dent Today 2001; 20:5868. Sonntag D, Guntermann A, Kim SK and Stachniss V. Root canal shaping with manual stainless steel files and rotary Ni-Ti files performed by students. Int Endod J 2003, 36(4):246-55 Pettiette MT, Metzger Z, Phillips C and Trope M. Endodontic complications of root canal therapy performed by dental students with stainless steel K-files and nickel-titanium hand files. J Endod 1999; 25 (4):230-234. Chirani RA and Vulcain JM. Undergraduate teaching and clinical use of rotary nickel-titanium endodontic instruments: a survey of French dental school. Int Endod J 2004; 37(5):320-324. Tu Ming-Gene, Chen San-Yue, Huang Heng-Li and Tsai Chi-Cheng. Endodontic shaping performance using nickel-titanium hand and motor ProTaper systems by novice dental students. J Formos Med Assoc 2008; 107(5):381-388


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Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

Regenerative Endodontics: A Review

Authors: Kundabala M MDS, Professor & Head, Department of Conservative Dentistry and Endodontics, Manipal College of Dental Science, Mangalore, Karnataka, India. Abhishek Parolia Faculty of Dentistry, International Medical University, KualaLumpur, Malaysia. Neeta Shetty MDS, Associate Professor, Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences,Mangalore.Karnataka, India.

Tissue regeneration is a rapidly growing field providing a beacon of hope in the field of restorative and endodontics. Root canal treatment involves the removal of pulp tissue and replacement by an inorganic materials where as regenerative endodontics deals with replacement with healthy pulp to revitalize the teeth .Research in the field of tissue engineering and material science have lead to significant progress but still is plague with lots of drawbacks and failures, hence it is still not being adapted as routine clinical procedures .The purpose of this article is to review the advances made in regenerative endodontics and the future scopes .

Key Words: Pulp tissue, Regeneration, Stem cells, Scaffolds, Dentinogenesis

Tissue engineering is the norm of the day and man is striving to play god .The amalgamation of bioengineering and medicine has resulted in the emergence of a new field known as tissue engineering. Tissue engineering is the restoration of lost tissue function through the delivery of synthetic or natural tissue constructs in the laboratory. It is also developing new frontiers in dentistry known as regenerative dentistry. Emphasis is on the formation of lost dentinal tissues and restoration of pulp function. The abuse sustained by a tooth during its life span is innumerous resulting in damage that needs constant treatment. This high susceptibility of teeth to damage combined with nonregerative nature of dental tissue stresses the need for regeneration of dental tissues to replace the lost dental structure.1 Preservation of pulp vitality continues to be a major challenge for the restorative dentist. The intensity and duration of injury to teeth, whether it be carious, traumatic or other origin, are the factors which have considerable implications for subsequent pulpal responses. The formation of tertiary dentin, reactionary and reparative dentin, represents an important defense mechanism and a regenerative property of the pulp-dentin complex. 2 In 1952 Dr.
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B.W. Hermann reported on the application of Ca(OH)2 in a case report of vital pulp amputation which was a stepping stone in regenerative dentistry. 3 In 1993 Langer and colleagues proposed tissue engineering as a possible technique for regenerating lost tissue. 4 Millions of teeth are saved each year by root canal therapy. Although current treatment modalities offer high rate of success in endodontics, pulpal tissue regeneration may be a model approach to replace the diseased pulpal tissues by healthy tissue to revitalize the teeth. Thus endodontics research should be focused on the ability to stimulate endodontic tissue regeneration. Regenerative endodontics procedures can be defined as Biologically based procedures designed to replace damaged structures including dentin and root structures ,as well as cells of pulp dentin complex. 3The regeneration of decayed tooth or lost tissue is of concern since no existing restorative material provides better protection to pulp than dentin. 5 Ex vivo and in vivo are the two approaches currently utilized in tissue engineering. Hence this scientific review article describes the objectives, cells,growth factors, procedure involved ,with emphasis on the technologies and research scopes in regenerative endodontics.

Kundabala M / Abhishek / Neeta

Objectives of regenerative endodontics The pulp-dentin complex regenerates the damaged coronal dentin, resorbed root, cervical or apical dentin3. Regenerative procedures are to be done with the use of tissue engineering materials, stem cells and suitable biochemical factors that will enhance or replace biological functions. Largely the objective of tissue engineering is the functional restoration of tissue structures. Clinical applications depends on the use of a potential material which would be antiinflammatory,antibacterial and can simultaneously enhance the proliferation and induce the differentiation of the present Dental Pulp Stem Cells (DPSC) into odontoblast-like cells leading to dentin formation. 6 Formation of a reparative dentin layer would provide an optimal barrier to avoid any bacteria infiltration to the pulp tissue, which is not provided by any artificial restorative materials. So application of a scaffold on an open pulp enabling odontoblast-like cells to grow into the scaffold and to convert it into dentin would be an ideal goal.7 The ultimate objective of regenerative endodontics would be creation of a replacement pulpal tissue. Cells and growth factors involved in regenerative endodontics Regenerative endodontics consists of research in stem cells, odontoblast, growth factors, organ-tissue culture and tissue engineering materials. Odontoblast Odontoblasts are dentin producing cells located at the periphery of the pulp. They are responsible for the formation of primary, secondary, and reactionary dentin. These cells produce reparative dentin or osteodentin, in reparative processes after pulpal injury. The cells forming reparative dentin are newly differentiated odontoblasts derived from mesenchymal progenitor/stem cells located in the pulp. 8 They are derived from pulpal cells. These cells differentiate into osteoblast-like or odontoblast-like cells, which are elongated and polarized cells. 9 Stem cells Stem cells are generally defined as clonogenic cells capable of both self renewal and multi-lineage differentiation. Post-natal stem cells have been isolated from various tissues, including bone marrow, neural tissue, skin, retina, and dental epithelium. Gronthos S et al demonstrated that Human dental pulp stem cells represent a novel adult stem cell population that possess the properties of high proliferative potential, the capacity of self-renewal, and multilineage differentiation. 10 They can theoretically divide without limit to replenish other cells as long as the person is still alive. There are two types of stem cells: the embryonic stem cells and the adult stem cells.11 Embryonic stem cells are derived from embryos and

they have the capacity to form all tissues. Ohazama et al cultured mouse embryonic stem cells and analyzed the ability of heterogeneous adult cell population to form teeth in tissue engineering rudiments. 12 Adult stem cells are undifferentiated cells that typically generate the cell types of the tissue in which they reside. They can renew themselves and their primary role in a living organism is to maintain and repair the tissue in which they are found. Adult stem cells may also exhibit the ability to form specialized cell types of other tissues, which is known as transdifferentiation or plasticity. Certain kinds of adult stem cells seem to have the ability to differentiate into a number of different cell types, given the right conditions. 11 Due to ethical issues the use of embryonic stem cells in the tissue engineering, is not feasible. So research is concentrated on adult stem cells Dental pulp stem cells (DPSC)- The Dental Pulp Stem Cells are implicated in dentinal repair by activation of growth factors, released after caries process and have the ability to regenerate the dentin-pulp-like complex. Various studies indicated DPSC derived from pulp tissue have the potential to differentiate into either odontoblast-like cells or fibroblasts. 13 DPSC like osteoblasts, express bone markers such as bone sialoprotein, alkaline phosphatase, type I collagen, and osteocalcin.11 The DPSCs have the ability to regenerate the dentin-pulp-like complex. 10 A population of high quality human stem cells was found in the exfoliated human primary teeth (SHED) .The SHEDs have the osteoinductive capacity in vivo, but failed to reconstitute a dentin-pulp-like complex. 11 Stem cell fractions are called side population (SP). The adult pulp tissue contains side population (SP) cells that have tissue stem cell activities, self-renewal and multilineage potential. 14 According to Gronthos S DPSCs were capable of forming ectopic dentin and associated pulp tissue in vivo. Stromal-like cells were reestablished in culture from primary DPSC transplants and retransplanted into immunocompromised mice to generate a dentin-pulp-like tissue, demonstrating their self-renewal capability.10Takeda T et al were able to isolate human DPSCs isolated from tooth germs at the crown-completed stage and found that these cells were highly proliferative and had the potential to generate a dentin-like matrix in vivo. However, these characteristics were lost in long-term culture, with a change in their gene expression profile. 15 Morphogens In both normal and abnormal biological processes, the basis for cell proliferation most likely lies in the response of cells to a group of molecules known as polypeptide mitogens in conjunction with extracellular matrix molecules.16 These are biologically active molecules and growth factors .Research suggest that application of biologically active growth and morphogenetic factors and extracellular matrix
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Regenerative Endodontics: A Review

molecules as capping materials resulted in hard tissue formation.17 BMPs may be useful morphogens for the regeneration of dentine. Growth factors normally expressed during primary odontogenesis,such as members of the transforming growth factor beta (TGF-beta) , the bone morphogenetic protein family (e.g. BMP-2, BMP-7), and insulin-like growth factor-1 (IGF-1) appear to play a key part in the induction of odontoblast-like cell differentiation from progenitor pulpal cells. A number of these growth factors are incorporated into the developing dentin matrix during initial tooth formation, forming a reservoir from which they can be released following dentin breakdown. 18 Recombinant human BMP-2 stimulates differentiation of adult pulp stem cells into odontoblastoid morphology in culture. According to studies by K. Iohara et al BMP2 can direct pulp progenitor/stemcell differentiation into odontoblasts and result in dentin formation. 13Researchers have demonstrated the similar effects of TGF1-3 and BMP-7 in cultured tooth slices.19, 20Also Recombinant BMP-2, -4 and -7 induce reparative dentin in vivo. 21 Scaffolds It provides a mechanical support until the tissue has regenerated and remodeled itself naturally. It refers to devices implanted into the body that are intended to restore form and function by creating a framework for cell attachment and differentiation, ultimately leading to the development of mature tissues.22 To create a practical endodontic tissueengineering therapy, investigators must organize pulp stem cells into a three-dimensional structure using tissue-engineering scaffolds. 20 Biomaterials for scaffold should provide optimal conditions for cell adhesion, migration, proliferation and differentiation. Requirement of a scaffold materials are 2 1) Biocompatible and nontoxic. 2) Biomechanical features including compressive and flexural strength, 3) Conductive for odontoblast-like cells, 4) Bioresorbable, 5) Bioactive tensile,

stimulation of dentin matrix secretion. These growth factors are secreted by odontoblasts and are deposited within the dentin matrix, where they remain protected in an active form through interaction with other components of the dentin matrix.23 Need for regenerative endodontics The general perception is that the pulp has no role to play on completion of tooth formation.So the replacement of the root canal with endodontic filling material is a viable option.But a tooth which loses its pulp also loses perception to pressure, its colour and translucency.Routine endodontic preocedures also makes the tooth fragile. A vital pulp is also very essential to prevent apical periodontitis.Potential to regenerate an injured or necrotic pulp would be advantageous especially in young permanent teeth, since there is a risk that filling materials and sealers may discolour the tooth crown.3, 24A retrospective study implicated that though root canal therapy prolonged tooth survival ,the removal of pulp in a compromised tooth may still lead to tooth loss in comparison with teeth with normal pulp. 25Ttechniques for replacement of pulp tissue or revascularization of the pulp has the potential to revitalize teeth. Concept of tissue engineering - A tissue engineering approach uses cultured cells and biodegradable polymer scaffolds. Tissue specific cells are isolated from a biopsy specimen, expanded in culture and combined with a porous biodegradable polymer scaffold. The cells adhere to the scaffold, proliferate and, over time, form a new tissue that can be returned to the tissue donor or to another patient. 26 Technologies Revascularization of pulp dentin complex Post natal stem cell therapy Pulp implantation Scaffold implantation Injectable scaffold delivery Three dimensional cell printing Gene therapy

Revascularization of pulp - dentin complex In 1960s Nygaard ostby and Hjortdal attempted Scaffolds revascularization of pulp space in a necrotic ,infected Spongeous collagen, porous ceramic and fibrous tooth with apical peridontitis. 24 Revascularization titanium mesh scaffolds, bioceramic calcium phosphate requires canal environment which is can effectively tissue scaffolds, polymer scaffolds are some of the disinfected, placement of antibiotics, creation of scaffolds which are used in regenerative endodontics. a blood clot which serves as a scaffold and can be The seeding of cells on tissue engineering scaffolds is sealed coronally.Revascularization of necrotic pulp known as creating a tissue construct. 20 To promote with fully formed apices might require instrumentation the formation of higher-ordered tissue structures, of the tooth apex to approximately 1-2 mm in apical tissue constructs are maintained in cell culture in the diameter to allow systemic bleeding into the root presence of growth factors or bioactive molecules. canal.3 There will be a formation of a blood clot which Growth factors, especially those of the transforming acts as a matrix that traps cells capable of initiating growth factor (TGF) family, are important in new tissue formation.Revascularization research has cellular signaling for odontoblast differentiation and studied collagen solution as artificial scaffolds in the
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Kundabala M / Abhishek / Neeta

canal space.Collagen with crystals of calcium and phosphate ,as nucleation centres for hydroxyapatite formation has been tried using bovine collagen for revascularization.27 Figure 1: Revascularization of pulp-dentin complex

root canals.Implantation of sheets of cultured pulp tissue is technique sensitive procedure that requires the cells to adhere to the root canal walls .The source of pulp tissue are purified pulp stem cell lines or cells taken from a biopsy and grown in the laboratory. 3 Pulp cells are grown on biodegradable membrane filters or sheets such as polymer nanofiber or extracellular matrix proteins. These cells lack vascularity, so they are implanted at the apical portion of the root canal and a scaffold is placed above it, which will support the proliferation of the cells.29 Scaffold implantation Scaffold is a three dimensional structure which will support the cell organization and vascularization. A scaffold should contain growth factors, nutrients and antibiotic to promote stem cell differentiation and proliferation ,survival ,growth and bacterial in growth . Types of scaffold materials

Triantibiotic paste containing ciprofloxin, metronidazole and minocycline has also been used for revascularization which is technically a simple inexpensive technique. Materials and instruments are easily available .Commercially available medicaments are used. Immune rejection and external pathogen transfer is minimum. Drawback of this method is the concentration and composition of cells trapped in the scaffold is not predictable. Enlargement of apical foramen and supply of oxygen to cells is crucial for the success of this method. E. Hoshino et al demonstrated that the bactericidal efficacy of the drug combination is sufficiently potent to eradicate bacteria from the infected dentine of root canals.28 A study conducted by Blayne et al on pulp revascularization of immature dog teeth with apical periodontitis concluded that revascularization of previously necrotic infected canals is possible provided they can be effectively disinfected.27 Post natal stem cell therapy- it involves injecting post natal stem cells into a disinfected root canal system after apex is opened.3 Sources for Dental stem cells can be Autologous Buccal mucosa biopsy Umbilical cord which is stored at birth Allogenic Disease and pathogen free purified pulp stem cells Xenogenic Animal pulp stem cells Pulp implantation A replacement pulp tissue grown in the laboratory is transplanted into cleaned and shaped

