Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011

Romanian Journal of Oral Rehabilitation

Vol. 3, No. 4, December 2011

Editor in Chief Emilian Hutu, Bucharest, România Norina Consuela Forna, Iaşi, România Constantin Ionescu-Tîrgoviște, Bucharest, România Vice-Editor Michel Jourde, Paris, France Viorel Păun, Bucharest, România Ion Lupan, Chişinău, Republica Moldova Senior Associate Editors Veronica Mercuţ, Craiova, România Pierre Lafforgue, Paris, France Patrick Missika, Paris, France Sammi Sandhaus, Lausanne, Switzerland Ostin Costin Mungiu, Iaşi, România Robert Sader, Germania Ady Palti, Kraichtal, Germany Zhimon Jacobson, Boston, USA Mihaela Păuna, Bucharest, România Phillipe Pirnay, Paris, France Editorial Board Constantin Popa, Bucharest, România Corneliu Amariei, Constanţa, România Sorin Popşor, Tg. Mureş, România Vasile Astărăstoae, Iaşi, România Dorin Ruse, Vancouver, Canada Mihai Augustin, Bucharest, România Valeriu Rusu, Iaşi, România Grigore Băciuţ, Cluj-Napoca, România Adrian Streinu-Cercel, Bucharest, România Constantin Bălăceanu-Stolnici, Bucharest, Dragoş Stanciu, Bucharest, România România Mircea Suciu, Tg. Mureş, România Marc Bolla, Nice, France Alin Şerbănescu, Cluj-Napoca, România Dorin Bratu, Timişoara, România Alexandru Bucur, Bucharest, România General Secretary Eugen Carasevici, Iaşi, România Magda Ecaterina Antohe, Iaşi, România Radu Septimiu Câmpean, Cluj-Napoca, Oana Țănculescu, Iaşi, România România Virgil Cârligeriu, Timişoara, România Legislation Committee Costin Cernescu, Bucharest, România Delia Barbu, Bucharest, România Yves Comissionat, Paris, France Marysette Folliguet, Paris, France Technical Committee Cristina Glavce, Bucharest, România Oana Țănculescu, Iaşi, România

Volum realizat în cadrul Casei Editoriale DEMIURG

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CUPRINS

FOREWORD 4 Prof. Univ. Dr. Norina Forna RADIOGRAPHIC STUDY ON MODIFICATIONS INDUCED BY EDENTATION 5 Cristina Cotea, Gabriela Ifteni, Cornelia Brezulian, Oana Țănculescu, Nicoleta Ioanid VESTIBULAR MANIFESTATIONS IN RETROCOCHLEAR TUMORAL PATHOLOGY 8 Loreta Ungureanu, Luminița Rădulescu, Sebastian Cozma, Costela Gegea, Dan Mârţu PARTICULARITIES OF CHEMICAL GASTRITIS IN CHILDREN 12 Gabriela Păduraru, Marin Burlea, Valeriu V. Lupu, Smaranda Diaconescu INFLUENCE OF RESTAURATIVE THERAPY ON MARGINAL PERIODONTAL 23 TISSUE Arina Ciocan-Pendefunda, Norina Consuela Forna, Valeria Pendefunda ASSESSMENT OF ORTHODONTIC TREATMENT NEEDS OF SCHOOLCHILDREN 27 FROM IASI ACCORDING TO INDEX OF ORTHODONTIC TREATMENT NEEDS (IOTN) AND DENTAL AESTHETIC INDEX (DAI) Andrei Corneagă, Ioan Dănilă, Carina Balcoş COMPARATIVE EVALUATION OF THE HYBRID LAYER IN LATERAL 33 PREVENTIVE RESTORATIONS Irina Maftei, Iulia Cătălina Săveanu, Oana Dragoș, Carina Balcoș, Ioan Dănilă DUAL EFFECTS OF FLAVONOIDS ON DYSLIPIDEMIA AND PERIODONTAL 38 DISEASE Sonia Nănescu, Silvia Mârțu, Georgeta Ciomaga, Vasilica Toma, Doriana Forna, Liliana Foia AUDITORY FUNCTION RECOVERY IN SUDDEN SENSORINEURAL HEARING 46 LOSS: 3-YEAR STUDY Bogdan Cavaleriu, Luminiţa Rădulescu, Daniel Rusu, Costela Gegea, Corina Butnaru, Dan Mârţu BONE DENSITY CHANGES IN PATIENTS WITH PERIODONTAL DISEASE 50 Silvia Teslaru, Liviu Zetu, Danisia Haba, Constanța Mocanu, Silvia Mârțu, Sorina Solomon IMAGE QUALITY ASSESSMENT OF ORTHOPANTOMOGRAMS 54 Mioara Decusară, Viorica Milicescu CORRELATION BETWEEN SEVERE PERIODONTITIS AND CARDIOVASCULAR 59 DISEASE: A RADIOGRAPHYC STUDY Liviu Zetu, Silvia Teslaru, Danisia Haba, Cătălina Dănilă, Oana Potârnichie, Ioana Rudnic, Liliana Păsărin, Gabriela Benghiac CORRELATIONS BETWEEN DENTAL EROSION SEVERITY AND SALIVARY 63 FACTOR IN PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE Corina-Florica Mihailopol, Ştefan Lăcătuşu, Carmen M. Codreanu, Galina Pancu, Claudiu Topoliceanu, Cristina Angela Ghiorghe ANTIINFLAMMATORY PERIODONTAL THERAPY IMPACT ASSESSMENT IN 67 PATIENTS WITH CARDIOVASCULAR DISEASES Liliana Păsărin, Ioana Rudnic, Dănilă Cătălina, Potârnichie Oana, Sorina Solomon, Amelia Surdu-Macovei, Alexandra Mârţu, Silvia Mârţu CARIES EXPERIENCE IN CHILDREN WITH SEVERE EARLY CHILDHOOD CARIES 72 Aneta Munteanu, Rodica Luca, Catalina Farcasiu, Ioana Stanciu

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DENTAL NANOROBOTS – SMALL INSTRUMENTS WITH LARGE POTENTIAL 77 Ana-Maria Dumitrescu, Cristina Dascălu THE INFLUENCE OF THE ETCHING TIME ON THE ENAMEL HYBRIDIZATION IN 84 PREVENTIVE SEALING. IN VITRO STUDY Cătălina Iulia Săveanu, Anca Todiraşcu, Irina Maftei, Ioan Dănilă STUDY ON THE FREQUENCY OF ENDOCRINE DISORDERS IN CHILDREN AND 90 TEENAGERS Adriana Bălan, Marinela Păsăreanu, Ana Petcu, Veronica Șerban Pintiliciuc STUDY REGARDING THE ASSESSMENT OF ENAMEL MICROHARDNESS IN 94 INCIPIENT CARIOUS LESIONS TREATED BY ICON METHOD Galina Pancu, Sorin Andrian, Gianina Iovan, Angela Ghiorghe, Claudiu Topoliceanu, Antonia Moldovanu, Andrei Georgescu, Ion Pancu, Simona Stoleriu MODIFICATION OF SALIVARY PROTEINS, GLUCOSE AND CALCIUM LEVEL IN 101 GENERAL DISEASES Bogdan Petru Bulancea, Maria Ursache

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FOREWORD

Dear colleagues,

We have the honour to invite you to participate to the 5th International Congress of the Romanian Society for Oral Rehabilitation, entitled "Excellency in Oral Rehabilitation". The Congress will take place in Iasi, 8 - 10, December, 2011, and is organised in collaboration with Romanian Dental Association for Education (ADRE) and the Faculty of Dental Medicine of the "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, under the aegis of CMDR Iasi. The field of oral rehabilitation is the result of some experiences accumulation and competences in dental medicine that assumes access to new concepts and technologies which makes it one of the most dynamic brunches of medicine. The Romanian Society for Oral Rehabilitation supports progress in this field and offers to all interested parties its own means of promotion but also education in dental medicine. The Romanian Journal of Oral Rehabilitation, the post-graduate courses, the European Programmes and the Centre for Specialisation and Resource Formation in Oral Rehabilitation, all come to support and prepare for obtaining competences in different fields of dental medicine. At its V-th edition, this Congress organised by ASRRO already demonstrated a level of maturity, supported by the subject which is a call for rigour, competence, in one word, excellence. We hope that the new and pleasant opportunity to meet again on Moldavian ground will contribute to a fruitful experience and knowledge exchange among high level specialists and practitioners attending this event. We warmly invite you to our congress with the conviction and with the firm believe that we can actively contribute to enhancement of communication and cooperation in this area of common interest.

Congress Chairman, Prof. PhD. Norina FORNA

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RADIOGRAPHIC STUDY ON MODIFICATIONS INDUCED BY EDENTATION Cristina Cotea, Gabriela Ifteni, Cornelia Brezulian, Oana Țănculescu, Nicoleta Ioanid Faculty of Dentistry, “Gr. T. Popa" University of Medicine and Pharmacy, Iași, Romania

ABSTRACT If you don’t replace a lateral missing tooth, you will be looking at a series of changes in the entire mouth. You may have the migration if adiacent teeth and of the antagonist tooth, changing the occlusion, also periodontal problems and cavities. In every one of these cases the prosthetic treatment becomes more difficult. In today’s literature we don’t have depicted all the consequences of alveolar bone loss. The purpose of this study was to determine the negative modifications registered after the tooth removal. Using radiographic investigations, we calculate the distance between the edentulous’s space and adiacent teeth to estimate the changes in the teeth position.

Key words: alveolar bone loss

INTRODUCTION result we have in all the cases an average of Loss of space was significantly associated 6.9 months. The Rx analysis has shown no with alveolar bone loss for the pre-molar but significant difference (0.05) on all parameters. not the molar. Extrusion of the opposing tooth The results are not conclusive because the was not significantly associated with any of study group was not large enough. the other measures. Correlations in TL Thus, changes in tooth position in these sample showed the same patterns, but the cases were examined separately. Finally, we small sample size prevented any coefficient compared change in the cases in which from being statistically significant. Analysis baseline radiographs were taken pre- and post- of changes for pre-and post-extraction extraction to estimate the amount of under radiographic measurements showed no measurement of movement that could occur. statistically significant differences (P = .05) Loss of space was significantly associated in mean movement for any of the four with alveolar bone loss for the pre-molar but measurements. not the molar. Extrusion of the opposing tooth However, small differences consistently was not significantly associated with any of indicated that measurements taken from post the other measures. Analysis of changes for extraction radiographs may have pre- and post-extraction radiographic underestimated tooth movement. measurements showed no statistically significant differences (P = .05) in mean MATHERIALS AND METHODS movement for any of the four measurements. The study was made on a 19 patient group However, small differences consistently (13 women and 6 men), age around 24 years. indicated that measurements taken from post We used radiographic results, recorded before extraction radiographs may have and 6 months after the tooth removal, using a underestimated tooth movement. digital scanner and electronic files to archive. Angular alignment errors that contribute to Between the first and last radiographic distortion in radiographic films typically are

5 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 attributed to film packet placement errors clinical films measured were bitewing and/or improper tube head position. In this radiographs exposed using commercially study, the effect of packet placement errors available bitewing tabs attached to was considered to be minimal because all conventional periapical films.

0,1 – 1mm 5 1,1 – 2mm 7 Amplitude (A) 2,1 – 3mm 5 over 3mm 2 0,1 – 1mm 11 Changes in the height of opposing teeth (h) over 1mm 8 0,1 – 1mm 6 1,1 – 2mm 3 Upper molars (C) 11cases 2,1 – 3mm 2 over 3mm - 0,1 – 1mm 3 1,1 – 2mm 4 Upper premolars (C) 8cases 2,1 – 3mm 1 over 3mm - Table 1 For example, in this study, the limitations “reproducible landmarks” on both baseline include potential selection bias and the use of and follow-up radiographs. The extent of this unstandardized radiographs. It is likely that error, however, was reduced by using two selection bias occurred within this sample of examiners, with each independently making cases, as dentists tend to provide fixed partial measurements and requiring a rather strict dentures to patients for whom they believe level of agreement: 0.5 mm. Unstandardized the prognosis is relatively good, relegating radiographs taken at different angulations many of those with a poor prognosis to the also can introduce error in measurements. untreated category. Thus, many of the The average amount of difference between patients in this sample may represent those properly oriented and angulated radiographs whom the treating dentists felt were not good is less than 0.5mm. These differences suggest candidates for restorative care. In contrast, if that the amount of error introduced by the use this was a controlled trial and assignment to of films exposed at rather divergent angles is the untreated category was truly independent similar to the amount of error in the of other factors, the consequences likely measurement process. would be even less severe. Unstandardized Still, some conclusions could be drawn: radiographs also can introduce measurement The edentulous space has the tendency for error through the imprecision of selecting bone loss.

Fig. 1 Fig. 2 Fig. 3

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This tendency can suggest an even greater patients, perhaps 10%, experience clinically risk of losing adjacent teeth. Future studies significant tilting of the teeth adjacent. should try to calculate the bone loss ratio, These results also suggest that the because it can be a predicting factor of profession needs to work diligently toward adjacent tooth survival. identifying the factors that do predict adverse We could see some changes in the consequences or that put this small proportion edentulous space – bone loss, different for of patients at risk of experiencing arch molar and premolars. collapse. Within the limitations imposed by the CONCLUSION design of our study, it appears that arch The effect of untreated edentulous space collapse is not as rapid or severe as on adjacent structures is significant in few conventional wisdom would suggest. cases. However, some small number of

BIBLIOGRAFIE 1 Rosenstiel SF, Land MF, Fujimoto J.Contemporary fixed prosthodontics. St. Louis: Mosby-Year Book; 2005:51. 2 Hirshfield I. The individual missing tooth: a factor in dental and periodontal disease. JADA 1937;24:67-82. 3 Malone WFP, Koth DL. Tylman’s theory and practice of fixed prosthodontics. 8th ed. St. Louis: Ishiyaku EuroAmerica; 1989:1-24. 4 Johnston JF, Phillips RW, Dykema RW. Modern practice in crown and bridge prosthodontics. Philadelphia: Saunders; 1971:17, 18. 5 Shillingburg HT Jr., Hobo S, Whitsett LD. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997:85. 6 Scion Corporation. Scion Image (program version). Version 1.0 for Windows. Frederick, Md.: Scion Corporation; 2007. 7 Fredriksson M, Zimmerman M, Martinsson T. Precision of computerizedmeasurement of marginal alveolar bone height from bite-wing radiographs. Swed Dent J 1989;13:163-7.

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VESTIBULAR MANIFESTATIONS IN RETROCOCHLEAR TUMORAL PATHOLOGY Loreta Ungureanu1, 2, Luminița Rădulescu1, 2, Sebastian Cozma1, 2, Costela Gegea2, Dan Mârţu1, 2 1University of Medicine and Pharmacy “Gr. T. Popa” Iaşi, Romania 2ENT and Audiology Department of Rehabilitation Hospital Iaşi, Romania

ABSTRACT Introduction Retrocohlear tumoral pathology is dominated by the vestibular schwannoma (VS). The VS involve the vestibular division of the 8th cranial nerve and grows slowly leading to a gradual installation of the unilateral vestibular impairment allowing simultaneous achievement of central compensation process. Sometimes only a careful history will reveal a slow imbalance, a tendency to move towards to a certain lateral part. Remarkable progress has been made in the VS early diagnosis so that treatment can take place earlier with good results. Materials and methods A representative case is presented. Beside general, neurological and ENT examination, the diagnostic workup comprised of computerized dynamic posturography, videonystagmography, pure tone audiometry, auditory brainstem evoked response, MRI brainstem evaluation. Results In VS computerized dynamic posturography allows an overall of the vestibular function with polymorphic results. Bithermal caloric testing is, combined to auditory brainstem responses a good tool to diagnose and evaluate unilateral vestibular impairment in vestibular schwannoma. Discussion Detailed history, careful exploration of vestibular and cochlear function can lead to the conclusion of possible retrocochlear injury. For confirmation of its existence and its nature contrast-enhanced CT or MRI are necessary. Conclusion Any unilateral cochlear or vestibular symptoms (unilateral or asymmetric sensorineural hearing loss, unilateral tinnitus, unilateral vestibular impairment of any degree with central compensation or not) should raise suspicion of possible VS.

Key words: vestibular schwanomma, vestibulocochlear symptoms, vestibular evaluation

INTRODUCTION metastatic tumours) representing 5 - 10% of Retrocohlear tumoral pathology is all intracranial tumours in adults. The dominated by the vestibular schwannoma prevalence is about 1 in 100 000 worldwide (VS), most often improperly called acoustic [1]. neurinoma. Neurinoma is a broader term, it The earliest clinical manifestations are can derive from any structure of the nerve. determined by the tumour growth in the Schwannoma is a benign tumour witch arises internal auditory canal, a small and bonny from Schwann cells and may develop over space. In this intracanalicular stage the the course of any nerve presenting this type of symptoms are attributed to the disruption of cells in his structure. The vestibular normal vestibulocochlear nerve function. As schwannoma typically involve the vestibular the tumour grows, it usually extends into the (especially the inferior vestibular nerve) posterior fossa to occupy the cerebellopontine rather than the acoustic division of the 8th angle. Growing in this position, the vestibular cranial nerve. It comprises about 80-85% of schwannoma may also compress the 5th, 7th tumors of the cerebellopontine angle (the rest and less often the 9th, 10th cranial nerve and being meningiomas, colesteatomas, later the pons with increased intracranial pressure [2).

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The role of ENT specialist is to diagnose, gradual emphasis. using a combination of vestibular and Vestibular function examination included: audiological tests, this tumour in the early Unterberger's stepping test – the patient intrameatal stage, thus allowing complete rotates to the right side, head - shaking resection of the VS with preservation of facial manoeuvre (a latent spontaneous vestibular nerve function and auditory function as well. nystagmus evoked by a rapid passive head A complete audiovestibular assessment shaking around a vertical axis), computerized using computerized dynamic posturography, dynamic posturography identify the presence videonystagmography with vestibular of the vestibular impairment without bithermal caloric stimulation, pure tone tendency of falling (fig. 1), videonystagmo- audiometry, auditory brainstem evoked graphy with vestibular bithermal caloric response can help diagnose VS of all sizes stimulation test (using water at 440 and 300) and are very useful in monitoring the recorded right vestibular weakness with a evolution of this tumour. right predominant direction of the caloric nystagmus. MATERIALS AND METHODS Pure tone audiometry shows right A representative case is presented. Beside moderate sensorineural hearing loss with normal general, neurological and ENT normal hearing on the left ear. Auditory examination, the diagnostic workup brainstem evoked response (ABR) were comprised of computerized dynamic recorded revealing changes in latency of III posturography, videonystagmography, pure and V waves and extension of I-III interval in tone audiometry, auditory brainstem evoked the right ear compared to those on the left ear response, brainstem's MRI evaluation. (signs of retrocochlear pathology). Patient DE, 47 years old, presented in our Brain's MRI examination with gadolinium clinic for unilateral hearing loss and tinnitus enhancement confirmed our supposition of in the right ear, imbalance with a tendency to vestibular schwannoma detecting a mass that shift slightly to the right accompanied by a starts in the right internal auditory canal with feeling of dizziness and headache. These extension in cerebellopontine angle and symptoms started six months ago but with moderate mass effect on the pons (fig. 2).

Fig. 1. Computerized dynamic Fig. 2. MRI –right vestibular schwanoma posturography - vestibular impairment with extension in cerebellopontine angle

RESULTS scan are required by results as: vestibular The final diagnosis was made using a impairment (computerized dynamic complete audiovestibular assessment. MRI posturography), head – shaking evoked

9 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 nistagmus and unilateral vestibular weakness neurological stages, a multi-sensory (videonystagmography) with changes on the impairment model (the lesion progresses audiological evaluation (unilateral cranial to vestibular nuclei or visual sensorineural hearing loss), signs of pathways) [3]. retrocochlear injury (auditory brainstem Additional and important elements are evoked response). provided by videonystagmography through From all these tests bithermal caloric various types of nystagmus recorded: testing constitutes, combined to auditory spontaneous, revealed, positional, induced brainstem responses a good tool to diagnose (caloric stimulation). Bithermal caloric and evaluate unilateral vestibular impairment testing is very useful because it allows in vestibular schwannoma. separate investigation, assessment of activity of each vestibule and the comparison between DISCUSSION them (left and right side). Induced vestibular Dizziness, vertigo, imbalance are nystagmus can record a significant reduction interdisciplinary symptoms. A superficial in the frequency, in amplitude, in duration examination of the patients complaining of compared with the other vestibule. It disturbed sense of balance and altered gait constitutes, combined to auditory brainstem can lead to delayed diagnosis of a serious responses a good tool to diagnose and pathology. evaluate unilateral vestibular weakness in Because of its origin, arising from the vestibular schwannoma [4, 5, 6]. Schwann cells of the vestibular nerve, we Detailed history, careful exploration of the could believe that the vestibular symptoms cochlear and vestibular function can lead to will dominate the clinical manifestation. In the conclusion of possible retrocochlear reality, VS grows slowly leading to a gradual injury. It should be emphasizes that no installation of the unilateral vestibular clinical test is 100% sensitive or specific. For impairment allowing simultaneous confirmation of its existence and its nature achievement of central compensation process contrast-enhanced CT or MRI are necessary. [2). Clinically, patients will complain more of CT detect almost all vestibular schwannomas a disturbed sense of balance and altered gait that are greater than 2 cm in diameter and (aggravated by dimness or sudden head those tumor that are smaller may be detected position changes) than the typical rotatory by MRI. A complete audiovestibular peripheral vertigo. Sometimes only a careful assessment and a MRI evaluation can help history will reveal a slow imbalance, a diagnose most cases of VS but false-negative tendency to move towards to a certain lateral results remain possible in small intrameatal part, a sensation of tilt or swing which doesn't tumours (1%). In these cases a periodic influence the patient's daily activity. The monitoring (using ABR and MRI) is earliest symptoms of VS are ipsilateral recommended. tinnitus and sensorineural hearing loss in a sudden or progressive manner [1]. CONCLUSIONS Computerized dynamic posturography Unilateral vestibular impairment in allows an overall of the vestibular function vestibular schwannoma development is being able to detect the presence of a slowly installed allowing the central vestibular impairment, or absence of sensory compensation process. Because of this the deficits (normal result) due to central vestibular symptoms are discrete, sometimes compensation process. It may also show, in requiring a detailed history.

