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BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141TUPNBUPMPHJDBM!!TPDJFUZForthcoming Meeting16 th Congress <strong>of</strong> the Balkan Stomatological Society28 April - 1 May, 2011, Bucharest, RomaniaBALKAN STOMATOLOGICAL SOCIETY&ROMANIAN DELEGATION OF THE BaSSInvite you cordially to Bucharest on the occasion <strong>of</strong> the16 th Congress <strong>of</strong> the Balkan Stomatological SocietyPresident <strong>of</strong> the CongressPr<strong>of</strong>. Norina FornaDear colleagues and friends,On behalf <strong>of</strong> the Local Organizing Committee, it gives me great pleasure to invite you for the 16 th Balkan StomatologicalSociety Congress (BaSS) to be held in Bucharest, Romania, in April 2011. This event will be organized by the Romaniadelegation <strong>of</strong> the BaSS with the support <strong>of</strong> the Romanian Society <strong>of</strong> Oral Rehabilitation (ASSRO), The Romania DentalCouncil (CMDR) and Romanian Association <strong>of</strong> Oral Implantology and Biomaterials (SRIOB), under the theme “Updatein dental medicine”.The success <strong>of</strong> the Annual Bass Congress underlines the crucial role <strong>of</strong> the scientifi c programme’s quality. In recent yearswe have not only seen an increase in the number <strong>of</strong> participants but also the growth and development <strong>of</strong> what is now anoutstanding scientifi c programme with continuing efforts to elevate Balkan <strong>stomatology</strong> to a higher level. This certainlycould not have been achieved without your valuable support at the BASS congresses and for that we are extremelygrateful.As the Local Organizing Committee, we hope that, in addition to intellectual and pr<strong>of</strong>essional growth, we can also provideyou with a relaxing and enjoyable social experience. The capital <strong>of</strong> Romania is an attractive tourist destination, which<strong>of</strong>fers the opportunity to all <strong>of</strong> you to pay a visit to the numerous historical sites and enjoy the extraordinary Romanianscenery.We look forward to seeing you all in Bucharest.Kind regardsPr<strong>of</strong>essor Norina FornaPresident <strong>of</strong> the CongressCo-Organizer:Eurolink Medical CongressesStr. Carpaţi nr. 2, Iaşi, 700729, Româniaemail: eurolink@eurolink-tours.co.ukwww.eurolink-tours.co.uk
BALKAN JOURNALOF STOMATOLOGYOfficial publication <strong>of</strong> the BALKAN STOMATOLOGICAL SOCIETYVolume 15 No 1 March 2011ISSN 1107 - 1141
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141TUPNBUPMPHJDBM!!TPDJFUZEditor-in-ChiefLjubomir TODOROVIĆ, DDS, MSc, PhDFaculty <strong>of</strong> DentistryUniversity <strong>of</strong> BelgradeDr Subotića 811000 BelgradeSerbiaEditorial boardALBANIARuzhdie QAFMOLLA - EditorEmil KUVARATIBesnik GAVAZIBOSNIA AND HERZEGOVINAMaida GANIBEGOVIĆ - EditorNaida HADŽIABDIĆMihael STANOJEVIĆAddress:Dental University ClinicTirana, AlbaniaAddress:Faculty <strong>of</strong> DentistryBolnička 4a71000 Sarajevo, BIHBULGARIANikolai POPOV - EditorAddress:Nikola ATANASSOVFaculty <strong>of</strong> DentistryNikolai SHARKOV G. S<strong>of</strong>iiski str. 11431 S<strong>of</strong>ia, BulgariaFYROMJulijana GJORGOVA - EditorAna STAVREVSKALjuben GUGUČEVSKIAddress:Faculty <strong>of</strong> DentistryVodnjanska 17, SkopjeRepublika MakedonijaGREECEAnastasios MARKOPOULOS - Editor Address:Haralambos PETRIDISAristotle UniversityLambros ZOULOUMISDental SchoolThessaloniki, GreeceROMANIAAlexandru-Andrei ILIESCU - Editor Address:Victor NAMIGEANFaculty <strong>of</strong> DentistryCinel MALITA Calea Plevnei 19, sect. 170754 Bucuresti, RomaniaSERBIAVojislav LEKOVIĆ - Editor Address:Slavoljub ŽIVKOVIĆFaculty <strong>of</strong> DentistryZoran STAJČIĆ Dr Subotića 811000 Beograd, SerbiaTURKEYEnder KAZAZOGLU - EditorPinar KURSOGLUArzu CIVELEKCYPRUSGeorge PANTELAS - EditorHuseyn BIÇAKAikaterine KOSTEAAddress:Yeditepe UniversityFaculty <strong>of</strong> DentistryBagdat Cad. No 238Göztepe 81006Istanbul, TurkeyAddress:Gen. Hospital NicosiaNo 10 Pallados St.Nicosia, CyprusInternational Editorial (Advisory) BoardChristoph HÄMMERLE - Switzerland George SANDOR - CanadaBarrie KENNEY - USA Ario SANTINI - Great BritainPredrag Charles LEKIC - Canada Riita SUURONEN - FinlandKyösti OIKARINEN - Finland Michael WEINLAENDER - AustriaBALKAN STOMATOLOGICAL SOCIETYTUPNBUPMPHJDBM!!TPDJFUZCouncil:President:Past President:President Elect:Vice President:Secretary General:Treasurer:Editor-in-Chief:Pr<strong>of</strong>. P. KoidisPr<strong>of</strong>. A. IliescuPr<strong>of</strong>. H. BostanciPr<strong>of</strong>. N. SharkovPr<strong>of</strong>. A.L. PissiotisDr. E. HassapisPr<strong>of</strong>. Lj.TodorovićMembers: R. QafmollaP. KongoM. GanibegovićS. KostadinovićA. FilchevD. Stancheva ZaburkovaM. CarčevA. MinovskaT. LambrianidisS. DalambirasA. AdžićM. DjuričkovićN. FornaA. BucurD. StamenkovićM. BarjaktarevićE. KazazogluM. AkkayaG. PantelasS. SolyaliThe whole issue is available on-line at the web address <strong>of</strong> the BaSS (www.e-bass.org)
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141STOMATOLOGICAL SOCIETYVOLUME 15 NUMBER 1 March 2011 PAGES 1-56ContentsOP T. Zarra Comparative Study <strong>of</strong> Calcium Hydroxide Extrusion with 5T. Lambrianidis Different Techniques <strong>of</strong> Intra-Canal PlacementE. KostiOP V. Biočanin Efficacy <strong>of</strong> Computer-Controlled Articaine Delivery for 11M. Milić Supplemental Intraoral AnaesthesiaD. BrajkovićB. BrkovićD. StojićLj. TodorovićOP D. Sapourides Caries Experience among Greek Pomak Children Living in 15V. Topitsoglou Rural North-Eastern Greece. A Cross-Sectional StudyS. MuronidisN. KotsanosOP A. Dimkov Effects <strong>of</strong> Orbit Sugar-free Chewing Gum for Kids in Overall and 24N. Panovski Cariogenic Salivary Micr<strong>of</strong>lora ReductionE. GjorgievskaOP E. Zabokova-Bilbilova Fluoride Released from Orthodontic Bonding Material: 31A. Sotirovska-Ivkovska An In Vitro EvaluationI. GjorgovskiOP N. Topouzelis Variation <strong>of</strong> Skeletal Cephalometric Variables in 35A. Zafiriadis Class II Division 2 Patients with AgeH. MarkovitsiOP M. Popovska Clinical Oral Manifestation in Gastrointestinal Disorders 41B. StavrovaA. Atanasovska-StojanovskaP. MisevskaS. StrezovskaL. KanurkovaJ. Gjurcheski
CR M. Lazaridou Recurrent Atypical Fibroxanthoma in a Patient with Scleroderma: 48L. Zouloumis Report <strong>of</strong> a CaseK. KontosA. NikolaidouK. VachtsevanosCR A. Ntomouchtsis Unusual Penetrating Metallic Foreign Bodies Injured 52D. Maggoudi Maxill<strong>of</strong>acial and Orbital Region with Minimal DamageH. PanidouA. KondylidouK. Antoniades
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141STOMATOLOGICAL SOCIETYComparative Study <strong>of</strong> Calcium Hydroxide Extrusionwith Different Techniques <strong>of</strong> Intra-Canal PlacementSUMMARYIntroduction: To investigate Ca(OH) 2 extrusion from the apicalforamen in relation to the placement mode.Methods: 200 teeth, prepared with ProTaper files with and withoutapical patency, were divided in Groups A and B respectively, and filled withCa(OH) 2 at 1 and 3 mm short <strong>of</strong> working length, using K-files manually andwith mechanical spiral techniques (Pastinject/Lentulo) at 500 and 700rpm.Extrusion was graded as present/absent. Experimental categories werecompared using Fisher’s exact test.Results: Extrusion was observed only in teeth with patency. Therewas no extrusion with K-files in all cases and with Pastinject andLentulo inserted at 3 mm short <strong>of</strong> working length. Speed elevation did notsignificantly increase the extrusion cases.Conclusions: K-files tend to be safer than mechanical techniques.Pastinject and Lentulo at 3 mm short <strong>of</strong> working length prevented Ca(OH) 2extrusion. Raising speed from 500 to 700 rpm did not significantly increasethe extrusion risk.Keywords: Calcium Hydroxide; K-files; Lentulo; Pastinject; Patency; Rotation SpeedT. Zarra, T. Lambrianidis, E. KostiAristotle University <strong>of</strong> ThessalonikiDental School, Department <strong>of</strong> EndodonticsThessaloniki, GreeceORIGINAL PAPER (OP)Balk J Stom, 2011; 15:5-10IntroductionCalcium hydroxide Ca(OH) 2 is widely used as anintra-canal medicament. A homogenous and sufficient inlength, obturation <strong>of</strong> the root canal space with Ca(OH) 2 isessential in order to benefit from the paste’s antimicrobialeffect.Several techniques and specialized instruments forintra-canal placement <strong>of</strong> Ca(OH) 2 have been advocated.These can be divided into 3 main categories: (a) spiraltechniques, performed with hand endodontic instruments,most commonly with K-files rotated counterclockwise,or by mechanically rotating instruments used in variousspeeds ranging from as low as 150rpm for Nickel-Titanium instruments, 500rpm to 1000 rpm for theLentulo paste carrier and the Pastinject (MicroMega,Besancon, France), moderate speed (5,000rpm) for theGutta-Condensor (Maillefer, Ballaigues, Switzerland)to even higher speed (10,000 rpm) for the McSpaddencompactor (Ransom and Randolph, Toledo, Ohio);(b) ultrasonic techniques using specifically designedinstruments mounted on an ultrasonic generator, such asK-type ultrasonic files and the Meca-Shaper (Maillefer,Ballaigues, Switzerland); and (c) injection techniques,such as the Messing Root Canal Gun (Dentsply Maillefer,Ballaigues, Switzerland), the Calasept injection system(Scania Dental AB, Sweden) and the Ultracal syringesystem (Ultradent, South Jordan, UT, USA). Theselast techniques use a syringe and a needle to insertthe Ca(OH) 2 into the prepared root canals. Althoughcommonly the above techniques are used separately,a combination has also been proposed 34 . Followingplacement <strong>of</strong> the paste, condensation can be achieved withfiles, absorbent paper points and manual pluggers.The effectiveness <strong>of</strong> current techniques forCa(OH) 2 filling <strong>of</strong> the root canal space varies. Deveauxet al 7 showed that Pastinject and Lentulo provideda better filling in single-rooted teeth compared toGutta-Condensor, Meca-Shaper and K-type ultrasonicfile. Estrela et al 8 concluded that K-files rotatedcounterclockwise, combined with the use <strong>of</strong> absorbentpaper points and pluggers, achieve better quality <strong>of</strong> fillingwith less empty spaces in all thirds <strong>of</strong> the root canalcompared to Mc Spadden compactors, Lentulo spirals
6 Theodora Zarra et al. Balk J Stom, Vol 15, 2011and syringes 8 . When the Pastinject and the Lentulo weredirectly compared, Pastinject proved to be more effectivefor placement <strong>of</strong> Ca(OH) 2 7,22 . Similarly, when comparingLentulo to an injection technique, the Lentulo provideda denser and up to the desired length filling <strong>of</strong> the rootcanal 30 . However, it has been suggested that if straight orslightly curved root canals are prepared up to at least size50, high quality Ca(OH) 2 fillings can be achieved with asyringe 32 . There is discrepancy in the literature regardingthe effectiveness <strong>of</strong> different techniques. However, thereis a consensus that better filling <strong>of</strong> the root canal spacewith Ca(OH) 2 is achieved in root canals that have beenadequately instrumented, when compared to those thathave been only minimally prepared as is <strong>of</strong>ten a caseduring an emergency appointment 31,32,34 .During root canal treatment, Ca(OH) 2 dressingmaterial might unintentionally escape through the rootapex into the periapical tissues 4,6,35,21 . Although theeffectiveness <strong>of</strong> various techniques in filling the root canalspace has been widely studied 7,8,30-32 , there are no reportsin the literature on the effectiveness <strong>of</strong> those techniquesin preventing extrusion into the periapical tissues. Onlyin a pilot study on plastic blocks 34 , extrusion was notedin cases <strong>of</strong> patent blocks with the carrier placed at theworking length and therefore, in the main study, this wasprevented and thus not studied by placing tape where thecanal exited the plastic block. The aim <strong>of</strong> this study wasto investigate the frequency <strong>of</strong> extrusion <strong>of</strong> Ca(OH) 2 fromthe apical foramen in relation to the technique <strong>of</strong> intracanalplacement, the distance from the apical foramen androtation speed.Materials and Methods200 freshly extracted, fully formed human permanentsingle-rooted teeth obtained from a pool <strong>of</strong> teethwere studied. Calculus and conjunctive deposits wereremoved and teeth were kept in 10% formalin until use.2 radiographs were taken, 1 from the buccal and 1 fromthe proximal side <strong>of</strong> the tooth to verify the existence<strong>of</strong> a single non-calcified root canal with a curvature <strong>of</strong>0-10 0 according to Schneider 28 . Once the access cavitywas prepared, the working length was establishedradiographically at a distance <strong>of</strong> 1 mm from theradiographic terminus. The teeth were divided in 2 groups:Group A: The root canals were instrumented withthe ProTaper rotary files (Dentsply, Tulsa Dental, Tulsa,OK, USA) according to the manufacturer’s instructions,starting with file S1 up to file F3. Between each file,the root canal was irrigated with 2.5% NaOCl using a27-gauge needle (Ultradent Products INC, South Jordan,UT, USA) placed passively in the canal at 2-3mm short<strong>of</strong> the working length, and a #10 K-file was placed intothe root canal and advanced until the tip <strong>of</strong> the file passed1mm from the apical foramen to maintain the patency <strong>of</strong>the apical constriction.Group B: The instrumentation procedure wasidentical to that <strong>of</strong> group A but patency file was not used.After instrumentation, the root canals were driedwith paper points and the teeth were adjusted to holescreated through the rubber stoppers <strong>of</strong> vials and weresecured in place using sticky wax. The vials were handheld.The operator was shielded from seeing the root apexduring the filling procedure by a rubber dam that coveredthe vial.Pure Ca(OH) 2 powder (Merck K GaA, Darmstadt,Germany) was moistened with saline and mixed to arelatively thick paste (corresponding to a toothpasteconsistency). Then, the specimens <strong>of</strong> each group wererandomly divided into 10 experimental groups comprising10 teeth each. The groups are presented in table 1.The entire length <strong>of</strong> a size # 30 Lentulo spiral(Maillefer, Ballaigues, Switzerland) and a size #30Pastinject (MicroMega, Besancon, France) file werecoated with the paste, introduced in the canal at 1 and 3mm short <strong>of</strong> the working length and then rotated at 500and 700 rpm using a handpiece mounted on a speedand torque control machine (X-Smart, Dentsply, TulsaDental, Tulsa, OK, USA). A size #30 K-file (Maillefer,Ballaigues, Switzerland) was coated with Ca(OH) 2and introduced into the canal at 1 and 3 mm short <strong>of</strong>the working length with a counterclockwise rotationresulting in 20 subgroups (Tab. 1). For all 3 techniques<strong>of</strong> placement, the paste was condensed with a size #10plugger (Maillefer, Ballaigues, Switzerland), then driedand compacted with the blunt end <strong>of</strong> a paper point andthe procedure was repeated for a total <strong>of</strong> 3 times for eachtooth.When the intra-canal placement <strong>of</strong> Ca(OH) 2 wascompleted, the tooth-rubber stopper unit was removedfrom the mouth <strong>of</strong> the vial and the root ends were viewedunder a microscope (OPMI, Carl Zeiss Surgical Inc,Dublin, CA, USA) at x 4.5 magnification. The extrusion<strong>of</strong> Ca(OH) 2 was recorded as either present or absentby 2 examiners masked on the group and techniqueexamined. Any amount <strong>of</strong> Ca(OH) 2 that past the apicalforamen was considered extrusion (Fig. 1a and 1b.).Only if the 2 examiners agreed upon their answer, theanswer considered valid. In case <strong>of</strong> disagreement, a thirdexaminer was consulted. Cases in which there was noconsensus were excluded from the study.Fisher’s exact test was used to compare theexperimental categories, with the level <strong>of</strong> significanceset at p
Balk J Stom, Vol 15, 2011 Calcium Hydroxide Extrusion during Intra-canal Placement 7Table 1. 20 experimental sub-groups and the extrusion <strong>of</strong> Ca(OH) 2 in relation to the method <strong>of</strong> intra-canal placement, distance fromthe apical foramen and rotation speed (rpm).Group Technique Length Rotation speed (rpm) ExtrusionYes (N)No (N)LENTULO (N=40)-1mm-1mm500700-3mm 500 0 1001109A (N=100) With patencyB (N=100) Without patencyPASTINJECT (N=40)K-FILE (N=20)LENTULO (N=40)PASTINJECT (N=40)K-FILE (N=20)-3mm 700 0 10-1mm 500 3 7-1mm 700 4 6-3mm 500 0 10-3mm 700 0 10-1mm - 0 10-3mm - 0 10-1mm 500 0 10-1mm 700 0 10-3mm 500 0 10-3mm 700 0 10-1mm 500 0 10-1mm 700 0 10-3mm 500 0 10-3mm 700 0 10-1mm - 0 10-3mm - 0 10Figure 1. Figure 1.