Natural Derivatives of extracellular matrix Collagen Fibrin Polysaccharides-chitosan,glycosaminoglycans Synthetic Biodegradable polymers Polylactic acids Polyglycolic acid polycaprolactone Collagen has the advantage to be cytocompatible and bioactive. Controlled production is possible, determined structure, porosity, degradation rate and mechanical properties can be precise varied and regulated, exhibits a high tensile strength. 2 Synthetic material has the advantage to perform a reproducible synthesis, to control the mechanical and chemical properties including the structure, size, viscosity, and porosity, as well as degradation rate of the desired scaffold. The incorporated bioactive molecules can locally be applied by controlled release of the biodegradable PLA, PGA or PLGA system and so influencing the cell phenotype expression. 2 The degradation rate of the synthetic material depends on various criteria besides the copolymer ratio, like configuration structure, crystallinity, morphology, stress, the amount of residual monomer, porosity and site of the implantation. The manufacturing techniques of various drug loaded biodegradable poly (lactide-coglycolide) (PLGA) devices.30 Injectable scaffold delivery A technique by which a soft three dimensional scaffold matrix such as polymer hydrogel is injected by syringe into the root canal .this scaffold supports the proliferation of stem cells. This technique is still at research stages.
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Regenerative Endodontics: A Review

Three dimensional cell printing of cells Early research describes this method by which layers of cells suspended in a hydrogel to create the structure of the tooth pulp tissue. This method is supposed to help in precision placement of cells. Gene therapy Gene therapy is another tool being employed in dentistry to regenerate lost tissue structures. It is a science of manipulation of the developmental processes that direct organ/tissue formation in the embryo, a source of cells with multipotential that can be easily cultured, and an ability of an organ rudiment to form the complete organ in the adult environment. Methods of gene transfer into cells are of two types, viral and non-viral (or physical) methods. 31 In endodontic stem cell therapy would consist of the transfer of materials that contain pulp stem cells grown in laboratory to generate new tooth tissues. C.S. Young et al dissociated porcine third molar tooth buds into single-cell suspensions recognizable tooth structures formed that contained dentin, odontoblasts, a well-defined pulp chamber, putative Hertwig's root sheath epithelia, putative cementoblasts, and a morphologically correct enamel organ containing fully formed enamel.32 In vivo gene therapy techniques will likely only be effective for dentin regeneration/pulp capping situations in which some viable, uninfected apical pulpal tissue containing an adequate number of pulp progenitor stem cells is still present after all infected/necrotic pulpal tissue has been excavated. Ex vivo approaches, in which growth factor-enhanced cells are transplanted into the tooth, might be viable alternatives for those situations in which there is substantial inflammation.18 Future Scope The scope for regenerative endodontics includes research on the the ability to stem cells to trigger regeneration hard tissues of the tooth ,vitalization of a nonvital pulp,replacementof periapical tissues and peridontal ligaments .The ability to generate biological tooth substitutes from autologous human tissues would be a valuable clinical tool. 32 The triad for dentine regeneration is responding cells, inductive morphogenic signals like BMPs, and an extracellular matrix scaffold . The human post-natal stem cells from accessible resources, like the ones derived from exfoliated primary teeth, can constitute in a potential clinical application, providing cells for stem cell therapies including cell transplantation and tissue engineering.11 Tertiary dentinogenesis is a form of tissue engineering that is naturally engineered by the body. There are two types of tertiary dentinogensis .Reactionary dentinogenesis represents the focal regulation of a group of primary odontoblasts surviving injury to the tooth, while reparative dentinogenesis
Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

represents the response of tertiary dentin secretion by a new generation of odontoblast like cells after death of the primary odontoblast cells. 19 Reparative dentinogensis involving progenitor cell recruitment and differentiation prior to matrix secretion at the site of injury. Dentin extracellular matrix does contain bioactive molecules potentially available for release during pulp healing and repair. Carious demineralization of the dentin causes the release bioactive molecules, which in turn signal the cascade of dentinogenic events.17 Application of a scaffold on an open pulp enabling odontoblast-like cells to grow into the scaffold and to convert it into dentin.7, 33 Thus, a deep carious lesion is turned into a rather small dentin wound that could easily be covered by a common restorative material acting as a substitute for enamel. The basis for cell proliferation most likely lies in the response of cells to a group of molecules known as polypeptide mitogens (or polypeptide growth factors) in conjunction with extracellular matrix molecules 16 . Studies have indicated that primary dentin is far more effective than reparative dentin (tertiary dentin) in protecting the pulp from bacterial threats and so regeneration of primary like dentin should be the ultimate goal for regenerative measures. This may be possible only by tissue-engineering methods by the formulation of biologically active matrices and molecules which can induce the differentiation. The goal of vital pulp therapy aims to maintain pulp vitality and function. Ideally under clinical conditions, complete healing of the exposed pulp with formation of dentin (complete dentin regeneration) cannot normally occur, due to total destruction of primary odontoblasts. Incomplete dentin regeneration often takes place at the exposure site when a new generation of odontoblast-like cells differentiates and reparative dentin is formed at the pulp-capping material interface.34 So research is focused on the prospect of inducing more extensive mineralized area that can fill the crown and root pulp partially or totally. 35 Calcium hydroxide is a time tested bioactive material which induces the formation of reparative dentinal bridge. New molecules such as bone morphogenic proteins (BMPs) or transforming growth factors beta (TGF-) have been implicated to cause dentin repair. Gene therapy is another tool being employed in dentistry to regenerate lost tissue structures. It is a science of manipulation of the developmental processes that direct organ/tissue formation in the embryo, a source of cells with multipotential that can be easily cultured, and an ability of an organ rudiment to form the complete organ in the adult environment. In endodontics stem cell therapy would consist of the transfer of materials that contain pulp stem cells grown in laboratory to generate new tooth tissues.36 M.T. Duailibi demonstrated successful bioengineering of mature tooth structures from singlecell suspensions of cultured rat tooth bud cells; PGA


Kundabala M / Abhishek / Neeta

and PLGA scaffolds supported the growth of mature tooth structures.33 Such approaches provide potential for restoration of the structural integrity of the dental tissues where the new tissues become an integral part of the tooth, thus minimizing some of the problems of restoration failure with traditional dental materials through interface failure and bacterial microleakage. 37 The future for regenerative and tissue-engineering applications to dentistry is of enormous prospective, capable of bringing quantum advances in treatment for our patients. Till date the design of suitable growth factor delivery system meeting all requirements and mimicking a natural biological environment still remains as one of the most important subjects in tissue engineering.





The concept of tissue engineering of dental tissues in the oral cavity is more practical compared to other sites in the body ,because it is less invasive, accessible and easy to monitor .This will also give the patients another alternative the dental implants .Stem cell therapy provides one of the most exciting future potential approaches to vital pulp therapy by eliciting a specific dentinogenic response into the pulp incase of severely compromised pulp, which is enhanced by use of synthetic scaffolds .Use of growth factor and gene therapy also have great value in dental repair. If research progresses in right direction, in next five years we can optimize the clinical outcomes of restorative treatment.


12. 13.

14. 15.

1 2. Yelick PC, Vacanti JP. Bioengineered teeth from tooth bud cells. Dent Clin North Am 2006; 50:191203. Mauth C, Huwig A, Graf-Hausner U , Roulet JF.Restorative applications for dental pulp therapy. Chapter3. Topics in tissue engineering, Vol. 3, 2007. Eds. N Ashammakhi, R Reis & E Chiellini 2007.(online) Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative Endodontics: A review of current status and a call for action. J Endod 2007; 33:377390. Nakahara T. A review of new developments in tissue engineering therapy for periodontitis. Dent Clin North Am 2006; 50:265-276. Hilton T J. Cavity sealers, liners, and bases: current philosophies and indication for use .Oper Dent 1996; 21:134-146. Nakashima M, Reddi AH. The application of bone morphogenetic proteins to dental tissue 16. 17. 18.


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engineering. Nat Biotechnol 2003; 21:1025-1032. Buurma B, Gu K, Rutherford RB. Transplantation of human pulpal and gingival fibroblasts attached to synthetic scaffolds. Eur J Oral Sci 1999; 107:282289. Mjor IA, Sveen OB, Heyeraas KJ. Pulp-dentin biology in restorative dentistry. Part 1: normal structure and physiology. Quintessence Int. 2001; 32:427-446. Goldberg M, Six N, Decup F, Buch D, Soheili Majd E, Lasfargues JJ, Salih E, Stanislawski L. Application of bioactive molecules in pulp-capping situations. Adv Dent Res 2001; 15:91-95. Gronthos S, Brahim J, Li W, Fisher LW, Cherman N, Boyde A, DenBesten P, Robey PG, Shi S. Stem cell properties of human dental pulp stem cells. J Dent Res 2002; 81:531-535. Casagrande L, Mattuella LG, de Araujo FB, Eduardo J. Stem cells in dental practice: perspectives in conservative pulp therapies. J Clin Pediatr Dent 2006; 31:25-27. Ohazama A, Modino SA, Miletich I, Sharpe PT. Stem-cell-based tissue engineering of murine teeth. J Dent Res 2004; 83:518-.522. Iohara K, Nakashima M, Ito M, Ishikawa M, Nakasima A, Akamine A. Dentin regeneration by dental pulp stem cells therapy with recombinant human bone morphogenetic protein 2. J Dent Res 2004; 83:590-595. Nakashima M.Tissue Engineering In Endodontics. Aust Endod J.2005; 31:111-113. Takeda T, Tezuka Y, Horiuchi M, Hosono K, Iida K, Hatakeyama D, Miyaki S, Kunisada T, Shibata T, Tezuka K. Characterization of dental pulp stem cells of human tooth germs. J Dent Res 2008; 87; 676-681. Terranova VP, Jendresen M, Young F. Healing, regeneration, and repair: prospectus for new dental treatment. Adv Dent Res 1989; 3:69-79. Tziafas D. The future role of a molecular approach to pulp-dentinal regeneration .Caries Res 2004; 38:314320. Edwards PC, Mason JM. Gene-enhanced tissue engineering for dental hard tissue regeneration: (2) dentin-pulp and periodontal regeneration. Head Face Med 2006; 25:2-16. Smith AJ, Murray PE, Sloan AJ, Matthews JB, Zhao S. Trans-dentinal stimulation of tertiary dentinogenesis. Adv Dent Res 2001; 15:51-54. Gotlieb EL, Murray PE, Namerow KN, Kuttler S, Garcia-Godoy F. An ultrastructural investigation of tissue engineered pulp constructs implanted within endodontically treated teeth. J Am Dent Assoc 2008; 139:457-465. Nakashima M. Bone morphogenetic proteins in dentin regeneration for potential use in endodontic therapy. Cytokine Growth Factor Rev 2005; 16:369-376.
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Regenerative Endodontics: A Review

22. Rekow D. Informatics Challenges in Tissue Engineering and Biomaterials. Adv Dent Res 2003; 17:49-54. 23. Smith AJ, Mattews JB, Hall RC. Transforming growth factor beta 1(TGF-beta1) in dentine matrix .Ligand activation and receptor expression. Eur J Oral Sci 1998; 106 (suppl 1):179-184. 24. Trope M. Regenerative potential of dental pulp. J Endod 2008; 34:13-17. 25. Caplan DJ, Cai J, Yin G. White B A. Root canal filled versus non root canal filled teeth. A retrospective comparison of survival times. J Public Health Dent 2005; 65:90-96. 26. Baum BJ, Mooney DJ. The impact of tissue engineering on dentistry. J Am Dent Assoc 2000; 131:309-318. 27. Thibodeau B, Teixeira F, Yamauchi M, Caplan DJ, Trope M. Pulp revascularization of immature dog teeth with apical periodontitis. J Endod 2007; 33:680-689. 28. Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, Iwaku M. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J 1996; 29:125-130. 29. Fukuda J, Khademhosseini A, Yeh J, Eng G, Cheng J, Farokhzad OC, Langer R Micropatterned cell co-culture using layer by-layer deposition of extracellular matrix components. Biomaterials 2006; 27:1479-1486. 30. Jain RA. The manufacturing techniques of various drug loaded biodegradable poly(lactide-coglycolide) (PLGA) devices. Biomaterials 2000; 21:2475-2490. 31. Baum BJ, O'Connell BC. The impact of gene therapy on dentistry. J Am Dent Assoc 1995; 126; 179-189. 32. Young CS, Terada S, Vacanti JP, Honda M, Bartlett JD, Yelick PC. Tissue Engineering of Complex Tooth Structures on Biodegradable Polymer Scaffolds. J Dent Res 2002; 81:695-700. 33. Duailibi MT, Duailibi SE, Young CS, Bartlett JD, Vacanti JP, Yelick PC. Bioengineered Teeth from Cultured Rat Tooth Bud Cells. J Dent Res2004; 83:523-528. 34. Tziafas D, Belibasakis G, Veis A, Papadimitriou S. Dentin regeneration in vital pulp therapy: design principles. Adv Dent Res2001; 15:96-100. 35. Goldberg M, Lacerda-Pinheiro S, Jegat N, Six N, Septier D, Priam F, Bonnefoix M, Tompkins K, Chardin H, Denbesten P, Veis A, A. The impact of bioactive molecules to stimulate tooth repair and regeneration as part of restorative dentistry. Dent Clin North Am 2006; 50:277-298.

36. Murray PE, Garca-Godoy F. The outlook for implants and endodontics:A review of the tissue engineering stratergies to create replacement teeth for patients. Dent Clin North Am 2006; 50: 299-315. 37. Smith A J. Tooth Tissue Engineering and Regeneration- a Translational Vision. J Dent Res 2004; 83:517.

Address for correspondence: Dr. Kundabala M. Professor & Head Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore Light House Hill Road, Mangalore Karnataka-575001, India Email: Ph (off): 91-824-2428716 Extn 5660 , Fax: 91- 824-2422653

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2


OZONE An Overview

Authors: Rizwan M Sanadi MDS (Periodontia), Reader, Dept of Periodontics, Yerala Medical Trust & Research Centres Dental College and Hospital. PG Institution, Institutional Area, Sector 4, Kharghar, Navi Mumbai- 410210, Maharashtra, India.

Ozone has been successfully used in medicine because of its microbiologic properties for more than 100 years. Its bactericide, virucide, and fungicide effects are based on its strong oxidation effect with the formation of free radicals as well as its direct destruction of almost all microorganisms. In addition, ozone has a therapeutic effect that facilitates wound healing and improves the supply of blood. For medical purposes, ozone may be applied as a gas or dissolved in water. This pale blue-coloured gas plays an important role as a natural constituent in the higher layer of the Earth's atmosphere. There is growing evidence that it can be employed as a useful therapeutic agent. Ozone is used to treat Dental unit water lines. It is now a proven fact that 10 seconds application of Ozone gas at a concentration of 2200 ppm could eliminate 99% of the carious microflora. Ozone acts as a strong oxidizer to cell wall and cytoplasmic membrane of bacteria in the plaque. Hence it can be inferred that Ozone therapy may provide a novel approach to treatment.

Key Words: Ozone, plaque, bactericide, fungicide, virucide.