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Any unilateral audiological or vestibular unilateral vestibular impairment of any symptoms (unilateral or asymmetric degree with central compensation or not) sensorineural hearing loss, unilateral tinnitus should raise suspicion of possible vestibular including in the presence of normal hearing, schwannoma.

REFERENCES 1. Sakata E, Ohtsu K, Itoh Y, Teramoto K. Early diagnosis of acoustic neurinoma after experience of 37 cases. Auris Nasus Larynx. 1991;18:125-32. 2. Diallo BK, Franco-Vidal V, Vasili Negrevergne M. The neurotologic evaluation of vestibular schwannomas. Laryngol Otol Rhinol . 2006; 127:203-9. 3. Levine SC, Muckle RP, Anderson JH. Evaluation of patients with acoustic neurinoma with dynamic posturography. Otolaryngol Head Neck Surg. 1993; 109: 392-8. 4. Gimeno-Vilar C, Rey- Martinez J, Perez N. Active versus passive head-shaking nystagmus. Acta Otolaryngol. 2007;127:722-8. 5. Lightfoot GR. Int J Audiol. The origin of order effects in the results of the bi-thermal caloric test. 2004; 43:276-82. 6. Hernandez Montero E, Fraille Rodrigo JJ, De Miguel Garcia F, Sampirez LM. The role of video- nystagmography in the diagnosis of acoustic neurinoma. Acta Otorrinolaringol Esp. 2003;54: 413-6.

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PARTICULARITIES OF CHEMICAL GASTRITIS IN CHILDREN Gabriela Păduraru1, Marin Burlea2, Valeriu V. Lupu3, Smaranda Diaconescu3 1PhD student “Gr. T. Popa” University of Medicine and Pharmacy of Iasi, Resident Physician – Pediatrics, “St. Mary” Children’s Clinical Emergency Hospital of Iasi, Romania 2Professor, Pediatrics, "Gr. T. Popa" University of Medicine and Pharmacy, 5th Pediatrics Clinic, “St. Mary” Children Clinical Emergency Hospital, Iaşi , Romania 3Assistant, Pediatrics, "Gr. T. Popa" University of Medicine and Pharmacy, 5th Pediatrics Clinic, “St. Mary” Children Clinical Emergency Hospital, Iaşi, Romania

ABSTRACT Objectives: The authors intend to show correlations between the clinical, endoscopic and echographic aspects of the chemical gastritis and the infection with Helicobacter Pylori. Materials and methods: A lot of 298 patients hospitalized in the 5th Clinic of Paediatrics of the „Sf. Maria” Emergency Children Hospital Iaşi during the period January 2008 – December 2010 was studied. The patients underwent upper digestive endoscopy, abdominal echography and esogastroduodenal transit. Results: The symptomatology was present in the majority of patients with epigastric pain, nausea, biliary vomiting. Anatomical changes of the gall bladder were echographically detected: septate cholecyst, hypotone, thickened walls. Macroscopic lesions of the gastric mucosa, especially of the antral region and large quantities of bile in stomach were endoscopically observed. Gastric biopsy was used to detect the presence of H. pylori. EGD transit has shown motility changes of the superior digestive tube in most patients. The treatment consisted in administration of gastric acidity inhibitors and ursodeoxicolic acid for 21 days. A positive response to this treatment was obtained for the majority of cases. Conclusions: The reflux gastritis is a new clinical and therapeutic entity in the paediatric practice, frequently occurring in anatomically normal stomach. The reflux gastritis can be associated with the HP infection and aggravates it clinically. It is also frequently correlated with anatomical anomalies of the gall bladder and changes in the digestive tract motility.

Key words: reflux gastritis, upper digestive endoscopy, child

INTRODUCTION from January 2008 to December 2010, and Reactive gastropathy is the second diagnosed with reflux gastritis, based on the frequent diagnosis established by gastric endoscopic, echographic and radiological biopsy after H. Pylori gastritis. The disease is aspects (the upper gastrointestinal series). secondary to the bile reflux and was initially described after partial gastrectomy (Billroth I RESULTS or II). At present, this pathologic entity is During the period of the study, after the considered a nonspecific response to a variety upper digestive endoscopy examination, 1170 of other gastric irritants. patients were diagnosed with various forms of gastritis, of which 25.5% associated the MATERIALS AND METHODS duodenal-gastric reflux. A group of 298 patients, hospitalized at the Being aware that the prevalence of the H 5th Clinic of Paediatrics of “St. Mary” pylori infection during the previously Emergency Clinical Hospital for Children of mentioned period was of 40.4%, we can state Iasi, was subject to studies, over the period that the duodenal-gastric reflux is, after the

12 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 bacterial infection, the second frequent cause the rural environment, in 95 cases (31.87%). of chronic gastritis at the paediatric age. This may be explained both by the nutrition The distribution on age groups shows that habits of this social category, with a diet rich this aetiology generally affects older age in cholecystokinetic foods, and by numerous groups, so that 78.2% of patients are aged stress factors, as well. Nevertheless, the between 11 and 18 year-old. specialty literature does not reveal a more The increased incidence of the duodenal- increased prevalence of reflux gastritis at a gastric reflux at the 15-18 year-old age group particular social category. is correlated with the increased frequency of Assessing the interdependence established acalculous cholecystitis and with a nutrition between acute or chronic forms of gastritis rich in cholecystokinetic foods. and the duodenal gastric reflux, we have Of the 298 patients suffering from this observed a statistic difference between the disease, 220 (73.8%) were female and 78 groups, in the sense that the duodenal-gastric (26.2%) were male. We remark a slightly reflux tends to statistically associate with increased incidence of reflux gastritis at chronic forms of disease (χ2 = 12,55; df=1; females. The specialty literature does not p=0,011). remark an increased prevalence of the disease Drawing a comparison between the group at girls, but genetic predisposition plays an of patients with H pylori infection and the important part. group with bile reflux, we have noticed that The distribution depending on the only 15.2% of those infected with H pylori environment of origin shows that this disease also suffered from duodenal-gastric reflux, appears more frequently at children whereas of the group diagnosed with originating from the urban environment, in duodenal-gastric reflux only 24.2% had a 203 cases (68.12%), and rarely at those from bacterial infection, as well.

Valid Cumulative Freq. % % % 1-3 yrs. 5 1,7 1,7 1,7 4-6 yrs. 6 2,0 2,0 3,7 7-10 yrs. 54 18,1 18,1 21,8 11-14 yrs. 92 30,9 30,9 52,7 15-18 yrs. 141 47,3 47,3 100,0 Total 298 100,0 100,0

Table I. Patients’ distribution on age groups Fig. 1. Patients’ distribution on age groups We can state that patients suffering from H does not promote the appearance of foveal Pylori infection develop forms of gastritis metaplasia, producing lesions that H. Pylori which are not associated with the duodenal- may colonize. Thus, a vicious circle is gastric reflux, whereas patients with a main created, further decreasing the ability of the aetiology of bile reflux tend not to be infected duodenal bulb to neutralise the acid, which with H pylori (χ2 = 43,92; df=1; p<0.001). overflows from the stomach, leading to the An increased quantity of duodenal gastric appearance of duodenal ulcerous. H. Pylori acid may precipitate and remove the bile salts can survive in areas of gastric metaplasia at normally inhibiting H. Pylori growth. This the duodenal level.

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The symptomatology was in 70.80% of the The echographic modifications signify- cases (211 patients) of recurrent chronic type. cantly associated with reflux chemical Clinic manifestations are polymorphic and gastritis are cholecystopathies, in particular, non-systematized. (χ2 = 9.33; df=1; p=0.002) appeared at At present, the correlation dyspepsia- 37.58% of patients, whereas the phi dismotility is studied on a large scale. indicator=0.176 for evaluating the scale of Symptoms such as borborygmus, abdominal effect shows that the alteration of the bile distension, feeling of gastric fullness, vesicle modestly influences the appearance of precocious satiety, nauseas, drew the attention a chemical gastritis. on a series of gastrointestinal motility Of all the echographic modifications of the anomalies. Nausea is the consequence of the cholecyst, the duodenal-gastric reflux effect of bile salts and pancreatic ferments statistically associated with: within the duodenal-gastric reflux. Overall  a hypotonic cholecyst (χ2 = 18,38; df=1; gastric motility disorders acquire an important p<0,001) role, as well, particularly the antral-pyloric  a cholecyst with thick walls (χ2 = 20,14; disorder. Post-alimentary epigastric pain, df=1; p<0,001) refractory at anti-ulcerous medication, may  a cholecyst with septum (χ2 = 15,38; df=1; suggest reflux gastritis. Bile vomiting is p<0,001) frequently met in this disease.  a prolonged cholecyst (χ2 = 3,62; df=1; In this study, the statistical analysis reveals p=0,050) a significant association only with digestive These echographic aspects are evocative signs and symptoms: of the coexistence of acalculous  abdominal pains non-ameliorated by cholecystopathy. 2 nutrition and anti-ulcerous drugs (χ = Radiological modifications are nonspecific 203,01; df=1; p<0,001); phi=0,417 – and generally indicate disorders of the demonstrate that this sign is moderately gastric-duodenal motility. In this study, the correlated with chemical gastritis; following radiological aspects were  epigastric pain (χ2 = 155,48; df=1; significantly associated with reactive p<0,001); phi=0,365 – show a moderate gastropathy: correlation established between the two  stomach with hyper-secretion liquid (χ2 = variables; 3,81; df=1; p=0,051) 2  flatulence (χ = 678,47; df=1; p<0,001);  oedema at the level of the stomach (χ2 = phi=0,716 – shows that this symptom is 2,47; df=1; p=0,0 43) strongly correlated with reflux chemical  spastic bulb with fast emptying (χ2 = 3,11; gastritis; df=1; p=0,048) 2  meteorism (χ = 741,32; df=1; p<0,001);  spastic pillory (χ2 = 3,84; df=1; p=0,050) 2  precocious satiety (χ = 769,50; df=1; From an endoscopic viewpoint, specific p<0,001); phi=0,811 – shows that this lesions are described as red strips of mucous symptom is highly correlated with reflux membrane with apparent bleeding. (Reactive) chemical gastritis; chemical gastritis is caused by the harming of  bile vomiting (χ2 = 322,31; df=1; the gastric mucous membrane through bile p<0,001); phi=0,513 – demonstrate that and pancreatic reflux or by some exogenous this sign is strongly correlated with reflux substances. Bile reflux causes epithelial chemical gastritis; lesions, erosions and ulcers followed by

14 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 foveal regenerative hyperplasia, mucous can extend as far as the oxyntic mucous membrane oedema, local vascularisation membrane. The histological alterations lesions, bleeding and hypertrophy of the associated with the bile reflux include the smooth muscles of the own limb. Lysolecitins oedema of the mucous membrane, and bile acids harm the gastric mucous congestion, fibro-muscular hyperplasia and membrane barrier, permitting the retro- foveal hyperplasia. Cell proliferation is diffusion of the positive ions of hydrogen and associated with nuclear reactive alterations. producing cell lesions. The overflow of Epithelial alterations are accompanied by a pancreatic juices aggravates this situation. As reduced inflammatory infiltrate. At patients of opposed to other chronic gastritis, chemical the studied group, it had a pathologic aspect gastritis is characterized by the presence of a in 42 cases. Out of these cases, 50% revealed minimum inflammatory infiltrate. an oedema-like pylorus, 35.71%- a In this study, we discovered significant punctiform pylorus and 14.28%- an eccentric association (χ2 = 35.63; df=8; p<0.001) only pylorus (Fig. 4). in the case of an antral purpura granular form. The duodenal endoscopic lesions which This result stresses upon the fact that bile were significantly associated with reactive reflux determines important gastric lesions, gastropathy are the granular, granular-purpura especially at antral level. and the pseudo-polypoid congestion (χ2= Of all the 298 reflux chemical gastritis, 72 88,512; df=9; p<0.001). cases revealed an infection with H pylori, To conclude with, we can state that whereas the endoscopic examination shown patients suffering from duodenal-gastric that when a patient presents both aetiologies, reflux are more likely to develop severe the antral region is affected in 93.1% of cases forms of duodenitis. (Table II). This result justifies the fact that Therapeutic conduct in reactive gastropathy both the bile reflux and the H pylori infection envisages three objectives: the prevention of determine the appearance of some chronic the duodenal reflux, the neutralization of the lesions at antral level (Fig. 2 and Fig. 3). overflow of substances and the reestablishment In chemical gastropathy, alterations are of the physiological properties of the structures more obvious in the pre-pyloric region, but modified by reflux.

Valid Cumulative Type of Gastritis Freq. % % % atrophic 1 1,4 1,4 1,4 nodular antral 11 15,3 15,3 16,7 nodular-purpura 36 50,0 50,0 66,7 antral purpura-antral 20 27,8 27,8 94,4 erosive 2 2,8 2,8 97,2 hypertrophic 2 2,8 2,8 100,0 Total 72 100,0 100,0

Table II. Distribution of gastritis with H Fig. 2. Distribution of endoscopic forms of pylori and the duodenal-gastric reflux reflux gastritis

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Fig. 3. Endoscopic images of hypertrophic, nodular-antral, granular gastritis

Fig. 5. Endoscopic images of pseudo-polypoid, granular, purpura duodenitis

Fig. 4. Endoscopic images of the oedema-like, punctiform, spastic pylorus The prevention of the duodenal-gastric treatment scheme to eradicate the bacterium reflux presupposes the synchronisation of the (triple or four-fold therapy). antral-pyloric / duodenal activity. The diet consists in fractional meals (4-5 CONCLUSIONS meals per day) that include all nutritional Reflux gastritis is a new clinical and principles, in balanced proportions, ensures a therapeutic entity in the practise of hormonal profile necessary for a gastric- Paediatrics, frequently appearing under the duodenal motility, which determines the conditions of an anatomically normal physiological direction of gastric and stomach. It can be associated with the H. intestinal chemistry. pylori infection, supporting and worsening it, The treatment consisted in ursodeoxycolic on a daily basis. acid and prokinetics, which have the role to From an endoscopic viewpoint, reflux increase the rate of gastric emptying and the gastritis is characterized by lesions of the pyloric tonus. The evolution was favourable, antral and pyloric region, and is frequently with the amelioration or disappearance of the correlated with anatomic anomalies of the symptoms. The patients also suffering from bile vesicle and with alterations of the H. pylori infection, were administered a digestive tractus motility.

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REFERENCES 1. Navarro J., Schmitz J.: Gastroentérologie Pédiatrique, 2e Edition, Médicine-Sciences Flammarion, Paris, 2000: 3-4, 6-7, 116-126, 167-181, 612-621 2. Meyer JH. The physiology of gastric motility and gastric emptying. In: Yamada T: Textbook of gastroenterology, Philadelphia: J.B. Lippincott 1991;137-157 3. Gao L, Weck MN, Raum E, Stegmaier C, Rothenbacher D, Brenner H. Sibship size, Helicobacter pylori infection and chronic atrophic gastritis: a population-based study among 9444 older adults from Germany. Int J Epidemiol. Jul 13 2009 4. Nelson DB, Block KP, Bosco JJ, Burdick JS, Curtis WD, Faigel DO, et al. Technology status evaluation report: ultrathin endoscopes esophagogastroduodenoscopy:March2000. Gastrointest Endosc.Jun2000;51(6):786-9. 5. Beers M, Berkow R, eds. Gastritis. In: The Merck Manual of Diagnosis and Therapy. 18th ed. 2006:Section 3, Chapter 23 6. Stein HJ, Smyrk TC, DeMeester TR, Rouse J, Hinder RA.Clinical value of endoscopy and histology in the diagnosisof duodenogastric reflux disease. Surgery 1992;112:796–803 7. RitchieW. Alkaline reflux gastritis: a critical reappraisal. Gut1984;25:975–87 8. Sobala GM, O’Connor HJ, Dewar EP, King RF, Axon AT,Dixon MF. Bile reflux and intestinal metaplasia in gastricmucosa. J Clin Pathol 1993;46:235–40 9. Niemelä S, Karttunen T, Heikkilä J, Lehtola J. Characteristicsof reflux gastritis. Scand J Gastroenterol 1987;22:349–54

17 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011

THE PARTICULARITIES OF AUDITORY PERFORMANCE EVALUATION IN BIMODAL HEARING REHABILITATION – COCHLEAR IMPLANT AND HEARING AID Raluca Olariu1,2, Luminița Rădulescu1,2, Gabriela Damean2, Cristian Mârţu1,2, Sebastian Cozma1,2 1University of Medicine and Pharmacy “Gr. T. Popa” Iaşi, România 2ENT and Audiology Department of Rehabilitation Hospital Iaşi, România

ABSTRACT Introduction Cochlear implantation is the standard intervention for hearing and speech rehabilitation of the patients with bilateral severe and profound hearing loss. The concomitant usage of a hearing aid in the contralateral ear offers a better sound localization and speech understanding in complex noise situation. Materials and methods The study group included twelve patients, adults and children, implanted in our cochlear implant centre, who still wear a hearing aid in the opposite ear. For all the subjects we considered the age at the implantation, the aetiology and the onset of the hearing loss, pre- and postimplantation audiological evaluation with the cochlear implant and with the hearing aid. Results The free field pure tone thresholds with the cochlear implants are superior to those with the hearing aid in the opposite ear. The cochlear implant offers a better audition for the high frequencies comparing to the reverse situation of the hearing aid. Discussions: The particularity of the auditory performance evaluation in bimodal rehabilitated patients – cochlear implant in one ear and hearing aid in the opposite ear is represented by the necessity to create a particular audiological evaluation algorithm adapted to that situation. Conclusions The results of the present study suggest an advantage of cochlear implant usage in conjunction with a hearing aid in the opposite ear. The cochlear implant alone performs better than the hearing aid alone, and the bimodal condition is superior to the cochlear implant alone. The bimodal hearing rehabilitation requires a regularly auditory re-evaluation to establish the limit line between the benefit / less benefit of bimodal hearing.

Key words: bimodal hearing, cochlear implant, hearing aids

INTRODUCTION individuals with severe and profound hearing Cochlear implantation has become the losses who used acoustic amplification [1]. standard intervention for providing improved It is well recognized that people with communication benefits to individuals with normal hearing combine auditory information bilateral severe and profound hearing loss. In from both ears to locate the sources of early stages of this technology, cochlear sounds, and to understand speech in complex implantation was offered as a treatment to listening situation. The benefits of binaural individuals with deafness that derived hearing are associated with three primary essentially no speech understanding from binaural mechanisms: the head shadow effect, conventional amplification. As the evidence for binaural squelch and binaural summation [2]. enhanced speech recognition accumulated, In the case of patients with a unilateral coupled with technological advances, it became cochlear implant and a hearing aid in the apparent that individuals with cochlear implants contralateral ear presents potentially a received benefits superior to those of many different situation in that acoustic and

18 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 electrical signals which offer different ear. The study is intended to be a first step in intensity levels, spectral information and a larger investigation aimed to offer support quality must be integrated [3, 4]. for clinical decision-making related to As an increasing number of patients with bimodal fitting. audible residual hearing undergo cochlear implantation, interest has grown in examining MATERIALS AND METHODS the advantages of bimodal stimulation. There We realized a retrospective case series is recent evidence pointing to binaural review. The study group was selected from advantages for better speech recognition in the total number of patients implanted in our quiet and noise as well as to improved sound clinic in the eleven-year period, from 2000 to localization and functional performance when 2011. The selection criteria were the usage of a hearing aid is used in conjunction with a a hearing aid in the contralateral ear after the cochlear implant [3, 5, 6, 7]. adaptation to their cochlear implant. The Ching et al. (2006) recommended bimodal database was built from the recordings of the device fittings as standard care, in the absence audiological assessment of the patients during of contraindications, in adults and paediatric the clinical sessions in the cochlear implant unilateral cochlear implants recipients who centre. We extracted information as the age at have residual hearing in the non-implanted ear implantation, severity and duration of hearing [6]. The decision on the part of the recipient to loss, deafness aetiology, audiological pre- continue hearing aid use in the non-implanted implant evaluation: pure tone audiometry and ear and on the part of the audiologist to speech recognition tests in unaided condition recommend a bimodal fitting may be affected and with one side or bilateral hearing aids. by several factors including patient’s experience The post-implant evaluation involved the free with hearing aids, costs, aesthetics, comfort, field pure tone audiometry with the cochlear clinician’s experience and clinical resources implant and with the hearing aid. We such as the additional time required for fitting considered for our study the hearing threshold both devices (personal communication). levels identified in the last fitting session The main concerns of the clinician might which corresponded to the best auditory be that signal interference may occur when rehabilitation level for the patient. The data electrical and acoustic stimulation is were statistically processed. combined [4]. Research indicates that prolonged periods of profound deafness RESULTS without auditory stimulation result in changes The study group included 12 patients (two in both the peripheral auditory pathways and adults and ten children) with cochlear implant the cortical areas of the brain [8, 9]. An who still use a hearing aid in the opposite ear. enhanced understanding of the potential The age at the implantation varied between advantages of bimodal hearing is particularly 2 years and 10 months to 53 years (Fig. 1), important in view of the recent trend towards with an average of 8 years and 2 months. bilateral implantation [5, 10]. The aetiology of the hearing loss was In this study, we assessed the hearing autoimmune in one case, genetic associated performances of twelve cochlear implanted with malformation in one case, genetic in two patients who still wear a hearing aid in the cases, caused by ototoxicity in three cases and opposite ear and tried to address the unknown in four cases (Fig. 2). The onset of advantage of cochlear implant usage in the hearing loss was prelingually in 25% of conjunction with a hearing aid in the opposite the cases, perilingually in 33 % of the cases

19 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 and postlingually progressive in 42 % of the thresholds determined with the cochlear patients (Fig. 3). implant and with the hearing aid were The levels of free field pure tone compared (Fig. 4).