8 Theodora Zarra et al. Balk J Stom, Vol 15, 2011ResultsThe number <strong>of</strong> teeth with extruded Ca(OH) 2 in eachgroup is shown in table 1. Patency <strong>of</strong> the apical foramensignificantly increased Ca(OH) 2 extrusion. In groupA, K-files used for intra-canal placement <strong>of</strong> Ca(OH) 2prevented extrusion; there were 8 cases <strong>of</strong> extrusionwhen mechanical spiral techniques were used; however,there was no statistically significant difference. Insertion<strong>of</strong> the paste carriers at 3 mm short <strong>of</strong> the working lengthconstricted the paste inside the root canal more efficientlycompared to insertion at 1mm short <strong>of</strong> the working length,but the difference between them was not statisticallysignificant. At 500 rpm and at 1 mm short <strong>of</strong> the workinglength, Pastinject caused extrusion <strong>of</strong> Ca(OH) 2 in 3 out <strong>of</strong>10 teeth, but the difference was not statistically significantwhen compared to the Lentulo technique, where noextrusion was detected. Elevating the speed from 500to 700 rpm did not lead to significantly more cases <strong>of</strong>extrusion for either Lentulo or Pastinject, although therewas a tendency (4 out <strong>of</strong> 10 cases) for extrusion whenusing Pastinject at 700 rpm and at 1 mm short <strong>of</strong> theworking length.DiscussionAlthough it is suggested that the deliberate extrusion<strong>of</strong> Ca(OH) 2 into the periradicular tissues may have adirect effect on inflamed tissue and epithelial cysticlinings and potentially favour periapical healing andencourage osseous repair 35 , it is not widely recommended.Extensive extrusion <strong>of</strong> Ca(OH) 2 into the periapicaltissues did not appear to compromise ultimate periapicalhealing 4,6,21 ; however, in the majority <strong>of</strong> cases, it seemedto delay it. Moreover, there are reports <strong>of</strong> immediate flareup induced by extrusion 6 . Cases with complete healing<strong>of</strong> the pre-existing periapical lesion even after 3 21 or 4years 16 with incomplete resorption <strong>of</strong> the extruded pastecontaining BaSO 4 (used to enhance its radiopacity) havealso been reported.The use <strong>of</strong> Ca(OH) 2 as an intracanal medicament hasbeen linked with a number <strong>of</strong> severe side effects. Therehave been case reports with necrosis <strong>of</strong> the gingiva andmucosa due to its alkalinity 3 , severe tissue necrosis afterintra-arterial injection 29 , orbital pain and headache 36 ,severe facial ischemia 18 , mental or inferior alveolarnerve paraesthesia after penetration <strong>of</strong> the materialinto the mandibular canal 1,24,27 , formation <strong>of</strong> antrolithsfollowing its extrusion into the antrum 10,12 and foreignbody granuloma in the nearby gingival tissues 15 . Inmice, inflammatory responses were reported followinginoculation <strong>of</strong> various Ca(OH) 2 pastes into subcutaneoustissue. The severity <strong>of</strong> the response varied by the pastetype used 5,20 .In our study, extrusion <strong>of</strong> Ca(OH) 2 was recordedas either present or absent. Similarly, previous studieson the extrusion <strong>of</strong> gutta-percha used the presence andabsence <strong>of</strong> extrusion as a criterion to evaluate the safety<strong>of</strong> filling techniques in obturating the root canals 25 . Thepositive/negative criterion is not sensitive enough todistinguish among techniques. However, the consistency<strong>of</strong> the extruded calcium hydroxide and its contact withthe root surface does not allow measurements as in thecases <strong>of</strong> debris or irrigant extrusion studied extensively inthe literature 14,17 . The techniques investigated are amongthe most widely recommended for intra-canal calciumhydroxide placement in clinical practice and they havebeen thoroughly investigated for their efficacy 7,8,22,30-32,34 .Thus, it was thought unnecessary to study their fillingefficacy. Therefore, this study presents only results <strong>of</strong> theextrusion <strong>of</strong> the material, regardless quality <strong>of</strong> the filling<strong>of</strong> the root canal in each case, as extrusion in clinicalpractice is not related to the quality <strong>of</strong> the filling.In the present study, extrusion <strong>of</strong> Ca(OH) 2 wasonly recorded in teeth where patency was preserved.Establishing patency <strong>of</strong> the apical foramen during rootcanal instrumentation to effectively prevent blockagesand loss <strong>of</strong> working length has been proposed 2,9,11 .Patency facilitates removal <strong>of</strong> debris from the entireroot canal space, especially in teeth with necrotic pulptissue and bacteria load 13 and improves tactile senseduring apical shaping and thus reduces the chances <strong>of</strong>canal transportation and ledge formation 2 . However, theconcept <strong>of</strong> apical patency is considered controversial dueto the differences in the amount <strong>of</strong> the extruded materialfound in cases with and without patency filing 2,19,33 . Inthis study, a #10 K-file was used as patency file as it wasfound that more material was extruded apically whendiameter <strong>of</strong> the apical patency increased 33 .A wide range <strong>of</strong> rotation speeds have been usedduring the spiral filling techniques, ranging from 150 upto 10,000 rpm 7,8,22,23,30-32,34 . In the present study, elevatingrotation speed from 500 to 700 rpm resulted in morecases <strong>of</strong> Ca(OH) 2 extrusion in teeth with patent apicalconstriction, but the difference did not reach statisticalsignificance.In previous studies on the effectiveness <strong>of</strong> intracanalplacement techniques <strong>of</strong> Ca(OH) 2 7,8,30-32,34 , thepaste carrier was introduced in the root canal at 0 to3 mm short <strong>of</strong> the working length. The most effectivedelivery <strong>of</strong> Ca(OH) 2 was achieved when the paste carrierswere introduced to working length 31 . In the other cases,some distance <strong>of</strong> Ca(OH) 2 from the working length wasobserved 22 . In the present study, the extrusion <strong>of</strong> Ca(OH) 2from the apical foramen was recorded when the carrierwas introduced at 1 and 3 mm short <strong>of</strong> the working length.The results <strong>of</strong> this study demonstrated that the distance<strong>of</strong> 3 mm short <strong>of</strong> the working length was safe to preventextrusion, even in teeth with patency and at 700 rpm
Balk J Stom, Vol 15, 2011 Calcium Hydroxide Extrusion during Intra-canal Placement 9rotation speed with any <strong>of</strong> the paste delivering techniquesevaluated.Our observations need to be interpreted withcaution as ex-vivo experimentation cannot be regardedas directly representative <strong>of</strong> the clinical situation. Tissuepressure and resistance by the periapical tissues in the invivo conditions may reduce the occurrence and extent <strong>of</strong>periapical extrusion <strong>of</strong> calcium hydroxide, although theexact effect <strong>of</strong> this variable is difficult to determine 36 .There is a need for more comparative studies on theefficiency <strong>of</strong> the various Ca(OH) 2 delivering techniques infilling the root canal space in order to educate the clinicianhow to maximize the antimicrobial properties <strong>of</strong> Ca(OH) 2 ,while avoiding the adverse effects caused by its extrusioninto the periapical tissues.References1. Ahlgren FK, Johannesen AC, Hellem S. Displaced calciumhydroxide paste causing inferior alveolar nerve paresthesia:Report <strong>of</strong> a case. Oral Surg Oral Mede Oral Pathol OralRadiol Endod, 2003; 96:734-737.2. Buchanan LS. Management <strong>of</strong> the curved root canals. JCalif Dent Assoc, 1989; 17:18-27.3. De Bruyne MAA, De Moor RJG, Raes FM. Necrosis <strong>of</strong> thegingival caused by calcium hydroxide: a case report. IntEndod J, 2000; 33:67-71.4. De Moor RJ, De Witte AM. Periapical lesions accidentallyfilled with calcium hydroxide. Int Endod J, 2002; 35:946-958.5. De Moraes Costa MT, De Oliveira SHP, Gomes-FilhoJE. Mechanism <strong>of</strong> calcium hydroxide-induced neutrophilmigration into air-pounch cavity. Oral Surg Oral Med OralPathol Oral Radiol Endod, 2008; 105:814-821.6. De Witte A, De Bruyne M, De Moor R. Accidental extrusion<strong>of</strong> calcium hydroxide based pastes into periapical lesions.Rev Belge Med Dent, 2003; 58 49-63.7. 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Human teeth withperiapical pathosis after overinstrumentation and overfilling<strong>of</strong> the root canals: a scanning electron microscopic study. IntEndod J, 1999; 32:40-48.14. Hülsmann MJ, Peters O, Dummer PM. Mechanicalpreparation <strong>of</strong> root canals: Shaping goals, techniques andmeans. Endodontic Topics, 2005; 10:30-76.15. Kim JW, Cho KM, Park SH, Song SG, Park MS, Jung HR,et al. Overfilling <strong>of</strong> calcium hydroxide-based paste CalcipexII produced a foreign body granuloma without acuteinflammatory reaction. Oral Surg Oral Med Oral PatholOral Radiol Endod, 2009; 107:e73-e76.16. Lambrianidis T. Risk management in root canal treatment.1 st ed, Thessaloniki: University Studio Press: 2001; pp 254-255.17. Lambrianidis T, Tosounidou E, Tzoanopoulou M. The effect<strong>of</strong> maintaining apical patency on periapical extrusion. JEndod, 2001; 27:696-698.18. Lingren P, Eriksson KF, Ringberg A. Severe facial ischemiaafter endodontic treatment. J Oral and Maxill<strong>of</strong>ac Surg,2002; 60:576-579.19. Lomcali G, Sen BH, Cankaya H. Scanning electronmicroscopic observations <strong>of</strong> apical root surfaces <strong>of</strong> teethwith apical periodontitis. Endod Dent Traumatol, 1996;12:70-76.20. Nelson Filho P, Silva LA, Leonerdo MR, Utrilla L,Figueiredo F. Connective tissue responses to calcium-basedroot canal medicaments. Int Endod J, 1999; 32:303-311.21. Orucoglu H, Cobankara F. Effect <strong>of</strong> unintentionallyextruded calcium hydroxide paste including barium sulfateas a radiopaquing agent in treatment <strong>of</strong> teeth with periapicallesions: Report <strong>of</strong> a case. J Endod, 2008; 34:888-891.22. Oztan MD, Akman A, Dalat D. Intracanal placement <strong>of</strong>calcium hydroxide: A comparison <strong>of</strong> two different mixturesand carriers. Oral Surg Oral Med Oral Pathol Oral RadiolEndod, 2002; 94:93-97.23. Peters CI, Koka RS, Highsmith S, Peters OA. Calciumhydroxide dressings using different preparation andapplication modes: density and dissolution by simulatedtissue pressure. Int Endod J, 2005; 38:889-895.24. Poveda R, Bagan JV, Fernandez MD, Sanchis JM. Mentalnerve paresthesia associated with endodontic paste withinthe mandibular canal: report <strong>of</strong> a case. Oral Surg Oral MedOral Pathol Oral Radiol Endod, 2006; 102:e46-e49.25. Robinson MJ, McDonald NJ, Mullally PJ. Apical extrusion<strong>of</strong> thermoplasticized obturating material in canalsinstrumented with Pr<strong>of</strong>ile 0.06 or Pr<strong>of</strong>ile GT. J Endod,2004; 30:418-421.26. Salzgeber RM, Brilliant JS. An in vivo evaluation <strong>of</strong> thepenetration <strong>of</strong> an irrigating solution in root canals. J Endod,1977; 22:394-398.27. Scanaro A, di Carlo F, Quaranta A, Piatelli A. Injury <strong>of</strong> theinferior alveolar nerve after overfilling <strong>of</strong> the root canal withendodontic cement: A case report. Oral Surg Oral Med OralPathol Oral Radiol Endod, 2007; 104:e56-e59.28. Schneider SW. A comparison <strong>of</strong> canal preparations instraight and curved root canals. Oral Surg, 1971; 32:271-275.29. Sharma S, Hackett R, Webb R, Macpherson D, Wilson A.Severe tissue necrosis following intra-arterial injection <strong>of</strong>endodontic calcium hydroxide: a case series. Oral Surg OralMed Oral Pathol Oral Radiol Endod, 2008; 105:666-669.30. Sigurdsson A, Stancill R, Madison S. Intracanal placement<strong>of</strong> Ca(OH) 2 : A comparison <strong>of</strong> techniques. J Endod, 1992;18:367-370.
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141STOMATOLOGICAL SOCIETYEfficacy <strong>of</strong> Computer-Controlled Articaine Delivery forSupplemental Intraoral AnaesthesiaSUMMARYObjective. The aim <strong>of</strong> this study was to investigate quality and safety<strong>of</strong> supplemental intraoral anesthesia - periodontal ligament anaesthesia(PDL) and intraseptal anaesthesia (ISA) after computer-controlled articainedelivery.Method. 54 ASA I volunteers randomly divided into 2 groupsparticipated in this study. 0.4 ml <strong>of</strong> 4% articaine with 1:100.000 epinephrinewere randomly administered with computer-controlled local anaestheticdelivery system on the mesial and distal side <strong>of</strong> maxillary lateral incisor forISA or PDL. An electric pulp tester was used to test the pulpal anaesthesia, in2-minute cycles for 60 minutes. Anaesthesia was considered successful when2 or more consecutive no-response at 80 readings were obtained. S<strong>of</strong>t-tissueanaesthesia was measured by pin-prick test.Results. Success rates for ISA and PDL were 77.8% and 55.6%respectively, but difference was not statistically significant (p>0.05). Duration<strong>of</strong> complete pulpal anaesthesia was significantly longer (p
12 Vladimir Biočanin et al. Balk J Stom, Vol 15, 2011tissue resistance 7 . CCLADS provides less painfulinjections than traditional system 19,22 . Likewise, thissystem enables clinicians to perform easier, faster,more reliable and less painful dental anaesthesia andis better accepted by patients than standard method <strong>of</strong>injection 4 . Traditionally, PDL and ISA have been usedwith a conventional or high pressure syringe 10,11,12with the possibility to change parameters <strong>of</strong> thecardiovascular function 3,15 . However, Nusstein et al 13reported that PDL used with CCLADS did not causeneither significant nor clinically meaningful increasein heart rate. Evaluation <strong>of</strong> the anaesthetic parametersshowed that duration <strong>of</strong> complete pulpal anaesthesiausing CCLADS with PDL was about 30 minutes incomparison with conventional pressure syringe whereduration was 10-15 minutes 2,8,9 .The aim <strong>of</strong> this study was to investigate quality andsafety <strong>of</strong> the intraoral supplemental anaesthesia (PDLand ISA) after computer-controlled articaine delivery(CCArtD).Method54 randomly selected ASA I volunteers participatedin this study. All patients were informed <strong>of</strong> the goals<strong>of</strong> the study and signed a written consent. The studywas approved by the Etical Committee <strong>of</strong> the Faculty <strong>of</strong>Dentistry, University <strong>of</strong> Belgrade. Persons were randomlydivided into 2 groups: (1) the 1 st group (27 volunteers)undergone the ISA; (2) the 2 nd group (27 volunteers)undergone the PDL. The tested tooth was upper lateralincisor. Previous clinical examination indicated that allthe tested teeth were free <strong>of</strong> caries, large restorations orperiodontal disease, and none had a history <strong>of</strong> trauma orsensitivity.The local anaesthetic injected was 4% articaine with1:100 000 epinephrine (Septanest ®, Septodont, France).The total dose <strong>of</strong> anaesthetic solution was 0.4 ml pertooth, both for ISA and PDL. Time <strong>of</strong> local anaestheticadministering, 0.2 ml mesially and 0.2 ml distally, wasapproximatelly 80 seconds (40 seconds at each side).Anaesthetic solution was injected with computercontrolledlocal anaesthetic delivery system (Anaeject®,Septodont, France) with constant pressure and speed,approximately 0.005 ml per second.The site <strong>of</strong> needle insertion for ISA was 2-3 mmabove the tip <strong>of</strong> interdental papilla, with 90° angulation <strong>of</strong>the needle to the surface <strong>of</strong> the papilla, until contact withthe bone. Blanching <strong>of</strong> the gingiva overlying bone wasindicator that the anaesthetic solution had been properlydeposited. The site <strong>of</strong> needle insertion for PDL was theregion <strong>of</strong> gingival sulcus at 30° to the tooth long axis atbucomesial and bucodistal aspect <strong>of</strong> the rooth. We used a30G short needle (Septodont®, Dental Needle, France),both for ISA and PDL.Duration and success <strong>of</strong> pulpal anaesthesia <strong>of</strong> theupper lateral incisor were evaluated using tooth vitalitytester (Vitality Scanner Model 2006®, Sybron Endo).Fluoride gel (Fluorogal forte®, Galenika, Beograd)was used as an electrolyte between the pulp tester probeand the tooth. Before the injections were given, theexperimental tooth and control contralateral canine weretested 3 times by means <strong>of</strong> a Vitality Scanner, Model2006, to record baseline vitality. After administeringanaesthesia, electrical stimulation was repeated every2 min until the reading became lower than 80 (max).Duration <strong>of</strong> complete pulpal anaesthesia was periodbetween the first and the last 80 readings on electricalpulp tester. Anaesthesia was considered successful when2 or more consecutive no response at 80 readings wereobtained.S<strong>of</strong>t tissue anaesthesia was measured as absence<strong>of</strong> pain when pin-prick test was used in the region <strong>of</strong>the attached gingiva. The width <strong>of</strong> the anaesthetic field,expressed in millimetres, was measured 5 min after thelocal anaesthetic injection by flexible ruler and pinpricktesting in the region <strong>of</strong> the attached gingiva and oralmucosa. We used 27 gauge needle (MonoJect®, DentalNeedle, Mansfield, USA) for pin prick testing. Pinpricktesting was done directly until contact with the periosteumoccured, immediately after the end <strong>of</strong> injection, every5 min during the first 20 min, and after that every 2 minuntil patient felt blunt pain.Patients were followed for 5 days to record anylocal postoperative side-effects, such as postoperativesensitivity to bite, papillary necrosis, postoperative pain orswelling.Statistical analysis was performed by using statisticals<strong>of</strong>tware SPSS, version 10.0. The results were analysed byunpaired t-test (2-tailed), Man-Whitney non-parametrictest and χ² test.ResultsThere were no statistical significant differences(p>0.05) between the groups in respect to the successrate <strong>of</strong> pulpal anaesthesia achieved by both techniques;ISA being slightly more successful (77.8%) than PDL(55.6%).Significantly wider area <strong>of</strong> the anesthetized attachedgingiva and oral mucosa at the buccal aspect <strong>of</strong> the toothwere obtained by ISA in comparison with PDL (Tab. 1).Duration <strong>of</strong> complete pulpal anaesthesia (Tab.2) was significantly longer with ISA than with PDL(p
Balk J Stom, Vol 15, 2011 Computer-Controlled Articaine Anesthesia 13ISAPDLpTable 1. Width <strong>of</strong> the anaesthetized field obtained by theemployed techniquesAnaesthetized area (mean ± SD)Attached gingiva (mm)20.33 ± 11.097.15 ± 7.81p
14 Vladimir Biočanin et al. Balk J Stom, Vol 15, 201111. Malamed SF. Supplemental injection techniques. In:Malamed SF (ed). Handbook <strong>of</strong> local anesthesia. 5th ed. St.Louis: Mosby, 2004; pp 255-261.12. Meechan JG. Intraligamentary anaesthesia. Review. J Dent,1992; 20:325-332.13. Nusstein J, Berlin J, Reader A, Beck M, Weaver JM.Comparison <strong>of</strong> injection pain, heart rate increase, andpostinjection pain <strong>of</strong> articaine and lidocaine in a primaryintraligamentary injection administered with a computercontrolledlocal anesthetic delivery system. Anesth Prog,2004; 51(4):126-133.14. Oertel R, Rahn R, Kirch W. Clinical pharmacokinetics <strong>of</strong>articaine. Clin Pharmacokinet, 1997; 33:417-425.15. Pashley D H. Systemic effects <strong>of</strong> intraligamental injections.J Endod, 1986; 12(10):501-504.16. Raymond SA, Steffensen SC, Gugino LD, Strichartz GR.The role <strong>of</strong> length <strong>of</strong> nerve exposed to local anesthetics inimpulse blocking action. Anesth Analg, 1989; 68:563-570.17. Roahen JO, Marshall J. The effects <strong>of</strong> periodontal ligamentinjection on pulpal and periodontal tissues. J Endod, 1990;16(1):28-33.18. Saadoun AP, Malamed SF. Intraseptal anesthesia inperiodontal surgery. JADA, 1985; 111:249-256.19. Sumer M, Misir F, Koyuturk E. Comparison <strong>of</strong> the wandwith a conventional technique. Oral Surg Oral Med OralPathol Oral Radiol Endod, 2006; 101:e106-e109.20. White JJ, Reader A, Beck M, Meyers WJ. The periodontalligament injection: a comparison <strong>of</strong> the efficacy inhuman maxillary and mandibular teeth. J Endod, 1988;14(10):508-514.21. Woodmansey K. Intraseptal anesthesia: a review <strong>of</strong> arelevant injection technique. Gen Dent, 2005; 53(6):418-420.22. Yeniseu M. Comparison <strong>of</strong> the pain levels <strong>of</strong> computercontrolledand conventional anesthesia techniquesin prosthodontic treatment. J Appl Oral Sci, 2009;17(5):414-420.Correspondence and request for <strong>of</strong>fprints to:Dr. Vladimir BiočaninUniversity <strong>of</strong> Belgrade, Faculty <strong>of</strong> DentistryClinic <strong>of</strong> Oral SurgeryBelgrade, Serbiae-mail: vladimirbiocanin@gmail.com
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141STOMATOLOGICAL SOCIETYCaries Experience among Greek Pomak ChildrenLiving in Rural North-Eastern Greece.A Cross-Sectional StudySUMMARYPomaks are a cultural and religious minority living in a rural area <strong>of</strong>Northeastern Greece, with several factors predisposing them to a very highcaries risk. The main aim <strong>of</strong> the study was to assess caries prevalence <strong>of</strong>Pomak schoolchildren. A cross-sectional survey was carried out on a total <strong>of</strong>700 children 6-12 years old, visually examined in the classroom according toWHO criteria. Generalized Linear Models (GLMs) with Poisson distributionwith over dispersion and Binomial models were preferred (SPSS v16).The SiC DMFT index was 5.64 (SD = 1.86) in 12-year-old Pomaks, whilethe mean DMFT was 3.85 (95%CI: 3.13; 4.56), almost twice the nationalaverage for Greece (2.05, SD 2.50). The proportion <strong>of</strong> children with severecaries (DMFT≥4) was about 70% at the age <strong>of</strong> 12. Similarly increasedvalues were found in 6-year-olds [dmft =5.49 (95%CI: 4.46; 6.51) andSiC dmft = 10.48 (SD 2.74)]. Cavity-free children varied by age between 17%for younger children and 3% for older ones. Despite the high dt and thesteeply rising DT values with age, Care indices were extremely low.In conclusion, Pomak schoolchildren have the worst caries indices inGreece, somewhat similar to the values found in urban children 30 years,ago. Thus, oral health promotion policies, using the whole populationapproach strategy, need to be particularly targeted on the Pomak villages.Keywords: Caries Prevalence; Children; Cross-Sectional; Rural;Poisson distribution; PomaksD. Sapourides 1 , V. Topitsoglou 2 , S. Muronidis 3 ,N. Kotsanos 1Aristotle University <strong>of</strong> Thessaloniki1 School <strong>of</strong> Dentistry Department <strong>of</strong> PaediatricDentistry2 School <strong>of</strong> Dentistry, Department <strong>of</strong> PreventiveDentistry, Periodontology and Implant Biology3 School <strong>of</strong> Mathematics, Section <strong>of</strong> Statistics andOperations ResearchThessaloniki, GreeceORIGINAL PAPER (OP)Balk J Stom, 2011; 15:15-23IntroductionAccording to the results <strong>of</strong> a recent Greek nationalsurvey <strong>of</strong> oral health status 25 , the caries experience <strong>of</strong>children and adolescents in Greece has significantlydeclined in the last 30 years. For example, the DMFTindex for 12 year olds has decreased from 4.30 to 2.05.These favorable data, however, mainly reflect cariesdecline in the urban population.Certain parameters e.g. residential area, age,education level and socio-economic status have an impacton caries scores, as previously reported for variouscountries 2,13,20,23,26,27 and specifically for Greece 6,8,25 .Additionally, some striking differences have been reportedin the oral health <strong>of</strong> children <strong>of</strong> ethnic minorities. Mostnotable inequalities were noted in Australia, whereindigenous 5-6 year-old children experienced from 2 to4 times higher caries scores than their non-indigenouscounterparts 10,19 . It is well documented that, in general,oral health in industrialized countries is associated withimproved living conditions and various social factors, oralhygiene, regular use <strong>of</strong> fluoride and implementation <strong>of</strong>public health policies 1,28 . However, preventive strategiesmay be relatively ineffective, and oral health related needssignificantly greater, among poor and disadvantagedgroups within these communities 26 .The dental care system in Greece is largely basedon the private sector and utilization <strong>of</strong> dental servicesis highly dependent on family income 16 . Primary carefor children, however, including the implementation <strong>of</strong>oral health educational programs, is to a large extentdelivered at Public Dental Health centres. In some areasthat are remote and isolated areas, or where centres arelacking or difficult to access, high caries scores havebeen recorded, especially for primary teeth 18 . Western