Ozone has been successfully used in medicine because of its microbiologic properties for more than 100 years. Its bactericide, virucide, and fungicide effects are based on its strong oxidation effect with the formation of free radicals as well as its direct destruction of almost all microorganisms. 1 Ozone is a blue gas, containing three oxygen atoms. It is irritant, toxic, very reactive and instable, needing to be incorporated to other substances.2 In addition, ozone has a therapeutic effect that facilitates wound healing and improves the supply of blood. For medical purposes, ozone may be applied as a gas or dissolved in water. 1 Chemistry of Ozone (O3): Ozone forms parts of the natural gas mix that surrounds the earth at high altitude and protects the world's population from excessive ultra-violet radiation. Ozone is produced naturally during thunderstorms and can be produced in a controlled manner using electrical corona discharge units. Ozone can also be produced in Ozone generators / Ozonisers by passing air through high voltage.3 Ozone is one of nature's most powerful oxidants which accounts for its ability to kill bacteria, spores and viruses. Ozone has the unique feature of decomposing to a harmless, non-toxic and environmentally safe

material (oxygen). Ozone is often found in ambient air at levels exceeding the national air quality standard of 0.12 ppm averaged over a period of one hour. Humans are continually exposed to Ozone during their daily life.3 Occupational exposure to Ozone can involve electric arc welding, mercury vapour lamps, laser printers, some office photocopying equipments, X-ray generators and other high voltage electrical equipments.3 Ozone Production: Ozone is produced constantly in the upper atmosphere as long as the sun is shining, and since ozone is heavier than air, it begins to fall earthward. As it falls, it combines with any pollutant it contacts, cleaning the air. This is natures wonderful self-cleaning system. If ozone contacts water vapour as it falls, it forms hydrogen peroxide, a component of rain water, and one reason why rainwater causes plants to grow better than irrigation. 4 Ozone is also created by lightning, giving the wonderful fresh smell after a thunder storm. Ozone is also created by waterfalls and crashing surf, which accounts for the energetic feeling and calm experienced near these sites. Another way ozone is produced is by photons from the sun breaking apart nitrous oxide, a pollutant formed by the combustion of hydrocarbons in the internal combustion engine. This ozone can
Malaysian Dental Journal July-Dec 2010 Vol 31 No 2 2010 The Malaysian Dental Association

OZONE An Overview

accumulate in smog due to temperature inversions and is a lung and eye irritant. It is this duality of ozone, and the negative effects that tends to be focused on by the media and the healing property of ozone is ignored. 4 HealOzone unit (CurOzone USA Inc):3 The HealOzone unit consists of two main parts: 1) The polyurethane console (14.5" high x 10.5" deep x 10" wide) 2) The hand piece (5" length) The Polyurethane console consists of: a) Ozone generator to produce ozone by passing air through high voltage. b) Vacuum pump to suction air at a preset rate through the Ozone generator to supply ozone to the treatment site. c) Flow sensor turns on the Ozone generator once a predetermined minimum flow rate is achieved at the hand piece. d) Peristaltic pump to deliver a liquid reducing agent to the patient after application of Ozone. e) Reductant bottle (8 fl oz) to hold reducing agent. f) Desiccant to dry the air before entering the Ozone generator. g) Ozone destructor to dissipate the Ozone connected in line with the vacuum pump, h) Hydrophobic filter to stop liquid from entering the Ozone destructor during suction, I i) Back lit LCD display to relay programme information to the user. The console houses a side compartment with hinged door that holds the reductant bottle, desiccant, filter and the peristaltic pump. The hand piece: is the means by which Ozone is applied to the patient. The stainless steel hand piece with an anodised rear cover has a standard contra angle shape for easy access to all treatment sites. The disposable sealing cup attaches to the head with an easy slip on fitting. This cup seals to a tooth to promote flow through the Ozone generator and contain the Ozone during treatment. A push button is located on the body of the hand piece to supply a signal to the console to select and start a treatment. The hand piece attaches to the console via a detachable hose. The hand piece delivers Ozone at a rate of 13.33 ml per second. Applications of Ozone: The antimicrobial effects of ozone have long been recognized. The ozone gas was discovered by Schonbein in 1840 and comprises an allotropic variation of oxygen. 5 During the First World War it was used as a heroic therapy of gangrene and today it is widely employed for the sterilization of water. Wehrli and Steinbarth were the first to expose human blood to oxygen
Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

plus ultraviolet irradiation, but Wolff invented the simpler technique of exposing blood directly to a gas mixture composed of oxygen+ozone. Thus, was born the ozonated autohemotherapy (O3-AHT) procedure that has been used millions of times.6 Because it is highly unstable, the ozone gas must be incorporated to fluids, such as vegetal oils (olive or sunflower oil). Ozone possesses strong antimicrobial activity, debriding effects, and can stimulate angiogenesis. It was used in a vapor-phase test as early as 1942 in an effort to reduce airborne bacterial infections. Ozone has been used for years as a disinfectant in France and has been suggested to be a good available alternative to present chlorination practice for treatment of domestic water. 5 A study revealed that ozone, at relatively low concentrations, effectively killed Escherichia coli cells as well as vegetative cells and spores of Bacillus cereus and Bacillus megaterium. More recently, Siqueira et al. evaluated the antibacterial activity of the ozonized oil and calcium hydroxide pastes against bacterial species commonly associated with the etiology of periradicular diseases. Of the tested medicaments, ozonized oil was the most effective against the evaluated bacterial species. The ozonized oil has the potential to be used as an intracanal medication. 5 Use of Ozone to treat Dental unit water lines: 7 A multicomponent evaluation of the oxidative consumption of the water from dental unit water lines (DUWL) by Ozone (O 3) has been performed using high-resolution proton (1H) nuclear magnetic resonance (NMR) spectroscopy. The Ozone generating equipment employed was Heal Ozone unit (CurOzone, USA). Water was collected from DUWL from ten dental units and each of the samples was divided into two equivalent portions (1ml). The first of these were treated with O3 generated from above device for a period of 10 seconds; the second group of portions served as controls. Samples were subjected to 1HNMR analysis at an operating frequency of 600 M Hz. Results revealed that some of the biomolecules in the DUW were acetate, proprionate, formate, the amino acid glycine, aromatic compounds and ethanol. Ozone treatment of the DUW gave rise to oxidation of ethanol and increase in formate levels presumably due to oxidation of carbohydrate.5 Effect of Ozone on Caries, Plaque, Saliva and Dental alloys: 3'9'8 Studies have shown that: 1) Ozone quickly dissipates in water and kills microorganisms via a mechanism involving the rupture of their membranes. 2) It is a strong oxidizer to cell walls and cytoplasmic membrane of bacteria.



3) Ozone treatment leads to oxidative decarboxylation of plaque pyruvate generating acetate and carbon dioxide as bye product. 4) It oxidizes volatile sulphur compound precursor methionine to its corresponding sulphoxide and thus prevents malodour associated with root caries. 5) It oxidizes polyunsaturated fatty acids. 6) Ozone has little influence on the oxidation of dental alloys. Ozone therapy for dental caries: It is based on the concept of complete elimination of acidophillic bacteria, fungi and viruses and thus creating a sterile environment for re-mineralisation to take place. It is now a proven fact that 10 seconds application of Ozone gas at a concentration of 2200 ppm could eliminate 99% of the carious microflora. 3 Salivary Oxidizing activity of Novel Antibacterial Ozone generating device: Ozone is an extremely powerful oxidant with potent bactericidal, sporicidal and viricidal properties and has been frequently employed for the purpose of water disinfection. The oxidative consumption of critical biomolecules by O3 is primarily responsible for its biocidal activities. Ozone treatment gives rise to: 1) Oxidative decarboxylation of the salivaryelectron-donor pyruvate (generating acetate and CO2 as products). 2) Oxidation of the volatile sulphur compound precursor methionine to its corresponding sulphoxide and 3) The oxidative consumption of salivary polyunsaturated fatty acids. Moreover, evidence for the O3-mediated oxidation of salivary urate to allantoin was also obtained. High field 1HNMR spectroscopy provides much useful data regarding the fate of 03 in human saliva, information which is of much relevance to its potential therapeutic actions in vivo. 8 Therapeutic oxidation of Human Plaque Biomolecules: Oxidative consumption of human plaque biomolecules by O3 has been evaluated using highresolution proton (1H) nuclear magnetic resonance (NMR) spectroscopy. Single plaque specimens were collected from each of 12 patients, weighed on a microbalance and then divided into two equivalent portions. The first of these was treated with O 3 for a period of 10 seconds, the second group of portions served as controls. Results revealed that O 3 treatment gave rise to oxidative decarboxylation of the electron donor pyruvate (generating acetate and CO2 as products), and the oxidation of volatile sulphur compound precursor methionine to its corresponding

sulphoxide. Moreover, evidence for the O3 mediated oxidation of 3-D-hydroxybutyrate was obtained, and formate was generated from plaque carbohydrates.9 Other Applications of Ozone: A small ozone dose well calibrated against the potent antioxidant capacity of blood can trigger several useful biochemical mechanisms and reactivate the antioxidant system. In detail, firstly ex vivo and second during the infusion of ozonated blood into the donor, the ozone therapy approach involves blood cells and the endothelium, which by transferring the ozone messengers to billions of cells will generate a therapeutic effect. Thus, in spite of a common prejudice, single ozone doses can be therapeutically used in selected human diseases without any toxicity or side effects. Moreover, the versatility and amplitude of beneficial effect of ozone applications have become evident in orthopedics, cutaneous, and mucosal infections.10 In medicine, the use of ozone therapy has been investigated as a treatment of ocular diseases, acute and chronic infections, ischemic diseases, orthopedic diseases, as well as dermatological, pulmonary, renal, hematological and neurodegenerative diseases. 11 Ozone can reduce the bacterial count in active carious lesions; therefore, it may temporarily arrest the progression of caries, resulting in the prevention or delay of the need for tooth restorations. By oxidizing the biomolecules featured in dental diseases, ozone has a severely disruptive effect on cariogenic bacteria, resulting in the elimination of acidogenic bacteria. 11 Ozone has been effectively used in management of occlusal and plain surface caries.12 Enamel pretreatment with ozone did not affect the SBS (shear bond strength) of tested adhesive systems used for bracket bonding. SBS values of the ozone pretreated specimens were somewhat higher. Ozone pretreatment prior to bracket bonding may result in less residual adhesives after debonding. 11 Future applications of Ozone for Periodontal Therapy: Bacterial plaque is considered as a major etiological factor for periodontal disease. Plaque initiates gingival inflammation which progresses to destruction of periodontal tissues. Ozone, an unstable, but highly beneficial molecule leads to oxidative consumption of human plaque biomolecules. Ozone acts as a strong oxidizer to cell wall and cytoplasmic membrane of bacteria in the plaque. Hence it can be inferred that Ozone therapy may provide a novel approach to treatment of periodontal diseases.


Malaysian Dental Journal July-Dec 2010 Vol 31 No 2

OZONE An Overview

Offering an alternative to conventional treatment, a new approach based on Ozone, a powerful biocide, to rapidly penetrate the bacteria and kill them in their protected niche has been introduced. Ozone alters metabolic products of bacteria, removes plaque pyruvate and hence may represent a useful therapeutic oxidant role.

Address for correspondence: Dr Rizwan M Sanadi MDS (Periodontia) Reader, Dept of Periodontics, Yerala Medical Trust & Research Centres Dental College and Hospital. PG Institution. Institutional Area, Sector 4, Kharghar, Navi Mumbai- 410210 Maharashtra, India. Ph no: 09632874332, 09730858235. Fax: 022-27744427 Email:

Stubinger S, Sader R, Filippi A. The use of ozone in dentistry and maxillofacial surgery: a review. Quint Int 2006; 37(5): 353-359. 2) Estrela C, Estrela CRA, Decurcio DA, Silva JA, Bammann LL. Antimicrobial potential of ozone in an ultrasonic cleaning system against staphylococcus aureus. Braz Dent J 2006; 17(2): 134-138. 3) Bogra P et al. Ozone therapy for dental caries - A revolutionary treatment for the future. J Ind Dent Assoc 2003; 74: 41-45. 4) Bocci V. Ozone as a bioregulator. Pharmacology and toxicology of ozone therapy today. J Biol Regul Homeost Agents 1996; 10: 31-53. 5) Silveira AMV, Lopes HP, Siqueira Jr JF, Macedo SB, Consolaro A. Periradicular Repair after twovisit endodontic treatment using two different intracanal medications compared to single-visit endodontic treatment. Braz Dent J 2007; 18(4): 299-304. 6) Bocci V. Ozone as Janus: this controversial gas can be either toxic or medically useful. Med of Inflam 2004; 13(1): 3-11. 7) Al Shoman H et al. Use of Ozone to treat dental unit water lines. J Dent Res 2001; 80:1169. 8) Lynch E et al. Salivary oxidizing activity of a novel antibacterial Ozone delivery system. J Dent Res 2001; 80: 1159. 9) Grootveld M et al, 2001: Therapeutic oxidation of human plaque biomolecules by a novel antibacterial Ozone delivery system. J Dent Res 2001; 80:1178. 10) Bocci V, Borrelli E, Travagli V, Zanardi I. The ozone paradox: ozone is a strong oxidant as well as a medical drug. Med res Rev 2009; 29(4): 646-682. 11) Cehrelia SB, Guzeyb A, Arhunc N, Cetinsahind A, Unvere B. The effects of prophylactic ozone pretreatment of enamel on shear bond strength of orthodontic brackets bonded with total or selfetch adhesive systems. Eur J Dent 2010; 4:367373. 12) Baysan A, Lynch E. The use of ozone in dentistry and medicine. Prim Dent care 2005; 12(2): 47-52. 1)

HealOzone (CurOzone USA) Unit

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2


67th MDA AGM/ FDI World Dental International Scientific Convention & Trade Exhibition, 10-13 June 2010 at Kuala Lumpur Convention Centre


CLINICAL DIAGNOSIS AND ORAL REHABILITATION OF SEVERELY WORN DENTITION IN A PATIENT WITH SECONDARY SJGREN'S SYNDROME: A CLINICAL REPORT. Al Jabbari YS.* Faculty of Dentistry, Kings Saud University, Saudi. Objectives: The aim of this clinical report is to describe the oral rehabilitation of a severely worn dentition in a middle aged female patient diagnosed with secondary Sjgren's Syndrome for more than 25 years. Materials and Methods: A 56 year-old female referred by her general dentist to restore all her existing severely worn dentition. Her chief complaint was very rapid disintegration of my teeth and Im worried I will lose them very soon. Additionally, the patient was very concerned about her smile, tooth color, and general appearance. Treatment of all her existing 28 teeth with full coverage restorations was completed after crown lengthening and elective root canal treatment for selected teeth. Results: It is not uncommon for the prosthodontist to be confronted by patients who are suffering from Sjgren's Syndrome. In this clinical report, the special considerations (as documented in the literature) for those patients which must be followed by the prosthodontist before, during and after treatment will be fully discussed. Conclusion: Commonly, secondary Sjgren's Syndrome is associated with sever wear of dentition. All aspects of patient management who are suffering from this disease will be presented including clinical examination and findings, diagnosis, sequenced treatment plan, and each step of clinical treatment and accompanying laboratory procedures. Key words: Sjgren's Syndrome, severely worn dentition, oral rehabilitation, xerostomia.


CURRENT DEVELOPMENTS AND APPLICATIONS OF TISSUE ENGINEERING IN DENTISTRY Malhotra N Manipal College of Dental Sciences, Mangalore, Manipal University, India With the reported startling statistics of high incidence of tooth decay and tooth loss, the current interest is focused on development of alternate dental tissue-replacement therapies. This has led to the application of dental tissue engineering as a clinically relevant method for the regeneration of dental tissues and creation of bioengineered whole tooth. Tissue engineering approach requires the three main key elements of stem cells, scaffold and morphogens, along with a conductive environment (fourth element), which is equally important for successful engineering of any tissue and/or organ. With advances in basic research, recent reports and studies have shown successful application of tissue engineering in the field of dentistry. Tissue engineering approaches can aid in either the replacement of damaged tooth structures (dentin and root structures) (Regenerative Endodontics) or in the repair/regeneration of dental tissues (pulp-dentin complex) (Regenerative Dentinogenesis). However, certain practical obstacles are yet to be overcome before dental tissue regeneration can be applied as evidence based approach in clinics. This poster focuses on current developments and future prospects of stem cell biology, tissue engineering and regenerative therapy in the field of dentistry. Keywords: Tissue engineering, Bioengineered tooth, Morphogens, Stem cells, Scaffolds, Regenerative endodontics.