Fig. 1. The age distribution of the patients at the moment of cochlear implantation

Fig. 2. The aetiology of the hearing loss Fig. 3. The onset of the hearing loss

Fig. 4. Comparison between free field pure tone audiometry with cochlear implant (left) and hearing aid (right)

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The final results show that all the patients compensating for limitations in the cochlear in our study were still wearing a hearing aid implant signal processing. This electro- in the contralateral ear in the moment of the acoustic benefit clearly depends on the last cochlear fitting session. Considering the patient’s amount of residual usable low last hearing threshold levels in free field frequency hearing. measured in two conditions, we can see that The particularity of the auditory the pure tone free field thresholds with the performance evaluation in bimodal cochlear implants are superior to those with rehabilitated patients – cochlear implant in the hearing aid in the opposite ear. The one ear and hearing aid in the opposite ear is majority of free field thresholds with the represented by the necessity to follow an cochlear implant were situated between 15 dB audiological evaluation protocol. The lack of HL to 35 dB HL compared to those with the a standard protocol in this clinical setting may hearing aid which belongs to the interval 30 have negatively impact on patient’s ability to dB HL – 55 dB HL. We can also see a combine a cochlear implant and a hearing aid, decreasing trend of the auditory levels from particularly for those patients who could the low to the high frequencies in the complain that sounds are unbalanced when implanted ear comparing to the reverse trend both devices are used. The bimodal hearing for the hearing rehabilitation of the ear with loss rehabilitation requires a good “loudness the hearing aid, where there is a better balance” for binaurally combined acoustic amplification in the low frequencies. We and electric hearing. compared the auditory level of the The mandatory audiological evaluation nonimplanted ear before the cochlear should include the free field pure tone implantation and after different periods from audiometry and speech audiometry with the the implant’s switch on. In our group, these cochlear implant and with the hearing aid. measurements showed the same levels in Also mandatory should be the periodic headphones pure tone audiometry and in free evaluation of the air and bone conduction field audiometry with the hearing aid, proving thresholds in nonimplanted ear. That offers no degradation of the hearing in the the possibility of monitoring the hearing loss nonimplanted ear. thresholds in the nonimplanted ear and to discover at the right time a progressive DISCUSSIONS hearing loss which would need a new device The advantages of binaural hearing are not adaptation. Although the cochlear available to a person who wears a cochlear implantation protocol allows normal visits implant in only one ear, but may be possible after reaching normal thresholds with the if a hearing aid is used with a cochlear cochlear implant, the audiological evaluation implant in contralateral ear (bimodal hearing). should be done regularly at 3 or 6 months, Fitting a hearing aid is non-invasive and helps precisely to evaluate the nonimplanted ear. to preserve the residual hearing abilities in the Another particularity of auditory non-implanted ear by providing performance evaluation in bimodal acoustic/auditory stimulation. rehabilitation consists in the determination of Similarly to others reported researches the global speech intelligibility with the [11], our results suggest that hearing aids can cochlear implant and with the hearing aid. lead to improvements whereby acoustic Although the usage of the hearing aid offers a information at low frequencies is combined good amplification for pure tones, the speech with high-frequency envelope information, evaluation with it could indicate a severe

21 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 alteration in speech intelligibility and further advantage of cochlear implant usage in the “jamming” of global speech performance. conjunction with a hearing aid in the opposite In that moment should be done a ear. The cochlear implant alone performs reconsideration of its usage. better than the hearing aid alone, and the Of course, the testing methodology for bimodal condition is superior to the cochlear speech intelligibility includes the list of words implant alone. Given the proven advantages or sentences. It is an easy methods for the of an implant and controlateral hearing aid evaluation of the patients with the over a unilateral cochlear implant, the postlingually onset of the hearing loss, but benefits of bilateral implantation must be difficult to use in the case of prelingually or demonstrated relative to an implant and a perilingually deafness, especially in very hearing aid combination rather than a single young children. In that cases, can be use a implant if the cost effectiveness of bilateral close-set word identification task according to implantation is to be established. The bimodal their level of speech recognition and hearing rehabilitation requires a regularly acquisition or the auditory frequency auditory re-evaluation to establish the limit discrimination with visual reinforcement. line between the benefit / less benefit of CONCLUSIONS bimodal hearing. The results of the present study suggest an

REFERENCES 1. NIH Consensus Development Program. 1995. Cochlear implants in adults and children. NIH Consensus Statement Online. Retrieved February 28, 2007 from: http//www:consensus.nih.gov/1995/1995CochlearImplants100html.htm. 2. Mencher GT, Davis A. Bilateral or unilateral amplification: Is there a difference? A brief tutorial. Int J Audiol. 2006; 45: 3-11. 3. Mok M, Grayden D, Dowell RC, Lawrence D. Speech perception for adults who use hearing aids in conjunction with cochlear implants in opposite ears. J Sp Lang Hear Res. 2006; 49: 338-351. 4. Blamey P, Dooley GJ, Parisi ES. Monaural and binaural loudness measures in cochlear implant users with contralateral residual hearing. Ear Hear. 2000; 21: 6-17. 5. Ching TY, Incerti P, Hill M. Binaural benefits for adults who use hearing aids and cochlear implants in opposite ears. Ear Hear. 2004; 25: 9-21. 6. Ching TY, Incerti P, Hill M, van Wanrooy E. An overview of binaural advantages for children and adults who use binaural/ bimodal hearing devices. Audiol Neurotol. 2006; 11: 6-11. 7. Holt RF, Kirk KI, Eisenberg LS, Martinez AS, Campbell W. Spoken word recognition development in children with residual hearing using cochlear implants and hearing aids inopposite ears. Ear Hear. 2005; 26: 82S-91S. 8. Hardie NA, Shepherd RH. Sensorineural hearing loss during development: Morphological and physiological response of the cochlear and auditory brainstem. Hear Res.1999: 128; 147-165. 9. Shepherd RK, Hardie NA. Deafness-induced changes in the auditory pathway: Implications for cochlear implants. Audiol Neurotol. 2001; 6: 305-318. 10. Perreau AE, Tyler RS, Witt S, Dunn C. Selection strategies for binaural and monaural cochlear implantation. Am J Audiol. 2007; 16: 85-93. 11. Kong YY, Stickney GS, Zeng FG. Speech and melody recognition in binaurally combined acoustic and electric hearing. J Acoust Soc Am. 2005: 117; 1351-1361.

22 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011

INFLUENCE OF RESTAURATIVE THERAPY ON MARGINAL PERIODONTAL TISSUE Arina Ciocan-Pendefunda1, Norina Consuela Forna2, Valeria Pendefunda3 PhD Student, Faculty of Dental Medicine, "Gr. T. Popa" University of Medicine and Pharmacy Iași Prof. Faculty of Dental Medicine, "Gr. T. Popa" University of Medicine and Pharmacy Iași, Romania Lecturer Ph.D, Faculty of Dental Medicine, "Gr. T. Popa" University of Medicine and Pharmacy Iași

ABSTRACT The aim of this study is to evaluate the influence of fixed prosthodontics on the periodontal health status, emphasising the pathological changes induced by the restorative materials. Materials and methods The study group was made by 112 patients with 282 dental fixed bridges evaluated by clinical and paraclinical exams. The clinical evaluation included the age of the dental bridge, the material it was made of, the periodontal changes, the bleeding index. For the statistical processing of the data it was used STATISTICA, a special program for medical research. Results and discussions Periodontal changes consisted of significant values of periodontal bleeding index for 46.43% of the cases, periodontal pockets in 12.5% of the cases, recession in 3.57% of the studied cases. Conclusions There is a significant correlation between the material in use for the dental bridges and the presence of the periodontal damage, especially for the metal-acrylic and cast metal crowns.

Key words: fixed restorations, periodontal disease, dental biomaterials

INTRODUCTION Treatment of partial edentation using a MATERIALS AND METHODS fixed prosthesis on abutment teeth can cause The study group was made by 112 patients a series of adapting changes on the gingival (54 men and 58 women), ages between 20-60 tissues. Because of the features of the years old. There were evaluated 282 dental gingival sulcus the adapting reaction of this fixed bridges by clinical and radiographic region will depend on the previous state of exams. The clinical examination evaluated the epithelium, the finishing degree of the the age of the dental bridge, the material was edges, the axial and transversal adaptation of made of, the periodontal changes, the the prosthesis and on the material type of bleeding index. which the dental bridge is made of and on the We run our data through STATISTICA, a luting material [1]. special program for medical research. For the Regarding the biological and prophylactic purpose of this study we used specific tests for principle a dental bridge witch respects the each type of data such as ANOVA test, state of health of the prosthetic field does not SCHEFFE test, SPJOTOVOL / STOLONE cause secondary lesions on the dento- test, correlation tests for quantitative and periodontal support. qualitative variables such us Pearson, CHI The purpose of this study is to evaluate square test, Mantel-Haenszel test, Fisher, the influence of fixed prosthodontics on the Spearman, Kendall, Gamma test. periodontal health status, emphasising the After using these tests the most important pathological changes induced by the parameters were discussed and conclusions restorative materials. were drawn so p which was calculated in

23 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 those tests was compared to p=0.05, meaning The study group had a homogenous a 95% value of trust, significant values distribution regarding the patients’ gender, meaning p calculated<0.05. 51.79% being women and 48.21% men (Fig. Describing the study group: 1). Regarding the patients’ age, 62.5% were The structure based on the patient's aged between 20-30 years and 8.9% were age gender: higher than 50 years (Table 1). Repartitia cazurilor in functie de sexul pacientilor Ages Cases % Female Feminin, 20 <=25 40 35.71% 51.79% 25 <=30 36 32.14% 30 <=35 10 8.93% 35 <=40 6 5.36% 40 <=45 6 5.36% 45 <=50 4 3.57% Male Masculin, 50 <=55 2 1.78% 48.21% 55 <=60 8 7.14% Total 112

Fig. 1. Cases distribution based on gender Table 1. Cases distribution based on age It is noticeable a heterogeneous years. distribution of the age factor, being Material used for dental bridges encountered two ranges in the number of For making dental bridges were use metal- studied cases. Thus for 20-30 years old is ceramic material, metal-composite material found a maximum decreasing with the and metal for cast crowns. In the study group increasing age, and for 55-60 years old period the metal-ceramic bridges presented the there was a slight increase. highest share (39.3%), than the metal- The mean age of the study group was composite bridges (28.6%), metal-acrylic 31.3±10.6 DS, with a minimum for 16 years bridges 32.1% and 10.7% cast metal crowns and maximum for 60 years. Quartile ranges (Table 3). show that 50% of the cases are aged up to 28

Material used No cases % Metal-ceramic 44 39.3% F (95% confidence Age p Metal-composite 32 28.6% interval) Metal-acrylic 24 21.4% ANOVA test 3.699259 0.057

Cast metal crown 12 10.7% Total 112

Table 2. Test for comparison of the mean Table 3. Cases distribution based on age by gender material type Age of Mean Cases Std. dev Std. err Min Max Q25 Med. Q75 dental bridge -95% +95% Male 16.3 11.9 20.7 16.0 2.2 0.4 48.0 2.0 12.0 24.0 Female 40.4 19.7 61.0 78.5 10.3 0.2 300.0 2.0 5.5 24.0 Total 28.8 17.8 39.7 58.6 5.5 0.2 300.0 2.0 7.5 24.0 Table 4. Statistical indicators of age according to patient’s gender (in months)

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Bleeding index cases % 0 60 53.57% 1 32 28.57% 2 20 17.86% Total 112

Table 5. Cases distribution based on bleeding index Cases % Absent 98 87.5% Present 14 12.5% Total 112

Fig. 2. Age of dental bridge according to Table 6. Cases distribution based on patients' gender (in months) periodontal pocket We compare the age of the dental bridge Dental bridges aggregated on organic based on patients gender, the conclusion we structures as treatment for partial edentation is drawn being that there are significant inducing a series of adaptive changes in the differences between genders, for men the gingival tissues. Acrylate is known to induce average value being lower than for women. irritation on marginal periodontal tissues due The age of the dental bridges to the residual monomer, because it can’t be The average age was 28.8 months, with a finished very well and favours plaque retention minimum of 2 months and a maximum of 25 while ceramic masses are biocompatible and years. very well accepted by the periodontal tissues [4, 6]. RESULTS AND DISCUSSIONS There is a significant correlation between By definition Periodontitis consists in loss the material in use and the presence of of epithelial attachment and reducing bone periodontal damage especially for acrylic support, often accompanied by bleeding bridges or cast metal crowns (Table 8, 9). [5] gums. Disease characteristics are assessed by Dental bridge age versus periodontal means of expressing gingival bleeding index, damage gingival retraction, presence of periodontal The average values for the age according pockets and radiographic bone loss. to periodontal damage were 10.4 months in Gingival bleeding index case of absent damage and 51.5 months for An important factor in assessing the the presence of periodontal damage. periodontal damage was the bleeding index. The Results for ANOVA test show significant bleeding index had important values for 46.43% differences between the average values for of the cases from the studying group (Table 5). dental bridge’s age in case of periodontal [3] damage / in absence of periodontal damage Periodontal pockets - analysing the (p=0.00015, 95%CI) (Tables 10, 11). dental bridges 12.5% of them presented Clinical trial on 282 dental bridges for 112 periodontal pockets (Table 6) [2]. patients showed that: Gingival retraction - was present for Periodontal changes were highlighted by 3.57% of the cases (Table 7), [2]. periodontal bleeding index, with significant Correlation in periodontal damage values for 46.43% of the cases, by Dental bridge material vs. periodontal periodontal pockets in 12.5% of the cases, by damage recession in 3.57% of the studied cases.

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Gingival retraction cases % Metal-ceramic 28 25.0% 16 14.3% 44 Metal-composite 22 19.6% 10 8.9% 32 Absent 108 96.43% Metal-acrylic 8 7.1% 16 14.3% 24 Present 4 3.57% Crown metallic 4 3.6% 8 7.1% 12 Total 112 Total 62 50 112

Table 7. Cases distribution based on Table 8. Cases distribution based on material gingival retraction vs. periodontal damage

p Chi-square 2 df 95% confidence interval Chi-square - 2 10.60880 df=3 0.01404 ML Chi-square 10.71584 df=3 0.01337 Correlation coefficient 0.591549 0.01142 (Spearman Rank R) Table 9. Estimated parameters in association testing material vs. periodontal damage

Age of Media Periodontal Dev. Er. Mi Media dental Max Q25 Q75 damage std std n n bridge -95% +95% Absent 10.4 2.4 18.4 31.4 4.0 0.2 240.0 1.0 3.0 7.0 Present 51.5 30.3 72.8 74.7 10.6 1.5 300.0 12.0 24.0 36.0 Total 28.8 17.8 39.7 58.6 5.5 0.2 300.0 2.0 7.5 24.0 Table 10. Statistical indicators for dental bridge’s age correlated with periodontal damage

Dental bridge age F (95% confidence interval) p ANOVA test 15.42233 0.000150 Table 11. Test comparing the mean values for dental bridge’s age depending on the presence of the periodontal damage

CONCLUSIONS 2. The average values for the dental bridges’ 1. There is a significant correlation between age according to the presence of the the material in use for the dental bridges periodontal damage were 10.4 months in and the presence of the periodontal case of absence of damage and 51.5 in damage, especially for the metal-acrylic case of presence of damage. and cast metal crowns.

REFERENCES 1. Burlui V., Norina Forna., Gabriela Ifteni.: Clinica şi Terapia Edentaţiei Intercalate Reduse. Ed. Apollonia, Iaşi 2001 2. Broadbent JM,Williams KB, Thomson WM, Williams SM.: Dental restorations: a risck factor for periodontal attachment Loss? J Clin Periodontol. 2006; 33(11):803-810. 3. Reitemeir B, Hansel K, Walter MH, Kastner C, Toutenburg H.: Effect of posterior crown margin placement on gingival health. J Prosthet Dent.2002; 87(2): 167-172. 4. Vanzeveren C, D’Hoore W, Bercy P. Influence of removable partial denture on periodontal indices and microbiological status. J Oral Rehabili. 2002; 29(3): 232-239. 5. Vult von Steyern P, Jonsson O, Nilner K. Five-year evaluation of posterior all-ceramic three-unit (In- Ceram) FPDs. Int J Prosthodont.2001; 14(4): 379-384. 6. Carranza FA. And Newman MG.: Clinical Periodontology, 8th edition, WB Saunders Co., 1996.

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ASSESSMENT OF ORTHODONTIC TREATMENT NEEDS OF SCHOOLCHILDREN FROM IASI ACCORDING TO INDEX OF ORTHODONTIC TREATMENT NEEDS (IOTN) AND DENTAL AESTHETIC INDEX (DAI) Andrei Corneagă, Ioan Dănilă, Carina Balcoş “Gr. T. Popa” University of Medicine and Pharmacy, Faculty of Dental Medicine, Department of Oro-Dental Prevention, Iasi, Romania

ABSTRACT To assess the distribution, prevalence and severity of malocclusion and orthodontic treatment needs in schoolchildren from Iasi, 12 years old. A sample of 200 schoolchildren (92 males and 108 females) randomly selected was obtained from 4 public schools from Iasi, Romania. The need for orthodontic treatment was measured using the IOTN and DAI. The DAI most of the subjects (77%) were deemed to require orthodontic treatment. Only about 5.8% had a handicapping malocclusion that needed mandatory treatment. A severe malocclusion for which treatment was highly desirable was recorded in 23% of the schoolchildren and 23.7% had a definite malocclusion for which treatment was elective. There were no significant differences (p>0.05) in mean DAI scores between males and females. The IOTN/DHC: 15.3 % (95 % CI) of the 12-year olds need orthodontic treatment (grades 4 and 5). IOTN/AC: 11.4 % (95 % CI) in the 12-year olds need orthodontic treatment. No significant differences in the treatment needs proportions by gender were found (p>0.05). 77% of the adolescents from Iasi were in need of orthodontic treatment for dental health reasons. This study provides baseline data on the need and demand for orthodontic treatment among schoolchildren from Iasi.

Key words: IOTN, DAI, orthodontic treatment need, schoolchildren

INTRODUCTION This index can be used for different A variety of occlusal indices have been communities and populations without developed to classify the treatment of requiring any modification [6]. malocclusion in groups according to urgency Unlike the DAI, the IOTN (Index of and the need of treatment [1]. The place of Orthodontic Treatment Needs) classifies aesthetic and functional criteria in malocclusions according to the presence of determining orthodontic treatment needs particular occlusal features which are cannot be underestimated as these are major considered important for dental health and indications for patients seeking orthodontic aesthetics in order to identify individuals who services [2]. Dental appearance that deviates would derive the most benefit from from social norms may have a negative orthodontic treatment. This index includes an impact on social and psychological functions. AC with 10 severity levels and a Dental A previous report has demonstrated the high Health Component (DHC) with 5 severity reliability and validity of this index [3], which levels (Table 1). The two components are also compares favourably with other indices analysed separately and although they cannot [4, 5]. Being compared with other indices, the be united into a single score, they can be DAI (Dental Aesthetic Index) was more combined to classify the patient as versatile, time-saving and simple to use [5]. “orthodontic treatment need, Yes or No”,

27 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 following the modifications [7]. different levels of dental attractiveness, grade The Aesthetic Component consists of a 1 representing the most attractive and grade scale of 10 colour photographs showing 10 the least attractive dentitions (Fig. 1).

IOTN 1 No need for treatment IOTN 2 No/slight need for treatment IOTN 3 Moderate/ borderline need for treatment IOTN 4 Great need for treatment IOTN 5 Great need for treatment Tabel 1. The Dental Health Component (DHC) has 5 Grades

1 6

2 7

3 8

4 9

5 10

Fig. 1. The Aesthetic Component of IOTN The DAI is an orthodontic index based on below, results in a numerical value that, socially defined aesthetic standards [3]. It is according to the creators of the index, useful both in epidemiological surveys to indicates the need for treatment as follows: up identify unmet need for orthodontic treatment to 25 points: no treatment need; 26 - 30 and as a screening device to determine points: treatment elective; 31 - 35 points: priority for public orthodontic treatment. This treatment highly desirable; 36 points or more: index integrates the psychosocial and treatment mandatory. physical elements of malocclusion. It is a The aim of this study was to evaluate the regression equation that mathematically links distribution, prevalence and severity of the public’s perception of dental aesthetics malocclusion and orthodontic treatment needs with the objective physical measurements of in a sample of 12-years-old schoolchildren the occlusal traits associated with from the urban zone of Iasi using IOTN and malocclusion. The components of DAI the DAI. This data would allow comparison regression equation are shown in Table 2. with previous and subsequent studies. The logical regression equation, shown

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DAI components 1. Number of missing visible teeth (incisors, canines and premolar teeth in the maxillary and mandibular arches) 2. Crowding in the incisal segments: 0 = no segments crowded, 1 = 1 segment crowded, 2 = 2 segments crowded 3. Spacing in the incisal segment: 0 = no spacing, 1 = 1 segment spaced, 2 = 2 segments spaced 4. Midline diastema (mm) 5. Largest anterior irregularity on the maxilla (mm) 6. Largest anterior irregularity on the mandible (mm) 7. Anterior maxillary over jet (mm) 8. Anterior mandibular over jet (mm) 9. Vertical anterior open bite (mm) 10. Antero-posterior molar relation: 0 = normal, 1 = ½ cusp, 2 = one full cusp Table 2. Components of the DAI regression equation [3]

MATERIALS AND METHODS register all the necessary malocclusion This study was conducted in 4 municipal features to obtain the DAI and the IOTN public schools in different districts of the Iasi (over jet, overbite, anterior and posterior city, selected by sampling from a list of all cross bite, open bite, displacement of the the municipal schools supplied by the teeth, diastema, impeded eruption, Educational Department. The sample hypodontia, clefts lip and/or palate, and molar consisted in 200 schoolchildren, comprising relationship), as well as personal details 92 boys (44%) and 108 girls (56%), 12 years (name, age, and gender). old at the time of the clinical examination. No Each subject was examined and scored for differentiation was made in terms of social the five components of Dental Health class as those attending public schools in Iasi Component (DHC) (Table 1), ten components and they belong to low social level families. of the AC (Fig. 1) of IOTN and the DAI For calculating the sample the following (Table 2), according to the standard parameters were employed: 4% margin of conventions [3]. Distance was measured in error, confidence interval of 95% and an whole millimetres using WHO periodontal estimated 50% prevalence of malocclusions. probes. The examiner used gloves and mask Individuals presenting a previous history of throughout the clinical examinations. The orthodontic or orthopaedic treatment, those subjects were examined at school during class undergoing treatment or with syndromes and hours in a predetermined order. those whose complete permanent dentition Data analysis was carried out on a did not include at least the first permanent personal computer using SPSS (the Statistical molar at the time of the clinical examination, Package for Social Sciences) software for were excluded from the study. Windows, Version 14. The chi-square test The examinations were conducted with was used to test the distribution differences permission from the education authorities and between the genders. head teachers, and with informed consent of the pupils’ parents. RESULTS All data on malocclusion were collected A high level of reliability in applying by one dentist calibrated at the Department of IOTN and the DAI was achieved by the Oro-Dental Prevention, Faculty of Dental examiner. A Kappa value of 0.90 indicates an Medicine, “Gr. T. Popa” University of excellent agreement. Medicine and Pharmacy Iasi. Orthodontic treatment needs according to Oral examinations were conducted to the IOTN

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Table 3 shows the different IOTN/DHC: According to the IOTN/AC, the treatment 15.3 % (95 % CI) of the 12-year old need was 11.4 % (95 % CI) for the 12-years presented grades 4 and 5 DHC, a definite old schoolchildren (AC grade 8 - 10). No need for orthodontic treatment. No significant significant differences in the treatment need differences in treatment needs proportions by proportions by gender were found (p > 0.05) gender were found (p > 0.05). (Table 4).