16 Balk D. J Stom, Sapourides Vol 15, et 2011 al. Caries Experience among Rural Greek Balk J Pomak Stom, Children Vol 15, 2011 16Thrace, the Northeastern region <strong>of</strong> mainland Greece, ishomeland to about 36.000 Pomaks, who live in raciallyautonomous communities, mainly in a deprived highlandrural area close to the border with Bulgaria. The villagesconstitute culturally unique Islamic communities,speaking a language with Slavic roots and receivingeducation in Greek, with Turkish as a foreign language 33 .Educational levels tend to be low, as a considerableproportion <strong>of</strong> children, especially girls, receive onlyelementary education. Transport to urban/semi-urbanplaces is complicated, especially during adverse weatherconditions, because <strong>of</strong> the topography and harsh landscape<strong>of</strong> the highland villages.There is only limited information available on theoral health status <strong>of</strong> the Pomak child population and thelast national oral health survey 25 did not contain any suchdata. Consequently, the main aim <strong>of</strong> the present study wasto assess prevalence and treatment needs for caries and,secondly, to record obvious orthodontic problems in thePomak child population <strong>of</strong> primary school age.MethodsThis cross-sectional study was conducted withinthe frames <strong>of</strong> social and health interests for the mainlandborder territories <strong>of</strong> the local Contingent <strong>of</strong> the HellenicArmed Forces, the Health Section <strong>of</strong> which acted asthe ethics committee. Invitation for schoolchildren toparticipate in this oral examination was extended toparents orally by informed school authorities.Population SampleOut <strong>of</strong> the existing 50 Pomak villages, 37 had a stateelementary school with a total student population <strong>of</strong> 1,430.13 schools were selected on the basis <strong>of</strong> geographicaluniform distribution and population size, and all theirstudents were included in the study. The great variability<strong>of</strong> student numbers prevented a perfect factorial design.All children present at school on the examination day wereexamined, comprising a total <strong>of</strong> 700 children (46% malesand 54% females) aged between 6 and 12 years (Tab. 1).Exact ages were calculated according to the formula: (date<strong>of</strong> examination - date <strong>of</strong> birth) / 365.The vast majority <strong>of</strong> Pomak families have lowincomestatus derived from agricultural work, cattleraisingor manual work. The natural fluoride content <strong>of</strong>water in the whole region is so low as to be negligible,except for one village called Μeses Τhermes with 0.65ppm F and only 4 child inhabitants 34 . There were no dataon fluoride toothpaste consumption.Table 1. Number <strong>of</strong> students (total n = 700) examined accordingto age, gender and number <strong>of</strong> inhabitants in their residenceVariablesAge (years)Sample distributionn (%)6 74 (10.6)7 148 (21.1)8 134 (19.1)9 131 (18.7)10 84 (12.0)11 96 (13.7)12 33 (4.7)GenderMale 321 (45.9)Female 379 (54.1)Residence (population size)
Balk J Stom, Vol 15, 2011 Caries Experience among Rural Greek Pomak Children 17Statistical AnalysisIn comparing caries levels with non-normaldistribution, the Generalized Linear Models (GLMs)with Poisson distribution with over dispersion waspreferred 11,19 . In addition, Binomial models were set upto model the dichotomous outcomes. Data processing wasperformed with SPSS s<strong>of</strong>tware program (v16, Chicago,IL, USA). The alpha level in all tests was set at 0.05.The dependent variables (responses) were: themagnitude <strong>of</strong> indices DMFT with 13 levels (0-12)and dmft with 20 levels (0-19), the presence <strong>of</strong> caries2 levels (Yes, No) and the presence <strong>of</strong> Orthodonticproblem (Yes, No). The independent variables (factors)were Age: 7 levels (6-12 year old), Residence accordingto population size: 3 levels (
18 D. Sapourides et al. Balk J Stom, Vol 15, 2011respectively) confirming the statistical analysis that “Age”plays an important role in the recognition <strong>of</strong> orthodonticproblems (Model-5).The DMFT was higher in girls (1.82, 95%CI: 1.63;2.01) than in boys (1.52, 95%CI: 1.32; 1.71), especiallyat ages older than 7, and as it was found in Model-1, thefactor “gender” statistically significantly affected themagnitude <strong>of</strong> DMFT. On the other hand, dmft was lowerin girls (3.40 CI: 95%, 3.07; 3.72) than in boys (3.84 CI:95%, 3.45; 4.23), but here the factor “gender” did notsignificantly affect the magnitude <strong>of</strong> dmft (Model-2). Inboys, as well as in girls, there were no differences in thepercentage <strong>of</strong> caries free children (%DMFT+dmft = 0)and <strong>of</strong> Care indices (FT/DMFT% and ft/dmft%).Table 2. Analysis <strong>of</strong> variance (ANOVA) using generalized linear models (n = 700)Type III analysis Factors Degrees <strong>of</strong> freedom (df) SignificanceModel-1 Gender 1 0.000(influence on DMFT)Age 6 0.000Residence 2 0.003Age * Residence 12 0.008Goodness <strong>of</strong> fit Deviance Value =1007.137, df=678, Value/df =1.485Excluded stepwiseFactor Orthodontic problem and all the 2-way interactions <strong>of</strong> Orthod- problem & Gender p>0.05)Model-2 Gender 1 0.354(influence on dmft)Age 6 0.000Residence 2 0.126Orthodontic problem 1 0.848Goodness <strong>of</strong> fit Deviance Value =602.651, df=689, Value/df =0.875Excluded stepwiseAll the 2-way interactions (p>0.05)Model-3 Gender 1 0.001(influence onDMFT≠0 or =0, Yes/No)Residence 2 0.000Orthodontic problem 1 0.007Goodness <strong>of</strong> fit Deviance Value =11.651, df=7, Value/df =1.664Excluded stepwiseFactor Age and all the 2-way interactions (p>0.05)Model-4 Gender 1 0.568(influence ondmft≠0 or =0, Yes/No)Age 6 0.000Residence 2 0.955Goodness <strong>of</strong> fit Deviance Value =40.421, df=32, Value/df =1.263Excluded stepwiseFactor Orthodontic problem and all the 2-way interactions (p>0.05)Model-5 Age 6 0.001(influence onOrthod. problem, Yes/No)Residence 2 0.017Goodness <strong>of</strong> fit Deviance Value =40.421, df=32, Value/df =1.263Excluded stepwiseFactor Gender and all the 2-way interactions (p>0.05)
Balk J Stom, Vol 15, 2011 Caries Experience among Rural Greek Pomak Children 19Table 3. Permanent dentition: Mean DMFT and its components per variable testedVariablesAge (years)DMFTMean (95% CI)DTMean (95% CI)MTMean (95% CI)FTMean (95% CI)6 0.46 (0.24;0.68) 0.46 (0.24;0.68) 0.01 (0.00;0.03) 0.07 (0.01;0.13)7 0.66 (0.48;0.83) 0.57 (0.41;0.74) 0.01 (0.00;0.03) 0.07 (0.01;0.13)8 0.99 (0.79;1.20) 0.91 (0.72;1.10) 0.01 (0.00;0.02) 0.07 (0.01;0.14)9 1.87 (1.60;2.14) 1.61 (1.35;1.88) 0.07 (0.02;0.12) 0.19 (0.10;0.28)10 2.50 (2.13;2.87) 2.26 (1.90;2.62) 0.12 (-0.03;0.27) 0.12 (0.03;0.21)11 3.45 (3.01;3.88) 2.88 (2.43;3.32) 0.28 (0.16;0.40) 0.29 (0.14;0.45)12 3.85 (3.13;4.56) 3.27 (2.66;3.89) 0.27 (-0.01;0.56) 0.30 (0.06;0.55)GenderMale 1.52 (1.32;1.71) 1.35 (1.16;1.54) 0.06 (0.03;0.10) 0.11 (0.06;0.15)Female 1.82 (1.63;2.01) 1.56 (1.39;1.74) 0.10 (0.05;0.15) 0.16 (0.10;0.21)Residence (population size)
20 D. Sapourides et al. Balk J Stom, Vol 15, 2011Figure 1. Mean caries indices (DMFT, dmft) and the respectiveSignificant Caries indices (SiC) for ages 6-12Figure 2. Permanent dentition. Percentage <strong>of</strong> children distributed in 3groups according to the magnitude <strong>of</strong> their DMFT index, per ageFigure 3. Primary dentition. Percentage <strong>of</strong> children distributed in 3groups according to the magnitude <strong>of</strong> their dmft index, per ageDiscussionThis survey documents the markedly low level<strong>of</strong> dental health <strong>of</strong> Greek Pomak children living inremote communities in a deprived highland region<strong>of</strong> Northeastern Greece. Apart from the unfavourableeducational, socioeconomic and geographical parametersalready described, dietary or cultural factors mayexacerbate the problem. Pomaks are Muslims and the diet<strong>of</strong> some Muslim populations is reported to be rich in sugarproducts 7,17,24 . Additionally, a study among rural Muslimwomen in Israel reported that 60% <strong>of</strong> all postpartumwomen gave sugar water during the first week <strong>of</strong> life 3and another in the USA described that Islamic women arerecommended to breast feed their <strong>of</strong>fspring for 2 years,if possible 30 . Both these practices, in the absence <strong>of</strong> oralhygiene and any fluoride exposure (i.e. through toothpasteor drinking water) may be reasons for early childhoodcaries 35,36 , affecting the caries status <strong>of</strong> the present studypopulation.The caries experience <strong>of</strong> 12-year-old Pomakschoolchildren (DMFT = 3.85, SD ± 2.02) <strong>of</strong> the presentstudy was much higher than that <strong>of</strong> Christian Orthodoxchildren <strong>of</strong> the same age from either the greater ruralThrace area, recorded ten years earlier (DMFT = 2.51,SD ± 1.96) 12,34 , or from the nearby rural lowland county(DMFT = 1.81, SD ± 2,12) 9 and the national rural average(DMFT = 2.23) 25 .The average 6-year-old Pomak had 6 carious teeth,5.5 primary and 0.5 permanent teeth. The presence <strong>of</strong>severe caries (dmft≥4) by age 7 in 71% <strong>of</strong> the Pomaksis disappointing and indicative <strong>of</strong> a very early onset <strong>of</strong>the disease, and this is not related to population size<strong>of</strong> community <strong>of</strong> residence (Model-2). By the ages <strong>of</strong>8, 9 and 10, about half <strong>of</strong> children had 1 to 3 cariouspermanent teeth. Furthermore, it is alarming that onethird <strong>of</strong> the 6-year-olds had almost twice the mean valuefor that age (SiC dmft =10.48 SD ± 2.74). Such a severecarious status vindicates the adequacy <strong>of</strong> visual toothexamination.Differences <strong>of</strong> at least this magnitude in cariousindices have relatively recently been reported in Australia.Indigenous 5 to 6-year-olds from South Australia had onaverage 3.2 carious primary teeth, while the equivalentAustralian mean was 1.44 10 . Even more strikingly,indigenous children from a Northern Territory <strong>of</strong>Australia at age 5 years had almost 4 times the dmft andat age 10 years had almost 5 times the DMFT <strong>of</strong> theirnon-indigenous counterparts 15 . The authors considered itmore appropriate that, from a health policy perspective,correcting this inequality would require a public healthand clinical effort aimed at the indigenous children as awhole.It can be seen in table 2 that factor Age wassignificant for the magnitude <strong>of</strong> DMFT (Model-1), butit did not have any significant influence on whether achild did or did not have caries (Model-3). Subsequently,it shows that children who have caries activity acquiremore and more affected teeth, as time (in this instance“Age”) has a cumulative effect 21 . For this reason it is clearwhy it is necessary to use statistical models that studythe outcome <strong>of</strong> caries experience as a binary variable incombination with models that study the complete DMFTor dmft scale as a whole.
Balk J Stom, Vol 15, 2011 Caries Experience among Rural Greek Pomak Children 21The next striking consequence <strong>of</strong> the high cariesindices is the very high level <strong>of</strong> treatment need, as DT andDMFT or dt and dmft differed very little (Tabs. 3 and 4).While the national 25 mean Care index for permanent teethin 12-year-old children was 55.3% and in the greater ruralThrace 47.5%, Pomak 12-year olds had a mere 7.9%.Regarding the quarter <strong>of</strong> 11 to 12-year-old Pomakchildren with orthodontic problems, none were currentlyundergoing treatment. This somewhat low prevalence<strong>of</strong> malocclusion can be explained mainly by the fact thatantero-posterior molar relationship was not recorded.Mesial drift, as a result <strong>of</strong> frequent space loss due tothe extensive carious lesions <strong>of</strong> primary molars makesdiagnosis <strong>of</strong> true Class II malocclusions difficult in fieldstudies where such high caries indices are prevalent.However, similar malocclusion figures, and even lower,have been recorded, e.g. in India in 12-15 year olds usingthe DAI index 31 .In general, children residing in rural areas <strong>of</strong> the USAtended to have less access to, and utilization <strong>of</strong> dental carecompared to children residing in urban areas 37 . In Greece,utilization <strong>of</strong> private dental services is highly dependenton family income 39 and, as a result, children from moredeprived areas have a significantly lower mean Careindex 16 . This situation probably also affects Pomaks whocould, however, visit the Public Health Centre, locatedin the largest village <strong>of</strong> our study area, or the dentaldepartments <strong>of</strong> the civic or military hospitals, locatedat a distance <strong>of</strong> 20-50 km away in the province capitaland receive basic treatment for free. However, access tohealth care except for an urban-rural dimension seemsto have one <strong>of</strong> cultural/religious isolation. The minimaldental care <strong>of</strong> Pomaks is characterized by a problemorienteddental visiting pattern similar to that reported forthe remote lands <strong>of</strong> Australia 29 , containing elements <strong>of</strong> avisible appearance visiting pattern reported for cariousteeth <strong>of</strong> Mexican immigrants’ children in a small UScity 14 .According to the proposals made by Bratthall 5 , theSiC index for 12-year-olds should be less than 3 by theyear 2015 and Pomak 12-year-olds had almost double thatfigure (SiC DMFT =5.64, SD ± 1.86). To achieve this goalin time needs careful planning by both the health and thetransport authorities. A person’s environment is the mostimportant caries-promoting factor and, fortunately, thefactor more amenable to change than, for example, geneticfactors. Facilitating the transportation <strong>of</strong> the children toPublic Health Centre, providing oral health educationand specific target treatment measures (e.g. fluoridetreatment and placement <strong>of</strong> fissure sealants on everyposterior erupting tooth) together with regular recalls,are among measures necessary to be taken for timelyimprovements. In this, the Muslim culture (tradition, diet,rules and habits) <strong>of</strong> our study area is worth additionalconsideration. Oral health education especially forgirls, who frequently become mothers at an early age 33 ,could significantly increase brushing with fluoridatedtoothpaste for themselves and their children.This studyidentified one pocket <strong>of</strong> rural Greek population - <strong>of</strong> adiverse religious and cultural background - exhibitingextreme caries indices and care needs, as it has beenreported for non-immigrant small population sectionselsewhere 15 . Inequalities in oral health care constitute anethical problem and these reports increase awareness forthe underprivileged in the making <strong>of</strong> political decisionsfor planning oral care 29 . Furthermore to alleviatingdental pain and discomfort for these children, a particularcountry’s attempt to improve caries indices <strong>of</strong> childpopulation is benefited when preventing dental disease inhigh-risk groups 32 .Possible limitations <strong>of</strong> the present study could bethose related to the adopted field study examinationprotocol. Recording dental plaque deposits, periodontalstatus, oral hygiene and dietary habits would allow betterclinical view <strong>of</strong> the oral situation <strong>of</strong> those children.Further studies could also investigate and compare theoral health status <strong>of</strong> Pomak children residing in evengreater numbers in neighbouring communities in Bulgaria.ConclusionsIt is remarkable that Pomak schoolchildren have thehighest caries indices in Greece today, and these indicesare similar to the values found in urban locations inGreece 30 years ago. Health promotion policies, usingthe whole population approach strategy, as opposedto high-risk, need to be particularly targeted on thisgeographically and socially isolated community <strong>of</strong>Pomaks.Acknowledgements. This survey was performed whilethe prime author was serving his duty in the HellenicArmed Forces as a dental <strong>of</strong>ficer. The authors wish tothank Pr<strong>of</strong>. I. Antoniou <strong>of</strong> the School <strong>of</strong> Mathematics,Aristotle University <strong>of</strong> Thessaloniki, for supportinginterdepartmental cooperation and Ch. Chatzipolichronis,DDS and K. Manthos, DDS for assistance during clinicalexaminations.References1. Aleksejūnienė J, Holst D, Balciūnienė I. Factors influencingthe caries decline in Lithuanian adolescents - trends in theperiod 1993-2001. Eur J Oral Sci, 2004; 112:3-7.2. Al-Malik MI, Holt RD, Bedi R. Prevalence and patterns <strong>of</strong>caries, rampant caries, and oral health in two- to five-year-oldchildren in Saudi Arabia. J Dent Child, 2003; 70:235-242.
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Ann N Y Acad Sci, 2008;1136:161-171.27. Petersen PE. Sociobehavioural risk factors in dentalcaries-international perspectives. Community Dent OralEpidemiol, 2005; 33:274-279.28. Petersen PE. Inequalities in oral health. The social contextfor oral health. In: Pine C, Harris R (Eds). CommunityOral Health. 2 nd ed. Quintessence Publishing Co. Ltd,2007; pp 31-58.29. Schwarz E. Access to oral health care - an Australianperspective. Community Dent Oral Epidemiol, 2006;34:225-231.30. Shaikh U, Ahmed O. Islam and infant feeding. BreastfeedMed, 2006; 1:164-167.31. Shivakumar KM, Chandu GN, Subba Reddy VV, ShafiullaMD. Prevalence <strong>of</strong> malocclusion and orthodontictreatment needs among middle and high school children <strong>of</strong>Davangere city, India by using Dental Aesthetic Index. JIndian Soc Pedod Prev Dent, 2009; 27:211-218.32. Swedberg Y, Fredén H, Norén JG. Caries extreme groupsamong adolescents, leaving organised dental care inGöteborg, Sweden. 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Balk J Stom, Vol 15, 2011 Caries Experience among Rural Greek Pomak Children 2336. Valaitis R, Hesch R, Passarelli C, Sheehan D, SintonJ. A systematic review <strong>of</strong> the relationship betweenbreastfeeding and early childhood caries. Can J PublicHealth, 2000; 91:411-417.37. Vargas CM, Ronzio CR, Hayes KL. Oral health status <strong>of</strong>children and adolescents by rural residence, United States. JRural Health, 2003; 19:260-268.38. World Health Organization. Oral health surveys - Basicmethods. 4 th ed. Geneva: WHO, 1997.39. Zavras D, Economou C, Kyriopoulos J. Factors influencingdental utilization in Greece. Community Dental Health,2004; 21:181-188.Correspondence and request for <strong>of</strong>fprints to:Dr. Nikolaos KotsanosAristotle University <strong>of</strong> Thessaloniki, School <strong>of</strong> DentistryDepartment <strong>of</strong> Paediatric Dentistry541 24, Thessaloniki, GreeceE-mail: kotsanos@dent.auth.gr
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141STOMATOLOGICAL SOCIETYEffects <strong>of</strong> Orbit Sugar-free Chewing Gum for Kids inOverall and Cariogenic Salivary Micr<strong>of</strong>lora ReductionSUMMARYThe effects <strong>of</strong> Orbit sugar-free chewing gum in plaque acid attackneutralisation, food debris removal, and saliva secretion rate stimulation,have already been clinically proven. Sugar alcohols, which have sincerecently been considered to have a direct impact on bacterial cells, areamong the ingredients <strong>of</strong> this chewing gum. The objective <strong>of</strong> this study wasto gain knowledge <strong>of</strong> the effects <strong>of</strong> Orbit sugar free chewing gum for kidswith calcium addition in overall salivary flora reduction, and particularlyin the reduction <strong>of</strong> the cariogenic oral microorganisms, as direct factorsleading to dental decay.The research included a group <strong>of</strong> 24 healthy schoolchildren <strong>of</strong> bothgender at the age between 8 and 13. All participants had good oral health,similar hygiene and diet regimens, and similar DMF indices. In order toobtain higher precision and accuracy, the same group was also used as acontrol group, so that saliva samples were taken twice: once before and once20 minutes after Orbit chewing gum had been chewed. The microbiologicalanalyses were performed at the Institute <strong>of</strong> Microbiology and Parasitology<strong>of</strong> Skopje Medical Faculty. The counts <strong>of</strong> Streptococcus mutans (SM) andLactobacillus species (LB) were determined by commercially available CRTbacteria strips, whereas the total count <strong>of</strong> saliva microbials was determinedby standard microbiological methods.Significant reductions in salivary SM and LB levels, and declines in thetotal count <strong>of</strong> aerobe and anaerobe bacteria, and Candida albicans as well,were observed in all cases.Keywords: Chewing Gum; Cariogenic Microorganisms; Salivary Microorganisms;Streptococcus mutans; Lactobacillus speciesAleksandar Dimkov 1 , Nikola Panovski 2 ,Elizabeta Gjorgievska 11 Faculty <strong>of</strong> Dental MedicineDepartment <strong>of</strong> Paediatric Dentistry2 Medical FacultyInstitute <strong>of</strong> Microbiology and ParasitologySkopje, FYROMORIGINAL PAPER (OP)Balk J Stom, 2011; 15:24-30IntroductionThe fact that microorganisms are one <strong>of</strong> the mostessential factors in dental disease etiology arousesthe question <strong>of</strong> how to eliminate or reduce them tominimal values. Because <strong>of</strong> that, the major prerequisiteis typological and numerical verification <strong>of</strong> themicroorganisms. On the other hand, the key factor <strong>of</strong> the“struggle” against them is proper maintenance <strong>of</strong> oralhygiene.In spite <strong>of</strong> a considerable number <strong>of</strong> substancesand methods for oral hygiene, since recently sugar-freechewing gums have gained strong influence, particularlyamong the young population. Sugar-free chewing gum hasa positive benefit for dental health by increasing salivaryflow during chewing, which helps to dilute and neutraliseplaque acidity. There is general scientific agreement nowthat chewing sugar-free gum, amongst other things, canhelp to protect teeth against decay.Over the last 25 years there has been considerableclinical research into the effect <strong>of</strong> salivary stimulation andthe role <strong>of</strong> saliva in oral health. Clinical evidence suggeststhat sugar-free gum not only will not decay teeth, but thatit will reduce the acidic effects caused by other foods, ifchewed after meals and snacks.Both the chewing action and the taste <strong>of</strong> sugar-freegum stimulate the production <strong>of</strong> extra saliva by up to10 times the normal rate. Stimulation <strong>of</strong> salivary flowchanges its composition and increase concentration <strong>of</strong>bicarbonate, which enhance its ability to neutralise plaque