EFFECT OF SURFACE SEALERS ON STAIN RESISTANCE OF PROVISIONAL RESTORATIVE MATERIALS. Chong C.W 1, Wong C.S 1, Ahmad M1, Tarib N.A1, Seow L.L 2. 1Faculty of Dentistry, Universiti Kebangsaan Malaysia,Kuala Lumpur, Malaysia 2School of Dentistry, International Medical University, Bukit Jalil, Malaysia Objective: The present study aims to evaluate the efficacy of surface coating agents (SCA) in reducing staining of provisional restorative materials. Methodology: Three different types of SCA were investigated: 1. G-Coat PLUS (GC)(a nanofilled resin), 2. Permaseal (Ultradent)(an unfilled resin) and 3. OptiGuard (Kerr)(an unfilled resin). Two types of provisional restorative materials were used to fabricate 40 discs specimens respectively: Protemp 4 (3M ESPE) and Trim (Bosworth). The specimens were divided into 4 groups with 10 specimens in each group. The first three groups were coated with the SCA and the fourth group was left uncoated (control group). The specimens were immersed in a coffee solution for 72 hours at 37 Celsius. The baseline and post-immersion colour of specimens were measured using reflection spectrophotometer (Datacolor international, Dataflash 100). Colour change (E) was calculated and data were analyzed with two-way ANOVA and Tukeys multiple comparisons test. Results: Colour change for Trim was well below E value of 3.3 (colour change to be visible clinically). Coating the Trim specimens increased the E
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value. Protemp 4 specimens exhibited significantly higher E. Coating the Protemp 4 specimens with G-Coat Plus has reduced the value of E. Discussion: Trim is more stain resistant than Protemp 4. Application of surface coating agents on Trim has resulted in increased colour change possibly due to incompatibility of the agents with the resin leading to uneven surface texture and increase stain adsorption. G-Coat PLUS has the potential to reduce stain uptake for Protemp 4. Keywords: surface coating agent, colour changes, stain resistance.


HISTOLOGICAL ANALYSIS OF HUMAN PULP FOLLOWING DIRECT PULP CAPPING WITH DIFFERENT MATERIALS: AN IN VIVO STUDY. Shetty N *1, Nangia U 2 1Faculty of Manipal College of Dental Sciences, Mangalore, India. 2Faculty of Narayana Dantalaya, Bangalore, India. Objective: The purpose of this study was to evaluate histologically,the effectiveness of hard setting Calcium hydroxide (Dycal),Mineral trioxide aggregate,(Pro-root MTA)and a Dentin bonding agent (Adper Single bond plus adhesive) when used as direct pulp capping agents in mechanically exposed pulp. Materials and Method: Class I cavities prepared with pulp exposure were made in forty five intact human (15-25 yrs) premolars, scheduled for extraction due to orthodontic reasons. Teeth were divided into three groups and were capped with Dycal, Mineral trioxide aggregate, and a Dentin bonding agent. Final restoration was done with posterior composites (3M ESPE) using Resin modified glass ionomer cement (GC Fuji,LC ) as a base. Some teeth in each group were extracted after 15 days and the remaining after 45 days. Extracted teeth were then sectioned and evaluated histologically under light microscope (Leitz Laborlux S) in 4X and 10X magnification .Results: Dycal took the least time for initiation of bridge formation and gave the best quality of bridge .Mineral trioxide aggregate showed milder inflammatory response than Dycal ,but quality of dentin bridge was comparable with Dycal. Dentin bonding agent showed a significantly higher degree of pulpal inflammation with a lower quality of bridge formation as compared to Dycal and Mineral trioxide aggregate. Conclusion: Based on the results, Mineral trioxide aggregate is an excellent pulp capping material and is comparable with Dycal. Keywords: Direct pulp capping agents, inflammation, bridge formation


CASE REPORT: TREATMENT OPTIONS IN ORAL REHABILITATION OF PARTIALLY EDENTULOUS GERIATRIC DENTAL PATIENT BAYATI O.H* School of Dentistry, International Medical University (IMU), Bukit Jalil, Malaysia. Introduction: Geriatric dental patient is a biologically compromised adult who may or may not be over 65 years of age, or a healthy adult over the age of 65 years. The proportion of edentulous adults is declining and demand for regular dental care is increasing. It has been shown in the USA that among the younger elderly a new dental consumers (retaining some natural teeth) is emerging, who are more physically active and more demanding of social and health services than before. Clinical Report: A 72 years old man complained of inability to chew properly. On examination, the maxillary arch was restored by a defective FPD (perforated retainer on tooth 14) and the mandibular arch was partially edentulous (Kennedy Cl I) with attritional wear of tooth 35 & Defective crowns on teeth 43 and 44.The mandibular residual ridges were moderately resorped. The primary treatment objective was set to conserve the remaining teeth and motivate the patient to achieve an optimal level of oral health. The patients complaint was addressed by a maxillary cantilever FPD & mandibular Co-Cr RPDs. Discussion: the functionally independent healthy geriatric patients present limited problem to dental treatment, the types of services appropriate to this group do not differ substantially from those for a younger patient, the bulk of dental care are reconstructive(replacing teeth with fixed and removable prosthesis), however, the financial limitation of this group requires more effort in developing an appropriate treatment plan to achieve an optimal oral health considering the patients financial limit. Keywords: Geriatric, Partially edentulous, Oral Rehabilitation.

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2


67th MDA AGM/ FDI World Dental International Scientific Convention & Trade Exhibition, 10-13 June 2010 at Kuala Lumpur Convention Centre


PREVALENCE OF COMBINATION SYNDROME AMONG DENTURE PATIENTS: A MULTICENTER STUDY Kamarul Hisham Kamarudin1*, Tan Yuan Yang2, Ng Shu Keng2, Natasya Ahmad Tarib2, Marlynda Ahmad2 1 Klinik Kesihatan Putrajaya, Putrajaya, Malaysia. 2 Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Objective: To assess the prevalence of Combination Syndrome (CS) in relation to oral manifestations and the quality of patients denture. Materials and Method: Patients with dental prostheses for edentulous maxillary arch and partially dentate mandibular arch with preserved anterior teeth were identified in three dental centers. Quality of maxillary complete dentures (CD) and mandibular removable partial dentures (RPD) as well as intraoral examinations were conducted. Oral manifestations for CS were identified. Results: Total of 27 patients participated in this study. Majority of patients were female (n=19) and age range between 55-59 years old (n=9). Majority of the samples presented with extrusion of mandibular anterior teeth (n=16) and severely resorption of mandibular posterior ridge (n=13). Hypermobility of maxillary anterior ridge (n=6), overgrowth of maxillary tuberosities (n=4) and papillary hyperplasia of hard palate (n=2) were least found in all samples. The overall prevalence index of CS was 22.2% (n=6). Conclusions: In conclusion, oral manifestations of CS were not presented in all patients examined in this study. The prevalence index was 22.2%. Keywords: Combination Syndrome, prevalence index, oral manifestation


EVALUATION OF PATIENT WAITING-ROOM TIME AS A KEY PERFORMANCE INDICATOR (KPI) IN ORTHODONTIC SPECIALIST CLINICS IN SELANGOR Loke S.T 1 , Cheong W.S 2 * 1 Orthodontic Clinic Klang, Malaysia. 2 Dental Clinic Banting, Malaysia. Objectives: This study evaluates patient waiting-room time as a key performance indicator (KPI) in all government orthodontic clinics in Selangor. This monitors the indicator set by the Ministry of Health Malaysia (MOH) compliance=not <50% of patients seen within 30 minutes of appointment time; excluding patients late for appointments. Materials and methods: This is a 5-month prospective pilot study of all patients seen in the four orthodontic clinics in Kajang, Klang, Shah Alam and Tanjong Karang. The appointment time, registration time and time called into the surgery was recorded. Descriptive analysis and cross-tabulations were carried out in SPSS version 11.0. Results: The total sample comprised 5286 patients; 488 (9.2%) Tg.Karang, 1963 (37.1%) Kajang, 1547 (29.3%) Klang and 1288 (24.4%) Shah Alam. Excluding 1160 (21.9%) late patients for KPI monitoring, 36.9% of punctual patients were seen within KPI. In the Early patients, 30.7% were compliant with KPI and 20% were seen earlier than their appointment time. Klang has the highest percentage of punctual patients (41.8%), Shah Alam the highest percentage of early patients (55.6%) and Tg.Karang the highest percentage of late patients (30.3%). The mean percentage of punctual, early and late patients was 33.8%, 44.2% and 21.9% respectively. Mean waiting time for punctual, early and late patients was 21.9 min, 40.3 min and 21.9 min respectively. There is significant difference in the punctuality of patients in the different centres (p<.0001). Conclusions: All the orthodontic clinics in Selangor have complied with this KPI with a mean compliance of 87.5%. Keywords: Orthodontic clinics, KPI, waiting-room time, government


PREVALENCE OF ORAL MUCOSAL LESIONS AND RELATED RISK HABITS IN OUTPATIENTS OF TWO DENTAL CLINICS IN MALAYSIA AND YEMEN Hajeb R. M*, Mohammed N. H , Jamaludin M , Zain R. B Department of General Dental Practice and Maxillofacial Imaging, Faculty of Dentistry, University of Malaya, Malaysia. Dental Bioinformatics Unit, Faculty of Dentistry, University of Malaya, Malaysia Department of Oral Pathology, Oral Medicine & Periodontology /Oral Cancer Research and Coordinating Centre, Faculty of Dentistry, University of Malaya, Malaysia. Objective: To determine and compare the prevalence of oral mucosal lesions (OML) and related risk habits in outpatients of two dental clinics in Malaysia and Yemen. Methodology: Adult outpatients aged 18 years and above of the Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia and the Al-Thawra General Hospital, Sanaa, Yemen were interviewed using a structured questionnaire to collect data on the sociodemographic characteristics
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(including risk habits). Clinical examination was conducted for these patients and lesions observed were recorded. A training and calibration session was conducted for the examiner prior to the study. Result: A total of 554 and 520 outpatients from Malaysia and Yemen with mean ages of 41.9 17.04 years and 3615.62 years respectively were included in the study. The prevalence of OML in Malaysia was 23.29% while the prevalence of oral mucosal lesions in Yemen was 22.03 %. Among the Malaysian outpatients 19.5 % (n=108) were smokers, 1.6 % (10) were betel quid chewers and 4.3 % (n=24) had alcohol drinking habit. In Yemen outpatients, the most frequent habit was qat chewing (40.8 %; n=212), followed by smoking (19%; n=99) and shammah (tobacco quid) chewing (4.4%; n=23). Conclusion: The prevalence of OML, smokers and quid users in Malaysia and Yemen are similar. There is a low prevalence of alcohol drinking habit among Malaysians with no such habit among Yemenis; while there is a high prevalence of qat chewing habit among Yemenis but not among Malaysian dental outpatients. Keywords: Prevalence, oral lesion, risk habits, Malaysia, Yemen


THE USE OF SKELETAL ANCHORAGE IN THE TREATMENT OF A SEVERE CLASS III MALOCCLUSION Tan C.L1, Sia J.Y2* 1Ministry Of Health, Klinik Pergigian Jalan Gambut, Kuantan , Malaysia. 2Ministry Of Health, Klinik Pergigian Jalan Gambut, Kuantan, Malaysia. Content: This case report illustrates the use of skeletal anchorage with mini-implants to correct a severe malocclusion. CSY was a 17 year old Chinese girl who complained of crooked upper front teeth. She presented with a Class III incisor relationship on a mild to moderate Class 3 skeletal base with a maximum reverse overjet of -5mm and severe crowding. She was treated with Roth Prescription 022 slot upper and lower Pre-adjusted Edgewise fixed appliances with four premolars extractions and two lower mini-implants. Keywords: skeletal anchorage, mini-implants, Class III malocclusion.


COMPLIANCE TO DELIVERY PERIOD OF ORTHODONTIC APPLIANCES FROM GOVERNMENT DENTAL LABORATORIES IN SELANGOR. Loke S.T1, Tan S.Y2* 1Orthodontic Specialist Clinic, Klang, Selangor, Malaysia. 2Dental Clinic, Klang, Selangor, Malaysia. Objectives: This prospective 8-month study aimed to assess compliance to delivery of orthodontic appliances within a specified period of time from 18 trainee/ trained technicians from 4 main government dental laboratories in Selangor. Materials and methods: Standard delivery times (working days) set by orthodontists was 1 day for plastic retainer, 3 days for acrylic retainer, 5 days for active plates (URA), 10 days for functionals, 10 days for transpalatal arch (TPA) and 10 days for quadhelix. Punctual delivery was recorded as compliant. Compliance was compared between appliances, clinics, technicians, and seniority of technicians. Results: The sample comprised appliances from 365 patients; 38 (10.4%) Tanjong Karang, 114 (31.2%) Kajang, 191 (52.3%) Klang and 22 (6.0%) Shah Alam. The majority of appliances were retainers (66.3%), followed by URA (13.4%), functionals (9.3%), TPA (9.0%) and quadhelix (1.9%). Mean compliance for all appliances in Selangor was 55%. Compliance in Shah Alam (86.4%) was highest followed by 71.7% in Klang and Tanjong Karang and 14.9% in Kajang. All technicians in Kajang had very low compliance although workload was comparable with Klang. Plastic retainers had highest compliance (77.8%), followed by acrylic retainers (59.9%), quadhelix (57.1%), functionals (47.1%), TPA (45.5%) and URA (24.5%). Senior technicians were more compliant than juniors. Conclusion: Seniority of technicians was positively associated with higher compliance (p<0.0001). Compliance and output was very variable in individual technicians. There is no clear association between compliance and workload. Key words: compliance, delivery, orthodontic appliances, dental laboratories

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2


67th MDA AGM/ FDI World Dental International Scientific Convention & Trade Exhibition, 10-13 June 2010 at Kuala Lumpur Convention Centre


QUALITY OF ORTHODONTIC APPLIANCES FROM GOVERNMENT DENTAL LABORATORIES IN SELANGOR Loke S.T1, Tan S.Y2* 1Orthodontic Specialist Clinic, Klang, Selangor, Malaysia. 2Dental Clinic, Klang, Selangor, Malaysia. Objectives: This study aimed to evaluate the quality of orthodontic appliances fabricated by government dental laboratories in Selangor. Materials and methods: Orthodontic appliances issued from four main Orthodontic clinics in Selangor were evaluated over an eight-month period by orthodontists. The appliances were upper removable appliance, acrylic/plastic retainer, functional appliance, transpalatal arch (TPA) and Quahelix. They were rated for good, satisfactory or poor quality in adherence to design, fit, retention, thickness, absence of porosity and soldering. Quality was compared between centres and seniority of technicians. Results: The sample comprised appliances fabricated by 18 trainee/trained technicians issued to 365 patients from Tanjong Karang (10.4%), Kajang (31.2%), Klang (52.3%) and Shah Alam (6.0%). The overall quality of removable appliances was high with mean good quality in design specification, fit, retention, thickness and absence of porosity above 86% and poor quality is less than 5%. Quality was much lower in TPA and quadhelix especially in soldering. Overall, junior technicians had marginally higher good quality rating than senior technicians. Trainees scored lower good quality rating in all aspects. Shah Alam consistently scored much lower good quality rating in all aspects compared with other centres although output from Shah Alam was the lowest and had the most equitable workload distribution. There was obvious disparity in output from individual technicians. Conclusion: Quality of appliances was generally good except in soldering. Quality was better in trained technicians than trainees. Workload did not appear to be associated with quality. Key words: orthodontic appliances, quality, dental laboratories, government


REPAIR OF MUCOSAL FENESTRATION OF A LOWER INCISOR USING DERMIS ALLOGRAFT TISSUE MATRIX: A CASE REPORT. Ong H.S.*, Chan Y.K. Unit Periodontik, Klinik Pergigian Jalan Mahmoodiah, Johor Bahru, Malaysia. Labial mucosal fenestration of the root apex is an uncommon occurrence. An unusual case in a 34-year-old, Chinese, female patient involving a lower left central incisor (#31) post orthodontic treatment is described. The tooth initially presented as vital with the labial root readily seen through the labial mucosa due to bony and soft tissue fenestration. A laterally positioned pedicle flap was performed in an attempt to repair the fenestration but subsequently failed with the fenestration reappearing one month post operatively. Subsequently the lower left central incisor became non-vital. A second attempt was performed after endodontic treatment and a Puros Dermis Allograft Tissue Matrix was used in conjunction with an envelope flap. Puros Dermis Allograft Tissue Matrix is a natural alternative to autogenous soft tissue grafts. It can be used for both horizontal and vertical soft tissue augmentation, to increase volume and provide a highly cosmetic clinical result. On follow up 2 months later, the fenestration had totally healed. Keywords: fenestration, dermis, allograft.