IOTN (DHC) 12 years old (n = 200) %(95% CI) Grade 1. Normal or minor malocclusion. No need 20.7 (18.8 - 22.6) No need; Grade 2. Minor malocclusion. Little need 32.3 (27.4 - 37.2) 84,7 Grade 3. Moderate malocclusion. Borderline need 31.7 (26.9 - 36.7) Grade 4. Severe malocclusion. Needs treatment 11.0 (12.4 - 20.1) Definite need; Grade 5. Very severe malocclusion. Needs treatment 4.3 (2.2 - 6.5) 15,3 Table 3. Distribution of the IOTN Dental Health Component (DHC) levels of orthodontic treatment need in the examined schoolchildren’s

IOTN (AC) 12-year-olds (n = 200) % (95% CI) AC grades 1–4. No need 75.1 (66.3–83.9) AC grades 5–7. Moderate need. 13.5 (9.2–17.8) AC grades 8–10. Definite need. 11.4 (8.5–14.2) Table 4. Distribution of the IOTN Aesthetic Component (AC) levels in the examined schoolchildren’s Orthodontic treatment need according to statistically significant (p<0.05). the DAI Table 6 presents the distribution of the Table 5 shows the distribution by age and treatment needs in the entire population gender, according to orthodontic treatment sample according to the DAI. Most of the needs. As may be seen in the table, the subjects (77%) had a dental appearance that majority of the schoolchildren were classified required orthodontic treatment. Only 5.8% in the category “treatment elective”. When had a handicapping malocclusion that needed we compared the need for treatment between mandatory treatment. A severe malocclusion males and females, we noted that the number with treatment being highly desirable was of subjects classified as “no treatment need” recorded in 23% of the subjects and 23.7% was greater for the females, while the had a definite malocclusion with treatment treatment considered “elective” was more being elective. No need for treatment or a frequent among the males. However, the “slight need” was observed in 47.5% of the associations found were not regarded as subjects.

12 years old M F n 92 103 No treatment need (%) 19.7 24.9 Treatment elective (%) 75.8 68.9 Treatment highly desirable (%) 4.5 6.2 Table 5. DAI Index Orthodontic Treatment Need according to gender and age

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DAI score Severity levels Frequency % < or = 25 Minor or no anomaly / NTN 46 47.5 26 - 30 Definite malocclusion / Elect 47 23.7 31 - 35 Severe malocclusion / HD 95 23.0 > or = 36 Handicapping malocclusion / mandatory 12 5.8 TOTAL 200 100.0 Table 6. Orthodontic treatment needs of Iasi schoolchildren according to the DAI Three main occlusal features were 15.3 % with the IOTN and 28,5 per cent with responsible for allocated subjects into the the DAI in 12-years-old. Johnson et al. (2000) group of “orthodontic treatment required”: [19] also found that both indices assessed the crowding (47.3%), tooth loss (22.3%) and same number of children with malocclusions maxillary over jet greater than 3 mm (21.8%) requiring orthodontic treatment, but not all (Fig. 2). were ranked similarly by each index. Previous studies [18 and19] found significant correlations between them. The differences found in the determination of orthodontic treatment need depending on which particular index (DAI or IOTN) has been used to reinforce the point of view of some authors [20 and 21] that normative measures should be used in combination with quality-of-life Fig. 2. Distribution of occlusal features into questionnaires to cover the malocclusion the group of “orthodontic treatment dimension of oral health. required” In the present study of among 12 years old DISCUSSION schoolchildren the prevalence of malocclusion The percentage of children in need of between genders was statistically not orthodontic treatment was in this study significant. This is consistent with the study comparable with that encountered in most among 12-15 years old schoolchildren of investigations that used the DAI [6, 8, 9 and Davangere city, India [22], Nigerian 10] or IOTN [11, 12, 13 and 14]. It was population aged 12-18 years old [23]. higher than that found in an African population [15] but lower than in Turkish CONCLUSION [16] and Japanese [17] populations. The prevalence of malocclusion in the It should be pointed out that, irrespective present study was 77%. At present, of the index employed in assessing treatment orthodontic care is generally provided on the need (DAI or IOTN), the results obtained basis of payment by the trained orthodontists, were not similar but there were no which makes it rather expensive and statistically significant differences in the unaffordable. proportion considered in need of treatment:

REFERENCES 1. Otuyemi and Jones, Methods of assisting and grading malocclusion, Australian Dental Journal 14: 21- 27, 1995 2. Onyeaso C, Aderinokun G. The relationship between dental aesthetic index (DAI) and perceptions of aesthetics, function and speech amongst secondary school children in Ibadan, Nigeria, International journal of paediatric dentistry / the British Paedodontic Society [and] the International Association of

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Dentistry for Children, 13(5), pp. 336-41, 2003. 3. Cons N C, Jenny J, Kohout F J, DAI: the Dental Aesthetic Index. College of Dentistry. University of Iowa, Iowa City, 1986 4. Beglin F M, Firestone A R, Vig K W, Beck F M, Kuthy R A, Wade D, A comparison of the reliability and validity of 3 occlusal indices of orthodontic treatment need. American Journal of Orthodontics and Dentofacial Orthopedics 120: 240–246, 2001 5. O. D. Otuyemi, J. H. Noar. Variability in recording and grading the need for orthodontic treatment using the handicapping malocclusion assessment record, occlusal index and dental aesthetic index, Community Dentistry and Oral Epidemiology, Volume 24, Issue 3, pages 222–224, June 1996 6. Estioko l J, Wright F A C, Morgan M V, Orthodontic treatment need of secondary schoolchildren in Heidelberg, Victoria: an epidemiologic study using the Dental Aesthetic Index. Community Dental Health 11: 147–151, 1994 7. Burden D J, Pine C M, Burnside G, Modified IOTN: an orthodontic treatment need index for use in oral health surveys. Community Dentistry and Oral Epidemiology 27: 413–418, 1999 8. Jenny J, Cons N C, Kohout F J, Jakobsen, J Differences in need for orthodontic treatment between native Americans and the general population based on DAI scores. Journal of Public Health 51: 234– 238, 1991 9. Esa R, Razak l A, Allister J H, Epidemiology of malocclusion and orthodontic treatment need of 12-13- year-old Malaysian schoolchildren. Community Dental Health 18: 31–36, 2001 10. Souames M, Bassigny F, zenati N, Roirdan P J, Boy-Lefevre M, Orthodontic treatment need in French schoolchildren: an epidemiological study using the Index of Orthodontic Treatment Need. European Journal of Orthodontics 28: 605–609, 2006 11. Brook P H, Shaw W C The development of an index of orthodontic treatment priority. European Journal of Orthodontics 11: 309–320, 1989 12. Burden D J, Holmes A The need for orthodontic treatment in the child population of the United Kingdom. European Journal of Orthodontics 16: 395–399, 1994 13. Nimri K, Richardson A, Interceptive orthodontics in the real world of community dentistry. International Journal of Paediatric Dentistry 10: 99–108, 2000 14. Manzanera D, Ortiz l A, Gandía J l, Cibrián R, Adobes-Martin M Índice de Necesidad de tratamiento Ortodóncico (IOTN) en escolares de 10 a 12 años. Revista Española de Ortodoncia 34: 209–217, 2004 15. Mugonzibwa E A, Kuijpers-Jagtman A M, Van’t Hof M A, Kikwilu E N Need for orthodontic treatment among Tanzanian children. East African Medical Journal 81: 10–15, 2004 16. Ucuncu N, Ertugay E, The use of the Index of Orthodontic Treatment Need (IOTN) in a school population and referred population. Journal of Orthodontics 28: 45–52, 2001 17. Ansai T et al. Prevalence of malocclusion in high school students in Japan according to the Dental Aesthetic Index. Community Dentistry and Oral Epidemiology 21: 303–305, 1993 18. Freer E, Freer T J, Variations in treatment need using four screening methods. Australian Orthodontic Journal 15: 214–218, 1999 19. Johnson M, Harkness M, Crowther P, Herbison P, A comparison of two methods of assessing orthodontic treatment need in the mixed dentition: DAI and IOTN. Australian Orthodontic Journal 16: 82–87, 2000. 20. Tsakos G, Gherunpong S, Sheiham A, Can oral health-related quality of life measures substitute for normative needs assessment in 11 to 12-year-old children? Journal of Public Health Dentistry 66: 263– 268, 2006 21. Klages U, Claus N, Wehrbein H, Zentner A, Development of a questionnaire for assessment of the psychosocial impact of dental aesthetics in young adults”. European Journal of Orthodontics 28: 103– 111, 2006. 22. Shivakumar, KM, Chandu, GN. et al., Prevalence of malocclusion and orthodontic treatment needs among middle and high school children of Davangere city, India by using Dental Aesthetic Index, J Indian Soc Pedod Prevent Dent, 27(4), pp. 211-18, 2009. 23. Otuyemi, O., Ogunyinka A. et al., Malocclusion and orthodontic treatment need of secondary school students in Nigeria according to the dental aesthetic index (DAI), International Dental Journal, 49, pp.203-10, 1999.

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COMPARATIVE EVALUATION OF THE HYBRID LAYER IN LATERAL PREVENTIVE RESTORATIONS 1 Irina Maftei , Iulia Cătălina Săveanu2, Oana Dragoș3, Carina Balcoș4, Ioan Dănilă5 1PhD student, Department of Oral- Dental Prevention, Faculty of Dental Medicine, "Gr. T. Popa" University of Medicine and Pharmacy, Iaşi, Romania 2Assist. Prof. Department of Oral- Dental Prevention, Faculty of Dental Medicine, "Gr. T. Popa" University of Medicine and Pharmacy, Iaşi, Romania 3Scientific Researcher, National Research and Development Institute for Technical Phisics IFT, Iaşi 4Jr. Assist. Department of Oral- Dental Prevention, Faculty of Dental Medicine, "Gr. T. Popa" University of Medicine and Pharmacy, Iaşi, Romania 5Prof., Department of Oral- Dental Prevention, Faculty of Dental Medicine, "Gr. T. Popa" University of Medicine and Pharmacy, Iaşi, Romania

ABSTRACT The purpose of this study was the OM = optical microscopy analysis of the dentinal HL=hybrid layer of two materials with metal alloy particles used in minimally invasive cavity preparations. The study included 10 human premolars and molars, extracted for orthodontic or periodontal reasons. The extracted teeth were used in the study after obtaining a informed consent from the patients, in compliance with the protocol approved by the ethics committee of UMF Gr.T.Popa Iasi. Samples were divided randomly into two equal groups (N = 5): GR.1 (N = 5), GR2 (N = 5). Minimally invasive occlusal cavities were made using a mechanical preparation. We used cylindrical diamond burrs and carbide globular no. 1 burrs. The restorative materials used were: PAA=PolyAcrylic Acid, SE = 3M ™ Scotchbond Etch ™, dental adhesive ASBP = Adper Single Bond Plus (3M ESPE), glass-ionomer with metal alloy particles MM = MIRACLE MIX (3M ESPE) and non gamma 2 amalgam A=ANA2000. The analyzed groups were: GR.1:(5)PAA;MM and GR.2:(5)SE™;ASBP;A. Materials were used according to the manufacturer's instructions, the resulting samples were thermo cycled 500 cycles (5 0 -55 0), sectioned, viewed by OM=ZEISS–AXIO-CAM-MRC5 and statistically analysed (ANOVA, p ≤ 0.05). Statistical data processing was performed with Microsoft Excel and SPSS 14.0, p ≤ 0, 05. The results obtained by quantitative analysis of the HL indicate that there are differences (p ≤ 0.05) between groups in favour of the samples filled with amalgam 10.37 (± 2.62). Conclusions: The restoration material and the use of a dentinal adhesive dimensionally influence the HL size.

Key words: amalgam, hybrid layer, glass-ionomer.

The research was supported by the CNCSIS grant budget nr.2669 in 2008- IDEI competition- exploratory research projects.

INTRODUCTION One of them would be the topography of Broadening the range of materials the lesion. In occlusal caries we must focus continues to make it difficult sometimes for on a wear-resistant material. When the practitioner to choose the optimal and physiognomic demands are low we can opt viable solution, restoration prognosis often for a wear-resistant material such as glass- being reserved if one quantifies a number of ionomer with metal alloy particles or clinical parameters. amalgam, the choice depending on the

33 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 patient's caries risk and the biological internal and external angles. We used properties of the material. cylindrical diamond burrs and carbide In the past, amalgam use cleared the test of globular no. 1 burrs. Preparation was made at time, but the need to sacrifice tooth substance high speed in enamel and low speed in for a retentive cavity design gradually made dentine under continuous irrigation with composite restorative materials more water. The burrs were operated inside a desirable. But due to high polymerization template to obtain cylindrical cavities of shrinkage, subsequent marginal leaching and approximately equal volume with the low resistance to wear, in certain situations following dimensions: 4 mm wide, 2 mm composite resins recommendation is made deep. with reluctance. The samples were randomly divided in Introduction of metal alloy glass-ionomers two equal groups GR.1 (N = 5), GR2 (N = 5). responds to imperatives related to resistance Each tooth was filled according to the to wear (higher then composite resins and protocol recommended by the manufacturer. lower then amalgam) and to the The restorative materials used were: polymerization contraction (very low). In PAA=PolyAcrylic Acid, SE = 3M ™ addition, metal alloy glass-ionomers show a Scotchbond Etch ™, dental adhesive ASBP = thermal expansion coefficient similar to the Adper Single Bond Plus (3M ESPE), metal dental hard tissues and induce a certain alloy glass-ionomer MM = MIRACLE MIX degree of mineralization of the surrounding (3M ESPE) and non gamma 2 amalgam A = hard tissues by slowly releasing fluoride. ANA 2000. The analysed groups were: Because restoration sustainability in time, GR.1:5 (M) PAA; MM and GR 2:5 (M) in favourable conditions, is a basic goal and SE™; ASBP; A. good wear properties are known, we wanted The resulting samples were thermo cycled to test two metal alloy dental materials and to 500 cycles between 5 0 and 55 0- 5 minutes at pursue options that could be best in terms of 37 0, 5 seconds at 5 0 then 5 minutes at 37 0 hybrid layer quality for these materials. followed by 5 seconds at 55 0- according to a protocol described by Guliz [1]. The prepared MATERIAL AND METHOD teeth were kept in saline vials for 48 hours The study included 10 human premolars and then were axially sectioned in half and molars, extracted for orthodontic or vestibulo-orally. The two halves were periodontal reasons. The extracted teeth were polished under water irrigation using discs used in the study after obtaining an informed with decreasing grit at low speeds. The consent from the patients, in compliance with section surface was treated with 37% ortho- the protocol approved by the ethics phosphoric acid for 10s, washed with distilled committee of "Gr. T. Popa" UMPh Iași. After water and blown dry. The samples were kept extraction the teeth were immediately cleaned in their vials around 24 hours. Visualisation of soft debris with hand scaling instruments, was performed with an optical microscope washed with running water and then stored up (Zeiss-Axio with Axio-CAM MRC 5). to 24 hours in saline. The number of sample Statistical data processing was performed vials was recorded. Teeth were brushed with with Microsoft Excel and SPSS 14.0 a non-fluorinated abrasive paste and then (Statistical Package for Social Sciences) washed with running water. On the occlusal setting a statistical significance threshold of p of each tooth we prepared mechanically (M) ≤ 0, 05. Comparative analysis was performed and minimally invasive cavities with rounded using the ANOVA test.

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RESULTS (± 2.62) for GR.2:5 SE™; ASBP; A with a Analysis of the hybrid layer in the studied minimum of 7.47 µm and a maximum of groups consisted of measuring its thickness in 13.93 µm (Table 1). three different points for each sample and We tested the equality of variances with then achieving the average. The the Levene test which resulted positive and measurements were done in mm and then applied the variance analysis ANOVA test transformed in µm according to the scale showing a statistically significant difference p shown in the images. This method of = 0, 015 (Table 2 and 3). assessment has been used before by other Ultra structural analysis of the hybrid layer authors in similar studies [2]. size revealed significant statistical differences Quantitative analysis of the HL size between groups p ≤ 0.05 (GR.1 MM -D and showed an average of 3.28 µm (± 0.69) for GR.2 A-D) in favour of the samples restored GR.1:5 PAA; MM with a minimum of 2.39 with amalgam (Fig. 1). µm and a maximum of 4.2μm and 10.37 µm

95% Confidence Interval for Between Std. Std. N Mean Mean Min Max Comp. Dev. Error Lower Upper Variance

Bound Bound GLASS IONOMER 5 3,282 ,690 ,308 2,424 4,139 2,39 4,20 MIRACLE MIX AMALGAM ANA 2000 5 10,37 2,623 1,173 7,114 13,629 7,47 13,93 Total 10 6,827 4,151 1,312 3,857 9,796 2,39 13,93 Fixed Effects 1,918 ,606 5,428 8,225 Model Random Effects 3,545 -38,216 51,870 24,398 Table 1. Descriptives - Glass Ionomer Miracle Mix-Amalgam Ana 2000

Sum of df Mean Square F Sig. Squares Between Groups 125,670 1 125,670 34,150 ,000 Within Groups 29,440 8 3,680 Total 155,110 9 Table 2. ANOVA - Glass Ionomer Miracle Mix-Amalgam Ana 2000

Levene df1 df2 Sig. Statistic 9,600 1 8 ,015

Table 3. Test of Homogeneity of Variances - Fig. 1. Average HL size în the studied Glass Ionomer Miracle Mix-Amalgam Ana groups 2000

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Fig. 2. OM aspect of the Miracle Mix-D Fig. 3. OM Aspect of the Amalgam ANA interface. It notes the presence of an 2000-D interface. It notes the presence of a optimal hybrid layer size, constant along constant, optimal size hybrid layer along the interface and metal alloy particles that the interface but with a certain give resistance to wear and to dissolution transparency. This layer could be a result time of the dental adhesive used

DISCUSSIONS The hybrid layer provides a sealing and Recent studies showed that retention may be a small retention for the resin–dentin obtained by using amalgam with adhesive bond (a hydrophilic primer and an adhesive system is equal or superior to traditional agent penetrates about 3 mm around and mechanical retention methods [3]. Optical inside the demineralised dentin on the cavity microscopy of the bonded amalgam-dentin walls). HL thickness obtained in this study is interface revealed in other studies as well as comparable to that obtained by other studies in our own the presence of a optimal and and considering correlation studies between constant HL in all experimental groups [4]. In the presence of micro-fissures and adherence addition, reducing sensitivity and a more power, we hope that success will be conservative preparation can be obtained guaranteed as long as the hybrid layer will be when using an adhesive system before able to seal the dental infrastructure [8]. applying the amalgam [5, 6]. The bond efficiency of glass-ionomers to An optimal adhesion to dentin involves enamel and dentin depends on: an increased removing all the affected demineralised powder - liquid report, smear layer removal dentin, which is not always desirable due to a and maintaining a hydrate equilibrium. possible interference with the pulp integrity. The use of metal alloy glass-ionomers is a To have an optimal adhesion to dentin several sustainable option when the practitioner is principles must be respected, namely: dentin unable to achieve an adequate isolation in must be acid etched with 37% patients with medium to high carious risk [9]. orthophosphoric acid for 15 seconds or weak Although the size of the hybrid layer was organic acids (itaconic, maleic, polyacrylic significantly smaller, we recommend the use 10%)to remove the detritus layer; etching of metal alloy glass-ionomer MIRACLE MIX should be sufficient to demineralise the (3M ESPE) due to its mineralising properties. surface of the dentin, leaving collagen fibres However, when faced with major occlusal exposed and available for a mechanical link stress areas, we recommend the use of with the resin; the surface should be washed amalgam, as it guarantees a good adhesion thoroughly to remove any acid trace; the and a higher resistance to wear. surface must remain moist but not soaked [7].

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CONCLUSION ACKNOWLEDGEMENTS The restoration material and the use of a The research was supported by the dentinal adhesive dimensionally influence the CNCSIS grant budget nr.2669 in 2008- IDEI HL size. competition- exploratory research projects.

REFERENCES 1. Guliz Gorgul, BDS, PhD, Tayfun Alacam, BDS, PhD, Director, Bagdagul H., Kivanc, BDS, Ozgur Uzun BDS, A Cemal Tinaz, BDS, PhD, Microleajage of packable Composite Used in Post Spaces Condensed Using Different Methods, The Journal of Contemporary Dental Practice, 2002 May;3(2). 2. Shashikiran N.D., Gunda S., Subba Reddy V.V., Comparison of Resin – Dentin interface in primary and prmanent teeth for three different durations of dentine etching, J Indian Soc Pedo Prev Dent 2002;20(4). 3. Staninec M, Retention of amalgam restorations, Quintessence International 1989;20:347-351. 4. Cianconi L, Conte G, Mancini M, ”Shear bond strenght, failure modes and confocal microscopy of bonded amalgam restorations”, Dental Materials Journal 2011;30(2):216-221. 5. Cobb DS, Denehy GE, Vargas MA, Amalgam shear bond strenght to dentin using single-bottle primer/adhesive system, A J Dent 1999;12:222-6. 6. Dhanasomboon S, Nikaido T, Shimada Y, Tagami J, Bonding amalgam to enamel:shear bond strenght and s.e.m. morphology, J Prosthet Dent 2001;86:297-303. 7. Qin M, HS Liu Clinical Evaluation of a Flowable Resin Composite and Flowable Compomer for Preventive Resin Restorations Quintessence International 2004;30(5). 8. Nasrien Z., Ateyah BDS, MSc, Ahmed, Elhejazi, BDS, MSc, PhD, Shear Bond Strengths and Microleakage of Four Types of Dentin Adhesive Materials Materials. J Contemp Dent Pract 2004 February;(5)1:063-073. 9. Garcia-Godoy F, Olsen BT, Marshall TD, Barnwell GM, Fluoride release from amalgam restorations lined with a silver-reinforced glass ionomer, Am J Dent 1990 Jun;3(3):94-6.