Balk J Stom, Vol 15, 2011 Effects <strong>of</strong> Sugarfree Chewing Gum on Salivary Micr<strong>of</strong>lora 25acid. Also, as salivary flow increases, the availability <strong>of</strong>minerals is increased, helping to repair early tooth decay.There are many indications that dissolved calciumcan inhibit demineralisation <strong>of</strong> the enamel, servingas a substrate for remineralisation <strong>of</strong> the teeth. Mostchildren love sweets and are very fond <strong>of</strong> eating betweenmeals. Because after each snack or drink that is rich incarbohydrates the pH <strong>of</strong> the plaque rapidly becomesacid. This has the effect <strong>of</strong> drawing <strong>of</strong>f calcium ions andother mineral ions from the tooth enamel (Fig. 1). If suchdemineralisation happens repeatedly in the course <strong>of</strong> aday, or if it lasts for an extended period, than caries candevelop. This process can happen very quickly in childrenbecause the enamel cap <strong>of</strong> a milk tooth is only half asthick as that <strong>of</strong> permanent teeth. For this reason children’steeth need special protection.Figure 1. The way <strong>of</strong> remineralization after the use <strong>of</strong> Orbit chewing gumPatients with dry mouth are more susceptible to toothdecay as their flow rate, pH level and buffering capacity islowered. Patients are <strong>of</strong>ten recommended to chew sugarfreegum to relieve the symptoms <strong>of</strong> dry mouth and also tohelp encourage the function <strong>of</strong> the salivary gland.Wrigley’s Orbit sugar-free chewing gums havebecome the first products given recognition by the WorldDental Federation for providing a significant contributionto oral health. Sugar-free chewing gums consist mainly <strong>of</strong>sugar alcohols, which are a combination <strong>of</strong> hexitols andpentitols. Xylitol and Sorbitol are the most frequent sugaralcohols, whereas Manitol is less frequent. Sugar alcohols,primarily Sorbitol and Xylitol, have a direct effect on thebacterial cell. The ways <strong>of</strong> action <strong>of</strong> polyols on bacterialsare illustrated in figure 2.After the uptake <strong>of</strong> Xylitol, the substance isphosphorylated to Xylitol-5-P. Since most cells lackxylitol-5-P dehydrogenase, it results in its intra-cellularaccumulation. Dephosphorilation <strong>of</strong> X-5-P takes placeeventually and Xylitol is then emitted from the bacteria.The consequence <strong>of</strong> the cycle is a futile PEP/energy -consumption leading to an inhibition <strong>of</strong> the glycolysisand none acid attack on the enamel. The bacterial uptake<strong>of</strong> the hexitols results in a phosphorylation to sorbitol-6-Pand mannitol-6-P. 2 separate dehydrogenases transformthe phosphorelated hexitols to fructose-6-P, whichparticipates in glycolysis. Ethanol, formic and lactic acidsare the end products in sorbitol and mannitol metabolism.Orbit sugar-free chewing gums are the most popularchewing gums in FYROM, which was proven by theresults <strong>of</strong> the poll conducted in 2002, according to which75% <strong>of</strong> the participants use Orbit chewing gum at leastonce a day (Figs. 3 and 4).GTF – GlycosyltransferasePMF – ProtonmotiveforcePTS – Phosphotransferase systemG-6-P – Glucose-6-PhosphateF-6-P – Fructose-6-PhosphateF-1,6P2 – Fructose 1, 6-bisphosphate3-PGA – 3-PhosphoglyceraldehydeDHAP – Dihydroxyacetonephosphate3 PG – 3-Phosphoglycerate2 PG – 2-PhosphoglyceratePEP – PhosphoenolpyruvatePYR – PyruvateE1 – Enzyme 1HPr – Histidine protein heat resistantE2 – Enzyme 2Figure 2. Ways <strong>of</strong> action <strong>of</strong> polyols
26 Aleksandar Dimkov et al. Balk J Stom, Vol 15, 2011Figure 3. Frequency <strong>of</strong> use <strong>of</strong> chewing gums among participantsFigure 4. Kind <strong>of</strong> chewing gum used by participantsThere are various types <strong>of</strong> Orbit chewing gums,differing from each other as follows:--The type <strong>of</strong> the sugar alcohols and their proportion;--Addition <strong>of</strong> mineral ions (e.g. calcium) to enhance theeffects <strong>of</strong> remineralisation;--Addition <strong>of</strong> sodium carbonate to maintain teethwhiteness by activating the natural protectivemechanisms <strong>of</strong> the saliva;--Addition <strong>of</strong> different aromas;--Menthol additions for stronger mouth freshness.In our investigation we used Orbit sugar-free chewinggum for kids because it contains both xylitol and sorbitolsugar alcohols, as well as calcium, and is produced in one<strong>of</strong> 2 fruit flavours that makes it more attractive to kids. Byinvestigating the effects <strong>of</strong> Orbit sugar-free chewing gumon cariogenic microorganisms and on the whole number<strong>of</strong> salivary micro-flora, we wanted to see whether we canadd yet another benefit <strong>of</strong> Orbit sugar-free chewing gum tothe already well-known benefits mentioned earlier in thistext. The aim <strong>of</strong> this study was: (1) to estimate the salivarylevels <strong>of</strong> Streptococcus mutans (SM) and Lactobacillusspecies (LB) before and after chewing Orbit sugar-freechewing gum for kids with calcium; (2) to compare thenumber <strong>of</strong> whole salivary flora by saliva analyses beforeand after chewing Orbit sugar-free chewing gum for kidswith calcium.Materials and MethodsThe group consisted <strong>of</strong> 24 healthy schoolchildrenaged 9-13 <strong>of</strong> both gender. The participants had good oralhealth, similar hygiene and normal dietary regimen andsimilar DMF indices. In order to obtain higher precisionand accuracy, the same group was used as a controlgroup, too. Saliva samples were taken before, and 20minutes after, chewing Orbit gum, early in the morning,after at least 12 hours without oral hygiene. The studysubjects were selected at the Faculty <strong>of</strong> Stomatology,Department <strong>of</strong> Pediatric Dentistry - Skopje. Themicrobiological analyses were carried out at the Institute<strong>of</strong> Microbiology and Parasitology, Medical Faculty inSkopje.In our study we used the Orbit sugar-free chewinggum for kids with calcium (Wrigley, USA). Itsingredients are:--Xylitol--Sorbitol--Manitol--Acesuflam--Aspartam--Calcium Lactate--Gum base--FlavorsCollecting Saliva SamplesPatients refrained from oral hygiene for at least 12hours before the treatment.First saliva sample was taken without any prior foodconsumption, mouth rinsing or saliva stimulation.Chewing the Orbit sugar free chewing gum for kidswith Calcium (Wrigley, USA), for approximately 20minutes.After chewing gum has been chewed, the mouth wasrinsed with 200 ml <strong>of</strong> water for about 15 sec.The second saliva sample was taken following a 20min. intermission.Quantitative Evaluation <strong>of</strong> SM, LB andTotal Number <strong>of</strong> Salivary MicroorganismsIn order to determine the total number <strong>of</strong> salivarymicroorganisms, saliva samples were taken by spittingapproximately 3-5 ml. <strong>of</strong> saliva before and after chewingthe Orbit sugar-free chewing gum for kids with calciuminto special sterile containers made particularly for thispurpose (Fig. 5). The specimens used to determine thecounts <strong>of</strong> SM and LB in the saliva were taken with CRTbacteria-commercially available strips (Ivoclar-Vivadent,Schaan, Liechtenstein). These strips have selective
Balk J Stom, Vol 15, 2011 Effects <strong>of</strong> Sugarfree Chewing Gum on Salivary Micr<strong>of</strong>lora 27Figure 5. Sterile containers for determining the total number<strong>of</strong> salivary microorganismsculture media for determination <strong>of</strong> the SM count in salivaor plaque on the blue agar surface and for determination<strong>of</strong> the LB count in saliva on the bright agar surface.The first step <strong>of</strong> the procedure was to remove the agarcarrier from the test vial. After that, a NaHCO 3 -tabletwas placed at the bottom <strong>of</strong> the vial. The protective foilswere carefully removed from 2 agar surfaces, taking carenot to touch the agar. Both agar surfaces are thoroughlymoistened with saliva using a pipette, allowing theexcess saliva to drip <strong>of</strong>f. Finally, the agar carrier was slidback into the vial, the vial was closed tightly and it wasthen sent to the Institute <strong>of</strong> Microbiology (Fig. 6).Figure 6. Procedure for determining SM and LBMicrobiological Processing <strong>of</strong> SamplesPlanting was performed simultaneously withsampling. After an incubation period <strong>of</strong> 48 hours at35-37 0 C, the grown colonies (colony forming units- CFU) were counted, provided their number wassmall, or were compared with the chart supplied by themanufacturer when their number was excessive, and werethen interpreted as 10,000; 10,000-100,000; 100,000-1,000,000 and > 1,000,000 CFUs. The SM colonies weretranslucent on the blue agar surface, while LB colonieswere grey-white on the green agar surface. By countingthe colonies only the approximate number <strong>of</strong> bacteriacould be determined, because <strong>of</strong> the notion that 1 bacterialcell causes the growth <strong>of</strong> 1 colony, and is thus beingdesignated as “a colony forming unit (CFU)” (Fig. 7).After drying up, strips can be stored in a refrigerator at2-8 0 C, where, being protected from light and temperaturefluctuations, they can last for years, and be used forcomparison purposes at any time.
28 Aleksandar Dimkov et al. Balk J Stom, Vol 15, 2011Figure 7. Colony forming units-CFU for SM and LB (standard according to manufacturer's instructions)Figure 8. Growth density sectors
Balk J Stom, Vol 15, 2011 Effects <strong>of</strong> Sugarfree Chewing Gum on Salivary Micr<strong>of</strong>lora 29Semi quantitative determination <strong>of</strong> whole salivarymicrobial counts was performed with a 4 mm diametercalibrated eza. On each <strong>of</strong> the 3 bases, 50 salivamicroliters were spread in the usual manner (routineprocessing). In order to obtain isolated colonies bydilution, the material was transplanted up to the half <strong>of</strong> thePetry dish (sector 1) on 3 sectors <strong>of</strong> the Petry dish (Fig. 8).Then the eza was sterilized by heating, and the materialsfrom the 2 lines <strong>of</strong> sector 1 were transplanted onto thequarter in the lower side <strong>of</strong> the Petry dish (sector 2). Atthe end, the eza was again sterilized by heating and thematerial from the last 2 lines <strong>of</strong> sector 2 was transplantedonto the last quarter <strong>of</strong> the Petry dish (sector 3).The results were read out in a semi quantitative way,i.e. the density <strong>of</strong> growth was marked with the capitalsA, B and C. The capital A was used to mark the growthdensity in the first sector, B was used for the secondsector and C for the third one. The sector marked withA presented a sector with such high density <strong>of</strong> growth<strong>of</strong> colonies that they could not be counted (A > 100colonies within the sector), B - a growth <strong>of</strong> 20 to 100Table 1. Growth density <strong>of</strong> salivary aerobic and anaerobicbacteria before and after use <strong>of</strong> Orbit sugar-free chewing gumfor kids with calciumGrowth densityAerobicAnaerobicBefore After Before AfterAAA 4 / 2 /+ + AAV 9 4 4 /AAS 1 3 1 /AVV 1 1 1 /+AVS 5 10 11 9AVO 4 2 1 1ASO / 3 3 8VVO / 1 1 5+ - VSO / / / 1OOO / / / /c2 – p > 0,05(p = 0,09)c2 – p < 0,05(p = 0,0047)colonies, C - 5 to 20, and 0 - 0 to 5 colonies. With theaim to present the results in a more convenient way, wehave split the growth density sectors in accordance withthe number <strong>of</strong> colonies into high growth density sectors(AAA, AAB, and AAC), medium growth density sectors(ABB, ABC, ABO, and ACO), and into sectors <strong>of</strong> low orno growth density (BBO, BCO, and OOO). The sectors <strong>of</strong>the first group were labelled with ++, those <strong>of</strong> the secondgroup with +, and the sectors <strong>of</strong> the third group with +-.ResultsThe results <strong>of</strong> this investigation are presented intables 1-3 and diagram 1. As it can be seen, the effects<strong>of</strong> chewing a sugar-free chewing gum with calcium weremore pronounced on the counts <strong>of</strong> anaerobic bacteria andCandida albicans than on the aerobic bacteria (Tab. 1 andDiagram 1). The effect <strong>of</strong> chewing was more pronouncedon SM than on LB (Tabs. 3 and 4).Diagram 1. CFU in subjects with isolated Candida albicans before andafter use <strong>of</strong> Orbit sugar-free chewing gum for kids with calcium161412108642040150 1 0 1 04071 2 0I II III IV V VI VIINumber Broj na <strong>of</strong> kolonii coloniesbefore predBroj na koloniiNumber <strong>of</strong> coloniesafterpoTable 2. Number <strong>of</strong> subjects with CFU (colony forming units)<strong>of</strong> SM and LB in 1 ml saliva before and after use <strong>of</strong> sugar-freechewing gum with calciumStreptococcusmutans CFU/mlLactobacillusspecies CFU/mlBefore After Before AfterWithout growth (3) 4 (2) /102-3 3 5 5 5103-4 2 2 1 5104-5 1 5 2 4105-6 9 5 4 8106-7 6 / 10 /N 21 21 22 22Table 3. Effects <strong>of</strong> sugar-free chewing gum with calcium on thereduction <strong>of</strong> cariogenic salivary micro flora counts (number <strong>of</strong>subjects with logarithmic reduction factor - log RF)log RFStreptococcusmutans0 2 61 10 122 5 43 2 /³ 4 2 /N 21 22Lactobacillusspecies
30 Aleksandar Dimkov et al. Balk J Stom, Vol 15, 2011DiscussionUsing the semi quantitative determination methodfor total microbial salivary counts 6 , aerobic and anaerobicmicroorganisms were separately processed. Therehas been a redistribution <strong>of</strong> the counts <strong>of</strong> aerobic andanaerobic microorganism colonies from sectors with highand medium growth density (++ and +) before chewing,to sectors with low or without any growth density(sectors + and + -) after chewing. However, statisticalanalysis (χ 2 test) has shown no statistical significance inthe case <strong>of</strong> aerobic microorganisms after chewing Orbitchewing gum (p = 0.09). Statistical analysis conductedfor anaerobic microorganisms have shown significantreduction after chewing Orbit chewing gum (p = 0.0047).However, when one considers duration <strong>of</strong> chewing, whichwas limited to 20 minutes, it becomes apparent that thedecrease in growth density after chewing Orbit sugar-freegum depends to a certain extent also on the mechanicalfunction <strong>of</strong> the saliva during mastication.Orbit sugar-free chewing gum performed veryeffectively in the reduction <strong>of</strong> Candida albicans yeastscolonies. Namely, only 1 <strong>of</strong> 7 participants, in which a total<strong>of</strong> 34 colonies had been isolated before chewing Orbitchewing gum, exhibited a growth density <strong>of</strong> only 1 colonyafter chewing. The total number <strong>of</strong> colonies was reducedby 34 times on the average.Over the last few years, numerous studies havebeen aimed toward research <strong>of</strong> the influence <strong>of</strong> the use <strong>of</strong>sugar-free chewing gum in dental caries prevention. Byreducing the principal amount <strong>of</strong> cariogenic micro-flora,mainly the salivary SM, the incorporation <strong>of</strong> bacteria intothe plaque is avoided, and their fermentable properties atlow pH-values are suppressed as well, which prevents thestart <strong>of</strong> the demineralisation process. In our investigationwe obtained a significant difference in the number <strong>of</strong>cariogenic microorganisms’ colonies before and afterchewing Orbit sugar-free chewing gum. The reduction washigher in SM than in LB counts, expressed by the number<strong>of</strong> subjects with logarithmic reduction factor <strong>of</strong> cariogenicmicro-flora. The number <strong>of</strong> subjects with log RF = 0for SM was 2, while it was 6 for LB. 2 subjects had alogarithmic reduction factor <strong>of</strong> 4 (log RF ≥ 4) for SM, andthere were no subjects with this reduction factor for LB.At the end <strong>of</strong> the discussion, we would like to emphasizethat until now no research <strong>of</strong> the effects <strong>of</strong> Orbit sugar-freechewing gum on the bacterial cell have been carried out,so that the results that were discussed can be consideredas the results <strong>of</strong> a pioneer experiment in this direction.However, considering the action <strong>of</strong> sugar alcohols reportedin literature, we can conclude that our results are inaccordance with the research <strong>of</strong> Birkhed 1 , Edgar 3 , Edgarand Gedds 4 , Mäkinen et al 5 and Szöke et al 7 .ConclusionSignificant reductions in salivary MS and LB levels,and declines in the total count <strong>of</strong> aerobe and anaerobebacteria and Candida albicans as well, were observed inall cases. Therefore, we can conclude that Orbit sugar-freechewing gum influenced very effectively in the reduction<strong>of</strong> cariogenic microorganisms.References1. Birkhed D. Cariologic aspects <strong>of</strong> xylitol and its use inchewing gum: a review. Acta Odontol Scand, 1994;52(2):116-127.2. Dawes C, MacPherson LMD. Effects <strong>of</strong> nine differentchewing - gums and lozenges on salivary flow rate and pH.Caries Res, 1992; 24:176-182.3. Edgar WM. Sugar substitutes, chewing gum and dentalcaries: a review. Brit Dent J, 1998; 184(1):29-32.4. Edgar WM, Gedds DAM. Chewing gum and dental health: areview. Brit Dent J, 1990: 173-177.5. Mäkinen KK, Soderling E, Isokangas P, Tenovuo J, TieksoJ. Oral biochemical status and depression <strong>of</strong> Streptococcusmutans in children during 24- to 36-month use <strong>of</strong> xylitolchewing gum. Caries Res, 1989; 23(4):261-267.6. Panovski N. Ispituvawe na faktorite odgovorni zaopstanokot na medicinski zna~ajnite soevi na nesporogeniteanaerobni bakterii “in vitro” (PhD Thesis). Skopje:Univerzitet “Sv. Kiril i Metodij”, Medical Faculty, 1990. (inMacedonian)7. Szöke J, Bánóczu J, Proskin HM. Effect <strong>of</strong> after-mealsucrose-free gum-chewing on clinical caries. J Dent Res,2001; 80(8):1725-1729.Correspondence and request for <strong>of</strong>fprints to:Dr. Aleksandar DimkovBul. Partizanski odredi 8/37Skopje, FYR MacedoniaE-mail: adimkov@mail.net.mk
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141STOMATOLOGICAL SOCIETYFluoride Released from Orthodontic Bonding Material:An In Vitro EvaluationSUMMARYEnamel demineralization is an undesirable but common complication<strong>of</strong> orthodontic fixed appliances therapy. The purpose <strong>of</strong> this study was to testlong-term benefits <strong>of</strong> resin-modified glass ionomer cement (GC Fuji Ortho TMLC) for the prevention <strong>of</strong> demineralization in patients receiving orthodontictreatment with fixed bonded appliances.90 healthy extracted premolars without any clinical signs <strong>of</strong>decalcification were selected. All teeth were cleaned and cut in half buccolinguallywith a diamond disc. Thus, the control and test specimens wereobtained from the same teeth. Orthodontic brackets were bonded with aresin-modified glass ionomer cement. The teeth were divided in 3 groupsaccording to the period <strong>of</strong> monitoring (1, 3 and 6 months). They were storedin artificial saliva until analyzing. Determination <strong>of</strong> the fluoride in enamelwas done by spectrophotometer.The amount <strong>of</strong> fluoride in enamel 1 month after the bracketsapplication was significantly higher, after 3 months it was even higher,and after 6 months it was still statistically significantly higher compared toinitial values, but lower than the previous 2 time intervals (and remainedon a constant level). The results <strong>of</strong> this in vitro study clearly indicate thatfluoride-releasing material used in fixed orthodontic treatment inhibitsdemineralization <strong>of</strong> enamel around orthodontic appliances.Keywords: Enamel; Brackets; Glass-ionomer Cements; Demineralization; RemineralizationEfka Zabokova-Bilbilova 1 ,A. Sotirovska-Ivkovska 1 , Icko Gjorgovski 21 Department <strong>of</strong> Paediatric DentistrySchool <strong>of</strong> Dentistry2 Faculty <strong>of</strong> Natural Sciences and MathematicsSts. Cyril and Methodius UniversitySkopje, FYROMORIGINAL PAPER (OP)Balk J Stom, 2011; 15:31-34IntroductionOrthodontists are still challenged by an “oldproblem” in their practices: enamel demineralizationaround orthodontic appliances. Patients undergoingorthodontic therapy are exposed to a higher risk <strong>of</strong> enameldemineralization 1 . Appliances are directly attached to toothsurface, increasing the difficulty <strong>of</strong> achieving adequateoral hygiene. Some <strong>of</strong> commonly used accessories,such as hooks, posts, elastic chains and springs, can alsoundermine dental bio-film removal. Thus, the incidence<strong>of</strong> white spot lesions can be significantly higher amongorthodontic patients with poor oral hygiene 8 .Enamel demineralization is an undesirable butcommon complication <strong>of</strong> orthodontic fixed appliancestherapy. Several studies have reported a significantincrease in the prevalence and severity <strong>of</strong> demineralizationafter orthodontic therapy compared with controls, and theoverall prevalence amongst orthodontic patients rangesfrom 2 to 96% 17,19 . The teeth most commonly affected aremolars, maxillary lateral incisors, mandibular canines andpremolars 15 .The potential risk <strong>of</strong> enamel surface decalcificationduring orthodontic treatment can be reduced by usingglass ionomer cements (GIC) for bonding the brackets 2-4 .GIC have been showed to consistently release fluorideover time. They also have ability to take up and re-releasefluoride after application <strong>of</strong> a topical fluorides source.Although the property <strong>of</strong> fluoride releasing would appearto make GIC an ideal bonding agent for orthodonticbrackets, the adequacy <strong>of</strong> strength for successfulclinical bonding 9,12,24 is less. Recently, Fuji Ortho TMLC developed the GIC for bonding brackets to teeth.The manufacturer claims it can be applied in a wet fieldand is not as technique-sensitive as composite resins.