SEX DIFFERENCES IN PATIENTS WITH OROFACIAL PAIN. Shoji Y, Toh C.G School of Dentistry, International Medical University, Bukit Jalil, Malaysia. Objectives: The purpose of the present study was to evaluate whether there are sex differences in the prevalence of Orofacial Pain in a sample of patients who visited an Orofacial Pain clinic. Methods: Subjects were 92 patients who visited the Center for Orofacial Pain, Tokyo, Japan during the year of 2006 with Orofacial Pain as their chief complaint. Patients with general dental pain such as odontalgia were excluded. The ratio between male and female patients was evaluated. In addition, the ratio according to each category of Orofacial Pain including the musculoskeletal, neurovascular, neuropathic and psychogenic pain was investigated. Dentists determined all diagnoses except psychogenic pain. The referred clinical psychologist determined psychogenic pain. Results: The ratio between the total male and female patients was 1:3 (n=92). According to each category of Orofacial Pain, there was the ratio of 1:4 for musculoskeletal pain (n=49), 1:4 (n=16) for neurovascular pain, 1:11 (n=12) for the neuropathic pain, 1:1(n=15) for the psychogenic pain. Conclusion: Although the prevalence of Orofacial Pain in these patients was higher in females,
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the pain type-specific ratio between male and female patients was variable especially in the category of neuropathic pain. Continued research for biological mechanisms underlying these differences is needed to develop gender-specific therapies for Orofacial Pain patients. Keywords: Orofacial Pain, Sex differences, Gender-specific therapy


COMPREHENSIVE DENTAL TREATMENT UNDER GENERAL ANAESTHESIA OF CHILDREN WITH SEVERE EARLY CHILDHOOD CARIES AND THEIR RECALL ATTENDANCE. Sinnumu SB*, Saripudin B Jabatan Pergigian Pediatrik, Hospital Serdang, Selangor, Malaysia. Objectives: The aims of this study are to analyze the demographic features of children who undergone comprehensive dental treatment (CDT) under general anaesthesia (GA) and the attendance pattern at recall visits. Materials and methods: An analysis of relevant data collected from patients clinical records was made. Patients with severe early childhood caries (ECC) who were diagnosed and treated under general anesthesia for a period between June 2006 and June 2008 were included. Results: A total of 123 patients received treatment under GA of which 61% (75) were males. The mean age of sample was 4.9 years with the majority age of 4 years and below. Treatment for each patient was individually customized; in average a child had undergone 5 extractions and 3 restorations. About two-third of children return for the first week review but only 36% came for the 6-month recall. Twelve of these children who returned after 6 months developed new caries and treatment was successfully carried out on the chair side. Conclusions: CDT was carried out mainly on boys who were 4 years and below. Only 36% of patients return for 6-month recall. Measures to increase the recall attendance are needed in order to get a realistic representation in assessment of quality of service provided. Keyword: Comprehensive dental treatment, early childhood caries, recall attendance


FACIAL FRACTURES PRESENTING TO A TERTIARY REFERRAL CENTRE IN MALAYSIA: A RETROSPECTIVE STUDY Muhammad H*, Khairuddin NA, Zakaria AR, Wan Mustafa WM Department of Oral Surgery, Hospital Kuala Lumpur, Malaysia. Objective: To describe the pattern of facial fractures presenting to a tertiary referral centre in Malaysia and to identify risk indicators for maxillofacial trauma. Methods: Clinical records of 1096 patients referred to a tertiary base hospital for the management of maxillofacial fractures from 2002 to 2007 were retrospectively analyzed. Age, gender, ethnicity, cause of injury, anatomic location of facial fractures and treatment received were recorded. Results: The number of facial fractures treated by the Maxillofacial unit in HKL annually averaged 183 cases, 87 % of those presenting with maxillofacial injuries were male. The majority ethnic group involved in trauma were Malays (572 patients; 52.2%). 39.5% were aged between 20 and 29 years. Road traffic accident (751 patients; 69%) and assault (169 patients; 15%) were the most frequent causes of facial fractures. Among the patients involved in RTA, 74% were motorcyclist ( 558 patients), car driver/ passenger ( 143 patients; 19%), pedestrian ( 43 patients; 6%) and bicyclist ( 7 patients; 1%). The mandible (568 fractures; 46%) was the bone most frequently involved followed by the zygomatic bone (265 fractures; 21%). The majority of cases (400; 36.5%) were treated conservatively. Conclusion: Risk indicator presentation for facial fractures were male gender, motorcyclist related road traffic accidents, age range between 2029 years. There is an urgent need for health promotion activities to reduce road traffic accident related facial fractures. Keywords: facial fractures, risk indicator, maxillofacial trauma, Hospital Kuala Lumpur.


SALIVARY GLAND TUMOURS IN HOSPITAL KUALA LUMPUR: A 10 YEARS REVIEW Wan Mahadzir Mustafa*, Nornaliza Basri, Abdul Rahim Zakaria Department of Oral Surgery, Hospital Kuala Lumpur, Malaysia. Objective: The purpose of this study was to document the pattern of salivary gland tumours that were treated in Department of Oral & Maxillofacial Surgery, Hospital Kuala Lumpur, during the 10-year period. Material and method: Data of 18 patients were retrieved from the operation theatre book from the year 2000-2009. The data collected included gender, age, location, histopathology and treatment of the tumour. Results: The patients ages ranged from 16 to 62 years and the peak incidence age of the tumour was in 5th to 6th decade. There was an equal sex distribution. The majority of patients were Malays (55.6%, n=10) followed by Chinese (22.2%, n=4) and the remaining patients were
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Indian (11.1%, n=2), Iban(5.6%, n=1) and Bajau(5.6%, n=1) . Among 18 incident cases, 8 cases were benign and 10 cases were malignant. Of 18 cases, 77.8% (n=12) were from minor salivary gland and the remaining cases were from major salivary glands (22.2%, n=4) . Pleomorphic adenoma was the most prevalent tumour and the only one benign lesion, and mucoepidermoid carcinoma was the most common malignant tumour. The palate was the main site of occurrence of the salivary gland tumour followed by the parotid region. Treatment modality was mainly surgical for both benign and malignant tumors. Combined surgery and radiotherapy was employed in three patients who had adenocarcinoma in the maxilla and polymorphous low grade adenocarcinoma in the cheek. Conclusion: On average the risk indicator age for salivary gland tumour was in the 5th to 6th decade. A higher frequency of salivary gland tumour in Malays than Chinese or Indians was noted. Consistent with reports from the English literature pleomorphic adenoma was the most common salivary gland tumour while mucoepidermoid carcinoma was the most frequently occurring malignant salivary gland tumour. Keywords: Salivary gland tumour, pleomorphic adenoma, mucoepidermoid carcinoma, Hospital Kuala Lumpur.


INCIDENTAL FINDING OF SARCOCYSTIS SPP IN TWO GLOSSECTOMY SPECIMENS FOR SQUAMOUS CELL CARCINOMA Ajura AJ*, Lau SH, Stomatology Unit, Cancer Research Centre, Institute for Medical Research, Kuala Lumpur, Malaysia. Sarcocystis species are intracellular protozoan parasites which require two-host life cycle based on a prey-predator host relationship. Sarcocystis spp form cysts in diverse intermediate hosts such as humans, horses, cattle, sheep, goats, pigs, birds, rodents, wildlife, and reptiles. The cysts vary in size from a few micrometers to several centimeters, depending on the host and species. High prevalence of human skeletal muscle sarcocystosis was reported in southeast Asia particularly in Malaysia. Muscular sarcocystosis is transmitted through the oral-faecal route by ingestion of sporocysts via contaminated food or drink. Symptoms of muscular sarcocystosis include fever, persistent myalgia and episodic weakness. During the routine histopathological examination for glossectomy specimens for squamous cell carcinoma, incidental finding of two cases of sarcocystosis were found in two females. It was not known whether these two patients had symptoms of muscular sarcocystosis or prior ingestion of contaminated food and drink. Sarcocystis infection presents little health hazard to humans as the parasite is destroyed by cooking. However, many patients probably consume food or drink contaminated with the sporocysts unknowingly and then develops muscular sarcocystosis which may go undiagnosed as the infection may present only as mild symptoms. Keywords: Sarcocystis spp, incidental finding, squamous cell carcinoma


PLEOMORPHIC ADENOMA OF MINOR SALIVARY GLAND OF THE UPPER LIP: A CASE REPORT Lim DKH*, Ma BC Klinik Pakar Bedah Mulut, Hospital Sultanah Aminah, Johor, Malaysia Objective: To report a case of a 25 years old Malay gentleman who presented with a painless rubbery swelling (pleomorphic adenoma) on his upper lip which was first noted by him about one year ago. Methodology: The lesion was excised under local anaesthesia and was sent for histopathological examination (HPE). HPE result was consistent with pleomorphic adenoma. Conclusion: Although it is a benign tumour of the salivary gland in nature, it can recur if islands of the neoplastic tissue in the tumour were not totally removed. Keywords: pleomorphic adenoma, tumour, salivary gland


PROFILES OF MAXILLOFACIAL INJURIES SEN IN AN URBAN HOSPITAL IN MAINLAND PENANG, NORTH MALAYSIA 1Hashim* H, 2Iqbal S 1Advanced Medical and Dental Institute, Universiti Sains Malaysia, Malaysia. 2Seberang Jaya Hospital, Penang, Malaysia. Objectives: Maxillofacial injuries are common injuries seen in Malaysian hospitals. The aim of this study was to determine the profiles of maxillofacial injuries seen in an urban government hospital of mainland Penang. Methods: This cross sectional study involved 194 cases that presented to the Oral and Maxillofacial Surgery Department of an urban hospital between May 2007 and May 2008. A case report form was developed and completed by the attending clinicians. Data were analyzed using SPSS version 12.0. Results: The majority were males and the mean age was 27.8
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years. The main cause was motorcycle accident. The most common injury involved the soft tissues, dentoalveolar and facial bones. Those involved in motorcycle accidents had a significantly higher incidence of sustaining facial bone fractures. Conclusion: More males were involved with the highest occurrence among those in the 20-29 age groups. The main cause was motorcycle accidents. Soft tissue injury was the most common. Bone fracture was found to be significantly higher among those who were involved in motorcycle accidents. Keywords: Maxillofacial injuries, urban hospital, mainland Penang


PREVALENCE AND ETIOLOGY OF IMPACTED MAXILLARY INCISORS AT KLINIK PAKAR ORTODONTIK MUAR *Wong PY, Yusoff UA Klinik Pakar Ortodontik, Muar , Malaysia. Objectives: This retrospective study was carried out to determine the prevalence and etiology of impacted maxillary incisors for referred cases to Klinik Pakar Ortodontik, Muar. Methods: A review of clinical records and radiographs of referred cases for orthodontic screening in 2008 and 2009 was done. Results: Out of the total number of 388 screening cases, there were 21 patients who have a total of 24 impacted maxillary incisors. Their mean age is 11 years 3 months. There was no gender predilection as males and females were rather equally affected. Results also showed that ectopic position constituting 28.5% was the most common etiological factor and this was followed by supernumerary tooth which caused 23.8% of the cases. 14.3% were associated with retained deciduous tooth and 9.5% were attributed to odontome, while dilaceration and trauma to the preceding deciduous tooth accounted for 4.8% of the cases respectively. However, etiology for 14.3% of the cases could not be ascertained. Conclusions: It can be concluded that the prevalence of impacted maxillary incisors was 5.4%. Most cases were referred late (71. 4% at the age later than 10) and hence there is a need to increase awareness of dental personnels on tooth impaction so that early diagnosis can be made for a more simple intervention and successful outcome. Keywords: prevalence, etiology, impacted maxillary incisors

COMPARING THE WHITENING EFFICACY OF 16% AND 35% CARBAMIDE PEROXIDE BLEACHING AGENTS. Onwudiwe UV1, Umesi-Koleoso DC1*, Orenuga OO2, Shaba OP1 1Department of Restorative Dentistry, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria. 2 Department of Child Dental Health, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria Objectives: To compare the whitening efficacy of 16% and 35% carbamide peroxide on vital teeth. Methods: Single blinded study using the split mouth technique. Thirty subjects having discolored teeth had two one-hour tooth bleaching sessions in-office separated by a week. Tooth colour change was recorded using vita shade guide arranged in value order and relapse monitored over six months. Side effects unpleasant taste, gum irritation, sore throat and tooth sensitivity were self-reported after each session using a visual analogue scale. Results: Twenty females and ten males, mean age of 27.83 years, range of 18-43 years participated. Both 16% and 35% carbamide peroxide were effective in whitening the teeth in all subjects. The mean colour change for 16% was 2.633 at first session and 5.566 at second session from baseline while that of 35% was 3.80 and 7.10 respectively, showing more significant whitening by 35% carbamide peroxide at both sessions, p=0.0001. Tooth sensitivity was the only side effect reported in mild intensity for both concentrations at first session and moderate intensity in one subject after second session with 35% concentration. At two weeks, three- and six- months review, colour relapse was recorded without significant difference between the two concentrations, p=0.5166, 0.3405 and 0.5840. Conclusion: Carbamide peroxide bleaching agent is effective in both 16% and 35% concentrations. However, 35% concentration produced more significant whitening without any additional side effects. At six months post-bleaching, the whitening effect of both concentrations was still statistically significant. Keywords: Carbamide peroxide concentrations, tooth whitening, tooth sensitivity.