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DUAL EFFECTS OF FLAVONOIDS ON DYSLIPIDEMIA AND PERIODONTAL DISEASE Sonia Nănescu1, Silvia Mârțu2, Georgeta Ciomaga3, Vasilica Toma4, Doriana Forna1, Liliana Foia1 1Department of Biochemistry, Faculty of Dental Medicine, “Gr. T. Popa” University of Medicine and Pharmacy Iasi, Romania 2Department of Periodontology, Faculty of Dental Medicine, “Gr. T. Popa” University of Medicine and Pharmacy Iasi, Romania 3Department of Internal Medicine, CI Parhon Hospital, Iasi, Romania 4Department of Pedodontics, Faculty of Dental Medicine, “Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania

ABSTRACT Introduction The association periodontal disease-systemic status has a dynamic role and is bi-directional therefore none of the two can be studied independently. Objective Taking into consideration that an increased level of lipids represents a risk predictor for atherosclerosis we aimed to investigate a group of patients that presented both, periodontal disease and dyslipidemia. Materials and methods After careful evaluation of systemic and periodontal indexes, we separated the initial group into three separate subgroups. In one subgroup we administered concentrated green tea, consumed as such and through rinsing after each teeth brushing, a second group was administered capsules of flavonoids and our third group was the control group where the classical treatment for the systemic and periodontal condition was administered. Results We noticed that the systemic biochemical parameters improved with the green tea or flavonoid administrations even better than the control group. A significant reduction of the gingival bleeding index was recorded both, in the green tea consumers group as well as in the group of patients that followed the flavonoid treatment. Conclusions Through its antioxidant, anti-inflammatory and actions on matrix metalloproteinases the green tea seem to slow the evolution of periodontal disease. The comparable anti-hyperlipemiant results of flavonoids capsules and green tea suggest another additional treatment tool besides the classical options when treating the systemic condition. Both the systemic and periodontal state seemed to improve when the green tea or flavonoids were administered.

Key words: periodontal disease, dyslipidemia, antioxidant, green tea, flavonoids

INTRODUCTION consequence of vasoconstriction, and also the The periodontal disease is a complex subsequent immune deficit), drugs (such as syndrome with multiple clinical expressions anti-anxiolytics), stress (especially after 50 and an aetiology that is not completely years old when other emotional factors start elucidated. Although the determinant to accumulate in addition to the depression of microbiological factor is certain, the severity the third age), malnutrition and certain of the disease is not correlated with a high systemic diseases, contribute to the evolution level of bacteraemia, the immune component of the disease [1, 2]. being the decisive factor in the subsequent The association periodontal disease- tissue destruction. Besides the immune systemic status has a dynamic role and is bi- characteristics, other factors such as: smoking directional. Therefore, the periodontium (through a defect vascularization as a cannot be studied independently, without

38 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 taking into consideration the general status, Moreover, in aggressive periodontitis the latter being also influenced by the patients, the activity of collagenases from the periodontal condition. On the other hand, crevicular fluid was found to be totally atherosclerosis emerged multiple studies, inhibited by green tea catechins [10]. most of them converting to the conclusion At systemic level, the beneficial effects of that, despite many unknowns, the immune green tea include: a reduction of neutrophil component plays a major role. Thus, the chemotactism, blocking the TNF (tumour multiple immune alterations found in the necrotic factor) gene expression, and NF-KB atheroma plaque at the endothelial level and blocking with protein synthesis inhibition, also the associated platelet changes, resulting in a reduction of inflammatory determine atherosclerosis to be considered as response and of subsequent atherosclerotic another autoimmune disease [3, 4]. Moreover, process [5]. The green tea catechins alter the suggestive common etiopathogenic changes lipid metabolism preventing atherosclerotic can be observed for periodontal disease and plaque installation. They also decrease the atherosclerosis [5, 6, 7] and thus, a common absorption of triglycerides and cholesterol therapy could be initiated and investigated. [11, 12, 13]. Green tea that contains a high concentration The catechins constitute the main of flavonoids could potentially have components with beneficial effects from the beneficial effects at both systemic and local green tea. Among these, the most level. representative are: EC (epicatechin), ECG At the gingival level the green tea has (epicatechin gallate), EGC (epigalocatechin), three major benefits: it is a powerful EGCG (epigallocatechin-3-gallate). antioxidant and thus it reduces the lesions The beneficial effects of green tea determined by free radicals; it is an anti- catechins are recorded for diet concentrations inflammatory agent and has an inhibitory of epigallocatechins that ranges between 0.01 action on bacterial collagenase, also and 2.5%, values that necessitate thus high incriminated in the periodontal destruction. amounts intake [9]. The tannins from green tea provide astringent properties and the polyphenolic compounds OBJECTIVE have also an astringent effect, the consequent The main objectives of the present study vasoconstriction determining a decrease of consisted of: gathering of a sufficient inflammation. Additionally, green tea was documentary material that would allow reported to favour tissue regeneration and identification of the common grounds for repair [5]. The experimental studies showed atherosclerosis and periodontal disease on that the flavonoids from green tea are one hand and that would permit a pertinent effective free radical scavengers and block analysis of the green tea actions, both at the production of NADPH-cytochrome 450 systemic and periodontal levels, on the other derived reactive oxygen species [8]. Certain hand; selection of a group of patients that studies that used local periodontal controlled would present both periodontal disease and delivery of green tea extract, there were dyslipidaemia, taking into consideration that noticed reductions of bacterial load of species an increased level of lipids represents a risk like Porphyromonas gingivalis, P. nigriscens predictor for atherosclerosis (moreover, and P. intermedia, decreases of periodontal dyslipidaemia is often associated to pocket depths of approximately 1.4 mm, and periodontal disease and an increased level of a reduction of peptidase activity [8, 9]. bacteremia at periodontal level); proving the

39 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 systemic and local therapeutic effect of green periodontal disease: bleeding, recession and tea consumed as such and through rinsing the presence of periodontal pockets, the after tooth brushing. Following these, the presence of tooth mobility and calculus. clinical cases were registered into a database Exclusion criteria that were used from the for statistical analysis, identification of beginning were: immune-compromised laboratory parameters and complementary patients, women that were pregnant or breast explorations associated to clinical feeding, patients with orthodontic appliances, observations that would represent the base for patients during odontal and periodontal positive and differential diagnosis, and therapy within 12 months or those that evaluation of green tea mediated effects upon followed antibiotic treatment 6 months prior dyslipidaemia and periodontal disease. to the beginning of the clinical study. We distributed the 41 patients that MATERIAL AND METHODS presented both periodontal disease and Forty one patients aging between 30-70 dyslipidaemia into three subgroups. The first years old, displaying both, periodontal subgroup followed concentrated green tea disease and dyslipidaemia were enrolled in administrations, consumed as such and the study, carefully being aware about the through rinsing after teeth brushing. This necessity of the correct recommended group comprised a total of 16 subjects, half alimentary regimen. males and half females. In the second In these patients, the clinical observation subgroup, consisting of 12 patients, five comprised personal and familial history of the males and seven females, we used capsules disease, complete general examination and that contained concentrated flavonoids thorough dental exam. The cardiologic exam (produced by Cali Vita Company). The third was performed with the complete clinical subgroup represented the control group with investigation and identification of the 13 individuals, subjected to exclusively cardiologic sounds on main blood vessels: classic treatment of the systemic condition, aorta, carotids, and renal vessels; additionally and scaling and root planning for an electrocardiogram was recorded for each management of the periodontal disease. enrolled subject. The ankle-arm test was All the patients were recommended and performed for identification of atherosclerotic followed a low animal fat diet. changes. Dyslipidaemia tests (cholesterol- Chol, triglycerides-TG, HDL and LDL) were RESULTS determined, considering that alterations of Within each group we analysed the these biologic parameters represent risk presence of dyslipidaemia, ischemic factors for atherosclerosis and/or metabolic cardiopathy, arteriopathy and diabetes syndrome. mellitus. However, the main focus of our At the oral cavity the gingival status (with study was on the analysis of the lipid the help of the OMS periodontal probe) was metabolism since the arteriopathy and evaluated, determining the 4 gingival units cardiopathy are a later stage consequence of (mesial, distal, buccal, and lingual). We such imbalances. The dyslipidemic syndrome analysed the presence of bleeding on probing is characterized by the increase of main lipids (BOP), and gingival and periodontal (cholesterol, triglycerides, LDL cholesterol) inflammatory signs, each tooth being and an imbalance of HDL cholesterol. subjected to careful analysis for potential A patient may present a perturbation of a discover of the characteristic symptoms of single type of lipids (for instance only

40 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 triglycerides) or several types of lipids (such the increased cholesterol values associated as cholesterol increase associated with the high levels of triglycerides (12 patients); increase of triglycerides and LDL increased cholesterol with a decreased HDL cholesterol). Hence, in our group (as seen in cholesterol (4 patients); high levels of table 1) there were patients that only had an triglycerides associated with an increased increased cholesterol (7 patients); other LDL and a decreased HDL (4 patients); and patients associated increased cholesterol, one last category displaying high values for triglycerides and LDL values (7 patients); cholesterol, LDL and decreased levels of some patients recorded elevated levels solely HDL (4 patients). for triglycerides (3 patients); or in other cases,

Total High Chol, High Chol, High TG, High Chol High Chol number high TG high LDL high LDL High Chol High TG and high and low of and high and low and low TG HDL patients LDL HDL HDL 41 7 patients 3 patients 12 patients 4 patients 7 patients 4 patients 4 patients Table 1. The distribution of altered lipid metabolism levels in the group of patients at the beginning of the study We tried to distribute the heterogeneous plasmatic levels of cholesterol (Fig. 1) after group in a balanced proportion and monitored 12 months since the start of the treatment, all 41 patients after 12 months of treatment. showed that all three therapeutic alternatives When analysing systemic parameters we recorded statistically significant effects on noticed a significant improvement of most of lowering the cholesterol values. The the lipid metabolism parameters, even for statistical analysis was performed using the t those that were within normal range at the test and Man-Whitney non-parametric test. beginning of the study. Comparison and The registered p values in all cases were < analysis of the effects of classic treatment, 0.0001 for the three treatment options. green tea and flavonoids administrations on

Fig. 1. Cholesterol levels in the three subgroups of patients, before and after the treatment. All three methods had significant effects in reducing excessive levels of cholesterol The analysis performed in the three groups with p<0.0001 for the three treatment options of patients consisted in evaluations of plasma (95% CI from 257.1 to 369.0 for classic triglycerides too (Fig. 2). The t test for paired treatment, from 284.6 to 367.7 for green tea and values showed statistically significant values from 342.2 to 386.8 for flavonoid treatment).

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Fig. 2. Triglycerides values for the three subgroups of patients, before and after the treatment. All three methods had significant effects in reducing excessive levels of plasma triglycerides The classic treatment, flavonoids and green <0.0001 for the classic treatment with 95% CI tea administrations had also statistically ranging from 233.8 to 331.9, for flavonoids p significant effects in lowering the values of values lower than 0.0001 with 95% CI from LDL cholesterol (Fig. 3). Thus, after analysing 120.9 to 254.1, and for green tea p = 0.0001 the paired t test, we obtained p values of with 95% CI from 137.6 to 291.7.

Fig. 3. LDL values for the three subgroups of patients, before and after the treatment. All three methods had significant effects in reducing excessive levels of LDL cholesterol No significant differences in potential with green tea and subgroup with classical evolution toward ischemic cardiopathy has been treatment associated with flavonoid recorded, despite that patients from all three administrations (Fig. 4). Although the groups that already had been diagnosed with difference between the two antioxidant ischemic cardiopathy when enrolling into the treatments when compared with the classical study displayed cardiac rhythm or conductance treatment was not such obvious, we noticed disturbances in time on the background of the however significantly improved results with p disease. Also, no acute coronary accident was values highly statistically significant diagnosed in any of the patients that followed p<0.0001 for the initial treatment versus the treatment instructions. green tea (95%CI 0.4895 to 1.939) and At gingival level there was a decrease in flavonoids (95%CI 0.4895 to 1.939) while the the papillary bleeding index, in a similar way classical treatment alone produced values in both, subgroup of patients that followed the with lower statistical significance with p classical periodontal treatment associated <0.005 (95%CI 0.06092 to 1.511).

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smooth texture, altered shape of interdentally papilla and abundant plaque deposits (Fig. 5A). Plaque indicators (Fig. 5B) indicated a poor hygiene, while systemic biochemical markers of lipid metabolism recorded cholesterol level of 421 mg/dl, 531 mg/dl of triglycerides, 32 mg/dl HDL and 327 mg/dl LDL. Following green tea treatment, 12 months later (Fig. 5C), the signs of acute

inflammation almost completely disappeared, Fig. 4. Papillary bleeding index recorded with significantly less redness, and a after the treatment options, when compared to the initial values. consistency and texture of gingival tissues apparently normal. The lipid metabolic Clinical case markers showed a cholesterol value of T.M., 40 years old, presents calculus on 197mg/dl, triglycerides of 142mg/dl, HDL buccal tooth surfaces, signs of gingival values 51mg/dl and LDL levels of 162 mg/dl, inflammation with a soft consistency and all in the normal range.

A B C Fig. 5A. T.M., plaque, calculus and signs of gingival inflammation; 3B: plaque revelators showing a poor hygiene; 3C: 12 months after green tea consistent administrations, significantly reduced inflammation could be noticed

DISSCUSIONS atherosclerosis was underlined in literature by The correlation between hypercholeste- the term “periodontitis-atherosclerosis” to rolemia, hypertriglyceridemia, cardiovascular suggest the common pathological links [16, disease and periodontal diseases that we 17]. noticed in our study has also been reported in The epigallocatechin-gallate (EGCG) is literature [7, 14]. However, our study the most powerful catechin and a 25-100 attempted to prove not only that the green tea times more potent antioxidant than vitamins and flavonoids in general have positive C and E. It was already suggested that these effects at periodontal and systemic levels, but catechins have anti-atherosclerotic effects also that there is a strong correlation between through their antioxidant, enzyme inhibition, the two apparently distinct markers. anti-hypercholesterolemia, anti-hypertensive, Some patients have a hyperactive immune anti-hyperglycemia, lowering the serum fats, response to the bacterial lipopolysaccharide, antibacterial, and antiviral effects [8, 18]. The manifested through and increased level of catechins decrease the triglycerides and monocyte-released immune mediators [15, cholesterol absorption and favour the increase 16]. The bacterial lipopolysaccharide might of fat excretion. Thus, they determine the also act as trigger for atherosclerosis. The decrease of LDL cholesterol (also known as association between periodontal disease and “bad cholesterol”) of up to 36% and the

43 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 concurential increase of HDL cholesterol [19, 20, 21]. CONCLUSIONS We deliberately chose two ways of The periodontal disease and administering green tea or flavonoids in two atherosclerosis are two diseases that have separate groups of patients, in order to try a certain common pathogenic links, especially significant differentiation between the local at the immune and genetic level. The transient effects obtained after using green tea bacteraemia can unleash a hyper-reactive concentrate as a mouthwash or the flavonoids immune response both in what concerns systemically administered as capsules. By activation of monocytes and perturbation of acting on both local and systemic levels, the the lipid metabolism. green tea extract has a synergistic effect that The green tea (especially through should result in a better response to the epigallocatechin-gallate component), and bacterial challenge. It is thus possible that by flavonoids in general, display a significant improving the systemic status alone, the potential of reduction for cholesterol, periodontal markers of acute inflammation triglycerides, and LDL cholesterol levels. such as the PBI index recorded in our study Through these effects, they can contribute to might also improve. We noticed improved lowering the risk for atherosclerosis. metabolic and periodontal parameters in all Moreover, their antioxidant, anti- groups. However the slightly better PBI values inflammatory and actions upon matrix in both, the case of green tea and flavonoids, metalloproteinases, also seem to be beneficial suggests that we evaluation of every patient as in reduction of the oral evolution toward a whole system and regard of both: the general periodontal disease. repercussion of the periodontal disease and The comparable anti-hyperlipemiant local periodontal effect of an imbalanced results of flavonoids capsules and green tea metabolic system, are beneficial in studying suggest another additional treatment tool the binomial relationship dyslipidaemia - besides the classical options. periodontal disorder.

REFERENCES 1. Volozhin AI, Poriadin GV, Kazimiski TI, Barer GM, Askerova SSh, Salmasi ZhM. Immunologic disorders in pathogenesis of chronic generalized parodontitis Stomatologiia (Mosk). 2005;84(3):4-7 2. Detert J., Pischon N., Burmester G.-R., Buttgereit F. Pathogenese der Parodontitis bei rheumatischen Erkrankungen - Pathogenesis of parodontitis in rheumatic diseases Zeitschrift für Rheumatologie. 2010, 69: 109-116. 3. Smith SC Jr, Blair SN, Bonow RO, et al. AHA/ACC Scientific Statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation. 2001; 104: 1577–1579. 4. Rosengren A., Dotevall A., Eriksson H., et al. Optimal risk factors in the population: prognosis, prevalence, and secular trends; data from Goteborg population studies. Eur Heart J. 2001; 22: 136–144 5. Loest, H. B., Noh, S. K. & Koo, S. I. Green tea extract inhibits the lymphatic absorption of cholesterol and alpha-tocopherol in ovariectomized rats. J. Nutr. 2002; 132:1282-1288. 6. Hasegawa, N., Yamda, N. & Mori, M. Powdered green tea has antilipogenic effect on Zucker rats fed a high-fat diet. Phytother. Res. 2003; 17:477-480. 7. Raederstorff, D. G., Schlachter, M. F., Elste, V. & Weber, P. Effect of EGCG on lipid absorption and plasma lipid levels in rats. J. Nutr. Biochem. 2003. 14:326-332. 8. Yokozawa, T., Nakagawa, T. & Kitani, K. Antioxidative activity of green tea polyphenol in cholesterol-fed rats. J. Agric. Food Chem. 2002; 50:3549-3552

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9. Imtiaz A. Siddiqui, Farrukh Afaq, Vaqar M. Adhami, Nihal Ahmad, Han Mukhtar. Antioxidants of the Beverage Tea in Promotion of Human Health Antioxidants & Redox Signaling. 2004, 6: 571-582. 10. Balbin M, Fueyo A, Tester AM, Pendas AM, Pitiot AS, Astudillo A, Overall CM, Shapiro SD, Lopez-Otin C (2003). Loss of collagenase-2 confers increased skin tumour susceptibility to male mice. Nat Genet. 2003; 35: 252-257 11. Saffari Y, Sadrzadeh SM.Green tea metabolite EGCG protects membranes against oxidative damage in vitro.Life Sci. 2004; 74:1513-1518. 12. Rietveld A, Wiseman S. Antioxidant effects of tea: evidence from human clinical trials.J Nutr. 2003;133 (10):3285S-3292S. 13. Duffy SJ, Vita JA, Holbrook M, Swerdloff PL, Keaney JF Jr. Effect of acute and chronic tea consumption on platelet aggregation in patients with coronary artery disease. Arterioscler. Thromb. Vasc. Biol. 2001;21:1084–9. 14. D.U. Ahn and K.C. Nam, Effects of ascorbic acid and antioxidants on colour, lipid oxidation and volatiles of irradiated ground beef, Radiation Physics and Chemistry 2004. 71: 149–154. 15. Cabrera C, Artacho R, Ginemez R. Beneficial effects of green tea - a review. J Am College Nutr 2006; 25(2): 79-99, 16. Rajesh Aneja, Paul W Hake, Timothy J Burroughs, Alvin G Denenberg, Hector R Wong, and Basilia Zingarelli Epigallocatechin, a Green Tea Polyphenol, Attenuates Myocardial Ischemia Reperfusion Injury in Rats Mol Med. 2004; 10(1-6): 55–62. 17. Gueders MM, Balbin M, Rocks N, Foidart JM, Gosset P, Louis R, Shapiro S, Lopez-Otin C, Noël A, Cataldo DD -Matrix metalloproteinase-8 deficiency promotes granulocytic allergen-induced airway inflammation. J Immunol 2005; 175: 2589-97. 18. Skrzydlewska, E., Ostrowska, J., Farbiszewski, R. & Michalak, K. Protective effect of green tea against lipid peroxidation in the rat liver, blood serum and the brain. Phytomedicine. 2002; 9:232-238. 19. Murase, T., Nagasawa, A., Suzuki, J., Hase, T. & Tokimitsu, I. Beneficial effects of tea catechins on diet-induced obesity: stimulation of lipid catabolism in the liver. Int. J. Obes. Relat. Metab. Disord. 2002; 26:1459-1464. 20. Schlachter, M. F., Elste, V. & Weber, P. (2003) Effect of EGCG on lipid absorption and plasma lipid levels in rats. J. Nutr. Biochem. 2003; 14:326-332. 21. Ullmann, U., Haller, J., Decourt, J. P., Girault, N., Girault, J., Richard-Caudron, A. S., Pineau, B. & Weber, P. (2003) A single ascending dose study of epigallocatechin gallate in healthy volunteers. J. Int. Med. Res. 2003. 31:88-101.

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AUDITORY FUNCTION RECOVERY IN SUDDEN SENSORINEURAL HEARING LOSS: 3-YEAR STUDY Bogdan Cavaleriu, Luminiţa Rădulescu, Daniel Rusu, Costela Gegea, Corina Butnaru, Dan Mârţu Discipline of ENT, ”Gr.T.Popa” University of Medicine and Pharmacy, Iasi, Romania

ABSTRACT Objectives: The goal of this study was to assess the post-therapeutic rehabilitation for a group of patients in order to evaluate the conventional treatment of sudden sensorineural hearing loss. Materials and methods: 45 patients diagnosed with sudden sensorineural hearing loss, where clinically examined. A careful examination is needed to exclude life threatening causes such as vascular events and malignant diseases. Conventional treatment that include corticosteroids, antiviral drugs, vasoactive and vitamins (B1, B6) was administered to patients. Results: Post-treatment rehabilitation degree varies. The greatest recovery of hearing has been shown when corticosteroids are started within the first 1—2 weeks after symptom onset. About 45% of patients show good recovery, usually in about 2 weeks. Patients in whom there is no change within 2 weeks are unlikely to show much recovery. Conclusions: In most cases the cause is not identified, although various infective, vascular, and immune causes have been proposed. It is recommended that patients with sudden sensorineural hearing loss with no clear underlying cause after investigation are treated with a short course of oral prednisolone started within 2 weeks after onset. There is much to learn about pathogenesis of sudden sensorineural hearing loss and more clinical trials are needed to establish evidence-based management.