32 Efka Zabokova-Bilbilova et al. Balk J Stom, Vol 15, 2011Specifically, it requires no etching <strong>of</strong> the enamel surfaceand should be applied in wet environment. Anotherattribute <strong>of</strong> glass ionomers is that they release fluoride,which is known to reduce the incidence <strong>of</strong> caries 13,22 . Theprocess <strong>of</strong> fluoride release is by way <strong>of</strong> polyacid attackon the alumino-silicate glass. As the glass network breaksdown, the Al 3+ , Ca 2+ , and F - ions are released 21 .The capacity <strong>of</strong> glass ionomers to absorb fluoridefrom rinses and tooth paste in essence allows the glassionomer to reconstitute itself and continuously releasefluoride. This should aid in the decreased incidence <strong>of</strong>decalcification and unsightly white spots around thebrackets. The advantages proposed to be gained by theoperator and patients are substantial. If all these factorswere true for the new Fuji Ortho TM LC product, it wouldbe more beneficial clinically than composite resin alone.Because <strong>of</strong> these possible improvements over compositeresin, a test <strong>of</strong> Fuji Ortho TM LC effectiveness in loweringbracket failure rate and incidence <strong>of</strong> decalcificationseemed in order 5,10 .Cook 6 compared the in vivo bond strength <strong>of</strong> GICKetac (ESPE Premier Denbol Products), with a compositeresin bonding agent. The result <strong>of</strong> his evaluation indicatedthat the bond strength <strong>of</strong> that GIC was not nearly asgood as that <strong>of</strong> the composite resin. Cook stated thatthorough drying <strong>of</strong> the teeth before GIC use was notnecessary, but that cotton rolls should be used to isolatethe field <strong>of</strong> operation. He also suggested that the surface<strong>of</strong> the teeth to be bonded should be wiped <strong>of</strong>f beforebracket placement and stressed that acid etching was notnecessary. The 40 cases studied showed a 12% failurerate, which is considered too great for routine orthodonticpractice.Fajen et al 11 evaluated the bond strength <strong>of</strong> 3different GIC against a composite resin in vitro, andlike Cook, found the bond strength <strong>of</strong> the GIC to be“significantly less”. The fluoride release is a result <strong>of</strong>2 processes: the short-term release is associated witha leakage <strong>of</strong> relatively loosely bound fluoride fromthe cement matrix. The long-term release is a result <strong>of</strong>diffusion controlled phenomena where the concentrationgradient is the moving force for the release.The purpose <strong>of</strong> this study was to test the long-termbenefits <strong>of</strong> resin-modified GIC (GC Fuji Ortho TM LC)for prevention <strong>of</strong> demineralization in patients receivingorthodontic treatment with fixed bonded appliances.Material and MethodIn this study, 90 healthy extracted premolars withoutany clinical signs <strong>of</strong> decalcification were selected. Allteeth were cleaned and cut in half bucco-lingually witha diamond disc. Thus, the control and test specimenswere obtained from the same teeth. Orthodontic bracketswere bonded with GC Fuji Ortho TM LC, resin-modifiedGIC. The teeth were divided in 3 groups according tothe period <strong>of</strong> monitoring (1, 3 and 6 months). Theywere stored in artificial saliva (20 mmol/l NaHCO 3 , 3mmol/l NaH 2 PO 4 and 1 mmol/l CaCl 2 , neutral pH) untilanalyzing. Determination <strong>of</strong> the fluoride in enamel wasdone by spectrophotometer. Determination started withdistillation, and then 50ml <strong>of</strong> the distillate was mixedwith 10ml SPADNS and acidic circonyl. The absorbancewas read on the spectrophotometer. Than the results werecalculated by the formula: F ppm= 50A/V, where A is ppm<strong>of</strong> fluoride measured by the spectrophotometer, and V ml<strong>of</strong> the sample.For statistical evaluation, a one-way analysis <strong>of</strong>variance (ANOVA) was initially used to see if there was asignificant difference between groups.ResultsTable 1 shows the value <strong>of</strong> F in enamel in theexperimental group <strong>of</strong> teeth 1 month after brackets werebonded. Average value <strong>of</strong> F in the examined group <strong>of</strong>teeth was 844,044 ppm, and in the control group <strong>of</strong> teeththe average value <strong>of</strong> F was 614,230 ppm. For this timeperiod, a statistically significant difference was foundbetween values <strong>of</strong> F in the examined groups <strong>of</strong> teeth.Table 1. Values <strong>of</strong> F (ppm) in enamel 1 month after bondingbracketsgroup N X¯ SD t ptest 30 844,044 314,130control 30 614,230 177,1593,490 0,00085*Table 2. Values <strong>of</strong> F (ppm) in enamel 3 months after bondingbracketsgroup n X¯ SD t ptest 30 946,260 449,995control 30 684,072 370,8222,462 0,01672*Table 2 shows the values <strong>of</strong> F in enamel in the group<strong>of</strong> examined and control teeth 3 months after bonding <strong>of</strong>brackets. Again, a statistically significant difference <strong>of</strong> thevalues was found (946,260 ppm and 684,072 ppm <strong>of</strong> F inthe examined and control group <strong>of</strong> teeth, respectively).
Balk J Stom, Vol 15, 2011 Fluoride Released from Orthodontic Bonding Material 33Values <strong>of</strong> the F in enamel <strong>of</strong> the examined andcontrol group <strong>of</strong> teeth 6 months after bonding bracketsare presented in table 3. The result was similar tothe previous. After treatment <strong>of</strong> 1, 3 and 6 months,statistically significant difference occurred in the averagevalues <strong>of</strong> fluoride in enamel between the experimental andcontrol groups. The differences were greater after 1 monthand smaller after 6 months (Tab. 4).Table 3. Values <strong>of</strong> F (ppm) in enamel 6 months after bondingbracketsgroup n X¯ SD t ptest 30 557,398 198,477control 30 454,539 185,1172,076 0,04438*Table 4. Comparative display <strong>of</strong> F values in enamel at the testand control groupgroupntame/monthstest 30 844,044 314,130X¯ SD t p1 3,490 0,00085*control 30 614,230 177,159test 30 946,260 449,9953 2,462 0,01672*control 30 684,072 370,822test 30 557,398 198,4776 2,076 0,04438*control 30 454,539 185,117DiscussionAfter completing the fixed orthodontic treatment,and as a reason that ideal oral hygiene usually is notachieved, demineralised zones are spotted. They are morenoticed in the gingival part <strong>of</strong> labial surface <strong>of</strong> the teeth,where plaque accumulation is significantly higher. Suchdemineralised zone appears as early as 4 weeks afterorthodontic brackets and bands placement. It is knownthat these demineralised zones are able to remineraliseand to restore the damaged apatite crystals. The process<strong>of</strong> remineralisation in the oral cavity is favoured byfluoride. This effect is one <strong>of</strong> the reasons why application<strong>of</strong> fluoride is recommended every time to prevent,neutralise or restore demineralised enamel (with goodoral hygiene). Its crystals are larger than the original ones,which is linked to the reducing possibility <strong>of</strong> dissolving.This explains the positive cariostatic effect <strong>of</strong> materialscontaining fluoride used for bonding the brackets 18,20 .Around some brackets bonded with such materials, dueto the released fluoride, a weaker demineralization <strong>of</strong>enamel appears than in cases where they are bonded withmaterials which do not release fluoride 7,16 .Results <strong>of</strong> this study clearly show that the content <strong>of</strong>fluoride in enamel significantly increased after application<strong>of</strong> GIC containing fluoride. Thus, the amount <strong>of</strong> fluoridein enamel before fixing the brackets was 614,230 ppm;after 1 month <strong>of</strong> their bonding, the amount <strong>of</strong> fluoridein enamel was 844,044 ppm, which is statisticallysignificantly higher <strong>of</strong> the initial coverage <strong>of</strong> fluoride inenamel. After 3 months, the value <strong>of</strong> fluoride in enamel inthe examined group was even higher (946,260 ppm). After6 months decrease the amount <strong>of</strong> fluoride (557,398 ppm)was noticed, although still significantly higher comparedto the control group.In our study enamel demineralization in vitro wasinhibited to a certain degree. Similar prevention <strong>of</strong>decalcification was reported by many authors for otherfluoride-releasing materials 14,23 . Besides the positiveimpact on local fluoride-released cement used for bondingthe brackets in inhibiting demineralisation <strong>of</strong> the enamelaround orthodontic brackets and bands, the release <strong>of</strong>fluoride from GICs provides continuous presence <strong>of</strong> lowconcentrations <strong>of</strong> fluoride in the oral medium, which alsoinfluence with inhibition on demineralised enamel aroundorthodontic brackets and bands.ConclusionsThe fluorides contribute to inhibition <strong>of</strong>demineralization process around the brackets andbands during fixed orthodontic treatment. The amount<strong>of</strong> fluoride in enamel after 1 month after the bracketsapplication was significantly higher, after 3 months itwas higher, and after 6 months it was still statisticallysignificantly higher compared to initial values; yet it isstill lower than the previous 2 time intervals (and remainson a constant level).The results <strong>of</strong> this in vitro study clearly indicate thatfluoride-releasing materials used in fixed orthodontictreatment inhibit demineralization <strong>of</strong> enamel aroundorthodontic appliances.References1. Artun J, Brobakken BO. Prevalence <strong>of</strong> caries white spotsafter orthodontic treatment with multibonded appliances.Eur J Orthod, 1986; 8:229-234.
34 Efka Zabokova-Bilbilova et al. Balk J Stom, Vol 15, 20112. Basdra EK, Huber H, Komposch G. Fluoride released fromorthodontic bonding agents alters the enamel surface andinhibits enamel demineralization in vitro. Am J OrthodDent<strong>of</strong>acial Orthop, 1996; 109:466-472.3. Bishara SE, Gordon VV, Von Wald L, Jakobsen JR. Shearbond strength <strong>of</strong> composite glass ionomer, and acidicprimer adhesive systems. Am J Orthod Dent<strong>of</strong>acial Orthop,1999; 115:24-28.4. Bishara SE, Olsen ME, Damon P, Jakobsen JR. Evaluation<strong>of</strong> a new light-cured orthodontic bonding adhesive. Am JOrthod Dent<strong>of</strong>acial Orthop, 1998; 114:80-87.5. Bishara SE, Saliman M, Lafton J, Warren J. Share bondstrength <strong>of</strong> a new fluoride release glas-ionomer adhesive.Angle Orthod, 2007; 78 (1):125-128.6. Cook PA, Youngson CC. An in vitro study <strong>of</strong> the bondstrength <strong>of</strong> glass ionomer cement in the direct bonding <strong>of</strong>orthodontic brackets. British J Orthod, 1988; 15:247-253.7. Corry A, Millett DT, Creanor SL, Foye RH, GilmourWH. Effect <strong>of</strong> fluoride exposure on cariostatic potential<strong>of</strong> orthodontic bonding agents: an in vitro evaluation. JOrthod, 2003; 30(4):323-329.8. Chang HS, Walsh LJ, Freer TJ. Enamel demineralizationduring orthodontic treatment. Aetiology and prevention.Aust Dent J, 1997; 42(5):322-327.9. Charles C. Bonding orthodontic brackets with glassionomercement. Biomaterials, 1998; 19:589-591.10. Chung CH, Cuozzo PT, Mante FK. Shear bond strength<strong>of</strong> a resin-reinforced glass ionomer cement: an in vitrocomparative study. Am J Orthod Dent<strong>of</strong>acial Orthop, 1999;115:52-54.11. Fajen VB, Duncanson MG, Nanda RS, Currier GF,Angolkar PV. An in vitro evaluation <strong>of</strong> bond strength <strong>of</strong>three glass ionomer cements. Am J Orthod Dent<strong>of</strong>acialOrthop, 1990; 97:316-322.12. Featherstone JD. The science and practice <strong>of</strong> cariesprevention. JADA, 2000; 131:887-899.13. Featherstone JD, Glena R, Sharaiti M, Shields CP.Dependence <strong>of</strong> in vitro demineralization <strong>of</strong> apatite andremineralization <strong>of</strong> dental enamel on fluoride concentration.J Dent Res, 1990; 69:620-625.14. Fricker JP. A new self-curing resin modified glass-ionomercement for direct bonding <strong>of</strong> orthodontic brackets in vivo.Am J Orthod Dent<strong>of</strong>acial Orthop, 1998; 113:384-386.15. Gorelick L, Geiger AM, Gwinnett AJ. Incidence <strong>of</strong> whitespot formation after bonding and banding. Am J Orthod,1982; 81(2):93-98.16. Lippitz SJ, Staley RN, Jakobson JR. In vitro study <strong>of</strong>24-hour and 30-day bond strengths <strong>of</strong> three resin-glassionomer cements used to bond orthodontic brackets. Am JOrthod Dent<strong>of</strong>acial Orthop, 1998; 113:620-624.17. Mizrahi E. Enamel demineralization following orthodontictreatment. Am J Ortod, 1982; 82(1):62-67.18. Mellberg JR. Remineralization. A status report. Part III. AmJ Dent, 1988; 1:85-89.19. Ögaard B, Rolla G, Arends J, ten Cate JM. Orthodonticappliances and enamel demineralization. Part 2: Preventionand treatment <strong>of</strong> lesions. Am J Orthod Dent<strong>of</strong>acial Orthop,1988; 94:123-128.20. Robinson C, Shore RC, Brookes SJ, Strafford S, Wood SR,Kirkham J. The Chemistry <strong>of</strong> Enamel Caries. Crit Rev OralBiol Med, 2000; 11(4):481-495.21. Trimpeneers LM, Dermault LR. A clinical evaluation <strong>of</strong>the effectiveness <strong>of</strong> a fluoride-releasing visible lightactivatedbonding system to reduce demineralization aroundorthodontic brackets. Am J Orthod Dent<strong>of</strong>acial Orthop,1996; 110(2):218-222.22. Underwood ML, Rawls HR, Zimmerman BF. Clinicalevaluation <strong>of</strong> a fluoride-exchanging resin as an orthodonticadhesive. Am J Orthod Dent<strong>of</strong>acial Orthop, 1989; 96:93-99.23. Vorhies AB, Donly KJ, Staley RN, Wefel JS. Enameldemineralization adjacent to orthodontic brackets bondedwith hybrid glass ionomer cements: an in vitro study. Am JOrtod Dent<strong>of</strong>acial Orthop, 1998; 114(6):668-674.24. White LW. Glass ionomer cement. J Clin Orthod, 1986;20:387-391.Correspondence and request for <strong>of</strong>fprints to:Efka Zabokova-Bilbilova, DDS, PHDDepartment <strong>of</strong> Paediatric DentistrySchool <strong>of</strong> DentistryVodnjanska 171000 Skopje, FYR Macedoniae-mail: efka_zabokova@hotmail.com
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141STOMATOLOGICAL SOCIETYVariation <strong>of</strong> Skeletal Cephalometric Variables inClass II Division 2 Patients with AgeSUMMARYApart from the dental and maxill<strong>of</strong>acial features, an importantconsideration in the treatment <strong>of</strong> Angle Class II division 2 malocclusions isfacial growth, particularly if the case requires not only tooth movement butchanging maxillo-mandibular relation as well. The purpose <strong>of</strong> this studywas to determine the effect <strong>of</strong> chronological age on certain skeletal features<strong>of</strong> Angle Class II division 2 patients. The material <strong>of</strong> the study included96 lateral cephalometric X-rays <strong>of</strong> patients with Angle Class II division 2malocclusion, ranging in age from 7 to 35 years; on each cephalometricimaging, 8 cephalometric measurements were performed. Statistical dataprocessing included analyses <strong>of</strong> 1 variable and correlation <strong>of</strong> 2 variables.In patients with Angle Class II division 2 malocclusion the facialpr<strong>of</strong>ile was convex and did not change significantly with age, theanteroposterior position <strong>of</strong> the chin in the children’s group approximated‘normal’, while there was a tendency for mandibular retrusion among adultpatients. Mandibular morphology changed and became more “square”among older patients.Key words: Class II/2; Skeletal Features; Cephalometric Analysis; AgeNikolaos Topouzelis, Andreas Zafiriadis,Helen MarkovitsiAristotle University <strong>of</strong> ThessalonikiDental School, Department <strong>of</strong> OrthodonticsThessaloniki, GreeceORIGINAL PAPER (OP)Balk J Stom, 2011; 15:35-40IntroductionDuring growth and in the period between deciduousand permanent dentition, the features <strong>of</strong> Angle Class IIdivision 2 malocclusion exacerbate due to increasingincisor over-occlusion, which leads to differential growthbetween the maxilla and the mandible, and consequently,to maxillary protrusion 1 . There was a view that AngleClass II division 2 malocclusion exacerbates with time notdue to a change in the growth pattern but due to increasinganterior rotation <strong>of</strong> the mandible, which results from theparticular effect <strong>of</strong> the masseter muscles 2 .Under conditions <strong>of</strong> normal mandibular growthand development, one would expect a lower incidence<strong>of</strong> mandibular retrusion among adults, as compared tominors. However, this is not so in cases <strong>of</strong> Angle ClassII division 2 malocclusion, probably due to palatalinclination <strong>of</strong> maxillary incisors and increased incisoroverjet, which result in stunting mandibular growth 3 . Thisfinding is confirmed by observation that in these cases,mandibular alveolar development, as assessed by theS-N-B angle, was more restricted than the development <strong>of</strong>osseous base <strong>of</strong> the mandible, as assessed by the S-N-Pogangle 1,4,5 .The range <strong>of</strong> views related to dental, skeletal andfacial features <strong>of</strong> Angle Class II division 2 malocclusionmake it necessary to further study such cases and followtheir particular development through time, which isimportant not only for clinical orthodontists’ needs, butalso for accurate determination <strong>of</strong> the case description. Theaim <strong>of</strong> the study was: (a) to examine possible differences<strong>of</strong> skeletal cephalometric measurements among 3 agegroups <strong>of</strong> Angle Class II division 2 malocclusion patients,and (b) to investigate possible correlations betweenpatients’ age and those cephalometric measurementsexamined.Subjects and MethodsResearch material included 96 lateral cephalometricX-rays <strong>of</strong> Angle Class II division 2 malocclusion patientswho had never had any type <strong>of</strong> orthodontic treatment.Their selection was based on the basis <strong>of</strong> dental occlusion
36 Nikolaos Topouzelis et al. Balk J Stom, Vol 15, 2011relations and patients’ ages, out <strong>of</strong> a total number <strong>of</strong> 174cases <strong>of</strong> Angle Class II division 2 malocclusion patientswho asked for orthodontic treatment. The X-rays <strong>of</strong>patients selected were divided into 3 groups.The first group, “a children group”, included 33X-rays. 13 patients were boys and 20 were girls. Theirmean age was 9.5 years; the youngest was 7 and the oldest11 years old. Their dentition was mixed and there wasno case <strong>of</strong> having lost a deciduous tooth early or missingsome permanent tooth.The second group, “an adolescent group”, included31 X-rays. 13 patients were boys and 18 were girls. Theirmean age was 14 years; the youngest was 13 and the oldest15.5 years old. Their dentition was permanent and therewas no tooth missing in any <strong>of</strong> the cases.The third group, “an adults group” included 32X-rays. 11 patients were men and 21 women. Their meanage was 21 years; the youngest was 17 and the oldest 35years old. Their dentition was permanent and there was notooth missing in any <strong>of</strong> the cases.Cephalometric VariablesOn every lateral cephalometric X-ray, 8 cephalometricmeasurements were performed, concerning bothsagittal and vertical dimensions <strong>of</strong> the facial skeletalstructures. Cephalometric measurements used were thefollowing (Figs. 1 and 2): (1) Facial angle (Po-Or/Na-Pog);(2) Facial Axis Angle (Pt-Gn/Ba-Na); (3) MandibularPlane Angle (Po-Or/Go-Me); (4) Mandibular Arc Angle(Dc-Xi-Pm); (5) Facial Convexity (AàNa-Pog); (6)Mandibular Corpus Axis (XiàPm); (7) Cranial Base Length(BaàNa); and (8) Anterior Cranial Base Length (CCàNa).Method ErrorIn order to determine the experimental methoderror for each variable used, 20 X-rays were selected atrandom. These were traced and re-measured by the sameresearcher 20 days after their initial analysis. T-test wasused to determine method error; the significance level wasa=0.05. No statistically significant differences were foundfor the 8 variables used in the 2 measurements performed.Statistical AnalysisData processing included analyses <strong>of</strong> 1 variable andcorrelations <strong>of</strong> 2 variables. All continuous variables werechecked using the Kolmogorov-Smirnov test. The resultswere analyzed with ANOVA and the Duncan test, whereasPearson’s correlation coefficient was used to determinewhether there was a statistically significant correlationbetween age and other quantitative variables or not.ResultsDescriptive statistics for 8 cephalometricmeasurements used concerned both sagittal and verticaldimensions <strong>of</strong> facial skeletal structures are presented inTables 1 to 8. ANOVA showed that there was no statisticallysignificant difference in the mean values <strong>of</strong> facial angle(Tab. 1), facial axis angle (Tab. 2) or facial convexity (Tab.5) in the 3 age groups. In the adult group, the mean valuepresented statistically significant differences (p
Balk J Stom, Vol 15, 2011 Cephalometric Variables in Class II Division 2 Patients 37Figure 2. A. Facial Convexity (AàNa-Pog), B. Mandibular Corpus Axis (XiàPm),C. Cranial Base Length (BaàNa), D. Anterior Cranial Base Length (CCàNa)Table 1. Statistical parameters <strong>of</strong> Po-Or/Na-Pog AngleAge group N Mean Value Standard deviation Minimum value Maximum7 - 11 33 86.5 2.8 81 9113 - 15 31 87.5 3.2 80 9317 - 35 32 88.4 3.8 79 95F = 2.960p = 0.057NSTable 2. Statistical parameters <strong>of</strong> Pt-Gn/Ba-Na AngleAge group N Mean Value Standard deviation Minimum value Maximum7 – 11 33 89.7 3.1 82 9513 – 15 31 89.7 4.5 80 9817 – 35 32 91.5 4.2 83 100F = 2.193p = 0.117NSTable 3. Statistical parameters <strong>of</strong> Po-Or/Go-Me AngleAge groupNMean ValueSub-groupsStandard deviation Minimum value Maximum7 – 11 33 20.9 (1) 4.2 13 3013 – 15 31 20.8 (1) 5.6 8 3217 – 35 32 16.8 (2) 6.9 2 30ANOVA (1) (2) Mean value differences appeared in 2 sub-groups (Duncan test)F = 5.549p = 0.005