Malaysian Dental Journal July-Dec 2010 Vol 31 No 2


67th MDA AGM/ FDI World Dental International Scientific Convention & Trade Exhibition, 10-13 June 2010 at Kuala Lumpur Convention Centre


8 YEARS CLINICAL REVIEW OF APEXIFICATION IN IMMATURE MAXILLARY TEETH FROM YEAR 2000 TO 2008 AT DEPARTMENT OF PAEDIATRIC DENTISTRY HOSPITAL SULTANAH BAHIYAH EXPERIENCE . Azillah M.A, * Farahwati M , Nazlia A.B. Siti Khatijah MZ Jabatan Pergigian Pediatrik , Hospital Sultanah Bahiyah , Alor Setar , Kedah, Malaysia. Objectives: The aim of the study was to determine type of teeth involved . 2. To determine the number of frequency changing of calcium hydroxide during the procedure .3. To determine period of time for complete calcific barrier formation 4. To determine the types of complication after obturation. Materials and Mehods: Retrospective study was carried out from 2000-2008. 8 cases were selected involving non vital immature permanent teeth with completed apexification . Clinical outcomes analyzed by clinical notes and periapical radiograph. Data collected were summarized and tabulated using Microsoft Excel. Results: 87.6 % of dental trauma cases involving central incisors. 5 out 8 cases were uncomplicated crown fracture while others were avulsion, extrusion and luxation.87.5 % of the cases succeed to form calcific barrier. 50 % of the cases (N=4) had no complication within 6 mths after obturation . However 25 % had external root resorption . 12.5 % had cervical discoloration and crown fracture. Conclusion: Most dental injuries involve the maxillary central incisor. Most of the cases succeed to form calcific barrier with calcium hydroxide as intra canal medication. Frequency of changing had no relationship with rapid calcific barrier formation. Most of the cases required less than 24 mths for apical barrier formation. 50 % of the cases had no complications within 6 months after obturation while cases with external root resorption and cervical crown fracture had to be extracted. Keywords : Apexification , calcific barrier formation, resorption


INDIRECT COMPOSITE RESTORATION : A CASE REPORT Hamirudin MM, Ng SC, Ahmad M, Tarib NA* Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Introduction: Indirect composites have been one of the restorative materials for extracoronal restorations since its first discovery. This type of composite is cured extra-orally, in a processing unit that is capable of delivering higher intensities and levels of energy. It will ensure full curing compared to direct composite, where the curing takes place intra-orally. Indirect composites can have higher filler levels, and are cured for longer times. As a result, they have higher levels and depths of cure than direct composites. State of problem: Fixed prostheses are not always excellent in replacing soft tissues. More often, ceramics could not match the shade of the gingivae. However, with indirect composites, dental technician could match the color of the gingivae more naturally. This case report showed how indirect composite crowns were constructed to replace gingivae at the recessed area, to get more acceptable esthetics. Keywords: extracoronal restoration, indirect composite, gingivae


CONFOCAL MICROSCOPIC ASSESSMENT OF SURFACE ROUGHNESS OF GLASS CERAMIC AFTER VARIOUS SURFACE TREATMENT; A PILOT STUDY Rahman M.K.A, Gubod E.R, Carlson L, Hamirudin* M.M Faculty of Dentistry, Universiti Kebangsaan Malaysia Objectives: To evaluate and compare the microstructures of glass ceramic surface after different treatments. Materials and methods: Four uniformly fabricated Specimens of glass ceramic IPS e.max Press disc (2mm thickness x10 mm in diameter) were prepared to undergone different surface treatment ; first specimens without surface treatments , as prepared from the laboratory (control) ; second specimens treated by using air borne particle abrasion with aluminum oxide at 2 bar pressure ; third specimens treated with 5% hydrofluoric acid etching for 20 seconds ; and last specimens treated first by using air borne particle abrasion with aluminum oxide at 2 bar pressure and followed by 5% hydrofluoric acid etching for 20 seconds. The surface of the specimens were qualitatively examined by use of laser reflection confocal microscope (The Spectral Confocal Scanning Microscope;LEICA) which produced 2D topographical images and 3D topographical images. Results: The topographical image of sandblasted specimen shows an increase in distribution of irregularities compare to control specimen image. The image from etched specimen shows highest distributions of irregularities and followed by combination of sandblasted and etched specimen. Conclusion: Glass ceramic that had been surface treated with 5% hydrofluoric acid produced the most consistent surface irregularities. Keywords: confocal microscopic, glass ceramic,surface treatment


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STAINING EFFECTS OF TEA, TOBACCO, AND TURMERIC ON MICROHYBRID AND NANOHYBRID RESIN-BASED COMPOSITES. Malhotra N1*, Shenoy P2, Acharya S3 1Manipal College of Dental Sciences, Mangalore, Manipal University, India. 2Kasturba Medical College, Manipal, Manipal University, India. 3Manipal College of Dental Sciences, Manipal, Manipal University, India. Objectives: Environmental discoloration by colored stains, especially food stains, is a commonly encountered problem with resin-based composite materials (RBCs). This study investigated the effects of three indigenous food stains (Tea, Tobacco,Turmeric) on a nanohybrid (Ceram-X-Mono), a microhybrid posterior (P 60), and an universal microhybrid (Z100) resin-based composite (RBC). Materials and Methods: Thirty six disk shaped specimens were fabricated (10 x 2 mm) for each type of resin-based composite material using a polytetraflouroethylene (PTFE) sheet. Specimens from each group were randomly distributed into three subgroups (n=12) for each of the used stains. The baseline color values were measured using a spectrophotometer according to CIELab color scale. They were immersed in the staining solutions for a period of 3h/day x 15days. Following this the color change value (E) was calculated. Results: All the tested groups showed a clinical perceptible color change (E values =3.3 or >3.3), except for tea stained P60 (E=3.15) and Z100 (E=1.63) groups. Turmeric caused the most significant color change for all the tested resinbased composites. Least amount of color change was observed in Z100 (Tea, E=1.63; Tobacco, E=13.59; Turmeric, E=38.77) group that was statistically significant from P60 (Tea, E=3.15; Tobacco, E=18.83; Turmeric, E=57.72) and Ceram-X-Mono (Tea, E=3.32; Tobacco, E=18.83; Turmeric, E=53.95) groups. Conclusion: Within the limits of the current investigation and for the concentrations of stain tested, it can be concluded that, Turmeric has the maximum staining capacity for all the tested RBCs, with P60 and Ceram-X-Mono having less stain resistance than Z100. Keywords: Filler content, Stainability, Tobacco, Turmeric


CLINICAL EVALUATION OF A BIORESORBABLE MEMBRANE (POLYGLACTIN 910) IN THE TREATMENT OF MILLER TYPE II GINGIVAL RECESSION Gupta Rajan Himachal Institute of Dental Sciences, Himachal Pradesh, India. Objectives: The purpose of the present study was to evaluate the use of bioresorbable membrane (Polyglactin 910) in the treatment of Miller type II gingival recession. Material & Methods: Fifteen subjects with a chief complaint of denuded roots with the presence of 4mm or more of buccal recession were selected. Clinical parameters like recession, probing depth (PD), clinical attachment level (CAL) and width of keratinized gingiva were measured before and after surgery. Surgical procedure involved two oblique releasing incisions so that trapezoidal full and split thickness flaps were raised. The exposed root surfaces were cleaned and debrided and a Polyglactin 910 membrane was trimmed and placed to cover the recession. GTR membrane extended from cemento enamel junction (CEJ) to cover the adjacent bone mesially, distally and apically. It was secured with vicryl sutures and the flap was coronally positioned to cover the membrane and retained there with the help of silk sutures. Result: Post operatively significant root coverage (mean coverage 2.466), reduction in probing depth, gain in clinical attachment level (mean gain 2.933) and highly significant increase in the width of keratinized gingiva was observed (mean 1.133). Conclusion: Polyglactin 910 resorbable GTR membrane is a suitable alternative to patients own palatal masticatory mucosa to cover denuded root surfaces as regards final aesthetics and colour match which is acceptable both to the clinicians and patients. Keywords: Gingival recession, Polyglactin 910, Root Coverage


A PILOT ASSESSMENT ON MICROBIAL LOAD OF OUTPUT WATER FROM DENTAL UNIT WATERLINE SYSTEM (DUWS) CHUA C.S. *, A. R. FATHILAH, W.H. HIMRATUL AZNITA Department of Oral Biology, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia. Objective: To examine the sanitary level of output water from dental unit waterline system (DUWS). Methods: A total of 13 dental units (A-dec) in the General Dental Practice Clinic, University of Malaya were included in this present study. These dental units utilise distilled water as the input water and deliver output water through air-water syringe and handpieces to the patients during dental treatment. Four types of water sources, namely air-water syringe,
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67th MDA AGM/ FDI World Dental International Scientific Convention & Trade Exhibition, 10-13 June 2010 at Kuala Lumpur Convention Centre

low speed handpiece, high speed handpiece and distilled water reservoir from each dental unit were tested. Water samples were collected in early morning before daily treatment session. Each water sample was examined for both physical parameters (temperature and pH) and biological parameters (total aerobic bacterial count, total coliform count, faecal coliform count, Escherichia coli count, faecal streptococci count and Pseudomonas aeruginosa count). The counts obtained were compared with recommendation made by American Dental Association (ADA). Results: The mean temperature of all water samples tested were found to be quite stable with a mean of 23.41 0.86 C and the pH was found to be slightly acidic with a mean of 5.46 0.17. The total aerobic bacterial count of all water samples exceeded the range recommended by ADA. There were also absence of total coliform, faecal coliform, E. coli, faecal streptococci and P. aeruginosa in all the samples tested. Conclusion: An effective approach need to be designed to ensure the output water from DUWS meet the recommendation proposed by ADA and eliminate potential crossinfection among dental personnel and patients. Keywords: Dental unit waterline system, bacterial count, cross-infection


THE RELATIONSHIP OF FACIAL AND DENTAL ARCH MORPHOLOGY IN MALAY ADULTS: 3D ASSESSMENT USING STEREOPHOTOGRAMMETRY Al-Khatib* A.R, Rajion Z.A, Masudi S.M, Hassan R. School of Dental Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia Objectives: The purpose of the study is to investigate the relationship between facial and dental arch dimensions in sample of Malaysian Malay. Methods: A cross sectional study was conducted on 50 volunteers (18-35 years) selected from Healthy Campus, Universiti Sains Malaysia. The participants had class I occlusion and minimal amount of dental crowding. Data were captured using stereophotogrammetry technique which consist of two Sony digital cameras, synchronize switch and a calibration control frame. The landmarks were digitized using Australis photogrammetric software and nineteen facial and six dental cast distances were measured and analyzed. The association between facial and dental arch measurements was calculated by multiple regression analysis. The level of significance was established at P<0.05 and statistical tests were performed with SPSS version 12 software. Results: The results showed significant positive association of the lateral facial measurements included orbital (ex-t), nasal (g-t, n-t), maxillary (sn-t), mandibular (gn-t, pog-t, go-gn) with most of the upper and lower dental arch dimensions. Although, there is no significant association of the frontal vertical and horizontal facial measurements with the dental arch dimensions, but, there was a trend that as the facial measurements increased the dental arch dimensions increased. Conclusions: The study concluded that there is possible association between the facial and dental arch dimensions. These relations may be helpful in prediction of the change in the soft tissue profile when orthodontic treatment of dental arch would be taken. Further investigations with bigger sample size are needed to evaluate the probable relations in depth. Key words: stereophotogrammetry, Malay face, dental arch dimensions.


CHOICE OF TOOTHPASTE AND TOOTHBRUSH- STUDENTS PREFERENCES Dhaliwal RS*, Shenoy R Manipal College of Dental Sciences, Mangalore, Manipal University, India. Objective: Aim of this study is to access factors affecting selection of toothpaste and toothbrush of medical, dental, engineering and law students. Materials and Methods: A semi-structured questionnaire was used to assess the various factors related to selection of toothpaste and toothbrush. A total of 180 students studying in dental, medical, law and engineering colleges were included in this study. Results: Results showed that majority of dental (88.2%) and engineering (56.8%) students preferred to have fluoride content in the toothpaste, but medical students (85%) favored taste over fluoride content. A greater part of dental, medical and law students were using soft toothbrush but preponderance of engineering students used hard toothbrush (62.2%). Keywords: Oral health, toothpaste, toothbrush, questionnaire survey


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RADIOGRAFPIC EVALUATION OF TWO DIFFERENT TYPES OF ATTACHMENTS OF IMPLANT SUPPORTED OBTURATOR. Abd El Aziz A N. Advanced Medical and Dental Institute, University Sains Malaysia, Kelantan, Malaysia. Objectives: This study is designed to evaluate radiographically maxillary obturator supported by osseointegrated implants retained by either a magnetic or ball and socket type of attachments. Methods: Ten male patients were selected. All the cases were completely edentulous and had maxillary defects not crossing the midline of the palate. The patients were randomly divided into two equal groups. Group one has maxillary obturator prosthesis retained to the implants by ball and socket attachment. Group two retained to the implants by magnet attachment. Results: Comparison of the increase of bone density around the implants of the two groups with different types of attachments found that the changes around the implants of the ball and socket group were significantly increase than that of magnetic group (P<0.05). Conclusion: The difference between the two groups is related to the difference of the attachments which influence force transmission to the implants and the movements of the maxillary obturator under load. The selection of suitable type of attachment is important to increase the survival rate of the implants. Keywords: obturator, implant, attachment.


A CROSS SECTIONAL STUDY OF WATER QUALITY FROM DENTAL UNIT WATER LINES IN THE DENTAL CENTERS OF MALAYSIAN ARMED FORCES Ma MS1*, Zalini Y2, Ahmad Razi MY2, Zukri A2, Norisah O2 1 Jabatan Dan Poliklinik Pakar Pergigian, Hospital Angkatan Tentera Tuanku Mizan, Malaysia. 2 Institut Penyelidikan Sains dan Teknologi Pertahanan, Kompleks Induk STRIDE, Malaysia. Objectives: To evaluate the water quality in the dental unit waterlines (DUWLs) of Malaysian Armed Forces dental centers. Materials and Method: 250 ml water sample was collected from high speed handpiece, scaler, air-water syringe, cup filler, water reservoir and the tap of the surgery respectively into sterile thiosulphite bags. Samples were transported to the laboratory within 24 hours and kept in the refrigerator at 40C. 100ml of each sample was filtered through a 0.45 m polycarbonate membrane filter. The filter was then inoculated onto plate agar and incubated at 370 C for 24 hours. The colonies formed were enumerated by Gel Imager (Biorad). A separate 100ml of water sample was investigated for Legionnella pneumophilia and Pseudomonas aeruginosa by pouring onto Buffered Charcoal Yeast Extract and Pseudomonas Cetrimide Agar. Presence of these bacteria were confirmed by polymerase chain reaction and sequencing. Results: A total of 100 samples were collected from DUWLs of 20 dental units in 11 dental centers. No Legionnella pneumophilia was detected and Pseudomonas aeruginosa was detected in 9.5% of the samples. 77% of the samples met American Dental Associations recommendation of less than 200 CFU/ml (colony forming unit per milliliter). Conclusion: Dental units with main water supply have less CFU than those with water reservoir. Dental units with chemical treatment have less CFU than those without. Flushing before surgery starts improved the quality of water from DUWLS. Keywords: dental unit water lines, water quality, colony forming unit per milliliter.