Key words: sudden hearing loss, corticosteroid, auditory recovery

INTRODUCTION Also tumours such a vestibular schwannoma Sudden sensorineural hearing loss or cerebellopontine angle tumours can cause (SSNHL) is an emergency in otolaryngology. SSNHL. There are many potential causes of It has been defined for research purposes and SSNHL, but despite extensive evaluation, the has been accepted by most authorities as 30 majority of cases remain idiopathic [1]. dB or more sensorineural hearing loss over at The goal of this study was to assess the least three contiguous audiometric post-therapeutic rehabilitation for a group of frequencies occurring within 3 days or less. patients in order to evaluate the conventional The specific cause is identified in about treatment of sudden sensorineural hearing 15% of the cases. Various infective loss. (especially viral), vascular, and immune causes (Cogan's syndrome and Lupus) have MATERIALS AND METHODS been proposed [1]. There are ototoxic drugs Retrospective study over a period of three that can damage hearing-antibiotics years (2008-2010) that included 44 patients (aminoglycosides), diuretics and certain anti- diagnosed with sudden sensineural hearing cancer drugs. Acoustic trauma or trauma such loss with age ranging between 19 and 67 as head injuries and temporal bone fractures years. A careful history and detailed medical can cause SSNHL. About 10% of the people examination was made with special attention getting Meniere's disease experience SSNHL. directed toward the onset time, possible

46 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 causes and associated simptoms. Clinical sudden hearing loss. Magnetic resonance examination should include otoscopy, the imaging (MRI) with gadolinium Rinne and Weber test to exclude a conductive diethylenetriamine-pentaacetic acid (DPTA) hearing loss (cerumen impaction, perforated enhancement is the criterion standard test for tympanic membrane, middle-ear effusion, diagnosing CPA masses. The cost issue for infection). Any patient with sudden hearing MRI has been addressed by performing limited loss should have an urgent assessment with a studies using fast spin echo techniques. In minimum of pure tone audiometry (with air young patients, for whom only a small and bone conduction thresholds) and possibility of detecting a vestibular impedance to avoid misdiagnosis. In some schwannoma exists, a noncontrast temporal cases additional audiovestibular tests were bone computed tomography (CT) scan could be necessary to identify the site of pathological obtained. Anatomic defects such as a Mondini change and to elucidate the nature of any dysplasia or enlarged vestibular aqueduct might vestibular symptoms, which could indicate account for a sudden hearing loss [2]. specific diagnoses (for example, stapedial reflex threshold and auditory brainstem RESULTS AND DISCUSSIONS evoked response, videonistagmography) This study of sudden sensorineural hearing Blood tests appropriate to most cases loss show a wide age distribution, with an include full blood count, erythrocyte average of 40—50 (Fig. 1) years and no sex sedimentation rate, C-reactive protein, preference (F/M=51%: 49%). The hearing phibrinogen, cholesterol and glucose values. loss is unilateral in most cases, with bilateral The detailed neurological and involvement reported in 11% (Fig. 2). cardiovascular examination was made to The severity of hearing loss was divided exclude cerebellopontine angle lesions, into mild, moderate, severe, profound and posterior circulation abnormalities, or cofosis (Fig. 3). The configuration of the demyelination, respectively atrial fibrillation, hearing loss varies and can affect high, low, aortic and mitral murmurs, and carotid bruits. or all frequencies. Tinnitus occurs in about 48% of patients, and vertigo, indicating an Imaging Studies associated peripheral vestibular dysfunction, Approximately 1-2% of patients with in about 7.5%. Up to 80% of patients report a ISNSHL have internal auditory canal (IAC) or feeling of ear fullness. Other common CPA tumours. Conversely, 3-12% of patients complaints are of the ear feeling numb or with vestibular schwannomas present with blocked.

Fig. 1. Age distribution Fig. 2. SNSHL location

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Fig. 4 shows the distribution of the number course of oral prednisolone started within 2 of cases after the time of onset. weeks after onset [3]. Sudden sensorineural hearing loss can Conventional treatment that includes present as an isolated problem or in the corticosteroids (metilprednisolon, prednison), course of an established diagnosis. In most vasoactive (pentoxyfilline) and vitamins (B1, cases the cause is not identified, although B6) was administered in most all of our various infective, vascular, and immune patients. Only two patients diagnosed with causes have been proposed. In our study in diabetes have not received corticosteroids only 22% cases could be established the treatment. cause [1] (Fig. 5). The post-therapeutic auditory recovery Because hearing tends to recover (revealed by performing pure tone spontaneously at a high rate, treatment is not audiogram) varied and was divided into always felt necessary, especially when several degrees (Fig. 6). The greatest impairment is minor. Nevertheless the recovery of hearing has been shown when prospect of being permanently deaf in one ear corticosteroids are started within the first 1— is daunting and has prompted many trials of 2 weeks after symptom onset. Patients with therapy. The lack of a standard protocol profound hearing loss and cofosis shows among trials made comparison difficult and a much lower recovery rates compared with conclusion unreachable. other groups. It is recommended that patients with There is much to learn about pathogenesis moderate to profound sudden sensorineural of sudden sensorineural hearing loss and hearing loss with no clear underlying cause more clinical trials are needed to establish after investigation to be treated with a short evidence-based management [4].

Fig. 3. Hearing loss degree Fig. 4. SNSHL onset

Fig. 5. Aetiology of Sudden sensoneural Fig. 6. Auditory thresholds rehabilitation hearing loss

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Many studies have been conducted in Patients with persistent symptoms should recent years to investigate hypothesis of be referred to the appropriate specialists for stress as a predisposing risk factor in the continuing management of their auditory development of sudden hearing loss. symptoms. This management can include Medication with antioxidant and anti- counselling, information about lifestyle inflammatory effects may help reduce the changes, and techniques (such as oxidative stress of the cochlea in SSNHL, amplification, cochlear implantation) for implying a new direction in the treatment of overcoming the communication handicap that this disease [2]. hearing loss imposes [4, 5].

REFERENCES 1. Benjamin E Schreiber, Charlotte Agrup, Dorian O Haskard, Linda M Luxon, Sudden sensorineural hearing loss, The Lancet, Volume 375, Issue 9721, Pages 1203 - 1211, 3 April 2010 2. Yang CH, Ko MT, Peng JP, Hwang CF, Zinc in the treatment of idiopathic sudden sensorineural hearing loss., Laryngoscope 2011 Mar;121(3):617-21. doi: 10.1002/lary.21291. Epub 2010 Oct 6 3. Neeraj N Mathur, MBBS, MS, Professor, University of Delhi, India, Michele M CARR Associate Professor, Department of Otolaryngology, Hershey Medical Center, Inner Ear, Sudden Hearing Loss: Follow-up 4. Wu CS, Lin HC, Chao PZ. Sudden sensorineural hearing loss: evidence from Taiwan. Audiol Neurootol 2006; 11: 151-156. PubMed 5. Penido NO, Cruz OL, Zanoni A, Inoue DP. Classification and hearing evolution of patients with sudden sensorineural hearing loss. Braz J Med Biol Res 2009; 42: 712-716. PubMed

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BONE DENSITY CHANGES IN PATIENTS WITH PERIODONTAL DISEASE Silvia Teslaru1, Liviu Zetu2, Danisia Haba2, Constanța Mocanu3, Silvia Mârțu1, Sorina Solomon1 1Periodontology Department, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania 2Radiodiagnostic and Medical Imagining Department, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania 3Periodontology Department, Appolonia University, Iasi, Romania

ABSTRACT Common radiologic exams offer information about the presence and type of marginal bone loss, but they cannot provide any data on the bone density assessment. Materials and methods We selected 69 CT scans of patients with different degrees of the supporting periodontal tissue diseases, and measured the interdental septum density. Results The present study confirms the dental CT scanning utility in diagnostic imaging of the proximal, interdental bone. The results of the mean alveolar bone density measurements in different depths of the interdental septum show that its correlation with periodontal diseases becomes evident between at a depth of 3 up to 5.5mm. Conclusion Classic or volumetric CT scanning provide valuable data on the interdental bone density, information that cannot be obtained with the same accuracy by any other classic radiologic exam.

Key words: periodontal disease, interdental alveolar density

INTRODUCTION utility of dental CT as a diagnostic exam of Common radiologic exams deep periodontal tissue diseases and of its (Ortopanthomography and apical x-rays) prognosis by assessing interdental septum offer information about the presence of density. marginal bone loss, its type (vertical or horizontal) and size, evaluated in mm or MATERIALS AND METHOD reported to the root or tooth length. As they We selected 69 CT scans of patients with are bidimensional images of tridimensional different degrees of deep periodontal tissue structures, it is obvious that they have certain diseases, in order to realize a complex limits regarding the number of osseous walls periodontal rehabilitation, to place dental of the vertical bone defects and their implants or to investigate the infrabony relationship with the interradicular area, position of impacted tooth, before orthodontic especially when considering upper molars. treatment. Although the CT scanning wasn’t This fact, which influences the right performed for periodontal assessment only, all diagnostic choice and the optimal treatment the study patients presented a certain degree of solution (regenerative/resective therapy), can periodontal disease. CT scans were performed be objectivised by classic or volumetric using Somaton Emotion by Siemens, at the computed tomography (CT) analysis which EXPLORA-RX Centre in Iasi, Romania. offers extremely important data on the SYNGO software (eFilm software by Merge alveolar bone and interdental septum density. eMed) was utilized to measure the bone The aim of this study is to evaluate the density in different points, on certain areas and

50 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 the distances in mm (Fig. 1). closest teeth, taking care that the measured Patients with general diseases, pathological area includes several central osseous lesions of the maxillary bones and those under trabeculae. medication that influences the bone We registered the size in mm of the metabolism were excluded from the study. horizontal bone loss, the presence or absence As interdental bone density assessment of dental caries, the presence of fixed was performed only on the homologue teeth, orthodontic treatment, endodontic treatments, we excluded from our study the teeth without periapical lesions and dental crowns. homologues on the CT scans. We also We excluded the vertical bone loss sites excluded the teeth on which we couldn’t because at the interdental septums of those perform the measurements because of the areas, on horizontal section, the measurement artefacts caused by the brackets and metal at the middle of the septum would have given restorations. false results as it was partially missing. The study lot included 35 women and 34 men, aged between 17 and 73 years old. RESULTS AND DISSCUTIONS The program allows direct measurements The age distribution of patients is in Hounsfield units (HU) of the mean density presented in table 1 and Fig. 2. in the central area of the interdental septum. The results of the mean alveolar bone We chose the middle of the septum to density measurements in different depths of avoid the errors given by the possible the interdental septum, according to the age measurement inclusion of an area of the group are presented in the following lines.

Age group Number of cases <20 years 5 21-30 years 12

31-40 years 18 41-50 years 23 >51years 11

Fig. 1. Pac CG. CT horizontal section. Table 1. The age distribution of the study group

Fig. 2. The age distribution of the study Fig. 3. The sex distribution of the study group group

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It is obvious that this correlation becomes 3mm depth of the interdental septum up to evident > 3mm depth of the interdental 5.5 mm depth; fact illustrated in Fig. 5. septum up to 5.5 mm depth, fact illustrated in The present study confirms the dental CT table 2. scanning utility in diagnostic imaging of the The sex distribution of the lot was proximal, interdental bone. Significant balanced, as the following chart shows (Fig. correlations with preceding studies on the 3). symmetry of bone changes in periodontal Although the measurements were diseases were obtained in our study performed up to 8mm depth from the tip of (Mombelli & Meier, 2001; Müller & Ulbrich, the septum, the calculations were made up to 2005). CT sections in DICOM format (Digital 7mm depth because, on the pilot study we Imaging and communications in Medicine) observed that the bone densities beyond this contain data on the bone density values, so limit are irrelevant (because of proximity of that the software program can measure it. the maxillary sinus, mental foramen and Misch (1993) established a bone periapical processes etc.). classification in five categories, according to The results of the correlations between the their density: D1- bones with >1250 HU depth of the interdental septum and the mean density, D2- bones with 850-1250 HU alveolar bone density according to the age density, D3- bones with 350-850 density, D4 group are shown in Fig. 4. It is obvious that bones with 150-350 HU density and D5- this correlation becomes interesting over the values less than 150 HU.

Age 0 0.5 1 1,5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 (years) mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm <20 261.6 404.6 529.2 517.2 478.6 418.6 349.2 336.7 287.4 264.5 266.1 268.3 334.0 292.7 268.5 20-30 340.1 625.8 855.8 889.7 877.5 792.7 661.1 600.3 573.3 537.8 529.7 511.1 510.3 492.1 480.8 30-40 238.0 509.2 587.2 590.5 562.8 508.9 482.2 457.1 413.0 337.5 348.6 374.2 329.9 355.9 324.2 40-50 197.7 392.9 548.6 608.3 593.9 579.4 543.4 483.9 456.0 476.3 392.6 379.9 307.6 290.1 436.8 >50 269.7 462.4 553.7 651.8 676.8 650.2 653.2 542.0 595.7 578.7 578.1 554.0 564.0 494.5 527.8 Table 2. The mean density of the alveolar bone in different depths of the interdental septum according to the age group

Fig. 4. Mean density of the interdental Fig. 5. Mean density of the interdental alveolar bone according to age group in alveolar bone according to age group in different depths, starting from the tip of the different depths, starting from 3mm up to septum up to 7 mm depth 5.5 mm depth Misch also demonstrated that bone density evaluation. Therefore, bone density measurements by CT scanning offer more measurement by this method can offer more precise results compared to radiologic valuable data than other methods (Park et al.,

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1008). CONCLUSION While dental CT offers tridimensional CT scanning is a precise method for bone images (3D), its capacity of marking out fine density assessment, which allows direct details remains limited. Nowadays, fine CT measurement in Hounsfield units by its multi-slice sections are capable of having software and offers important data on the sub-millimeter resolution in all three spatial quality of a major component of the deep dimensions (in pixels). Although the detail periodontal tissues. level remains considerably lower than compared to conventional intra-oral ACKNOWLEDEMENTS radiologic images, the use of CT satisfies The study was supported by the Ministry almost all situations in which periodontal of Education, Research, Youth and Sport tissues images analysis is demanded by a (grant CNCSIS-IDEI nr. 2034/2008-2011 and right diagnosis. "Gr. T. Popa" University of Medicine and The studies showed that CT evaluation of Pharmacy Iasi. the infrabony pockets and alveolar bone height is reasonably precise (Mol, 2004).

REFERENCES 1. Misch CE. Density of bone: effect in treatment planning, surgical approach, and healing. In: Misch CE, editor. Contemporary implant dentistry. St Louis: Mosby; 1993. p. 469-85. 2. Mol A. Imaging methods in periodontology. Periodontol 2000. 2004;34:34-48. 3. Mombelli A, Meier C. On the symmetry of periodontal disease. J Clin Periodontol. 2001;28:741-5. 4. Müller HP, Ulbrich M. Alveolar bone levels in adults as assessed on panoramic radiographs. (I) Prevalence, extent, and severity of even and angular bone loss. Clin Oral Investig. 2005;9:98-104. 5. Park HS, Lee YJ, Jeong SH, Kwon TG. Density of the alveolar and basal bones of the maxilla and the mandible. Am J Orthod Dentofacial Orthop. 2008;133:30-7.

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IMAGE QUALITY ASSESSMENT OF ORTHOPANTOMOGRAMS Mioara Decusară, Viorica Milicescu “Carol Davila” University of Medicine and Pharmacy, Bucureşti, Romania

ABSTRACT Orthopantomography examination is a method of dental and maxillofacial radiology and consists of a panoramic image, the overall of a dental arches, the elements supporting the teeth, the maxillofacial skeleton and the related anatomical structures (maxillary sinus, nasal complex, temporomandibular joints, ets.), recorded on a large format radiographic film. Practitioners that recommend orthopantomograms should be aware and had knowledge about radiation doses, risks to patients, previous exposure history, so as to affect the patient less. To achieve a high-quality image of orthopantomogram need special attention to the correct positioning of the patient, followed by the optimal processing of the radiograph. Many deviation from the correct panoramic technique can lead to the production of a low quality of orthopantomograms and this may compromise or prevent the diagnosis.

Key words: orthopantomograms, quality image, errors.

INTRODUCTION  The image should show the entire Ortopantomogram consists of a series of mandible, including TMJ; sequentially narrow tomograms scanned into  The dimensions of anatomical structures in the detector (film, storage phosphor or vertical and horizontal plan must be digital) resulting a complete view of both „relatively” equal and symmetrical; dental arches and their adjacent structures  The right and left molars should be equal with minimal distortion and with minimal in size; overlap of anatomic details from the  Density image appearance should be contralateral side. As any other radiographic uniform, free of air over the tongue, with method, optimum interpretable diagnostic the appearance of transparent tape (black) images can be achieved only if the following over the roots of upper teeth; criteria are met: correct patient positioning,  The image of hard palate must be appear selecting appropriate exposure parameters above the apices of upper teeth; and correct processing or film handling [4].  The ghost images (artefacts) of the The aim of this paper is to outline the cervical spine and mandibular angle on the range of problem that can affect panoramic contralateral side must be very little image quality and to emphasize the evidenced; importance of identifying the causes that  The panoramic image should not occur generated poor quality of orthopantomogram. artefacts due to dentures or removable 325 orthopantomograms of treated patients orthodontic appliances, glasses, earrings in the author's private dental practice were and another jewellery, apron, “forgotten” analysed, taking into account the following to the patient: typical quality criteria of ideal image [5, 6]:  Label of patient’s identification data does  Alveolar processes with all upper and not cover anatomical structures visible on lower teeth must be clearly represented; ortopantomogram;

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 The patient’s identity data must be clearly overexposure to radiation, the film is dark, written and should include patient name with loss of anatomical elements detail and date of examination; (Fig. 2);  The image must be clearly marked with  Incorrect preparation of orthopanto- the letters Right and Left. (Fig. 1) mograph device, when the collimators are Getting a low quality of orthopanto- not set by the size of anatomical area. mogram is due to errors caused by incorrect  Incorrect handling of port-film cassette or preparation of panoramic machine, incorrect image receptor or using of damages tapes positioning of patient for radiographic which can penetrate light; it can see gray exposure and incorrect processing or film or dark stripes on radiographic film, handling [5, 7, 8]; these errors will be briefly scratches or under-represented images of presented in the following, with examples of anatomical structures of jaws (Fig. 3). panoramic radiographs of author’s patients. Patient preparation errors: Incorrect preparation of panoramic  If the patient did not remove the jewellery machine: (earrings, necklaces, piercings), hairpins,  Inappropriate selection of exposure spectacles, dentures and removable parameters, depending on physical orthodontic appliances, they can cause constitution (weak, athletic, overweight) “ghost” images on radiographic film (Fig. and patient age (child, adult); to a low 4) or “cover” any existing pathological exposure, radiographic images are under- processes in the area of the sinus (Fig. 5) represented, deleted, unclear, and to

Fig. 1. Correct positioning of patient's head Fig. 2. Radiological overexposure-dark in the panoramic machine (personal image and poor representation of casuistry). anatomical details- (personal casuistry).

Fig. 3. Orthopantomogram with black Fig. 4. Orthopantomogram with patient vertical stripes and poor representation of preparation errors: failure to remove the ascending mandibular ramus and TMJ earrings (which cause “ghost” images of them (personal casuistry). in the maxillary second molars areas), chin tipped up (vertical error) and head movement during exposure (personal casuistry)

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Fig. 5. Failure to remove upper metallic Fig. 6. Orthopantomogram with the partial dentures: are not clearly the presence of two radiopaque images, maxillary canine-premolar-molar areas, paramedian, represented by the edge of the hard palate, inferior walls of sinus. protective lead apron (personal casuistry). (personal casuistry).

Fig. 7. The patient’s head is positioned Fig. 8. The patient bitten too far back on anterior to the focal trough, producing the bite rod, resulting in an enlarged image horizontal demagnification, giving the of the jaw, with incisors wide and blurry illusion of missing anterior teeth; note the and ghosting of mandible (bilateral, on upward curvature of the occlusal plane and mandibular ascending ram area) and the the meadial tilt of the ascending cervical spine (a radiopacity in the midline) mandibular ramus (personal casuistry). – (personal casuistry).

Fig. 9. Vertical positioning errors: patient's Fig.10. Patient's head is in extension and the head is tilted downwards, that is, the chin is chin is positioned upwards; note flattened positioned too low; note the upward occlusal plane, the palate is superimposed on curvature of the occlusal plane and the the apices of the maxillary incisors and the rami are tilted medially- (personal mandibular ascending ramus are tilted casuistry). laterally (personal casuistry)

 If the radiological protection apron is are in head-to-head position, can result placed unproperly, extending above the anterior-posterior errors. Thus, when the collar, it may appear on the X-ray film, in patient bites too far forward on bite-block, the mandible body area, of some the anterior teeth appear narrow and radioopaque artefacts (Fig. 6) elongated and cervical vertebrae are more Patient positioning errors: visible on both sides on the film (Fig. 7);  If the pacient did not bite correct, into the when the patient bites too far back on bite groove of the bite rod, so that the incisors rod (back on grooves of bite rod), the incisors appear blurry and wide and the

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condyles are near the lateral and top edges ram is wider on one side than the other and of radiographic film (Fig. 8). anatomical structures of the nose and are  Improper adjustment of the chin support or not clear (Fig. 11). incorrect positioning of the patient’s chin  Failure to instruct the patient to swallow, onto the support, according the guidelines press the tongue against the roof of the (alar-tragus line), can result a vertical mouth and hold still during the exposure (air positioning errors. If the chin is tilted far shadow error) and this causes the presence down (head is in flexion), lower incisors on the radiographic film of dark and large roots appear blurred, the mandible is V- shadow over maxillary teeth (Fig. 12) shaped, “smile line” is much deepened and  Inadequate training of the patient to stand mandibular condyles are at the top of the with shoulders straight and to remain still radiographic film (Fig. 9). When the chin throughout the exposure (approximately is tipped too far up (the patient’s head is 10-15 seconds), resulting in reduced image tilted backwards, in extension), maxillary quality with unclear areas, which not helps incisors are blurred, hard palate establish a full diagnosis and correct superimposed on roots, occlusal plane is treatment plan (movement error) (Fig. 13). flattened, mandible is flat and broad (Fig. Patient movement during exposure may 10). cause on the panoramic radiograph the  If the patient’s head is twisted or rotated, presence of indentations of the body of the result a midline asymmetry. Thus, the mandible; a similar image is produced teeth appear wide on one side and narrow when the patient chews gum during the X- on the other side, ascending mandibular ray exposure (Fig. 14).