38 Nikolaos Topouzelis et al. Balk J Stom, Vol 15, 2011Table 6. Statistical parameters <strong>of</strong> Mandibular corpus axis XiàPmAge group NMean ValueSub-groupsStandard deviation Minimum value Maximum7 – 11 33 64.3 (1) 3.6 58 7313 – 15 31 69.1 (2) 3.5 60 7517 – 35 32 71.9 (3) 5.7 59 88ANOVA (1) (2) (3) Mean value differences appeared in 3 sub-groups (Duncan test)F = 24.636p = 0.000
Balk J Stom, Vol 15, 2011 Cephalometric Variables in Class II Division 2 Patients 39X-ray imaging, cephalometric X-rays should also berestricted to those absolutely necessary and performedonly for diagnostic purposes 6 . Therefore, when toomany X-ray examinations are performed on the sameperson for research purposes, this is criticized due to theincreased radiation the person is exposed to, which isunacceptable 7 . This ethical reasoning has meant fewerX-ray examinations for research purposes, which resultedin avoiding longitudinal growth assessment and repeatedX-ray imaging <strong>of</strong> the same person.This paper aimed at studying Angle Class II division2 malocclusion cases and determining the improvementor exacerbation <strong>of</strong> facial skeletal structure relationshipsat various ages. Due to ethical considerations mentionedabove, the material <strong>of</strong> the study comprised initial lateralcephalometric X-rays <strong>of</strong> cases with Angle Class IIdivision 2 malocclusion who asked for treatment; thesepatients ranged in age from 7 to 35 years.Initially, 8 cephalometric measurements wereperformed to determine Angle Class II division 2malocclusion in 3 patient groups - a children’s group, anadolescents’ group and an adults’ group - and differenceswere later identified among these 3 groups. Furthermore,it was investigated whether these measurements areaffected by age in all the patients examined.Facial angle, which determines chin position alongthe anterior-posterior axis, was used to assess the position<strong>of</strong> the mandible along the sagittal axis. Facial angle(Po-Or/Na-Pog) showed no significant increase in theadolescents’ and adults’ groups, although it was found toincrease with patient’s age. Facial angle increase with agewas attributed mainly to the significant increase <strong>of</strong> thelength <strong>of</strong> the mandibular corpus axis. Values found forthe facial angle indicate a “normal” mandibular position<strong>of</strong> the mandible in children. On the contrary, there is atendency for slight mandibular retrusion among adults 8 ,which seems to agree with similar findings by numerousauthors 9-12 . Besides, the difference in mandibular positionbetween children and adult patients tends to support theview that Angle Class II division 2 malocclusion is nota primary skeletal syndrome, but a deformation, whichnumerous authors attribute mainly to the pronouncedpalatal inclination <strong>of</strong> maxillary central incisors, whichresults in stunting mandibular growth 3,13-15 .Mandibular corpus axis length (Xi àPm) appearedsignificantly increased in adults as compared to that<strong>of</strong> children and adolescents. Furthermore, all patientsexamined showed significant differences since this lengthincreased with patient age.Skeletal facial convexity was found increased in all3 groups examined. Furthermore, it was not significantlydifferent in all the groups and showed no negativecorrelation with age, although it appeared decreased in theadolescents’ and adults’ groups. Skeletal facial convexitydevelopment is caused by the significant increase foundin mandibular corpus axis length and cranial base lengthwith age, in particular, the increased anterior cranial baselength. Cranial base length (BaàNa) presented significantincrease among adolescents and adults as compared to thechildren’s group, while the difference between adolescentsand adults was not significant. On the contrary, cranialbase length showed a particularly significant positivecorrelation with age, which was expected.Anterior cranial base (CCàNa) was found to besignificantly longer among the adults’ group as comparedto that <strong>of</strong> the children, while it was not different in theadolescents’ group when compared to the other 2 groups.Similar to “normal” individuals, all patients examinedshowed positive correlation <strong>of</strong> anterior cranial base lengthwith age.The face, in all 3 groups <strong>of</strong> patients examined,showed a “normal” direction <strong>of</strong> increase, since meanvalues <strong>of</strong> facial angle (Pt-Gn/Ba-Na) in minors andadolescents showed no difference from what wasproposed as “normal” 8,16,17 . Facial angle did not showsignificant differences among all groups examined, norany correlation with age. Brezniak et al 18 used Downs’axis and Ricketts’ facial axis, and found that Angle ClassII division 2 malocclusion patients presented a morehorizontal type <strong>of</strong> increase in comparison to “normal”individuals.Mandibular angle (Po-Or/Go-Me) and mandibulararc angle (Dc-Xi-Pm) mean values measured supportthe view that patients with Angle Class II division 2malocclusion tend to have a “strong” and “square”mandible with a “strong” muscular system, a smallmandibular angle and a large mandibular arc angle 12,18,19 .Mandibular angle mean values in children andadolescents showed no differences, while in the group<strong>of</strong> adult patients this angle was significantly lower thanin the other 2 groups. In all the patients examined, themandibular angle presented a statistically significantdifference, since it reduced with age. The reduction <strong>of</strong>mandibular angle with age might be due to the anteriormandibular rotation during its growth 11,20,21 , a fact whichmainly appears in cases with insufficient incisor support 20 .Mandibular arc angle increases with normal growthas a result <strong>of</strong> increased adaptive changes occurringin the mandible 8 . In the children’s and adolescents’groups, it showed no significant difference, while it wassignificantly increased in adult patients in comparisonto the other 2 groups. In all the patients examined,mandibular arc angle showed particularly significantdifferences with growth since it increased with age.Assessment <strong>of</strong> findings <strong>of</strong> this research has led to theconclusion that in patients with Angle Class II division2 malocclusion facial pr<strong>of</strong>ile was convex and did notsignificantly change with age, while anteroposteriorposition <strong>of</strong> the mandible showed significant differences inthe 3 groups examined: in the children’s group it might beconsidered “normal”, while among adolescent and adultpatients it showed a tendency for retrusion. Mandibular
40 Nikolaos Topouzelis et al. Balk J Stom, Vol 15, 2011corpus axis presented significant differences in length,since it grew with age. As for mandibular morphology,this was found to significantly change with age andbecome more “square” in older patients. The direction <strong>of</strong>facial growth was found to be within normal range andshowed no difference at the various ages.In patients with Angle Class II division 2malocclusion, who are still growing, exacerbation <strong>of</strong> theanteroposterior position and morphology <strong>of</strong> the mandibleneed to be taken into consideration so that necessarymechanisms may be activated in good time to inhibit thestunting <strong>of</strong> mandibular growth in the anteroposterior andvertical directions. This view is compatible with mostclinicians’ views, which support that, when a patient whois still growing is developing an Angle Class II division 2malocclusion, this would not be corrected by mandibulargrowth without any intervention 15,22,25 .ConclusionsThe cephalometric study and assessment <strong>of</strong> findings<strong>of</strong> this study suggest that:1) Anteroposterior chin position in childrenapproximated “normal”, while adult patients showed atendency for retrusion;2) Facial pr<strong>of</strong>ile was convex and showed no significantdifferences among the groups <strong>of</strong> children, adolescentsand adults and no change with age;3) Mandibular morphology was found to varysignificantly at various ages: it changed and becamemore “square” with age;4) During orthodontic treatment <strong>of</strong> patients with AngleClass II division 2 malocclusion, it is necessary toconsider and activate in time those mechanismsthat inhibit the stunting <strong>of</strong> mandibular growth in theanteroposterior and vertical dimensions.References1. Korkhaus G. Über den Aufbau des Gesichtschadels beimDeckbiss. Fortschritte der Kieferorthopädie, 1953; 14:162-171. (in German)2. Maj G, Lucchese F. The mandible in Class II, Division 2.Angle Orthod, 1982; 52:288-292.3. Pancherz H, Zieber K, Hoyer B. Cephalometriccharacteristics <strong>of</strong> Class II division 1 and Class II division2 malocclusion: a comparative study in children. AngleOrthod, 1997; 67:111-120.4. Hausser E. Zur Atiologie und Genese des Deckbisses.Fortschritte der Kieferorthopädie, 1953; 14:154-161. (inGerman)5. Arvystas M. Non extraction treatment <strong>of</strong> severe Class IIdivision 2 malocclusions Part 1. Am J Orthod Dent<strong>of</strong>acOrthop, 1990; 97:510-521.6. Indication and frequency <strong>of</strong> X-ray in connection withorthodontic treatment. Statement by the DeutscheGesellschaft für Kieferothopädie. J Or<strong>of</strong>ac Orthop, 1997;58:286-287.7. Melsen B, Baumrind S. Clinical research applications<strong>of</strong> cephalometry. In: Athanasiou AE (ed). OrthodonticCephalometry. London: Mosby-Wolfe, 1998; pp 181-202.8. Ricketts R, Roth R, Chaconas S, Schulh<strong>of</strong> R, Engel G.Orthodontic diagnosis and planning. Vol 1. USA: RockyMountain Data Systems, 1982.9. Demisch A, Ingervall B, Thuer U. Mandibular displacementin Angle Class II division 2 malocclusion. Am J OrthodDent<strong>of</strong>ac Orthop, 1992; 102:509-518.10. Binda S, Kuijpers-Jagtmann A, Maertens J, Van H<strong>of</strong> M.A log term cephalometric evaluation <strong>of</strong> treated Class IIdivision 2 malocclusions. Eur J Orthod, 1994; 16:301-308.11. Karlsen A. Crani<strong>of</strong>acial characteristics in children withAngle Class II division 2 malocclusion combined withextreme deep bite. Angle Orthod, 1994; 64:123-130.12. Pancherz H, Zieber K. Dentoskeletal morphology inchildren with Deckbiss. J Or<strong>of</strong>ac Orthop, 1998; 59:274-285.13. Godiawala R, Joshi M. A cephalometric comparisonbetween Class II, Division 2 malocclusion and normalocclusion. Angle Orthod, 1974; 44:262-267.14. Zieber K, Pancherz H. Cephalometric characteristics <strong>of</strong> ClassII, division 2 malocclusions. Eur J Orthod, 1995; 17:462.15. You Ζ, Fishman S, Rosenblum R, Subtelny D. Dentoalveolarchanges related to mandibular forward growth in untreatedClass II persons. Am J Orthod Dent<strong>of</strong>ac Orthop, 2001;120:598-607.16. Langlade M. Diagnostic. Editeur Paris: Orthodontiquemaloine SA, 1981.17. Slavicek R, Schadlbauer E. Etude et comparison de valeurscephalometriques regionales en Autriche et en Allemagne.Rev Orthop Dent<strong>of</strong>ac, 1982; 16:417-471. (in French)18. Brezniak N, Arad A, Heller M, Dinbar A, Dinte A,Wasserstein A. Pathognomonic cephalometric characteristics<strong>of</strong> Angle Class II Division 2 malocclusion. Angle Orthod,2002; 72:251-257.19. Houston W. A cephalometric analysis <strong>of</strong> Angle Class IIdivision 2 in the mixed dentition. Dental Practice, 1967;17:372-376.20. Bjork A. Prediction <strong>of</strong> mandibular growth rotation. Am JOrthod Dent<strong>of</strong>ac Orthop, 1988; 55:585-599.21. Björk A, Skieller V. Normal and abnormal growth <strong>of</strong>the mandible. A synthesis <strong>of</strong> longitudinal cephalometricimplant studies over a period <strong>of</strong> 25 years. Eur J Orthod,1983; 5:1-46.22. Subtelny J. To treat or not to treat. Int Dent J, 1973;23:292-303.23. Bishara S, Hoppens B, Jacksen J, Kohout F. Changes in themolar relationship between the deciduous and permanentdentitions: a longitudinal study. Am J Orthod Dent<strong>of</strong>acOrthop, 1988; 93:19-28.Correspondence and request for <strong>of</strong>fprints to:Nikolaos Topouzelis, Associate Pr<strong>of</strong>essorAristotle University <strong>of</strong> ThessalonikiDental School, Department <strong>of</strong> OrthodonticsGR-54124 Thessaloniki, GreeceE-mail: ntopouz@dent.auth.gr
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141STOMATOLOGICAL SOCIETYClinical Oral Manifestation inGastrointestinal DisordersSUMMARYAim: to evidence extraoral and intraoral, subjective and objective,symptoms by patients with Crohn’s disease and ulcerative colitis, depending<strong>of</strong> the disease’s phase.Material and Method: to realize the established aim, 12 patients(8 with Crohn’s disease and 4 with ulcerative colitis) were followed at theClinic for gastrointestinal diseases. All patients went through exceptionalanamnesis and clinical control (inspection and palpation). All examineeswere examined in both phases - exacerbation and reemission.Results: As extraoral symptoms, arthralgia, sarcoidosis,thrombophlebitis, anaemia, oedema <strong>of</strong> the face and mouth were pointed out.The anaemia is mostly present in patients with Crohn’s disease (63%) andulcerative colitis (75%). After that, on the patients oedema <strong>of</strong> the mouth isevidenced in 38% <strong>of</strong> patients with Crohn’s disease and 25% <strong>of</strong> patients withulcerative colitis. From the subjective symptoms, symptoms such as illness,firing/fry, and glow were indicated; at the phase <strong>of</strong> exacerbation, thesesymptoms were indicated by all 8 patients with Crohn’s disease. Also by allpatients with clinical diagnosis <strong>of</strong> ulcerative colitis, illness was present andonly 3 out <strong>of</strong> 4 had an indication <strong>of</strong> firing and glow. From intraoral dentalsymptoms in both diseases, aphtous stomatitis and glositis were <strong>of</strong>ten present.In the exacerbation phase, in patients with Crohn’s disease, aphtous stomatiitswas always present, and glositis in 88% <strong>of</strong> patients. In the remission phases,the subjective dental symptoms evidently decreased. Considering ulcerativecolitis, the findings were identical, aphtous stomatitis and glositis werepresent in all 4 examinees. Piostomatis vegetans was present by 63% <strong>of</strong>patients with Crohn’s disease, and <strong>of</strong> patients with ulcerative colitis.Conclusion: the pr<strong>of</strong>ound clinical manifestation in examinees in theexacerbation phase is due to pathogenetical activities in the gastrointestinaltract. The oral cavity as a beginning part <strong>of</strong> the gastrointestinal tract, asimilar histological changes and disruptions are shown. For that reason, themost important role <strong>of</strong> the dentist is to diagnose gastrointestinal disruptions.Keyword: Crohn’s disease; Colitis, ulcerative; Gastrointestinal DisruptionsM. Popovska 1 , B. Stavrova 1 ,A. Atanasovska-Stojanovska 1 , P. Misevska 3 ,S. Strezovska 4 , L. Kanurkova 2 , J. Gjurcheski 11 Faculty <strong>of</strong> DentistryDepartment <strong>of</strong> Periodontology and Oral Pathology2 Faculty <strong>of</strong> DentistryDepartment <strong>of</strong> Orthodontics3 Faculty <strong>of</strong> MedicineDepartment <strong>of</strong> Gastroenterohepatology4 Dental Office IdadijaSkopje, FYROMORIGINAL PAPER (OP)Balk J Stom, 2011; 15:41-47IntroductionDentists and gastroenterohepatologysts put their effortand attention for diagnosis and treatment <strong>of</strong> certain diseases<strong>of</strong> digestive system. Contrary to gastroenterohepatologysts,dentists take care <strong>of</strong> the oral cavity as the initial part <strong>of</strong>digestive system. Although, each one is diagnosing andthreat different pathology, their points <strong>of</strong> view and focusescorrelate very <strong>of</strong>ten in the clinical practice. Digestivesystem is a long muscular tube which initial part is the oralcavity, through which food and secretions are transmittedtoward rectum. Histological analogy, familiarity andcorrelation <strong>of</strong> oral cavity and other parts <strong>of</strong> the digestivesystem determinate certain gastrointestinal disorders togive repercussions in the oral cavity.Having that in mind, dentists should recognize,diagnose and treat oral lesions and infections that are
42 M. Popovska et al. Balk J Stom, Vol 15, 2011related with digestive diseases. In fact, the role <strong>of</strong> thedentist is quite heterogeneous: from disease detectionwhich is not diagnosed yet, to adjusting dental treatmentwith medical treatment that impacts oral health.Gastrointestinal diseases that mostly affect oralcavity are: ulcerative colitis and Crohn’s disease.There are many articles in medical and dental literaturethat describe extra abdominal and oral expression <strong>of</strong>Crohn’s disease and ulcerative colitis. Well-knownand in practice <strong>of</strong>ten found oral expressions in relationwith inflammation <strong>of</strong> the large intestine are: vegetativepyostomatitis, aphthous ulcers, cobbled look <strong>of</strong>oral epithelium, epithelium shrinks granulomatousinflammation <strong>of</strong> small salivary glands, candidiasis andangular cheilitis 2,4- 6,8,12,14,18 .Ficcara at al 6 were examining the connectionbetween Crohn’s disease and vegetative pyostomatitis<strong>of</strong> oral mucosa, which is the marker <strong>of</strong> intestinalinflammation. The authors describe a 45-year-old womanwith diarrhoea present around 6 months and persistentpainful oral ulceration. The tongue was striated and inthe area <strong>of</strong> oral commisurrae pustules were present fromwhich Staphylococcus simulans was isolated.It is well known that changes in the oral cavity mayappear year or more before the first signs <strong>of</strong> inflammationin the bowel has been registered 4,15 . However, Crohn’sdisease and ulcerative colitis are <strong>of</strong> special interest todentist due to accompanying changes in the mouth and theinfluence <strong>of</strong> the medical therapy over the dentist treatment.Clinical course <strong>of</strong> these diseases is characterizedby episodes <strong>of</strong> acute attacks (phases <strong>of</strong> exacerbation)and phases <strong>of</strong> remission. This results in patient’s longtime suffering due to difficulties and slow treatment.Nowadays, dental literature presents data that indicatethe presence <strong>of</strong> antimicrobial proteins in saliva, as wellas bacterial and fungal infection in patients with Crohn’sdisease and ulcerative colitis having oral changes 1,9,13,16,17 .The aim <strong>of</strong> the study was to find out extra abdominalchanges in patients with Crohn’s disease and ulcerativecolitis and to evidence subjective symptoms and objectivechanges in the oral cavity in both stages <strong>of</strong> the diseases(exacerbation and remission), as well as to register intraoralsimilarities and differences in patient with these 2 diseases.Material and MethodFor realization <strong>of</strong> the established aim, 12 patients (8with Crohn’s disease and 4 with ulcerative colitis) werefollowed at the Clinic for gastrointestinal diseases (Faculty<strong>of</strong> Medicine) and the Department <strong>of</strong> periodontology and oraldisease (Faculty <strong>of</strong> Dentistry) in Skopje. Exceptional medicalhistory data (epidemiological characteristics <strong>of</strong> the disease -gender, age, duration <strong>of</strong> disease) and subjective symptoms(pain, glow, burning) were collected from all the patients.With clinical evaluation we noted extraoral andintraoral symptoms. Extraoral signs were: arthralgia,sarcoidosis, thrombophlebitis, anaemia, face oedema,lips swelling. Intraoral signs were: aphthous stomatitis,vegetative pyostomatitis, deep linear ulceration, angularcheilitis, indurative polypoid formation, glossitis, palemucosa, oral hairy leukoplakia. All examinees wereexamined in both phases <strong>of</strong> exacerbation and reemission.ResultsThe results <strong>of</strong> our research are presented in tablesand charts. Charts 1 and 2 present gender and age <strong>of</strong>patients with Crohn’s disease and ulcerative colitis. Of thetotal number <strong>of</strong> patient suffering from Crohn’s disease,50% were women and 50% were men. 1 male patient(25%) had ulcerative colitis and 3 women (75%). Bothdiseases were found in population older than 20 years,mostly at the age 31-50 years.Table 1 presents extraoral characteristics <strong>of</strong>patients with Crohn’s disease and ulcerative colitis inphases <strong>of</strong> exacerbation and remission. In the phase <strong>of</strong>exacerbation, in patients with Crohn’s disease anaemiawas most frequent, in 5 <strong>of</strong> 8 patients (63%). In the phase<strong>of</strong> remission, anaemia was present only in 2 <strong>of</strong> 8 patientsin phase <strong>of</strong> exacerbation or remission. In patients withulcerative colitis, in the phase <strong>of</strong> exacerbation, anaemiawas also the most frequent (3 out <strong>of</strong> 4 patients) and otherconditions (arthralgia, sarcoidosis, thrombophlebitis lipoedema) were less frequent. Some intraoral consequences<strong>of</strong> the anaemia in patients with Crohn’s disease andulcerative colitis are presented in figures 1 and 2.Subjective symptoms (pain, burning and glowing)in patient with Crohn’s disease and ulcerative colitis, inboth phases <strong>of</strong> the diseases (exacerbation and remission)are presented in table 2. In the phase <strong>of</strong> exacerbation, all8 patients with Crohn’s disease (100%) had subjectivehardship <strong>of</strong> pain and burning; however, in the phase<strong>of</strong> remission, only 2 <strong>of</strong> these patients (25%) felt pain inthe oral cavity, while one patient (13%) felt burning. Inthe phase <strong>of</strong> exacerbation, all 4 patients with ulcerativecolitis had subjective hardship <strong>of</strong> pain, while burning waspresent in 3 patients (75%). In the phase <strong>of</strong> remission,subjective hardship was less prominent.Intraoral characteristics among patients with Crohn’sdisease and ulcerative colitis, in phases <strong>of</strong> exacerbationand remission are presented in table 3. Among intraoralsigns, we have noticed aphthous stomatitis, Pyostomatitisvegetans, indurated polypoid formation, deep linearulcers, pale mucosa, oral hairy leukoplakia, glossitis, andangular cheilitis. Some <strong>of</strong> these signs are presented infigures 3-6.Charts 3 and 4 present a comparative view <strong>of</strong>intraoral signs among patients with Crohn’s disease andulcerative colitis in both phases <strong>of</strong> the diseases.