MICROLEAKAGE IN BONDED AMALGAM RESTORATIONS USING DIFFERENT ADHESIVE MATERIALS WITH DYE UNDER VACUUM- AN IN VITRO STUDY Parolia A Manipal College of Dental Sciences, Mangalore, Manipal University, India. Objective: In an effort to minimize tooth preparation, yet provide additional retention to compromised tooth structure, bonded amalgam restorations were introduced. In this technique, a dentin bonding system is used in conjunction with a viscous resin liner to enhance the amalgams retentiveness to tooth structure. Various adhesives have been tried earlier under bonded amalgam restorations still there are controversies regarding its outcome. Hence the aim of this study was to verify the ability of different adhesive materials to prevent microleakage in bonded amalgam restorations. Materials and Methods: Standard Class I cavities were prepared on occlusal surfaces of 60 human molars. Teeth (n=60) were divided into 3 groups. Group I- Amalgam with glass-ionomer cement (Type I). Group II- Amalgam with resin cement (Panavia F 2.0). Group III- Amalgam with Copalex varnish as a control. Following restoration, the teeth were immersed in rhodamin- B dye under vacuum for 48 hours and sectioned to allow assessment of microleakage under stereomicroscope. Results: Results were statistically analyzed using Anova and
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Kruskal Wallis test. Bonded amalgam with type I GIC showed the least leakage with no statistically significant difference with bonded amalgam with panavia F 2.0 and amalgam with varnish. Conclusion: Bonded amalgam with type I GIC is a good alternative to amalgam with resin cement and amalgam with varnish for large restorations with added advantages of glass ionomer cements. Keywords: Bonded amalgam, adhesives, Dye under vacuum


EFFECT OF POROSITY ON COMPRESSIVE STRENGTH OF RESIN MODIFIED GLASS IONOMER CEMENTS Aws.H.Ali1*, H.Abdullah2, O. Nabeel3 1 Faculty of Dentistry, Universiti Sains Islam Malaysia (USIM), Malaysia. 2 Faculty of Dentistry, University of Malaya (UM), Malaysia. 2 Faculty of Dentistry, International Medical University (IMU), Malaysia. Objective: The objective of this study was to evaluate the effect of porosity size (1-100) m on the compressive strength of Fuji CEM (GC Corp, Tokyo, Japan) and Fuji PLUS CAPSULES (GC Corp, Tokyo, Japan). Materials and Methods: A total of thirty cylindrical specimens 6mm height and 4mm in diameter were prepared for both cements and stored in distilled water at 37C for 24 hour. Each cement type was tested using Universal Testing Machine SHIMADZU (SHIMADZU Corp, Tokyo, Japan), then the fractured surfaces of 10 randomly selected specimens for each cement type were examined using scanning electron microscopy (SEM) to determine the amount and size of porosity present. Results: Non-parametric Mann-Whitney Test was used to compare the compressive strength of these luting cements. There was no statistically significant difference in compression strength of Fuji CEM and Fuji PLUS CAPSULES (p=0.372). The mixing method found to be statistically significant with the porosity size of (10-50)m and (50-100)m diameter, however it was not significant with the porosity size of (1-10)m in diameter (p>0.04). The mechanical mixing produced a significantly higher percentage of porosity size of (10-50)m and (50-100)m in diameter with (p=0.001, p=0.04 respectively). Porosity was incorporated in all samples. Conclusions: there was no linear relationship between compressive strength and porosity size (1-100)m in diameter for Fuji CEM and Fuji PLUS CAPSULES which were used in this study. Keywords: Compressive strength, Porosity, Resin modified GIC.


THE EFFECTS OF AN ALCOHOL-FREE 0.12% w/v CHLORHEXIDINE GLUCONATE MOUTHRINSE ON ORAL HEALTH Subramaniam U Periodontal Specialist Clinic, Seremban, Malaysia. Objective: A randomized, double-blind, cross-over, placebo-controlled clinical study was carried out to determine the effects of an alcohol-free mouthrinse compared to a placebo without the active ingredient chlorhexidine gluconate. Materials & Methods: A group of 60 subjects were randomly assigned into two groups of 30 each. The first group started using the test product for 2 weeks followed by a washout period of 4 weeks. After this duration, this group used the placebo for a further 2 weeks. Results: The second group underwent similar protocol except that this group started with the placebo. Measurements consisting of the following scores were recorded at baseline and after 2 weeks for each group: Plaque, Gingivitis, Papilla Bleeding, Stain and Calculus. Full-mouth prophylaxis was carried out for all subjects after measurements at baseline as well as after the 2-week period. Each subject was told to rinse with 15ml of the designated mouthrinse twice daily for 30s each after toothbrushing. The results of this study indicated that there was significant reduction in the plaque (p<0.05). gingival (p<0.05) and papilla bleeding (p<0.05) scores compared to the placebo. Stain and calculus scores were significantly increased (p<0.05) for the test product. Conclusion: this clinical study showed that this alcohol-free 0.12% w/v chlorhexidine gluconate mouthrinse has an effect in improving plaque and gingival status of subjects but causes stain and calculus formation. Keywords: Chlorhexidine, Mouthrinse, Plaque


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A COMPARATIVE STUDY OF A NEW ENDODONTIC RADIOGRAPHIC HOLDER WITH ENDORAY Kathiravan Purmal1*, Tuan Mohammad Yusof Shah2, Ahmad Hafizuddin Abdul Aziz2, Phrabhakaran Nambiar1 1 Faculty of Dentistry, University Malaya, Malaysia. 2 Faculty of Engineering, University Malaya, Malaysia. Objectives: To compare the diagnostic quality of radiographs taken with the new prototype endodontic holder (K-Endo) and Endoray. Material and methods: Forty two radiographs were taken with the K-Endo holder and 55 radiographs were taken with Endoray by the final year dental students who were randomly selected for this study. All radiographs were done on molar tooth that was undergoing root canal treatment. Each radiograph was examined for diagnostic acceptability by one calibrated examiner. Results: The unacceptable radiographs taken with K-Endo were 28.6% and with Endoray was 18.2%. Most of the radiographs taken with K-Endo were in acceptable category (55.6%) while most of the radiographs taken with Endoray were in excellent category (83.3%). This result was statistically significant with Chi-Square test (p<0.05). Conclusion: Although K-Endo does provide a high rate of acceptable radiographs, Endoray is still better in getting excellent views. Keywords: radiograph film holder, endodontic, intraoral.



SHEAR BOND STRENGTH EVALUATION AND CHEMICAL ANALYSIS OF RESIN COMPOSITE BONDED TO GIC USING SELF ETCHING BONDING AGENTS WITH DIFFERENT pH IN VITRO STUDY. Jeyavel Rajan. Faculty of Dentistry, Penang International Dental College, Penang, Malaysia. Objectives: The purpose of this study was to evaluate the bonding ability of composite to unset glass-ionomer cement (GIC) using different self etching bonding systems. Materials and methods: Hundred samples of composite bonded to unset GIC were prepared and were divided into 4 groups. In Group A, composite was bonded to unset GIC employing a strong (pH 1) self etch primer [Adper Prompt Self-Etch, 3M ESPE]. In Group B, intermediary strong (pH 1.4) Self etch primer [AdheSE, Kuraray Medical Inc] was employed . In Group C and D, mild (pH 2) [Clearfil SE Bond, Kuraray Medical Inc] and (pH 2.2) [One Coat SE Bond, Coltene Whaledent ] Self etch primer was employed. Shear bond strength analysis was performed at a cross-head speed of 0.5mm/minute. Statistical analysis was performed with one way ANOVA and Tukeys test. Results: were tabulated and it showed that the bond strength of composite to unset GIC was significantly higher for the mild Self etch primer group . In addition we used energy dispersive x-ray (EDX) analysis to determine the composition of various structural phases identified by FE-SEM along the GIC-bonding agent interfaces. Conclusion: This study proves that, clinically the use of mild self etching bonding agent over unset GIC improves the bond strength compared to the use of strong & intermediate self etching bonding agents. Keywords: Self etch primer pH, GIC-Composite bond, FESEM analysis


HOW MANY, 28 OR 32 TEETH? WHERE DO WE MALAYSIANS STAND? John J*, Murad N.F.A, Azman N, Mohamed N.H, Nambiar P Department of General Dental Practice and Oral and Maxillofacial Imaging, Faculty of Dentistry, University of Malaya, Malaysia Objective: To establish the prevalence and distribution of third molar agenesis in Malaysian population. Methods: A total of 192 routine preoperative panoramic radiographs of dental patients, aged between 10 and 19 years of age, who visited the Oral Radiology Division of Faculty of Dentistry, University of Malaya, were examined and each instance of a missing M3 was recorded. The study population represented subjects from the 3 major races of Malaysian population, namely the Malays, Chinese and Indians. Results: A quarter of the study population had at least one third molar agenesis. This was highest seen among the Chinese. There were more females than males with missing third molars. The incidence of missing third molar is highest in the right maxillary region. The Malays and Indians showed greater tendency towards agenesis of maxillary third molars. However, among the Chinese, the third molar agenesis was equally high in both the arches. The findings show that Malaysian Chinese were twice more likely to have mandibular third molar agenesis than the Indians. Conclusion: With more missing third molars, the burden of managing diseases, complications and treatment cost associated with this particular tooth decreases. However, the use of third molars for age estimation, forensic identification and medicolegal purposes will be compromised in the future. Keywords: third molars; dental agenesis; panoramic radiography
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COMPARATIVE EVALUATION OF THE CURVE OF SPEE AND POSTERIOR DISCLUSION IN TWO AGE GROUPS Mohan M. Manipal College of Dental Sciences, Mangalore, Manipal University, India. Objective: This study aims to compare the Curve of Spee and disclusion during protrusion in two age groups. Method: 60 subjects were chosen and divided into two age groups, Group A (30) 18 - 25 years and Group B (30) 35 - 44 years. The left side of the mandibular dental casts was photographed using digital camera. The cusp tip of canine, mesiobuccal cusp of first molar and distal cusp of second molar were marked and AUTOCAD software was used to obtain the radius for this arc. A protrusive interocclusal record was made using bite registration material to measure the amount of posterior disclusion during protrusion. A dial gauge was used to measure the distance at the mandibular 2nd premolar and 1st molar region. The results obtained were statistically analyzed. Results: The Curve of Spee radius increases with age significantly showing a mean value of 19.1498 mm in group A and 26.5328 mm in group B. The mean disclusion values measured in premolar region for group A are 1.7173 mm and in group B 1.0375 mm, showing a non significant decrease with age. The mean disclusion values measured in molar region for group A are 1.6157mm and in group B 1.0320 mm, showing a nonsignificant decrease with age. Conclusion: There is a flattening of the curve of Spee as age advances. A concurrent reduction in the disclusion values during protrusion also occurs. KeyWords: Spee, Disclusion, Protrusion


ASSESSMENT OF BONE-IMPLANT INTERFACE ASSOCIATED WITH BIOMIMETIC COATED COMMERCIALLY PURE TITANIUM: IN VIVO STUDY Al-Mudarris B.A.A. 1*, Salim S.A.L.2, Al-Zubaydi T. L. 3, Al-Hejazee A. Y.4, Hashim H.1 1 Advanced Medical and Dental Institute, Universiti Sains Malaysia, Malaysia 2 Department of Prosthodontic Dentistry, College of Dentistry, University of Baghdad, Iraq 3 Directorate of Material Science, Ministry of Science and Technology, Iraq 4 Department of Oral Pathology, College of Dentistry, University of Baghdad, Iraq Objectives: In an attempt to modify the surface properties of an implant, this study was conducted to evaluate the effect of biomimetic calcium phosphate coating on the quality bone-implant interface associated with screw-shaped implants made from the commercially pure titanium. Materials and Methods: In vivo experiment was done by implantation of 2 titanium implants, one is uncoated and the other one is biomimetically coated, into the tibia of New Zealand rabbit. The screw-shape implants were biomimetically coated with calcium phosphate by immersion in a concentrated simulated body fluid (5 times), which simulates the inorganic part of human blood plasma, under static conditions in a biological thermostat at 37oC for 6 days. The uncoated screws were passivated with 28% nitric acid. After different healing periods (2, 6, and 18 weeks), 5 rabbits were sacrificed for each period. The influence of modified surface on the bone-implant interaction was analyzed by a light microscope using Hematoxelin & Eosin and Van Gausian special stain. Results: The results obtained from this experiment showed that the quality of bone response was greatly improved among the coated screws. The osteoconductive action of calcium phosphate was shown by the presence of fibrovascular tissue, osteoblastic activity and new bone formation. Conclusions: Biomimetic coatings play an active role in the bone-remodeling process by creating a friendly surface for cell adhesion and proliferation, which is a key issue for bone regeneration. One might suggests that CaP prompts an earlier remodelling either due to better biocompatibility or increase the surface irregularity. Keywords: biomimetic coating, titanium implant, bone-implant interface.


CONGENITAL EPULIS: A CLINICOPATHOLOGICAL STUDY OF 12 CASES Lukman M.A*, Ajura A.J, Lau S.H Stomatology Unit, Institute for Medical Research, Kuala Lumpur, Malaysia. Congenital epulis is a fairly rare soft tissue tumour that occurs exclusively on the alveolar ridge of newborns. Method: A retrospective study was carried out on all congenital epulis cases diagnosed at the Stomatology Unit, Institute for Medical Research, Kuala Lumpur from 1967 to 2009. All the data regarding gender, race, clinical presentation and diagnoses were retrieved from the computerized data. Result: There were 12 cases in which all were females. The presentation age ranged from 2 days to 90 days. The patients comprised of 6 Malays, 3 Chinese, 2 Indians, and 1 Orang Asli. Most cases (n=7) occurred on the maxillary ridge and presented as pedunculated well defined lump (n=8).
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Excisional biopsy was carried out in all cases. Keywords: congenital epulis, newborn, maxillary and mandibular ridge.


ANTIBACTERIAL EFFECT OF CHLORHEXIDINE MODIFIED CONVENTIONAL GLASS IONOMER CEMENT AGAINST L.CASEI AND A.VISCOSUS AN IN VITRO STUDY Vamsi. K. Faculty of Dentistry, Penang International Dental College, Penang, Malaysia. Objectives: To compare the antibacterial efficacy of chlorhexidine modified glass ionomer cement with conventional type II glass ionomer cement against L.casei and A.viscosus, immediately after manipulation (unset) and 1 hour after manipulation (set). Methods: An in vitro study using agar diffusion method of testing the materials against the organisms L.casei and A.viscosus was carried out. The materials were tested for their inhibition zones immediately after manipulation (unset specimens) and 1 hour after manipulation (set specimens). The inhibition zones were than calculated and subjected to statistical analysis. Results: There was no statistical significant difference found between set and unset specimens for both the materials against the two organisms. Statistically significant difference was observed in the inhibition zones produced between L.casei & A.viscosus for both unset (p-value = 0.0001) and set (p-value = 0.021) specimens. For both the materials the zones against L.casei was greater than against A.viscosus for unset and set specimens. Conclusion: CHX diacetate when added to glass ionomer cement had increased antibacterial properties over the conventional glass ionomer against both A.viscosus and L. casei significantly but greater against L.casei, suggesting the use of this material in various clinical situations. Keywords: glass ionomer cements, chlorhexidine, deep caries micro organisms.