Fig. 11. Due to incorrect positioning of the Fig. 12. The patient did not swalow and patient’s head (rotated), are not observed press the tongue against the palate, creating ascending mandibular ramus and TMJ of radiolucent areas (round and band) across the left part and the cortical mandibular the film (personal casuistry). midline (personal casuistry).

Fig. 13. Panoramic radiograph that not allow Fig. 14. Multiple vertical movements to clearly be seen the lower anterior teeth (personal casuistry). and median mandibular basilar edge, because patient’s head is tilted downwards, the chin is positioned too low and the patient moved during exposure (personal casuistry).

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Fig. 15. Errors due to incorrect preparation Fig. 16. Low quality of radiographic image of the patient (with the head slightly rotated) due to the incorrect positioning of the and operator mistakes during exposure patient and the inadequate chemical (personal casuistry) processing of film (personal casuistry) Errors during exposure due to operator panoramic machine, also due to lack of  If the exposure settings is changed during minimum measures to prepare the patient for the exposure or the cassette is not correctly radiological examination. This leads to used (properly inserted in the panoramic deformities, asymmetries and incomplete machine), it will appear a blurred image images of anatomical structures present in the with radiolucent areas which overlay some image. Improper preparation of the patient of anatomical structures (Fig. 15). will be reflected, as we illustrated above, in Processing or film handling errors can the appearance of artefacts on the image of lead to unclear, washed-out images (when it objects held by the patient. However as used for developing the depleted or worn panoramic machine performance it cannot fix solutions) (Fig. 16) or to very dark images, the errors of patient preparation, exposure, blurred (when it not use the red filter that positioning, processing or film handling. prevents awareness of X-ray film from visible Using this systematic approach to green light). orthopantomogram’s image production, the dentist should recognize the problems that CONCLUSIONS can affect panoramic image quality and have The most common failures in obtaining the the necessary knowledge of how to rectify good quality orthopantomograms are them, to establish a correct diagnosis and for determined by incorrect positioning of the the minimum patient radiation dose. head’s patient and the patient to the

REFERENCES 1. Pasler F.A. Color Atlas of Dental Medicine Radiology, Ed. Thieme, 1993 2. Farman A.G. Panoramic radiology–Seminars on Maxillo-facial Imaging and Interpretation, Ed. Springer, 2007. 3. Milicescu Viorica - Ortopantomograma în practica stomatologică, Curs postuniversitar, Buc., UNAS, iunie 2006. 4. Login S. Tehnică radiologică dentară. Ed. Univ., Buc., 2000. 5. Whaites E. Essentials of dental radiography and radiology. Fouth edition, Churchill Livingstone Elsevier 2007. 6. White SC, Pharoah MJ. Oral Radiology.Principles and Interpretation. Firth Edition. Mosby, St. Louis, 2004. 7. Rushton Vivian E., Rout J. Panoramic Radiology, Quintessence, Londra, 2005. 8. Junfin Glass Birgit – Successful panoramic radiography, 1999.

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CORRELATION BETWEEN SEVERE PERIODONTITIS AND CARDIOVASCULAR DISEASE: A RADIOGRAPHYC STUDY Liviu Zetu1, Silvia Teslaru1, Danisia Haba2, Cătălina Dănilă1, Oana Potârnichie1, Ioana Rudnic1, Liliana Păsărin1, Gabriela Benghiac3 1Periodontology Department, "Gr. T. Popa" UMPh Iasi, Romania 2Radiodiagnostic and Medical Imagining Department, "Gr. T. Popa" UMPh Iasi, Romania 3MSc Student, Restorative Dentistry Department, "Gr. T. Popa" UMPh Iasi, Romania

ABSTRACT Introduction: Cardiovascular diseases are one of the main causes of morbidity and mortality in the European countries, including Romania. Over the last several years, many studies on the relationship between oral infections, especially periodontitis and cardiovascular diseases were published. The aim of this study was to analyse a possible association between cardiovascular diseases and periodontitis by marginal bone loss assessment on orthopantomographs (OPGs). Materials and methods: 171 patients with history of cardiovascular diseases diagnosed by specialist doctors (cardiologist, neurologist) were selected. Several parameters were evaluated in the dental office according to the health questionnaire and the recommended blood tests (cholesterol, triglycerides, complete hemoleucogram, C-reactive protein etc.). The same examiner assessed the dental and periodontal status of each patient on the OPGs. We analysed irredeemable teeth, periapical lesions, interradicular lesions, 4-5mm bone loss from the enamel-cement junction (ECJ) and >6mm bone loss from the enamel-cement junction (ECJ). Results: The study group presented high percents of irredeemable teeth (11%), teeth with periapical lesions (>3 mm; 4%), interradicular lesions (12%), 4-5 mm proximal bone loss (11%) and >6 mm bone loss (17%). Conclusions: The present study confirms the existence of correlations between endodontic infections, periodontal infections and cardiovascular diseases; idea supported by authors and justified by the influence of permanent discharge of proinflammatory factors (cytokines, Il-1 β, TNF-α, etc.) from the oral cavity into the bloodstream, contributing with other factors (cholesterol, triglycerides, etc.) to the appearance and evolution of cardiovascular diseases.

Key words: severe periodontitis, cardiovascular disease, radiography

INTRODUCTION tooth loss) and angina pectoris. Cardiovascular diseases are one of the The aim of this study was to analyse a main causes of morbidity and mortality in possible association between cardiovascular Romania and worldwide [1]. Some studies diseases and periodontitis by marginal bone established a causality relationship between loss assessment on orthopantomographs periodontitis and cardiovascular diseases, (OPGs). while others did not find a direct causality report. Söder and Yakob [2, 3] observed that MATERIALS AND METHODS women with high levels of dental plaque and 171 patients with history of cardiovascular severe gingival inflammation were at risk for diseases diagnosed by specialist doctors atherosclerosis. Ylöstalo [4] showed the (cardiologist, neurologist) were selected. correlations between several dental conditions Several parameters were evaluated in the (self-reported gingivitis, dental caries and dental office according to the health

59 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 questionnaire and the recommended blood assessment of marginal bone loss along the tests (cholesterol, triglycerides, complete root (Fig. 6) and along the tooth (Fig. 7). hemoleucogram, C-reactive protein etc.). The In order to achieve a comparative same examiner assessed the dental and assessment of marginal bone loss in incisives, periodontal status of each patient on the canines, premolars and molars, the ANOVA OPGs. The OPGs were scanned and the statistical analysis showed the pairs of marginal bone loss was measured in pixels different statistically significant means for a using software and transformed in mm, significance level of p=0.5: incisives- according to the 10mm grid on the OPG. premolars, incisive-molars, canines- From the 3376 teeth, we analysed on the premolars, canines-molars. OPG the irredeemable teeth, periapical There were no statistically significant lesions, interradicular lesions, 4-5mm bone differences regarding bone loss between loss from the enamel-cement junction (ECJ), incisives and canines and between premolars >6mm bone loss from the enamel-cement and molars (Fig. 5). junction (ECJ) (A), tooth length (T) and root In order to achieve a comparative length (R) (Fig 1). assessment of marginal bone loss related to root length in incisives, canines, premolars RESULTS AND DISCUSSIONS and molars, the ANOVA statistical analysis We measured on the 3376 teeth from 171 (multiple comparisons) showed the pairs of patients: >4mm marginal bone loss in 1396 different statistically significant means for a teeth (41.35%) (Fig. 3), <4mm marginal bone significance level of p=0.0001: incisive- loss in 92 patients (53.80%) (Fig. 4) and canines, incisive-premolars, incisive-molars. interradicular bone loss in 68.74% of mollars. There were no statistically significant Using ANOVA statistical analysis, the differences regarding bone loss between measured values offered us the possibility to canines and premolars, between canines and compare the medium bone loss in incisives, molars and between premolars and molars canines, premolars and molars (Fig. 5), the (Fig. 6).

Fig. 1. The measurement of bone lose (OPG) Fig. 2. Schei ruler in mm on the OPG

Fig. 3. Teeth distribution according to the Fig. 4. Patients distribution according to the marginal bone loss marginal bone loss level

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Vol. 3, No. 4, December 2011 Figura 11. Evaluarea comparativa a rezorbtiei osului alveolar raportat la lungimea radacinii la nivelul incisivilor, caninilor , premolarilor si molarilor (P<0.0001) 0.7 *** *** 0.6 ***

0.5

0.4

0.3

0.2

0.1

0 Incisivi Canini Premolari Molari Fig. 5. Comparative evaluation of marginal Fig. 6. Comparative evaluation of marginal bone loss in incisives, canines, premolars and bone loss related to root length in incisives,

molarsFigura (p<0.05) 12. canines, premolars and molars (p, 0,0001) Evaluarea comparativa a rezorbtiei osului alveolar raportat la lungimea dintelui la nivelul incisivilor, caninilor, premolarilor si molarilor (P<0.0001)

0.6 *** ***

0.5 ***

0.4

0.3

0.2

0.1

0 Incisivi Canini Premolari Molari

Fig. 7. Comparative assessment of marginal Fig. 8. Patient DD, 43 years old, severe bone loss related to tooth length in incisive, periodontitis - clinical image canines, premolars and molars (p<0.0001)

Fig. 9. Patient DD, 43 years old, severe Fig. 10. Patient DD, 43 years old, severe periodontitis, radiographic images - OPG periodontitis, radiographic images - periapical radiography Similar results were obtained regarding Several studies [6] suggest that marginal bone loss related to tooth length periodontitis plays a role in cardiovascular (Fig. 7). These analyses show that the diseases pathogenity. marginal bone loss evaluated on the OPGs of Our study shows that there is a correlation the patients with cardiovascular diseases is between >4mm marginal bone loss evaluated higher in the lateral areas (premolars-molars) on OPGs and the existence of cardiovascular compared to anterior areas (incisive-canines). diseases. Periodontal diseases are known as Within the limits of this evaluation on the inflammatory diseases of microbial origin OPGs, from a statistical point of view, our which contribute to the increase of study allows us to demonstrate the association inflammation markers levels [5]. between marginal bone loss and

61 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 cardiovascular diseases. infections are a real risk factor for the overall Various other studies found similar results: health and welfare of the population [9]. Oikarinen [7] shows in a radiographic study a Thus, periodontal examination becomes significant correlation between marginal bone necessary as a part of general health loss and cardiovascular diseases and Persson, examination of the population in Romania mentioned by Hamdan [8] demonstrated that also. the existence of >4mm marginal bone loss in >50% of teeth increases the risk of CONCLUSIONS myocardial infarction (by 14.1 times). Our study confirms the association In Romania also, the prevalence of these between >4mm marginal bone loss two diseases (periodontitis and cardiovascular (registered on the OPGs) and cardiovascular diseases) is increasing. There is no data diseases. regarding the prevalence of moderate and Periodontal examination and periodontal severe periodontitis in the general population. infections treatment should be part of the Further studies are necessary taking into overall treatment of patients with account the fact that untreated periodontal cardiovascular diseases.

REFERENCES 1. Zubaid M., rashed WA., Husein M., Ridha M., Basharuthulla M., and others. A registry of acute myocardial infarction in Kuwait: patient characteristics and practice patterns. Can J cardiol 2004; 20(8) 783-7. 2. Söder B., Yakob M., Risk for development of atherosclerosis in women with a high lvele of dental plaque and severe gingival inflammation. Int J Dent Hyg 2007; 5(3):133-8. 3. Kinane D, Bouchard P, Periodontal diseases and health: Consensus report of the sixth european workshop on periodontology. J Clin Periodontol 2008; 35:333-337. 4. Ylöstalo PV., Järvelin MR., Laitinen J., Knuuttila ML., Gingivitis, dental caries and tooth loss: risc factors for cardiovascular diseases or indicators of elevated health risks. J Clin Periodontol 2006; 33(2):92-101. 5. Friedewald V, Kornman KS, Beck JD, Genco R, Goldfine A,Libby S, Offenbacher S, Ridker PM, Van Dyke TE,Roberts WC. The American Journal of Cardiology and Journal of Periodontology Editors Consensus: Periodontitis and atherosclerotic cardiovascular disease. J Periodontol 2009:1021-1026 6. Kim HD,Sim SJ, Moon JY, Hong YC, Han DH. Association between periodontitis and hemorrhagic stroke among koreans: A case-control study. J Periodontol 2010; 81(5): 658-665. 7. Oikarinen K, Zubaid M, Thalib L, Soikkonen K, Rashed W, Lie T Infectious dental Disease in patients with coronary artery disease: an orthopantomographic case-control study.JCDA 2009;75 (1):35a-e. 8. Hamdan A, Mora F, Sautier JM, Bouchard P. Maladies parodontales et risque cardio-vasculaire. JPIO 2008; 27(4): 261-271. 9. Bourgeois D, Muller-Bolla M, Llodra J. Indicatoirs essentiels de santé parodontale appliqués à la santé publique en Europe. JPIO 2008; 27(4): 246-260.

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CORRELATIONS BETWEEN DENTAL EROSION SEVERITY AND SALIVARY FACTOR IN PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE Corina- Florica Mihailopol1, Ştefan Lăcătuşu2, Carmen M. Codreanu3, Galina Pancu4, Claudiu Topoliceanu4, Cristina Angela Ghiorghe5 1PhD Student, Discipline of Cariology and Restorative Dentistry, Faculty of Dental Medicine, "Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania 2Professor, PhD, Discipline of Cariology and Restorative Dentistry, Faculty of Dental Medicine, "Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania 3Lecturer, Faculty of Economy, "Petre Andrei" University, Iaşi, Romania 4Assistant lecturer, Discipline of Cariology and Restorative Dentistry, Faculty of Dental Medicine, "Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania 5Lecturer, Discipline of Cariology and Restorative Dentistry, Faculty of Dental Medicine, "Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania

ABSTRACT The aim of our study was to assess the relation between the age of dental erosion and the parameters of quality and quantity for salivary secretion in patients with gastroesophageal reflux disease (GERD). Materials and methods: The study group included 50 patients with gastroesophageal reflux disease (GERD), diagnosed at Gastroenterology and Liver Pathology Institute. The patients were examined by same dentist that recorded data related to erosion severity. Scores for TWI index, evaluations of stimulated and resting saliva flows (RFS, RFR), pH and buffering capacity of saliva, were included in the dental chart used for recording of patient oral health within the Discipline of Cariology and Restorative Dentistry. Data were submitted to statistic tests using software SPSS 17.0. Results: The age of dental erosion presented a strong correlation with RFS, followed by RFR, salivary pH and buffering capacity. Conclusions: Patients with gastroesophageal reflux disease (GERD) have a high risk of salivary disorders. Dentists should rebalance the saliva functions related to quantity and quality, for a long term success in dental erosions therapy.

Key words: gastroesophageal reflux disease (GERD), dental erosions, salivary flow, salivary buffering capacity.

INTRODUCTION exposed to gastroesophageal reflux disease The association between endogenic and (GERD) was discussed in numerous studies. exogenic acids and dental erosions has been The salivary volume, clearance and buffering well documented. The erosive effect of capacity of saliva can be determined both in endogenic acids was demonstrated in patients basic conditions and under induced acid with gastric disorders. The monitoring of intra- environment [2]. esophageal pH for 24 hours and gastroscopy are the most common tests for diagnosis of MATERIAL AND METHODS patients with gastroesophageal reflux disease The study group included 50 patients with (GERD) and severe erosion [1]. gastroesophageal reflux disease (GERD), The protective role of saliva in patients diagnosed at Gastroenterology and Liver

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Pathology Institute. The patients were not 10-12; treated with medication that could affect  RFR, RFS, salivary pH and buffer capacity salivary function. The patients were examined (BS) present positive values for skewness, by the same dentist. Data related to erosion indicating that distribution is oriented to severity (TWI index), salivary flow rates in right side. The age of dental erosions is stimulated and non-stimulated conditions negative and is associated with orientation (RFS, RFR), and buffering capacity (BS), to left side. To establish the degree of were included in the dental chart used for distribution deviation, each value was recording of patient oral health within the divided to standard error: RFR, salivary Cariology and Restorative Dentistry pH and age of dental erosion are under 2, Discipline. Data were submitted to statistic indicating that distribution is not tests using software SPSS 17.0. significantly deviated from normal values; for RFS and BS distribution is RESULTS AND DISCUSSIONS significantly deviated from normal values. Table 1 presents minimal and maximal  Kurtosis represents a measure of values, mean, standard deviation, variation, distribution height; all analysed parameters Skewness and Kurtosis values, as follows: present negative values, associated with a  Normal values of RFR (rate of resting platikurtik distribution; distribution is not salivary flow) vary between 0.4-0.6 deviated from normal values. ml/min. The study group presented values Table 2 shows the existence and intensity of between 0,4-0,7 ml/min; the maximum relations between the assessed parameters. The limit is overpassed; age of dental erosion presents a strong  Normal values of RFS (rate of stimulated correlation with RFS (-0,992), followed by salivary flow) vary between 1-2 ml/min). RFR, salivary pH (0,983) and BS (-0,935). The The study group presented values between links between age of dental erosion and these 0,6-1,0 ml/min; parameters are strong and the values of  The recorded values of salary pH (minimal correlation coefficient are negative, oriented to 6,0, maximal 6,6); the normal values vary 1; this means that the age of dental erosion between 6,8-7,4; conduct to the decrease of these parameters.  Both values of salivary buffering capacity The strongest correlation was determined (minimal value 2 and maximal value 6) are between salivary pH and RFR, indicating a inferior comparing with a normal range of direct strong relation between these parameters.

Std. N Min. Max. Mean Variance Skewness Kurtosis Deviation Std. Std. Stat. Stat. Stat. Stat. Stat. Stat. Stat. Stat. Error Error RFR 50 ,4 ,7 ,532 ,1115 ,012 ,521 ,337 -1,091 ,662 RFS 50 ,6 1,0 ,762 ,1550 ,024 ,707 ,337 -1,155 ,662 pH 50 6,0 6,6 6,264 ,2229 ,050 ,521 ,337 -1,091 ,662 BS 50 2 6 3,12 1,769 3,128 1,010 ,337 -,952 ,662 Age of dental erosion 50 5 12 8,98 2,752 7,571 -,603 ,337 -1,266 ,662 Valid N (listwise) 50 Table 1. Descriptive statistics

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Age of dental RFR RFS pH BS erosion Pearson Correlation 1 -,983** -,992** -,983** -,935** Age of dental Sig. (2-tailed) ,000 ,000 ,000 ,000 erosion N 50 50 50 50 50 Pearson Correlation -,983** 1 ,993** 1,000** ,932** RFR Sig. (2-tailed) ,000 ,000 ,000 ,000 N 50 50 50 50 50 Pearson Correlation -,992** ,993** 1 ,993** ,962** RFS Sig. (2-tailed) ,000 ,000 ,000 ,000 N 50 50 50 50 50 Pearson Correlation -,983** 1,000** ,993** 1 ,932** pH Sig. (2-tailed) ,000 ,000 ,000 ,000 N 50 50 50 50 50 Pearson Correlation -,935** ,932** ,962** ,932** 1 BS Sig. (2-tailed) ,000 ,000 ,000 ,000 N 50 50 50 50 50 **. Correlation is significant at the 0.01 level (2-tailed). Table 2. Pearson correlation The strong relations were also determined rate within normal limits seems to exclude between RFR and RFS as well as between drug side effects in determining the observed salivary pH and RFS (0,993). salivary hypofunction, while the inability to The stimulated salivary flow has an reach adequate stimulated performances important role for clearance and cleaning of seems to suggest a defect in ‘oesophago- oral cavity, preventing formation of bacterial salivary reflex’, that is to say the phenomenon biofilm. by which the upper gastrointestinal mucosal The properties of saliva that prevent dental irritation has long been thought to stimulate erosions are as follows: salivation. An insufficient salivary flow is  clearance of potential erosive agents; associated with low clearance and reduced  buffering capacity of food acids; capacity of oesophageal acids neutralisation  formation of dental pellicle through and can conduct to lesions at the level of salivary proteins and glycoproteins oesophageal mucosa [4]. Finally, adsorption; gastroesophageal reflux disease can be  supply of calcium, phosphate and fluoride considered a major etiopathogenic factor in for remineralisation process. salivary dysfunction. Only unstimulated salivary flow and buffering capacity can be associated with CONCLUSIONS dental erosion. Unstimulated saliva presented Patients with gastroesophageal reflux a lower pH and a lower buffering capacity. disease (GERD) have a high risk of salivary The saliva alterations associated with disorders. Dentists should rebalance the saliva gastroesophageal reflux disease (GERD) can functions related to quantity and quality, for a be considered as a pathogenic factor [3]. In long term success in dental erosions therapy. particular, the maintenance of the basal flow

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REFERENCES 1. Sachin Varma, Avijit Banerjee, David Bartlett. An in vivo investigation of associations between saliva properties, caries prevalence and potential lesion activity in an adult UK population. Journal of Dentistry 2008; 36:294–299. 2. Dawes C: What is the critical pH and why does a tooth dissolve in acid? J Can Dent Assoc 2003, 69:722-724. 3. G. Campisi and colab. Saliva variations in gastro-oesophageal reflux disease. Journal of Dentistry 2008; 36: 268–271 4. Campisi G, Di Fede O, Roccia P, Di Nicola F, Falaschini S, Lo Muzio L. Saliva: its value as biological matrix and current methods of sampling. European Journal of Inflammation 2006;4:11–9.