Balk J Stom, Vol 15, 2011 Oral Manifestations in Gastrointestinal Disorders 43ABChart 1. Gender distribution <strong>of</strong> patient with: (A) Crohn’s disease and(B) ulcerative colitisChart 2. represents age distribution <strong>of</strong> patient with : A)Morbus CrohnB) Colitis ulcerativeTable 1. Extraoral characteristics <strong>of</strong> patients with Crohn’sdisease and ulcerative colitis in phases <strong>of</strong> exacerbationand remissionExtraoral characteristicsPhase <strong>of</strong>exacerbationCrohn’sdisease (n=8)Ulcerativecolitis (n=4)n =12 number % number %Arthralgia 2 25 1 25Sarcoidosis 1 13 1 25Thrombophlebitis 1 13 1 25Anaemia 5 63 3 75Facial oedema 0 0 0 0Lips oedema 3 38 1 25AArthralgia 1 13 1 25Phase <strong>of</strong>remissionSarcoidosis 1 13 0 0Thrombophlebitis 1 13 0 0Anaemia 2 25 1 25Facial oedema 0 0 0 0Lips oedema 2 25 1 25BFigure1. Oedema <strong>of</strong> the lip in the patient with:(A) ulcerative colitis, and (B) Crohn's diseaseABFigure 2. Consequences <strong>of</strong> anaemia present in patients with Crohn's disease:(A) angular cheilitis; (B) cheilitis exfoliativa
44 M. Popovska et al. Balk J Stom, Vol 15, 2011Table 2. Subjective symptoms in patients with Crohn’s disease and ulcerative colitis inphases <strong>of</strong> exacerbation and remissionSubjective symptoms Crohn’s disease Ulcerative colitisnumber % number %Phase <strong>of</strong> exacerbationPhase <strong>of</strong> remissionpain 8 100 4 100fry and glow 8 100 3 75pain 2 25 1 25fry and glow 1 13 1 25Table 3. Intraoral signs <strong>of</strong> Crohn’s disease and ulcerative colitis inboth phases <strong>of</strong> the disease (in patients with oral symptoms)Phases <strong>of</strong> thediseaseIntraoral signs Crohn’s disease Ulcerative colitisnumber % number %Aphthous stomatitis 8 100 4 100Pyostomatitis vegetans 5 63 2 50Indurated pylipoid formation 2 25 1 25ExacerbationDeep linear ulcers 2 25 2 50Angular cheilitis 4 50 2 50Pale mucosa 2 25 2 50Glossitis 7 88 4 100Oral chairy leukoplakia 1 13 1 25Aphthous stomatitis 3 38 1 25Pyostomatitis vegetans 2 25 2 50Indurated pylipoid formation 1 13 1 25RemissionDeep linear ulcers 1 13 1 25Angular cheilitis 2 25 1 25Pale mucosa 2 25 2 50Glossitis 2 25 1 25Oral chairy leukoplakia 1 13 1 25
Balk J Stom, Vol 15, 2011 Oral Manifestations in Gastrointestinal Disorders 45Figure 3. Cobbled look <strong>of</strong> the buccal mucosa in patient withCrohn’s diseaseAFigure 4. Pyostomatitis vegetans in patients with Crohn's diseaseBFigure 6. Aphthous stomatitis in patient with ulcerative colitis:(A) buccal mucosa; (B) apex <strong>of</strong> the tongueFigure 5. Hyperemia in oral epithelium in the patient withulcerative colitisChart 3. Comparison <strong>of</strong> intraoral characteristics among Morbus Crohnin a phase <strong>of</strong> exacerbation and remissionChart 4. Comparison <strong>of</strong> intraoral characteristics among Colitisulcerative in a phase <strong>of</strong> exacerbation and remission
46 M. Popovska et al. Balk J Stom, Vol 15, 2011DiscussionUlcerative colitis and Crohn’s disease are 2 <strong>of</strong> themost frequent intestine irritations in the group <strong>of</strong> idiopathicinflammations. Ulcerative colitis affects mucosa andsubmucosa <strong>of</strong> the large intestine and Crohn’s disease isactually regional enteritis, inflammatory condition thataffects all layers <strong>of</strong> the intestine. Nevertheless, these2 diseases share many common features, including anunknown etiology and not so clear pathogenesis. Bothdiseases are <strong>of</strong> crucial interest to dentist because <strong>of</strong> theassociated changes in the mouth and the consequencesarising from therapy (especially the use <strong>of</strong> corticosteroids).Therefore, many editorials in medical and dental literatureare devoted to extra-abdominal and oral signs <strong>of</strong> intestineinflammation 1,7,18 , or to oral cavity findings 9,10 .From epidemiological aspects <strong>of</strong> view, both diseasesdemonstrate 3 well-known peaks <strong>of</strong> incidence. The first,which is the highest, in the period between 20 and 24years <strong>of</strong> age, the second between 40 and 44 years <strong>of</strong> age,and the third between 60 and 64 year. After 60 years <strong>of</strong>age, the incidence <strong>of</strong> ulcerative colitis far exceeds theincidence <strong>of</strong> Crohn’s disease 4 . Women from England andNorthern Europe have 30% higher risk for development<strong>of</strong> ulcerative colitis and Crohn’s disease. They <strong>of</strong>ten affectwhites and Jewish people, particularly those originatingfrom Central Europe: Russia and Poland.Our results are somehow contradictory to thefindings obtained from the literature: the biggest incidencewas registered in the period between 30 and 50 years <strong>of</strong>age. This study went through the subjective and objectiveextraoral and intraoral changes in phase <strong>of</strong> exacerbationand remission. In phase <strong>of</strong> exacerbation, <strong>of</strong> the extraoralfindings found in patients with ulcerative colitis andCrohn’s disease, anaemia was dominantly present. Webelieve that pernicious anaemia arises as a result <strong>of</strong> bloodand iron loss, which is more emphasized in the activephase <strong>of</strong> both diseases. Inflammatory bowel mucosacan distort absorption <strong>of</strong> vital nutrients, such as Ca, Fe,or folates, which are absorbed in the small intestine.Therefore, the reduced absorption due to inflammationresults in lack <strong>of</strong> the previously mentioned nutrients,which is more noticeable in patients with Crohn’s diseasethan in patients with ulcerative colitis. Diarrhoea is amajor cause for dysfunctional balance <strong>of</strong> electrolytes andlow level <strong>of</strong> albumin. Lack <strong>of</strong> iron and folates reflectthe occurrence <strong>of</strong> anaemia. In the phase <strong>of</strong> remissionsymptoms are less prominent. Anaemia is also presentas a main extraoral symptom, but only in the half <strong>of</strong> therespondents. The applied treatment corrects abdominalfindings and decreases the number <strong>of</strong> patients withanaemia, which explains the obtained findings <strong>of</strong> ourstudy. Concerning other extraoral signs, oedema <strong>of</strong> lipswas noticed more <strong>of</strong>ten in patients with ulcerative colitis,which was also noticed by Ming 14 and Yamada 10 .Among intraoral objective findings in patients withulcerative colitis in the phase <strong>of</strong> exacerbation, aphthousstomatitis was the most prominent symptom, followed byglossitis, pyostomatitis vegetans and angular cheilitis. Wepresume that aphthae are the consequence <strong>of</strong> the lack <strong>of</strong> iron,folic acid, Vitamin B 12 , intestinal absorption dysfunctionand loss <strong>of</strong> blood. Aphthae were still present, althoughin a smaller number, even in the phase <strong>of</strong> remission <strong>of</strong> thedisease. We believe that their persistence is due to the effect<strong>of</strong> the applied therapy (treatment with sulfasalizine, sal<strong>of</strong>alkand other drugs results in occurrence <strong>of</strong> new ulcers orlonger persistence <strong>of</strong> already existing aphthae - these drugsare excreted through saliva and they irritate oral mucosa).The new eruptions in these patients are <strong>of</strong>ten a forerunner<strong>of</strong> a new surge <strong>of</strong> the disease. Question which needs to beanswered is the following: are aphthae a typical sing <strong>of</strong> thedisease, disease forerunner, only a random clinical finding,or the consequence <strong>of</strong> the present anaemia?By frequency <strong>of</strong> presence, at these patients intraoralPyostomatitis vegetans (deep proliferative lesions) ispresent. Their appearance in the oral cavity is related tothe impact <strong>of</strong> circulating human immune complexes,whose creation shall encourage the intestine antigen ordamaged lining <strong>of</strong> the colon. The other very <strong>of</strong>ten presentsign <strong>of</strong> the Crohn’s is a cobbled mucous look 21 . Thismorphological change is a reflection <strong>of</strong> granulomatouschanges that represent the main reason <strong>of</strong> Crohn’s disease.The consequences <strong>of</strong> dysfunctional absorption are visiblethrough other present signs: pale mucosa, angular cheilitisand glossitis. These signs are more prominent amongundiagnosed cases, in the acute phase <strong>of</strong> the disease, orwhen the disease is poorly controlled.In a phase <strong>of</strong> remission, intraoral clinical signs inpatients with Crohn’s disease could still be present, but ina fewer number <strong>of</strong> patients. We believe that the improvedabsorption in the intestine has a positive effect on thepatients’ oral status.Subjective symptoms in a phase <strong>of</strong> exacerbation,as pain, burning and glowing, are due to the presence <strong>of</strong>eroded or ulcerated areas. In the phase <strong>of</strong> remission, thereis a gradual normalization <strong>of</strong> the regulatory mechanismsand a decrease <strong>of</strong> subjective symptoms in patients withulcerative colitis and Crohn’s disease.Finally, it might be concluded that clinical symptomsamong most <strong>of</strong> the respondents in the phase <strong>of</strong> exacerbationwhere the consequence <strong>of</strong> the events in the gastrointestinaltract. The oral cavity, as mirror <strong>of</strong> general health status<strong>of</strong> each individual, especially reflects disorders <strong>of</strong> thedigestive system. Therefore, the important role <strong>of</strong> thedentist is to recognize oral changes, diagnose them andtreat the consequences <strong>of</strong> ulcerative colitis and Crohn’sdisease. From this point <strong>of</strong> view, the inter-departmentalclinical and technical cooperation with the colleaguesfrom gastroenteropatology departments is <strong>of</strong> particularimportance. We hope that it would facilitate treatment andincrease the quality <strong>of</strong> life <strong>of</strong> this category <strong>of</strong> patients.
Balk J Stom, Vol 15, 2011 Oral Manifestations in Gastrointestinal Disorders 47References1. Calobrisi SD, Mutasim DF, McDonald JS. Pyostomatitisvegetans associated with ulcerative colitis: temporaryclearance with fluocinonide gel and complete remissionafter colectomy. Oral Surg Oral Med Oral Pathol OralRadiol Endod, 1995; 79:452-454.2. Chan SWY, Scully C, Prime SS, et al. Pyostomatitisvegetans: oral manifestation <strong>of</strong> ulcerative colitis. Oral SurgOral Med Oral Pathol, 1991; 72:689-692.3. Bevenius J. Caries risk in patients with Crohn’s disease: apilot study. Oral Surg Oral Med Oral Pathol, 1988; 65:304-307.4. Greenberg MS, Glick M. Burketova oralna medicina,dijagnoza i lečenje. Zagreb: Medicinska naklada. 2006. (inCroat)5. Ghandorour K, Moneim I. Oral Crohn’s disease with lateintestinal manifestations. Oral Surg Oral Med Oral Pathol,1991; 72:565-567.6. Ficarra G, Cicchi P, Amorosi A, et al. Oral Crohn’s diseaseand pyostomatitis vegetans: an unusual association. OralSurg Oral Med Oral Pathol, 1993; 75:220-224.7. Halme L, Meurman JH, Laine P, et al. Oral findings inpatients with active or inactive Crohn’s disease. Oral SurgOral Med Oral Pathol, 1993; 76:175-181.8. Hansen LS, Silverman SJ, Daniels TE. The differentialdiagnosis <strong>of</strong> pyostomatitis vegetans and its relation tobowel disease. Oral Surg Oral Med Oral Pathol, 1983;55:363-373.9. Healy CM, Farthing PM, Williams DM, et al. Pyostomatitisvegetans and associated systemic disease: a review andtwo case reports. Oral Surg Oral Med Oral Pathol, 1994;78:323-328.10. Yamada T (ed). Textbook <strong>of</strong> gastroenterology. Philadelphia:JB Lippincott, 1995.11. Kano Y, Shiohara T, Yagita A, et al. Erythema nodosum,lichen planus and lichen nitidus in Crohn’s disease report<strong>of</strong> a case and analysis <strong>of</strong> T-cell receptor V gene expressionin the cutaneous and intestinal lesions. Dermatology, 1995;190:59-63.12. Malins TJ, Wilson A, Ward-Booth RP. Recurrent buccalspace abscesses: a complication <strong>of</strong> Crohn’s disease. OralSurg Oral Med Oral Pathol, 1991; 72:19-21.13. Meurmen JH, Halme L, Laine P, et al. Gingival and dentalstatus salivary acidogenetic bacteria, and yeast counts <strong>of</strong>patients with active or inactive Crohn’s disease. Oral SurgOral Med Oral Pathol, 1994; 77:465-468.14. Ming SC, Goldman H (eds). Pathology <strong>of</strong> thegastrointestinal tract. 2 nd ed. Baltimore: Williams andWilkins, 1998.15. Plauth M, Jeness J, Meyle J. Oral manifestations <strong>of</strong> Crohn’sdisease: an analysis <strong>of</strong> 79 cases. J Clin Gastroenterol,1991; 13:29-37.16. Rooney TP. Dental caries prevalence in patients withCrohn’s disease. Oral Surg Oral Med Oral Pathol, 1984;57:623-624.17. Schnitt SJ, Antonioli DA, Jaffe B, et al. Granulomatousinflammation <strong>of</strong> minor salivary gland ducts: a new oralmanifestation <strong>of</strong> Crohn’s disease. Hum Pathol, 1987;18:405-407.18. Siegel MA. Oral manifestations <strong>of</strong> gastrointestinal disease:diagnosis and treatment. In: Bayless TM (ed). Currenttherapy in gastroenterology and liver disease. Burlington(Can): BC Decker, 1989; pp 1-5.19. Sundh B, Emilson CG. Salivary and microbial conditionsand dental health in patients with Crohn’s disease: a 3-yearstudy. Oral Surg Oral Med Oral Pathol, 1989; 67:286-290.20. Sundh B, Johansson I, Emilson GC, et al. Salivaryantimicrobial proteins in patients with Crohn’s disease.Oral Surg Oral Med Oral Pathol, 1993; 76:564-569.21. Ward CS, Dunphy EP, Jagoe WS, et al. Crohn’s diseaselimited to the mouth and anus. J Clin Gastroenterol, 1985;7:516-521.Correspondence and request for <strong>of</strong>fprints to:Mirjana PopovskaVodnjanska 171000 SkopjeFYR MacedoniaE-mail: popovskam2002@yahoo.com
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141STOMATOLOGICAL SOCIETYRecurrent Atypical Fibroxanthoma in a Patient withScleroderma: Report <strong>of</strong> a CaseSUMMARYAtypical fibroxanthoma is an uncommon mesenchymal tumour, whichusually has a benign clinical course and an excellent prognosis. Treatment<strong>of</strong> choice is wide surgical incision since the possibility <strong>of</strong> recurrence ishighly correlated to positive tumour margins.We report a case <strong>of</strong> atypical fibroxanthoma in a female patientsuffering from scleroderma. Despite the aggressive treatment, the tumourrecurred several times. This is the first documented case <strong>of</strong> atypicalfibroxanthoma occurring a patient with a collagen disorder.Keywords: Fibroxanthoma, atypical; SclerodermaMaria Lazaridou 1 , Lambros Zouloumis 1 ,Konstantinos Kontos 1 , Anastasia Nikolaidou 2 ,Konstantinos Vachtsevanos 21 Aristotle University <strong>of</strong> Thessaloniki, Greece2 Theageneio Hospital, Thessaloniki, GreeceCASE REPORT (CR)Balk J Stom, 2011; 15:48-51Atypical fibroxanthoma is an uncommon, cutaneousmesenchymal tumour. It usually appears as a solitarynodule or ulcerous nodule on sun-damaged skin <strong>of</strong> theelderly people. Histologically, an anaplastic activitywith marked cytological atypia, increased number <strong>of</strong>mitotic figures and presence <strong>of</strong> multinucleated giant cellsbelies its usually benign clinical course and excellentprognosis 1,2 .Atypical fibroxanthoma is regarded as a superficial, lessaggressive counterpart <strong>of</strong> malignant fibrous histiocytoma.These 2 tumours are histologically indistinguishable buttheir clinical presentation differs 3,4 . Atypical fibroxanthomaarises superficially; it is usually confined in the dermis <strong>of</strong> theactinically damaged skin <strong>of</strong> the head and neck <strong>of</strong> the elderly,whereas malignant fibrous histiocytoma arises in deep s<strong>of</strong>ttissues <strong>of</strong> the extremities and in the retro-peritoneum <strong>of</strong>younger people 3 . Moreover, atypical fibroxanthoma hasalmost always a benign clinical course, unlike malignantfibrous histiocytoma, which is characterized by a highincidence <strong>of</strong> metastasis and a high recurrence rate 1 .The treatment <strong>of</strong> choice <strong>of</strong> atypical fibroxanthoma iswide surgical excision, since the possibility <strong>of</strong> recurrenceis highly correlated to positive tumour margins 5 . Wereport a case <strong>of</strong> atypical fibroxanthoma in a female patientwho suffered from scleroderma. To our knowledge, thisis the first documented case <strong>of</strong> atypical fibroxanthomareported in a patient with a collagen disorder.Case ReportA 57-year-old Caucasian woman presented to ourdepartment <strong>of</strong> Oral and Maxill<strong>of</strong>acial Surgery with an8-month history <strong>of</strong> a painless ulcerative pre-auriculartumour measuring 3x3cm. She reported the appearance<strong>of</strong> a small nodule 8 months ago which had grownrapidly and become ulcerated. The lesion was fragileand asymptomatic, but due to its cosmetic appearancethe patient had to cover it with a piece <strong>of</strong> gauze. Therest <strong>of</strong> the examination was unremarkable with nopalpable cervical adenopathy. The chest film was free<strong>of</strong> metastatic lesions, although there was an extendedpulmonary fibrosis due to scleroderma. The patient had asmaller lesion resected from the same area one year ago.The histological examination <strong>of</strong> this tumour revealed akeratoacanthoma.The patient suffered from scleroderma diagnosed 10years ago, being controlled with Prezolon 5 mg (1x3) andCyclophosphamide 50 mg (1x3). Despite the aggressiveimmunosuppressive therapy, she had developedpulmonary hypertension due to the disease, but she hadno gastrointestinal symptoms. Her medical history alsorevealed moderate hypertension and coronal disease.A punch biopsy <strong>of</strong> the pre-auricular tumour wasperformed and the patient was initially treated withradiotherapy due to her compromised medical status. Theradiotherapy started immediately because the tumour was
Balk J Stom, Vol 15, 2011 Fibroxanthoma in a Patient with Scleroderma 49growing fast and was clinically diagnosed as a squamouscell carcinoma.The biopsy showed an atypical spindle cellneoplasm, which did not stain with cytokeratin, S-100protein, HMB-45, MelanA and SMA. The tumour washistologically characterized as sarcoma. Radiotherapywas subsequently abandoned. Under general anesthesiaa wide excision <strong>of</strong> the tumour was performed. Part <strong>of</strong>the superficial temporal fascia and part <strong>of</strong> the zygomaticarch were also excised (Figs. 1 and 2). The defect wascovered with free skin grafts because the duration <strong>of</strong> thesurgery should be kept to a minimum due to compromisedmedical status <strong>of</strong> the patient.The biopsy specimen demonstrated a wellcircumscribed,non-encapsulated tumour localized in thedermis, contiguous with the ulcerated epidermis. The cellswere large, pleomorphic, longitudinal and spindle-shapedwith an abundant eosinophilic cytoplasm and frequentmitotic figures (Fig. 3). The margins <strong>of</strong> the specimen werenot infiltrated and the nearest distance from the margins<strong>of</strong> the tumour was 1cm. Immunohistochemical staining<strong>of</strong> proliferative cells was strongly positive for vimentin,S-100 (Fig. 4) and CD68, but much more weakly positivefor cytokeratin 8/18 and smooth muscle actin (SMA).Tumour cells did not show any reactivity with HMB45, MelanA, KerAE1/AE3, Ker LMW, KerHMW,Ker7, Ker20, EMA and CD34. The diagnosis <strong>of</strong> atypicalfibroxanthoma was established.2 months later the patient presented to ourdepartment with 2 nodules located at the margins <strong>of</strong> theskin graft. Excision <strong>of</strong> one nodule under local anesthesiawas performed. The histological examination <strong>of</strong> thespecimen revealed a recurrence <strong>of</strong> the primary tumour.The next month the patient underwent a wide excision<strong>of</strong> the nodules under general anesthesia and the defectwas again reconstructed with free skin grafts (Figs. 5and 6). Once again biopsy was indicative <strong>of</strong> an atypicalfibroxanthoma. The patient has been closely followed for18 months and she has shown no evidence <strong>of</strong> a recurrenceor distant metastasis. The patient eventually died from thesystemic disease.Figure 1. The patient after the wide removal <strong>of</strong> the lesion. Part <strong>of</strong> thezygomatic arch was also excised since the initial diagnosis <strong>of</strong> thelesion was sarcomaFigure 3. Biopsy <strong>of</strong> the tumour shows atypical fibroxanthoma abuttingthe epidermis (H&E, orig. magn. x 10)Figure 2. The excised specimen. The appearance <strong>of</strong> the lesion is similarto the appearance <strong>of</strong> a squamous cell carcinomaFigure 4. Positive staining <strong>of</strong> the tumour cells with S-100 protein(orig. magn. x10)
50 Maria Lazaridou et al. Balk J Stom, Vol 15, 2011Figure 5. Recurrence <strong>of</strong> the tumour can be seen in the periphery <strong>of</strong> theskin graftFigure 6. The operative field following the wide excision <strong>of</strong> the tumour.A skin graft was again used for the reconstruction <strong>of</strong> the defectDiscussionAtypical fibroxanthoma was first reported by Helwigin 1963 6 . He described a solitary spindle cell neoplasmarising on the sun damaged skin <strong>of</strong> an elderly patient.Atypical fibroxanthoma begins as a small, firmand solitary nodule, which may be ulcerated (36%) orbleeding (26%) 7 . It usually grows rapidly, but remainsasymptomatic. Some nodules have a pigmentedappearance due to hemosiderin deposits. In this case,differential diagnosis from melanomas may be difficult.Atypical fibroxanthoma usually appears on the head andneck <strong>of</strong> elderly people with a mean age <strong>of</strong> 71-86 years 5 ,and less <strong>of</strong>ten on the trunk and extremities <strong>of</strong> youngerpeople. Very rarely it can affect the eye 8 . Our patient was57 years old and presented with a large painless ulcer onthe pre-auricular region.The pathogenesis <strong>of</strong> atypical fibroxanthoma is stillunknown, although many predisposing factors havebeen reported. Ultraviolet radiation seems to play amajor role by inducing p53 mutations at dipyrimidinesites 9 . Other predisposing factors include trauma,burns, radiotherapy, post-cardiac and post-renaltransplantation and immunosuppressive therapy 10,11 .A high incidence <strong>of</strong> cutaneous malignancies has beenreported in transplant recipients, which is attributed tothe need <strong>of</strong> lifelong maintenance immunosuppressivetherapy 12 . Immunosuppressive therapy impairs the tumoursurveillance mechanism <strong>of</strong> lymphocytes, disrupting thebalance between tumourigenesis and tumourilysis 13 .Immunosuppressive therapy and perhaps the initialradiation therapy may have contributed to the presence <strong>of</strong>multiple recurrences in our patient despite wide surgicalexcision.The diagnosis <strong>of</strong> atypical fibroxanthoma is basedon histological examination and immunohistochemistry,since its clinical course and appearance leads to avariety <strong>of</strong> preoperative diagnosis, such as squamous cellcarcinoma, basal cell carcinoma, pyogenic granuloma,melanoma, dermatosarcoma, cutaneous lymphoma andmalignant fibrous histiocytoma 5,10 .Immunohistochemical studies are helpful inestablishing the diagnosis and in differentiating atypicalfibroxanthoma from other cutaneous malignancies.Atypical fibroxanthoma stains positively with vimentinonly, and shows variable reaction with a1-antitrypsin,factor XII and smooth muscle actin (SMA) 13,14 .Squamous and spindle cell carcinoma stain positivelywith cytokeratin and epithelial membrane antigen,whereas atypical fibroxanthoma does not stain with thesemarkers 15 . Moreover, atypical fibroxanthoma does notstain with S-100 protein and HMB-45, which are usuallypositive in melanomas 16 . However, the absence <strong>of</strong> positivereaction with these markers can not confirm the diagnosis<strong>of</strong> atypical fibroxanthoma, because in some cases spindlecell carcinomas may not stain with cytokeratin andmelanomas may not stain with S-100 protein 5 . In our case,the tumour stained with vimentin and there was a mildreactivity with SMA, which has been reported before 5 .Interestingly, in our case, there was a strong reactionwith S-100 protein, which has not been reported before.It seems that reactivity with S-100 protein cannot excludethe diagnosis <strong>of</strong> atypical fibroxanthoma.Immunohistochemical studies are also used in orderto differentiate atypical fibroxanthoma from its malignantcounterpart, namely malignant fibrous histiocytoma.LN-2 is a 35kDa protein mainly expressed on the nuclearmembrane <strong>of</strong> B-lymphocytes. This protein has beenconsistently identified in malignant fibrous histiocytomasbut not in atypical fibroxanthomas 17 . It seems that LN-2 isa reliable marker in distinguishing between the 2 lesions.