THE APPLICABILITY OF LOWER RIGHT THIRD MOLAR DEVELOPMENT IN AGE PREDICTION FOR KELANTANESE MALAYS Johan N.A, Ahmad B, Khamis* M.F School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia. Objectives: The aims of the present study were to investigate the association between sex, lower right third molar development and age, and to evaluate their prediction accuracy. Materials and methods: The sample consisted of 1028 orthopantomograms from young Kelantanese Malay subjects of known chronologic age (range 13-26 years) and sex (510 males and 518 females). The teeth were assessed according to eight stages method of Demirjian et al. (1973). Regression analysis was performed with sex and third molar developmental stages as independent variables and age as a dependent variable. Significance level was set at 5%. Results: There was a significant association for both independent variables and age (p<0.001). A prediction model, Age=8.01-(0.46*sex) + (1.78*stage), fitted reasonably well and explained 68% of variation of the age in the study sample. The accuracy of this new prediction model varies according to age groups. For age groups 13 to 21.5 years, the highest overestimates were less than 1.03 years for females and 1.33 years for males while for older age groups between 21.5 and 25.5 years old the highest underestimation was 3.4 years (males) and 2.9 years (females). Conclusions: Sex and lower right third molar development are associated with age. The lower right third molar development is applicable for age prediction in human identification process. Keywords: age prediction, third molar development, Malays


FRACTURE RESISTANCE COMPARISON OF FEW TECHNIQUES IN REPAIRING FRACTURED PORCELAIN WITH COMPOSITE RESIN Abd Wahab M.H.K, Wan Bakar* W.Z, Husein A School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia. Objective: The aim of this study was to investigate the fracture resistance of few different techniques in repairing fractured porcelain using composite resin. Materials and methods: Eighty samples of 6mm length x 5mm width and 2mm thick of porcelain blocks were prepared before divided into 4 groups of 20 samples each. Samples was prepared with one fracture side that undergone different surface treatments following groups either using commercially available (Cimara) repairing kit, Porcelain etch kit with hydrofluoric acid, Panavia F resin cement or sandblasting with aluminium oxide. Later they were bonded with composite resin to gain a size of 12mm x 10mm x 2mm. Twenty
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different samples are prepared from pure porcelain with size of 12mm x 10mm x 2mm as a control group. Results: Fracture resistance of each samples were tested using Instron machine (UK). Repaired porcelain with hydrofluoric acid showed the highest value of fracture resistance (3.038 1.0444 Mpa), which was the only not significant result when compared to control group (3.046 1.4184MPa) at (p< 0.05). Conclusions: Hence etching with hydrofluoric acid could be used to repair fractured porcelain with composite resin at chairside. This could minimize the cost and time rather than remaking the prostheses. Keywords: Fracture resistance, fractured porcelain, surface treatments

VARIATIONS IN MUCOSAL DISPLACEMENT OF DISTAL-EXTENSION RIDGES AT FOUR LOCATIONS. Nabeel O. 1*, Ahmad S.F 2, Ariffin Y.T 2, Ali A.H 3 1 Faculty of Dentistry, International Medical University, Malaysia. 2 Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia. 3 Faculty of Dentistry, Universiti Sains Islam Malaysia, Nilai, Malaysia. Objective: To compare clinically the mucosal vertical displacement of the distal-extension ridges at four different locations within three different impressions using hydrophilic vinyl polysiloxane regular body impression material. Method: Fifteen subjects participated in the study. Cast obtained from irreversible hydrocolloid impression made with special tray of each subject was used as control. First impression (M) and second impression (C) were with special tray, which differed from each other in the amount of relief of the special tray at the distal-extension ridge; for M, wax of 1mm thickness was used as relief; while for C, wax of 0.5mm thickness was used as relief. Third impression was altered cast impression technique (ACT). Four standardized locations were identified on each left and right ridge on the cast; 5mm distal to last abutment tooth, midway between 5mm and centre of retromolar pad, centre of retromolar pad, and buccal shelf. Three standardized points at each location were measured using Digimatic indicator (Mitutoyo, Japan). Comparisons were done using mean differences between the three different impressions and control. Oneway ANOVA and Kruskal-Wallis tests were used to analyze the data. Results: There were differences in the vertical displacement among the different locations; however they were small and not significant (P>0.05). Regardless of the impression technique, the displacement increases by the increase the distance from the abutment tooth Conclusions: The least displacement was at the buccal shelf area. Retromolar pad is the least supported area on the ridge, due to its farthest location from the abutment tooth. Keywords: Prosthodontics, Mucosal displacement, Distal-extension ridge.


CHEMILUMINESCENT ILLUMINATION IN THE DETECTION OF ORAL PREMALIGNANT AND MALIGNANT EPITHELIAL LESIONS Subashini S 1*, S Shanmugam. 2 1 Dept. Of Oral Medicine and Radiology, Penang International Dental College, Penang, Malaysia. 2 Dept of Oral Medicine and Radiology, Ragas Dental College, Chennai, India. Objectives: The purpose of the study was, to identify dysplastic changes early, thus enabling the oral health care provider to diagnose early cancerous and precancerous abnormalities, to delineate the dysplastic areas, in a chair side procedure, so as to visualize the exact location of the biopsy site and to practice routine oral screening procedure with chemiluminescent light. Materials and methods: This is a cross sectional hospital based study and the sample included about 50 patients irrespective of age, sex, and socioeconomic background, who had a red and white lesion, clinically diagnosed as leukoplakia or Lichen planus or Lichenoid reaction or Oral Sub Mucous Fibrosis or a malignant lesion. About 20 patients with apparently normal mucosa and who had no history of any deleterious habits were also selected. All the patients were screened with vizilite kit, a chemiluminescent illumination tool. Routine blood investigation and confirmatory histopathological examination was also done followed by statistical analysis. Results: It was observed that chemiluminescent illumination is 100% sensitive and specific for leukoplakia. For all subjects, sensitivity is 100 %, specificity is 90.5%, positive predictive value is 87.5% and negative predictive value is 100 %. Conclusions: Complete oral screening with chemiluminescent illumination is highly indicated in routine dental examination as a chair side screening device for early detection of potentially malignant lesions. Keywords: chemiluminescent illumination, potentially malignant lesions, dysplasia


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SERUM TISSUE NON SPECIFIC ALKALINE PHOSPHATASE ISOENZYME (TNsALP) ESTIMATION AND SEVERITY OF CHRONIC PERIODONTITIS P Gopu Chandran lenin 1*, Senthil Kumar 2 1 Faculty of dentistry, Penang International Dental College, Penang, Malaysia. 2 Department of Periodontics, Rajah Muthiah Dental College, India. Objective: Main purpose of this study was to determine the specificity of TNsALP level with severity of chronic Periodontitis. Materials and method: Total of 32 systemically healthy male individuals of age 35-55 years were included in the study. Periodontal status were recorded and grouped in four categories as control, mild, moderate and severe based on their CAL recordings as per Extent and Severity index criteria. Serum samples were used for the analysis of total ALP level and TNsALP levels using automated gel agrose electrophoresis method. Values obtained were compared and correlated using ANOVA and Spearmans Correlation coefficient test. Results: The total ALP level for all the patients were found to be in the normal range with slight variations within the range. Surprisingly, the TNSALP (Bone type) values were found to be decreased in moderate and severe group individuals as compared to control and mild group which were more or less same. Moreover, this lowered value was found compensated by the TNSALP of liver type to maintain the total ALP values. Conclusion: The results have proved that there is a decrease in TNsALP from bone in chronic periodontitis patients. Hence TNsALP level can be used as one of the diagnostic test for chronic periodontitis as compared to total ALP level alone. Keywords: Total Alkaline Phosphatase, Tissue Non specific Alkaline Phosphatase isoenzymes (TNsALP), Clinical attachment loss.

THE INFLUENCE OF SURFACE ROUGHNESS AND CONDITIONER ON THE SHEAR BOND STRENGTH OF GLASS IONOMER CEMENT TO DENTIN Muharriri A.F 1*, Suprastiwi E, 2 Djauharie N 2 1 Faculty of Dentistry, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia. 2 Faculty of Dentistry, University of Indonesia, Indonesia. Objectives: The purpose of this study was to analyze the influence of surface roughness and conditioner on the shear bond strength (SBS) of glass ionomer cement (GIC) to dentin. Methods: Thirty-six dentin specimens were created by grinding the buccal/lingual surfaces of extracted sound human premolars using wet No.1000-grit rotary abrasive paper, until smooth dentin areas were exposed. The specimens were then immersed in artificial saliva, incubated in 37C, cleaned, and then randomly divided into 4 groups. Group (G) 1: GIC was inserted without any pretreatment. Group 2: conditioner was applied prior to inserting the GIC. Group 3: specimen was roughened by wiping for three times using rough diamond burs, rinsed and dried, GIC was then inserted. Group 4: same procedures as to group 3, but conditioner was applied prior to inserting the GIC. The SBS was measured after 24 hours using a universal testing machine, and statistically analyzed using One Way ANOVA. Results: The highest score was found in group 4 (mean: 5.71 1.08 Mpa), and the lowest score was in group 1 (mean: 3.12 0.22 Mpa). However, regarding the influence of surface roughness, the rough dentins, even revealed higher scores, but were not statistically different from the smooth ones. Meanwhile the conditioned dentins significantly showed higher scores than the unconditioned ones, with the significance level of G.1:G.2 and G.3:G.4 were 0.002 and 0.010, respectively (P< 0.05). Conclusion: Shear bond strength of GIC to dentin was proved to increase by application of conditioner, but not by surface roughness. Keywords: roughness, conditioner, shear bond strength, glass ionomer cement.



TO INVESTIGATE THE KNOWLEDGE OF EMERGENCY MANAGEMENT OF PERMANENT OF AVULSED PERMANENT TEETH AMONG HEALTH PROFESSIONAL IN ACCIDENT AND EMERGENCY DEPARTMENT AT HOSPITAL SULTANAH BAHIYAH Azillah M A, Fathiyah E*, Yew C.C Jabatan Pergigian Pediatrik , Hospital Sultanah Bahiyah, Alor Setar , Kedah, Malaysia Objective: To investigate the knowledge of healthcare professionals in managing permanent tooth avulsion and compare the knowledge based on their professional role. Methods: An 11-questionnaire was sent to the Accident and Emergency (A&E) department to be distributed to 3 groups of health care professionals. Results were analyzed using SPSS and T-test performed to investigate any significance in difference. Results: 61 subjects completed the
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67th MDA AGM/ FDI World Dental International Scientific Convention & Trade Exhibition, 10-13 June 2010 at Kuala Lumpur Convention Centre

questionnaire, a response rate of 83.8%. The mean knowledge score of the respondents was only 5.83 out of the possible full score of 11. 21 respondents (31.3%) have experience of managing tooth avulsion before. Nearly three quarter of the respondents (71.6%) realized the importance to treating an avulsed tooth as soon as possible and 54 respondents (80.6%) would attempt to locate the avulsed tooth. Less than 50 % respondents have correct knowledge on handling (41.8%) and cleaning (44.8%) an avulsed tooth. Awareness of the correct storage medium of an avulsed tooth only 26.9%. Nevertheless, nearly all of the respondents (92.5%) agreed to the importance of immediate referral for tooth avulsion. There is a significant difference on knowledge of tooth avulsion between medical officers compared with staff nurses and assistant medical officers. Conclusion: The healthcare professionals in A&E department do not have adequate knowledge on management of permanent tooth avulsion. There is a need to organize a Continuous Medical Education (CME) to improve the general knowledge on management of permanent tooth avulsion. Keywords: avulsion , health care professional , awareness


SALIVARY CHARACTERISTICS AND DENTAL CARIES OF THE CHILDRREN WITH HEARING IMPAIRMENT Fatin Noor K 1, Normastura A.R 1*, Azizah Y 1, Mohd Khairi MD 2 1 School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia. 2 School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia. Objective: To determine the caries prevalence and experience as well as its association with salivary characteristic (resting flow rate, pH) among the children with hearing impairment. Materials and method: A cross sectional study was done on 63 hearing impaired children aged between 7-14 years old who attended special school for deaf in Kelantan, Malaysia. Sociodemographic data was obtained and salivary parameters were measured for resting flow rate and resting pH using Saliva-Check BUFFER by GC co. Japan. Clinical oral examination was done using disposable probe and mirror. Caries experience was calculated based on the index of decay, missing and filling teeth (DMFT) for permanent dentition and decay and filling (dft) for deciduous dentition. Data were analysed by using SPSS version 12.0. Results: The mean age was 11.5 (SD 2.39) years with 53.8% were being female. Majority (98.5%) of them were Malays. The prevalence of dental caries in primary dentition was 88.0% (95% Cl: 73.0, 100.0) and permanent dentition was 85.0% (95% Cl: 73.0, 96.0) respectively. The mean dft was 6.1 (SD 4.14) and the mean DMF(T) was 4.9 (SD 3.28). The mean resting flow rate was 0.14 (SD 0.08) ml/min while mean pH was 6.8 (SD 0.79). Pit and fissure sealants as well as restoration were the highest (83.1%) treatment need compared to topical fluoride (64.6%), extraction (44.6%) and pulp care (12.3%). Only 3.1% of the children do not require any treatment. There were no significant correlation in both salivary flow rate and pH with primary (p=0.342, p=0.610 respectively) and permanent (p= 0.99, p=0.70 respectively) caries experience. Conclusion: Caries prevalence was high in primary and permanent dentition in the children with hearing impairment. Saliva characteristics like pH and resting flow rate were not influence the caries experience. Keywords: saliva resting flow rate, saliva pH, hearing impairment


PERIODONTAL STATUS IN DIABETIS MELLITUS TYPE II PATIENTS ATTENDING HUSM DIABETIC CLINIC. Jamrin N.M, Roselinda A.R*, Taib H , Rahman N.A School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia. Objective: to determine the prevalence and status of periodontal disease as well as its association with diabetes mellitus type 2 (DM type 2). Method: A cross sectional study was done where diabetic patients and non-diabetic patients were randomly selected.. Sociodemographic data were obtained and periodontal status was determined according to plaque index, gingivitis index and probing pocket depth. Data were analysed using SPSS version 12.0. Results: Seventy eight patients (25 DM type 2 and 53 non-diabetic) were randomly selected..The mean age was 36.5(SD 11.12) and 53.5 (SD 8.45) years old in non diabetic and diabetic patients respectively. The prevalence of periodontal disease were significantly higher in diabetic (64%; 95% CI: 44.0%-84.0%) compared to non-diabetic patients (15%; 95%CI: 5.0%-25.0%); (P<0.001). There was a significant difference of plaque index in diabetic compared to non diabetic patients (mean difference -0.397; P <0.001). However, the mean gingivitis index was not significantly different between these groups (mean difference -0.069; P=0.305). The mean pocket depth of diabetic patients was significantly higher [2.46 (SD 0.827)] compared to non-diabetics [1.15(SD0.472)]; P<0.001.The periodontal disease was significantly associated with DM type 2 (P<0.001). Conclusion: There was a significant association between periodontal disease and DM type 2. Advocating regular dental check up especially for uncontrolled diabetic patients to prevent or control periodontal disease would improve their diabetic status. Keywords: periodontal disease, diabetes mellitus, periodontal status
123 Malaysian Dental Journal July-Dec 2010 Vol 31 No 2