Balk J Stom, Vol 15, 2011 Fibroxanthoma in a Patient with Scleroderma 51The treatment <strong>of</strong> choice is wide surgical excisionwith at least 1 cm margin 18 . We absolutely agree withGonzalez-Garcia et al 5 that curettage and cryosurgery arenever indicated since they can lead to a remarkably higherrecurrence rate. Mohs microsurgery is a conservativeapproach that should only be reserved for tumoursadjacent to important anatomic structures. Radiotherapyis advocated by some authors, but some others suggestthat following radiotherapy the tumour may show a moreaggressive clinical course 7,19 . We chose to treat our patientwith wide surgical excision despite her compromisedmedical status.Atypical fibroxanthomas are known to recur in about12% <strong>of</strong> cases 20 , with a mean time <strong>of</strong> 2 years betweensurgery and recurrence. Recurrences are usually aconsequence <strong>of</strong> inadequate surgical margins 7,21 . However,multiple recurrences occurred in our patient despite thewide excision <strong>of</strong> the primary tumour, suggesting thatimmunosuppressive therapy and radiotherapy might alsoplay an important role in clinical course <strong>of</strong> the tumour.The existence <strong>of</strong> occasional recurrences advocates for aclose follow-up <strong>of</strong> the patient, at least for the first 2 yearsfollowing surgery.Although extremely uncommon, metastatic spreadhas been described by some authors 6,22 . Metastasis isusually associated with large tumours with deep vascularinvasion and with immunocompromised hosts. Accordingto Helwig 6 , metastasis usually occurs within 12 to 18months. Metastasis from atypical fibroxanthoma is notalways fatal, since surgical control or even cure may alsohappen.References1. Fretzin DF, Helwig EB. Atypical fibroxanthoma <strong>of</strong> the skin:A clinicopathologic study <strong>of</strong> 140 cases. Cancer, 1973;31:1541-1552.2. Kroe DJ, Pitcock JA. Atypical fibroxanthoma <strong>of</strong> the skin:Report <strong>of</strong> ten cases. Am J Clin Pathol, 1969; 51(4):487-492.3. Weiss SW, Enzinger FM. Malignant fibrous histiocytoma: Ananalysis <strong>of</strong> 200 cases. Cancer, 1978; 41:2250-2266.4. Kempson RL, Kryiakos M. Fibroxanthosarcoma <strong>of</strong> the s<strong>of</strong>ttissues: A type <strong>of</strong> malignant fibrous histiocytoma. Cancer,1972; 29:971-976.5. Gonzalez-Garcia R, Nam-Cha SH, Munoz-Guerra MF, Sastre-Perez J, Rodriguez-Campo FJ, Naval-Gias L. Atypicalfibroxanthoma <strong>of</strong> the head and neck: Report <strong>of</strong> 5 cases. JOral Maxill<strong>of</strong>ac Surg, 2007; 65:526-531.6. Helwig EB. Tumor Seminar. Tex State J Med, 1963; 59:664-667.7. Starink T, Hausman R, Van Delden L, Neering H. Atypicalfibroxanthoma <strong>of</strong> the skin. Presentation <strong>of</strong> 5 cases andreview <strong>of</strong> the literature. Br J Dermatol, 1977; 97:167-177.8. Engelbrecht NE, Ford JG, White WL, Yeatts RP. Combinedintraepithelial squamous neoplasia and atypicalfibroxanthoma <strong>of</strong> the cornea and limbus. Am J Opthalmol,2000; 129:94-96.9. Dei Tos AP, Maestro R, Doglioni C, Gasparotto D, BoiocchiM, Laurino L, et al. Ultra-violet-induced p53 mutationsinatypical fibroxanthoma. Am J Pathol, 1994; 145:11-17.10. Ferri E, Iaderosa GA, Armato E. Atypical fibroxanthoma <strong>of</strong>the external ear in a cardiac transplant recipient: Case reportand the causal role <strong>of</strong> the immunosuppressive therapy. AurisNasus Larynx, 2008; 35:260-263.11. Kanitakis J, Euvrard S, Montazeri A, Garnier JL, Faure M,Claudy A. Atypical fibroxanthoma in a renal graft recipient.J Am Acad Dermatol, 1996; 35:262-264.12. Veness MJ. Aggressive skin cancer in a cardiac transplantrecipient. Australia Radiol, 1997; 41(4):363-366.13. Longacre TA, Smoller BR, Rouse RV. Atypicalfibroxanthoma. Multiple histologic pr<strong>of</strong>iles. Am J SurgPathol, 1993; 17:1199.14. Kindblom LC, Jabobsen GK, Jacobsen M.Immunohistochemical investigations <strong>of</strong> tumors <strong>of</strong> supposedfibroplastic histiocytic origin. Hum Pathol, 1982; 13:834-840.15. Rice CD, Gross DJ, Dinehart SM, Brown HH. Atypicalfibroxanthoma <strong>of</strong> the eyelid and cheek. Arch Ophthalmol,1991; 109:922-923.16. Weiss SW, Langloss JM, Enzinger FM. Value <strong>of</strong> S-100protein in the diagnosis <strong>of</strong> s<strong>of</strong>t tissue tumors with particularreference to benign and malignant Schwann cell tumors.Lab Invest, 1983; 49:299-308.17. Lazova R, Moynes R, May D, Scott G. LN-2: A marker todistinguish atypical fibroxanthoma from malignant fibroushistiocytoma. Cancer, 1997; 79:2115-2124.18. Stadler FJ, Scott GA, Brown MD. Malignant fibrous tumors.Semin Cutan Med Surg, 1998; 17:141-152.19. Fish FS. S<strong>of</strong>t tissue sarcomas in dermatology. DermatolSurg, 1996; 22:268.20. Davis JL, Randle HW, Zalla MJ, Roenigk RK, BrodlandDG. Comparison <strong>of</strong> Mohs micrographic surgery and wideexcision for the treatment <strong>of</strong> atypical fibroxanthoma.Dermatol Surg, 1997; 23:105-110.21. Helwig EB, May D. Atypical fibroxanthoma <strong>of</strong> the skin withmetastasis. Cancer, 1986; 57:368-376.22. Kemp JD, Stenn KS, Arons M, Fischer J. Metastasizingatypical fibroxanthoma. Coexistence with chroniclymphocytic leukemia. Arch Dermatol, 1978; 114:1533.23. Giuffrida TJ, Kligora CJ, Goldstein GD. Localisedcutaneous metastasis from an atypical fibroxanthoma.Dermatol Surg, 2004; 30:1561.Correspondence and request for <strong>of</strong>fprints to:Mrs Maria Lazaridou, DDS,MDAristotle University <strong>of</strong> ThessalonikiIoannou Xatzoudi 9, Neapoli56727, ThessalonikiGreece
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141STOMATOLOGICAL SOCIETYUnusual Penetrating Metallic Foreign Bodies InjuredMaxill<strong>of</strong>acial and Orbital Region with Minimal DamageSUMMARYPenetrating injuries during work accidents represent a rare butcomplex variety <strong>of</strong> crani<strong>of</strong>acial trauma. Generally, the penetrating materialis stiff enough to cross through different anatomic structures and can causean impressive problem for the patient. On the arrival at the emergencydepartment, clinical situation <strong>of</strong> the patient must be evaluated to decide thetype <strong>of</strong> examination. Functional and cosmetic problems must be taken underconsideration and an immediate decision must be taken by the specialists fora rapid surgical treatment. The surgical approach depends on the position <strong>of</strong>a foreign body.2 penetrating head injuries during work accident are presented, thepre- and intra-operative approach described and the particularities <strong>of</strong> thesecases are pointed out.Keywords: Penetrating Trauma; Metallic Foreign BodyA. Ntomouchtsis 1 , D. Maggoudi 2 , H. Panidou 3 ,A. Kondylidou 4 , K. Antoniades 11 Papanikolaou HospitalDepartment <strong>of</strong> Oral and Maxill<strong>of</strong>acial Surgery2 Theagenion HospitalDepartment <strong>of</strong> Oral and Maxill<strong>of</strong>acial Surgery3 Papanikolaou HospitalDepartment <strong>of</strong> Ophthalmology4 Aristotle UniversityDepartment <strong>of</strong> Dentoalveolar SurgeryOral Implantology and RadiologyThessaloniki, GreeceCASE REPORT (CR)Balk J Stom, 2011; 15:52-56IntroductionAccording to Agrillo et al 1 , a good cosmetic andfunctional outcome <strong>of</strong> penetrating injuries depend on 4main factors: (1) the extent <strong>of</strong> the traumatic injury; (2)clinical condition and age <strong>of</strong> the patient; (3) diagnosticaccuracy; and (4) the amount <strong>of</strong> time that has passedbetween trauma and operation. First aid for traumapatients requires their transportation to an emergencydepartment by qualified personnel. After this, amultidisciplinary approach is recommended, taking intoaccount all the anatomic structures involved and planningthe most suitable surgical strategy 1 .In order to assess the exact extent <strong>of</strong> themaxill<strong>of</strong>acial injuries, it is necessary to perform someexaminations, such as standard skull radiographs in 4projections, 2-dimensional computed tomography (CT)scans in axial and coronal projections, or 3-dimensionalCT scans <strong>of</strong> the maxill<strong>of</strong>acial area 2 . Preoperativeknowledge <strong>of</strong> the shape <strong>of</strong> the foreign body andits relationship to the surrounding structures usingappropriate imaging modalities is imperative 3 .Report <strong>of</strong> CasesCase AA 52-year-old farmer sustained an injury <strong>of</strong> hisleft eye during outdoor activity. After the injury, he wasexamined in the nearby hospital <strong>of</strong> his town and thenreferred to Papanikolaou Hospital <strong>of</strong> Thessaloniki nearly48 hours after being injured, under broad-spectrumantibiotic coverage and anti-tetanus prophylaxis.At the time <strong>of</strong> examination, he had hyposphagma,slight oedema around the left orbit, blepharoptosis anda dermal injury <strong>of</strong> the left upper eyelid. On furtherexamination by ophthalmologists, the left eye had peribulbaroedema, hyphema, intravitreous haemorrhage andreduction <strong>of</strong> visual acuity to counting fingers at 1 m. TheIOP was 15 mmHg. A slit lamps examination disclosediridoschesis at 6 o’clock. ENT examination revealed noabnormality <strong>of</strong> the nasal cavity. There was no systemicinvolvement.X-rays at the time <strong>of</strong> the injury and the requestedposttraumatic computer tomography revealed a metalbody with intra- and extra-conal extension, in immediatecontact to the left frontal, ethmoidal and nasal bones. The
Balk J Stom, Vol 15, 2011 Penetrating Injuries <strong>of</strong> the Maxill<strong>of</strong>acial and Orbital Regions 53distal part <strong>of</strong> the foreign body ended in the left superiorconcha. The optic nerve appeared normal. There wereno signs <strong>of</strong> any injures <strong>of</strong> the globe or any fractures orintracranial involvement (Figs.1-3).It was decided to explore the wound under generalanaesthesia. Through the entry wound the metallic bodywas found to be embedded in the medial wall <strong>of</strong> the orbit.On manipulation, the body showed slight movement andappeared to be fixed to deeper structures. In order to avoidfurther injuries <strong>of</strong> the orbital contents, with mild manoeuvresand under direct visual contact, the entry wound wasextending and the foreign body removed (Fig. 4).The patient recovered uneventfully. 3 months laterthe ptosis improved. New ophthalmologic examinationrevealed visual acuity <strong>of</strong> 3/10 and IOP <strong>of</strong> 9 mmHg.Fundus examination showed small hemorrhage near theoptic disc.Figure 3.Figure 1.Figure 4.Figure 2.Case BA 57-old man was brought to the emergencydepartment after a work accident. He was slightlyconfused, but able to answer to some questions. He hada metal foreign body <strong>of</strong> irregular shape embedded in hisleft mid-face, in the area <strong>of</strong> the left sinus. He presenteds<strong>of</strong>t tissue injuries <strong>of</strong> the lips and the chin, dermal lossat the tip <strong>of</strong> the nose, 3 broken teeth in the front <strong>of</strong> themandible and burning injuries on the neck, the cheekand the forehead (Figs. 5 and 6). After the evaluationby specialists <strong>of</strong> other disciplines and since there wereno signs <strong>of</strong> any injury <strong>of</strong> vital anatomic structures,
54 A. Ntomouchtsis et al. Balk J Stom, Vol 15, 2011radiographs (Figs. 7-9) and no computer tomography,were taken to estimate the exact position <strong>of</strong> the metalbody, because time was more critical in view <strong>of</strong> thepatient distress.The patient was transferred directly to surgery inthe operating room for careful removal under generalanaesthesia, with all facilities available in the event <strong>of</strong> anycomplication. A metal body <strong>of</strong> irregular shape and size 8cm x 5 cm was removed from the left side <strong>of</strong> the patient’sface (Fig. 10), along with a high number <strong>of</strong> small pieces<strong>of</strong> plastic which were also embedded in the trauma areaand seemed to have caused the burning injuries <strong>of</strong> theface. There was no intra operative haemorrhage or othercomplications.The front wall <strong>of</strong> the left sinus, along with thezygomaticomaxillary buttress was completely destroyedand there was no possibility <strong>of</strong> reconstruction. An antrorhinostomawas performed at the meatus inferior. Aprimary plastic closure <strong>of</strong> the face injuries was achieved.Antibiotic cover with cephalosporine secondgeneration, intra- and post-operatively, for 14 days wasrecommended. Our patient recovered uneventfully andhad no recurrent maxillary sinusitis or nasal obstruction.Figure 7.Figure 5.Figure 8.Figure 6. Figure 9.
Balk J Stom, Vol 15, 2011 Penetrating Injuries <strong>of</strong> the Maxill<strong>of</strong>acial and Orbital Regions 55DiscussionFigure 10.Foreign bodies can cause injuries <strong>of</strong> the orbitand extensive damage to the surrounding structures 4 .They may give rise to severe orbital complications andusually inorganic foreign bodies cause visual loss ororbital complications from direct trauma 5-8 . A retainedmetallic orbital foreign body may cause a variety <strong>of</strong>signs, symptoms, and clinical findings, based on its size,location and composition 9,10 . There have been describedcases with pyogenic infection, periostitis and fistulaformation. There may also be a risk <strong>of</strong> gas gangreneformation, development <strong>of</strong> tetanus, chronic sinusitis,when a sinus is involved, meningeal infection or cerebralabscess formation if cranial cavity is involved 11 . Evensight-threatening complications have been described 12 .Complications can appear long time after the injury 13 . Inthe case A, the 24-month follow-up period was uneventful.CT scan is the standard diagnostic test, becauseit demonstrates most foreign bodies and it is safe in thepresence <strong>of</strong> metallic bodies 14,15 . Recent reports haveshown helical CT scans to be as accurate as conventionalCT scans, while reducing the radiation exposure for thepatient 16,17 .The surgical approach used, depend on the position<strong>of</strong> the foreign body. Most commonly, this is through theentry wound. Posteriorly located foreign bodies have anincreased risk <strong>of</strong> motility disturbances or optic neuropathyafter surgical removal 18 , whereas anteriorly placed foreignbodies are more easily removed 19-22 .In the case B, the examination was performed withsimple radiographs, because <strong>of</strong> the metallic nature <strong>of</strong> theforeign body and the possible artefacts in other imagingprocedures 23 , the urgency <strong>of</strong> the situation and becauseit was thought that any other method, like CT, wouldnot add anything important for the planed surgicalintervention.The proposed algorithms for the approach <strong>of</strong>penetrating injuries <strong>of</strong> the face 24,25 , after the exclusion <strong>of</strong>any life threatening situation for the patient and with nocomplication from the orbital area, had no importancein the case A, because <strong>of</strong> the unique shape and size <strong>of</strong>the embedded foreign body. In the second case, theforeign body lost kinetic energy during the impact withthe maxillary region, saving, in this way, the orbitalstructures and the brain. Since there was no possibility<strong>of</strong> osteosynthesis in the maxilla because <strong>of</strong> the extensivedestruction <strong>of</strong> the bone structures <strong>of</strong> the area, we decideda double approach from intraoral and through the facetrauma that left behind the metal body. A Caldwell- Lucoperation was unnecessary. The metallic object wascarefully removed because <strong>of</strong> the danger <strong>of</strong> a majorhaemorrhage and to avoid secondary iatrogenic injuryduring removal.Injury to the paranasal sinuses should beappropriately treated to decrease the risk <strong>of</strong> recurrentsinusitis and mucocele formation. Wound tracts shouldbe thoroughly irrigated and devitalized tissue debrided.Intraoral wounds should be closed early when possible.Prophylactic antibiotic coverage and tetanus toxoidbooster should be given. Long term follow-up isrecommended. Sometimes further imaging studies arenecessary to evaluate delayed traumatic injuries to cranialnerves and paranasal sinuses 26 .Although seldom fatal, the treatment <strong>of</strong> penetratingcrani<strong>of</strong>acial injuries requires a methodical approachbecause <strong>of</strong> the possible immediate complications that mayfollow the removal <strong>of</strong> the foreign body. The therapeuticrecord should be based on a multidisciplinary approach toobtain the best aesthetic and functional results. It must beemphasised that the prognosis <strong>of</strong> every injury by a foreignbody is strongly influenced by the nature and the location<strong>of</strong> the injury and the extent <strong>of</strong> initial damage.References1. Agrillo A, Sassano P, Mustazza MC, Filiaci F. Complex-Type Penetrating Injuries <strong>of</strong> Craniomaxill<strong>of</strong>acial Region. JCrani<strong>of</strong>ac Surg, 2006; 17(3):442-446.2. Gasparini G,Brunelli A, Rivaroli A, Lattanzi A, De PonteFS. Maxill<strong>of</strong>acial Traumas. J Crani<strong>of</strong>ac Surg, 2002;13(5):645-649.3. Boahene KO, Thompson DM, Schulte DL, Brissett AE.Crani<strong>of</strong>acial Metal Bolt Injury: An Unusual Mechanism. JTrauma, 2004; 56:716-719.4. Peyman GA, Sanders DR, Goldberg MF. Principles andPractice <strong>of</strong> Ophthalmology. Vol III. 1st Ed. WB Saunders,1981; p 2466.
56 A. Ntomouchtsis et al. Balk J Stom, Vol 15, 20115. Macrae JA. Diagnosis and management <strong>of</strong> a wooden orbitalforeign body: case report. Br J Ophthalmol, 1979; 63:848-851.6. Charteris DG. Posterior penetrating injury <strong>of</strong> the orbit withretained foreign body. Br J Ophthalmol, 1988; 72:432-433.7. Wang WJ, Li CX, Sebag J, Ni C. Orbital fistula. Causes andtreatment <strong>of</strong> 20 cases. Arch Ophthalmol, 1983; 101:1721-1723.8. Lustrin ES, Brown JH, Novelline R, Weber AL. Radiologicassessment <strong>of</strong> trauma and foreign bodies <strong>of</strong> the eye andorbit. Neuroimaging Clin North Am, 1996; 6:219-237.9. Cooper W, Haik BG, Brazzo BG. Management <strong>of</strong> orbitalforeign bodies. In: Nesi FA, Levine MR, Lisman RD (eds).Smith’s Ophthalmic Plastic and Reconstructive Surgery. St.Louis: Mosby; 1998; pp 260-269.10. Spoor TC. Penetrating orbital injuries. In: Spoor TC, NestFA (eds). Management <strong>of</strong> Ocular, Orbital, and AdnexalTrauma. New York: Raven; 1988; pp 271-292.11. Vander JF, Nelson CC. Penetrating orbital injury withcavernous sinus involvement. Ophthalmic Surg, 1988;19:328-330.12. Duke-Elder S, MacFaul PA. Intraocular Foreign bodies. In:Duke-Elder S (ed). System <strong>of</strong> Ophthalmology. Vol XIV, PartI. London: Henry Kimpton, 1972; p 481.13. Dimitrakopoulos I, Lazaridis N, Karakasis D. Unusualretained foreign body in the orbit. J Oral Maxill<strong>of</strong>ac Surg,1991; 49:420-421.14. Fulcher TP, McNab AA, Sullivan TJ. Clinical features andmanagement <strong>of</strong> intraorbital foreign bodies. Ophthalmology,2002; 109:494-500.15. Thomaidis V, Mangoudi D, Lazaridis N. An unusual case <strong>of</strong>a low velocity bullet lodged in the parotid gland. Greek JOral Max Fac Surg, 1999; 14:1-5.16. Lakits A, Prokesch R, Scholda C, Bankier A. Orbital helicalcomputed tomography in the diagnosis and management <strong>of</strong>eye trauma. Ophthalmology, 1999; 106:2330-2335.17. Lakits A, Prokesch R, Scholda C, et al. Helical andconventional CT in the imaging <strong>of</strong> metallic foreign bodies inthe orbit. Acta Ophthalmol Scand, 2000; 78:79-83.18. In-Young Chung, Seong-Wook Seo, Yong-Seop Han, EurieKim, Jim-Myung Jung. Penetrating Retrobulbar OrbitalForeign Body: A Transcranial Approach. Yonsei MedicalJournal, 2007; 48(2):328-330.19. Finkelstein M, Legmann A, Rubin PAD. Projectilemetallic foreign bodies in the orbit. A retrospective study<strong>of</strong> epidemiologic factors, management, and outcomes.Ophthalmology, 1997; 104:96-103.20. Michon J, Liu D. Intraorbital foreign bodies. SeminOphthalmol, 1994; 9:193-199.21. Holt GR, Holt JE. Management <strong>of</strong> orbital trauma andforeign bodies. Otolaryngol Clin North Am, 1988; 21:35-52.22. Gönül E, Akbörü M, Izci Y, Timurkaynak E. Orbital foreignbodies after penetrating gunshot wounds: retrospectiveanalysis <strong>of</strong> 22 cases and clinical review. Minim InvasNeurosurg, 1999; 42:207-211.23. Fuller DG, Hutton WL. Prediction <strong>of</strong> postoperative vision ineyes with severe trauma. Retina, 1990; 10(Suppl 1):S20-34.24. Gussack GS, Jurkovich GJ. Penetrating facial trauma: amanagement plan. South Med J, 1988; 81:297-302.25. Dolin J, Scalea T, Mannor L, Sclafani S, Trooskin S. Themanagement <strong>of</strong> gunshot wounds to the face. J Trauma,1992; 33:508-515.26. Boahene KO, Thompson DM, Schulte DL, Brissett AE.Crani<strong>of</strong>acial Metal Bolt Injury: An Unusual Mechanism. JTrauma, 2004; 56:716-719.Correspondence and request for <strong>of</strong>fprints to:A. NtomouchtsisPapanikolaou HospitalDepartment <strong>of</strong> Oral and Maxill<strong>of</strong>acial SurgeryThessaloniki, Grece
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141TUPNBUPMPHJDBM!!TPDJFUZInstructions to authorsThe BALKAN JOURNAL OF STOMATOLOGY providescontributors with an opportunity to publish review and originalpapers, preliminary (short) communications and case reports.Review papers (RP) should present an analytic evaluation<strong>of</strong> certain problems in <strong>stomatology</strong> based on a critical approachto personal experience and to the published results <strong>of</strong> otherauthors.Original papers (OP) should be related to the results <strong>of</strong>scientific, clinical and experimental research. 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New York,London, Toronto, Sydney, San Francisko: Academic Press, 1974;pp 20-30.3. Koulourides T, Feagin F, Pigman W. Experimental changes inenamel mineral density. In: Harris RS (ed). Art and Science <strong>of</strong>Dental Caries Research. New York: Academic Press, 1968, pp355-378.