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ANTIINFLAMMATORY PERIODONTAL THERAPY IMPACT ASSESSMENT IN PATIENTS WITH CARDIOVASCULAR DISEASES Liliana Păsărin1, Ioana Rudnic1, Cătălina Dănilă 1, Oana Potârnichie 1, Sorina Solomon2, Amelia Surdu-Macovei3, Alexandra Mârţu4, Silvia Mârţu5 1Assist., Ph.D., Discipline of Periodontology, Faculty of Dental Medicine, "Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania 2Lecturer Ph.D., Discipline of Periodontology, Faculty of Dental Medicine, "Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania 3PhD Student, Discipline of Periodontology, Faculty of Dental Medicine, "Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania 4Student, Discipline of Periodontology, Faculty of Dental Medicine, "Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania 5Prof., Discipline of Periodontology, Faculty of Dental Medicine, "Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania

ABSTRACT The purpose of this study is to determine whether eliminating periodontal infection may have a favourable impact in patients with risk to inducing a cardiovascular disease. Materials and methods The study included 94 patients with generalized severe periodontitis, during their 6 months follow-up period, which were evaluated for periodontal changes after initiation of non-surgical periodontal therapy. Serological and clinical periodontal parameters were assessed at baseline, at 2 and 6 months after the initiation of non-surgical treatment. Also were evaluated the effects of systemic treatment for severe periodontitis by examination of changes produced by treatment on inflammatory markers that are otherwise involved in atherosclerotic cardiovascular disease. Results It was shown that the control of periodontal infection causes a reduction for markers of inflammation in a small proportion of the population with severe and acute forms of periodontal diseases. Given the limitations of this study, the data demonstrates an interrelation between the general health and periodontal disease. Conclusions We recommend regular check-ups to the dentist to avoid the occurrence and progression of a periodontal pathology influenced by systemic administration of drug therapy in cardiovascular diseases.

Key words: cardiovascular diseases, periodontal disease, drug therapy, non-specific treatment

INTRODUCTION that periodontitis and atherosclerosis have In recent years a large number of common risk factors, but even if this epidemiological studies have shown that association has been established, may be false subjects with periodontitis have an increased many times [5, 6, 7]. If the association was risk for cardiovascular disease [1, 2]. However, firmly established the question regarding the the association periodontitis-cardiovascular nature of causality plays an important role in disease remains an open debate [3]. research on periodontal disease [8]. Recently, discussions focused on the Two hypotheses have been proposed contradictory results that were obtained after regarding etiological mechanisms association analysis of different groups from the same of periodontitis with systemic inflammation study material [4]. Critics have pointed out and cardiovascular diseases:

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1. Chronic periodontitis is a source of their 6 month’s follow-up period after the chronic infection for the body representing initiation of non-surgical periodontal therapy. the pathway of microorganisms and Serological and clinical periodontal endotoxins [9]; parameters were assessed at baseline, at 2 and 2. Periodontal disease is a source of systemic 6 months after the initiation of non-surgical inflammatory mediators [10]. treatment. Participants were recruited from The purpose of this study is to determine those who were referred at the Clinic of whether eliminating periodontal infection Periodontology, Faculty of Dental Medicine, may have an impact on systemic disease in UMF Iaşi, for periodontal treatment. The patients at increased risk to develop inclusion criteria were: presence of cardiovascular disease. Also were evaluated generalized periodontal disease without other the effects of systemic treatment of severe systemic signs of infection (Table 1). periodontitis by assessment of changes The average age was 46  9 years, 54% were produced by treatment on inflammatory women, 42% were chronic smokers and 26% markers that are otherwise involved in had a family history of cardiovascular disease. atherosclerotic cardiovascular disease [11]. Subjects must present periodontal pockets greater than 6 mm and marginal bone loss MATERIAL AND METHODS greater than 30%, at least 50% of the teeth. The study evaluated for periodontal In the group 75% of patients presented changes a group of 94 patients diagnosed chronic periodontitis and 25% had forms of with generalized severe periodontitis, during generalized periodontitis for ages (Fig. 1).

Age (years) 46_ 8 Gender Women 51 (54%) Men 49 (46%) Smoking Yes 39 42% No 55 (58%) Body mass index (kg/m2) 25.3  3.7 Family history of cardiovascular disease Yes 25 (26%) No 69 (74%) Chronic periodontitis 70 Aggressive periodontitis 24 Periodontal diagnosis (75%) (25%) No. of teeth at baseline 27 3 No. of teeth extracted 2  2 Values reported are  SD (standard deviation). Table 1 At each of the three examinations (baseline, after 2 months and 6 months) the assessed parameters were:  Bleeding record, performed in six sites per tooth  Plaque score expressed as a percentage representing the total area covered by plaque (O'Leary and collaborators)  Number of periodontal pockets Fig. 1. Group structure upon the clinical  Periodontal pocket depth semiology of disease

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 Gingival recession pockets was 7723%, mean attachment loss was 4.93 1.13 mm and deep pockets average RESULTS AND DISCUSSION was 4.360 .59mm (Table 2). No patient received surgical treatment. Oral hygiene was significantly improved, Periodontal treatment consisted of oral plaque index average 20% between 2 and 6 hygiene measures, ultrasonic subgingival months (Fig. 2). scaling and root planning under local Bleeding indices decreased and reached anaesthesia. average values of 16% at 2 months and 17% at Therapy was not limited in time and 6 months (initial value was 63.57%) (Fig. 3). number of interventions, treatment ending in Subjects presented a decrease in number of 1-3 months after primary consultation. periodontal pockets from 7723 at first Periodontal treatment was completed with meeting to 2816 at 2 months and 2315 at 6 extraction for compromised teeth and dental months (Fig. 4). restorative and endodontic treatments. Mean periodontal pocket depths decreased Registration for periodontal clinical from 4.36 mm at baseline, to 3.25 mm at two parameters emphasizes the severity and months and 3.19 mm at 6 months (Fig. 5). extension of periodontal infection. At the first Gingival recessions have stagnated and appointment patients had a plaque index attachment loss mean values improved from averaged 58 20.7% and 63.5  16.4% 4.93 mm at baseline to 4.74 at 2 and 4.85 mm bleeding index; average of deep periodontal at 6 months (Fig. 6).

Baseline At 2 months At 6 months Standard Mean Standard Mean Standard Average deviation value deviation value deviation Plaque index 58.04 20.70 20.90 14.29 20.08 10.42 Bleeding index 63.57 16.39 15.80 11.57 17.10 11.91 No pockets >4mm 77.08 23.23 27.82 16.36 22.91 15.04 Depth pockets 4.36 0.59 3.25 0.47 3.19 0.47 Recession (mm) 0.56 0.88 1.56 0.94 1.72 0.94 Attachment loss (mm) 4.93 1.13 4.74 1.14 4.85 1.13 Table 2

Fig. 2 Plaque index Fig. 3. Bleeding index

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Iniţial Val medie Iniţial Val medie 77.08 5 80 4.36 4 60 3 6 luni DS Iniţial DS 6 luni DS Iniţial DS 40 2

20 23.23 1 15.04 0.47 0.59 0 0 0.47 22.91 27.82 16.36 3.19 3.25 6 luni Val medie 2 luni Val medie 6 luni Val medie 2 luni Val medie

2 luni DS 2 luni DS

Fig. 4. Number of periodontal pockets Fig. 5. Periodontal pocket depth

Iniţial Val medie 2 Iniţial Val medie 4.93 5

1.5 4

6 luni DS Iniţial DS 3 1 6 luni DS Iniţial DS 0.56 2 0.94 0.5 0.88 1.13 1 1.13 0 0

1.14 1.56 6 luni Val medie 2 luni Val medie 6 luni Val medie1.72 2 luni Val medie 0.94 4.85 4.74

2 luni DS 2 luni DS

Fig. 6. Recession index Fig. 7. Attachment loss The results of this study showed a systemic inflammation, which may lead to the significant association between poor hypothesis that periodontitis can cause periodontal health and coronary heart disease atherogenesis. regarding periodontal indices. The average age in these three groups is 42 CONCLUSIONS years. It was shown that periodontal infection Average number of teeth is approximately control leads to a reduction of inflammatory 27 teeth, generalized periodontitis with bone markers in a small proportion of the loss included 14.8 teeth, localized population with severe and acute form of periodontitis included 3.5 teeth. periodontal disease. Correlations regarding gender and history Given the limitations of this study, the data of hypertension had no significant variations. demonstrates an interrelation between the Furthermore, our results showed that general health and periodontal disease. generalized severe periodontitis causes

REFERENCES 1. Arbes S, Slade G, Beck J; Association between extent of periodontal attachment loss and self- reported history of heart attack: an analysis of NHANES III data. J Dent Res, 1999; 78:1777-82. 2. Beck J, Offenbacher S, Williams R, Gibbs P, García R; Periodontitis: a risk factor for coronary heart disease?. Ann Periodontol, 1998;(3):127-41. 3. Armitage GC. Periodontal infections and cardiovascular diseases-how strong is the association?.Oral Diseases, 2000; (6):335-50. 4. Silvia Mârţu, Pasarin Liliana, Solomon Sorina, Rudnic Ioana; Studies regarding the interrelation and

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interdependence between periodontal disease and sistemic diseases Romanian Dentistry J., 2006,10,(4):62-69. 5. Naconecinîi D., Prodan Maria Rodica, Mârţu Silvia; Correlation between psycho cognitive impairment in early post-stroke period and dental status, J. of Romanian Medical Dentistry, 2008,12,(3):2-15 6. Fayad ZA, Fuster V; Clinical imaging of the high-risk or vulnerable atherosclerotic plaque. Circ Res. 2001; 89:305–316. 7. Kolitveit KM, Eriksen HM; Is the observed association between periodontitis and atherosclerosis causal? Eur J Oral Sci, 2001;109: 2-7. 8. Garcia RI, Henshaw MM, Krall EA; Relationship between periodontal disease and systemic health. Periodontology 2000, 2001, 25:21-36 9. Page RC, Kornman KS; The pathogenesis of human periodontitis: an introduction. Periodontology 2000, 1997,14:9-11. 10. Liliana Pasarin, Silvia Martu, Constanta Mocanu; Studiu privind corelatia dintre bolile cardiovasculare, markerii inflamatori sistemici si parametrii sangvini din singele periferic la pacientii cu boala parodontala. Romanian Dentistry J. Supl , 2007,11,(1):377-383 11. Slots J, Jorgensen MG; Efficient antimicrobial treatment in periodontal maintenance care. J Am Dent Assoc, 2000; 131:1293–1304.

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CARIES EXPERIENCE IN CHILDREN WITH SEVERE EARLY CHILDHOOD CARIES Aneta Munteanu, Rodica Luca, Cătălina Farcașiu, Ioana Stanciu Pedodontics Department, Faculty of Dentistry, Carol Davila University, Bucharest, Romania

ABSTRACT Introduction Caries experience indexes in children with severe early childhood caries (S-ECC) reported in literature are lower in the general population than in children referred to paediatric dental clinics. The aim of the study was to compare different samples of children (two samples from dental clinics and one from general population) from this point of view. Methods Retrospective analysis upon 3 samples of children 5 years old or under: sample A – 685 children (392 boys, 293 girls) referred to Pedodontics Department, Faculty of Dentistry, Carol Davila University, Bucharest, sample B – 233 children (124 boys, 109 girls) examined in a private dental clinic and sample C – 552 children (284 boys, 268 girls) from 12 kindergartens from Bucharest. Prevalence index (IpS-ECC) and caries experience indexes (dmft, dmfs and SiC) from S-ECC children were evaluated. Caries topography was also noted. Data were analyzed using a chi-square test (p<0.05). Results a) IpS-ECC – sample A = 40.29% (IpS-ECCboys = 39.79%, IpS-ECCgirls = 40.95%, NS), sample B = 38.18% (IpS-ECCboys =

40.32%, IpS-ECCgirls = 35.77%, NS), sample C = 15.04 (IpS-ECCboys = 17.25%, IpS-ECCgirls = 12.68%, NS) ; b) dmft index: sample A = 9.14±4.51, sample B = 8.54±3.82, sample C= 9.11±3.35 (NS); c) dmfs index: sample A = 21.92±14.54, sample B = 18.43±11.96, sample C = 17.65±9.37 (NS);d) SiC: sample A = 14.38, sample B=13.00, sample C =12.60 (NS); e) Children with caries in upper and lower molars and front teeth (rampant caries) : - sample A = 23.91%, sample B = 19.10%, sample C = 19.28%. Conclusions 1) Although S-ECC is more prevalent in children referred to state or private clinic, the severity of caries experience is the same across all samples; 2) There are no differences between the sexes with regard to the prevalence index and caries experience indexes.

INTRODUCTION boys, 109 girls) aged 3 to 71 months (mean Caries experience indexes in children with age=4.1±1.4 years) examined and treated in a severe early childhood caries (S-ECC) private dental clinic in Bucharest during reported in literature are lower in the general 2003-2007. Sample C included 552 children population than in children referred to (284 boys, 268 girls), aged 25 to 71 months paediatric dental clinics. The aim of the study (mean age=4.4±0.7 years) from 12 public was to compare different samples of children kindergartens in Bucharest. (two samples from dental clinics and one A retrospective study using patients’ files sample from the general population) from this was done in samples A and B. Patients’ point of view. examination at the first visit was conducted by one investigator (A.M.) in a dental office. MATERIALS AND METHODS. The examination of children from Sample A consisted of 685 children (392 kindergartens was performed by 4 doctors, boys, 293 girls) aged 1 to 71 months (mean who were calibrated before this. Children’s age=3.9±1.4 years) referred to the examination was done in kindergartens, under Pedodontics Department, Carol Davila natural light, using dental probes and mirrors. University, Bucharest during 2002-2006. Dental caries were detected by visual Sample B consisted of 233 children (124 examination and the dental explorer was used

72 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 only when needed. No X-rays were taken. 40%), whereas in the other 2 samples, the A child was diagnosed with S-ECC when prevalence index was higher in boys as the following criteria were fulfilled: children compared to girls, but the differences were younger than 3 years – the presence of any not statistically significant in either sample sign of decay on smooth tooth surface; in (p>0.05) (Fig. 1). children aged 3 to 5 years – one or more decayed, filled or missing smooth surfaces on the upper front teeth. Prevalence index for S-ECC and caries experience indexes (dmft, dmfs and SiC) in S- ECC children were calculated. The topography of the lesions was also recorded. Statistical analysis was performed using a chi-square test. The level of statistical significance was set at p<0.05. Fig. 1. Sex distribution of IpS-ECC

RESULTS 2. Caries experience indexes 1. S-ECC prevalence (IpS-ECC) The values of the dmft index are similar IpS-ECC for children referred to the across the 3 samples. Instead, the values of Pedodontics Department was 40.29%. The the dmfs index are different from one sample 276 children with S-ECC were aged 12 to 71 to the orher: 21.55 in sample A, 18.43 in months, mean age 3.4±1.3 years. 38.19% of sample B and 17.65 in sample C, although the the 233 children in the private dental clinic differences are not statistically significant had S-ECC. The 89 patients with S-ECC were (p>0.05).SiC (Significant Index Caries) – aged between 16 and 70 months, mean age calculated for 1/3 of children with the highest 4.0±1.3 years. In kindergarten children the values of dmft index – had close values, value of IpS-ECC was the lowest – 15.04%. without differences statistically significant The 83 children with S-ECC were aged 40 to between samples (Table 1). 71 months, mean age 4.6±0.6 years. Although there are some differences In children examined at the state clinic, the between the values obtained for the girls and value of the prevalence index was sensibly for the boys, these are not statistically equal in both sexes (boys – 39%, girls – significant (Table II).

dmft SiC dmfs mean value p range mean value p range Sample A 9.14±5.51 2-20 14.38 21.92±14.54 2-77 Sample B 8.54±3.82 NS 2-18 13.00 18.43±11.96 NS 2-64 Sample C 9.11±3.35 2-16 12.60 17.65±9.37 2-43 Table 1. Caries experience indexes

dmft dmfs boys girls p boys girls p Sample A 9.25±4.49 9.50±4.55 NS 21.66±14.39 21.40±14.11 NS Sample B 8.44±3.73 8.67±3.98 NS 19.06±13.35 17.62±10.01 NS Sample C 9.57±3.10 8.44±3.63 NS 17.35±8.06 18.09±11.10 NS Table 2. Sex distribution of caries experience indexes

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3. Caries topography Most children in all study samples had caries both in the upper front teeth, and in the molars. In all samples, the percentage of children with rampant caries (also involving the lower front teeth) was around 20% (Fig. 2). Although rampant caries were more prevalent in boys than in girls in all samples, differences are not statistically significant Fig. 2. Caries topography (Table 3).

Sample A Sample B Sample C boys girls boys girls boys girls S-ECC 156 120 50 39 49 34 Rampant Nr. 40 26 10 7 11 5 caries % 25.64 21.67 20 17.95 22.45 14.71 p NS NS NS Table 3. Sex distribution of rampant caries

DISCUSSION Sudan, Croatia, South Africa, Brazil, Korea There are no comparative studies in the or Iran [7-12]. literature concerning the severity of S-ECC in Regarding the gender-related distribution children referred to specialised clinics (state of IpS-ECC, our study showed that in sample or private) and in children from the general A the values were almost equal, and in population. This is why the purpose of this children examined at the private clinic study was to compare various samples of (sample B) and in kindergarten children children from this point of view. (sample C), the prevalence index was higher The analysis of S-ECC at the 2 clinics in boys than in girls, although the differences shows that the prevalence indexes were were not statistically significant. The results approximately equal – 40.29% (the state of our study are concordant with the results clinic) and 38.19% (the private clinic). The reported by other authors. Thus, Iida et al. peer-reviewed literature includes few studies (2007) reported in a study conducted in a on the prevalence of S-ECC in children sample of 1,576 children aged 2 to 5 in the examined at dental clinics, and the values of USA, the same value of IpS-ECC for both indexes ranges between 11 and 94% [1-3]. sexes (10%) [6]. Hallet and O’Rourke (2006) The studies investigating the frequency of found that in children referred to a paediatric S-ECC in children from the general hospital for specialised dental therapy, the S- population are much more numerous. They ECC percentage had the same value in girls report values of the prevalence index ranging and boys (96%) [3]. Virdi et al. (2010) between 7 and 50% [4-12]. The present study showed, in a study conducted in a sample of provided a prevalence index of 15.04%, 709 Indian children aged 1 to 5, a prevalence which is higher than the index reported in index of the S-ECC higher in girls than in studies conducted in such countries as Italy, boys (43.8% as compared to 40.6%), Australia or USA [4-6], yet lower that the although the differences were not statistically indexes reported in studies conducted in significant [2]. Nevertheless, studies

74 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 conducted in Turkey reported a higher with no statistically significant differences. prevalence of the disease in boys, supported In a study by Hallet and O’Rourke (2006), by the tendency in Asian cultures for the mean value found for the dmft index was overindulging boys [13, 14]. Likewise, a 10.5 ± 3.8, close to the value found in our study conducted in Brazil showed that boys study, but the value of the dmfs index was were more affected by S-ECC. Authors much higher (27.1 ± 15.1) [3]. suggested that mothers play an important role In a study upon 117 children aged below 4 in the establishment of sweetness preference from Beijing (China), Qin et al. (2008) in their children and boys may be favoured reported that the mean value of the dmft index with more sweets [15]. was 9.2+3.6 (similar to our results), whereas With regard to caries experience indexes the value of the dmfs index was lower in children with S-ECC, the results show that (15.5+7.7) [16]. the number of damaged teeth was similar The values of the caries experience throughout the 3 samples (9 teeth as an indexes calculated for the children in the average), while the number of decayed, filled general population (sample C) are similar to or missing smooth surfaces was higher in the values reported in studies conducted in children examined at the university clinic Sudan and Lithuania [7, 17], though much (21.55) as compared to the private clinic higher than in studies conducted in Belgium (18.43) or the kindergarten children (17.65), or Italy [4, 18] (Table IV).

Authors (year) Country/ No. Age dmft dmfs city Present study (sample Romania/ 83 40-71 9.11 ± 3.35 17.65 ± 9.37 C) (2006) Bucharest months De Grauwe et al. Belgium/ 47 24-35 - 5.98 ± 5.467 (2004) [18] Ghent months Petti et al. (2000) [4] Italy/ 114 3-5 years 6.9 ± 4.2 - Rome Slabsinskiene et al. Lithuania/ 62 3 years 7.8 ± 0.1 18.1 ± 0.6 (2010) [17] Kaunas FathEl Rahman & Sudan/ 140 3-5 years 8.12 19.15 Ibrahim (2008) [7] Khartoum Table 4. Caries experience indexes in S-ECC children from general population In all 3 study samples, there are no severity of the clinical appearance in children statistically significant differences concerning with this pattern of caries, both referred to the dmft/dmfs indexes between sexes. Hallet dental offices and from the general and O’Rourke (2006) also reached the same population, was equally high, posing real conclusion for the dmfs index (25.7 in boys problems in oral rehabilitation, which and 26.8 in girls) [3]. supports the need for implementing The comparison between the three study community prevention programs. samples showed high prevalence indexes, with almost equal values in children referred CONCLUSIONS to the state clinic and the private clinic, as 1. Although S-ECC is more prevalent in compared to the prevalence indexes found in children referred to state or private dental the general population. On the other hand, the clinic, the severity of caries experience is

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the same in all samples; regarding the prevalence index and the 2. There are no differences between sexes caries experience indexes.

REFERENCES 1. Bălan A, Păsăreanu M, Săilă V. Baby bottle caries syndrome – risk factors. Jurnal de Medicină Preventivă 2000; 8(3): 44-47. 2. Virdi M, Bajaj N, Kumar A. Prevalence of Severe Early Childhood Caries in Pre-School Children in Bahadurgarh, Haryana, India. The Internet Journal of Epidemiology 2010; 8(2). 3. Hallet KB, O’Rourke PK. Caries experience in preschool children referred for specialist dental care in hospital. Aust Dent J 2006; 51(2): 124-129. 4. Petti S, Cairella G, Tarsitani G. Rampant early childhood dental decay: an example from Italy. J Public Health Dent 2000, 60 (3): 159-166. 5. Hallet KB, O’Rourke PK. Pattern and severity of early childhood caries. Community Dent Oral Epidemiol 2006; 34(1): 25-35. 6. Iida H, Auinger P, Billings RJ, Weitzman M. Association Between Infant Breastfeeding and Early Childhood Caries in the United States. Pediatrics 2007; 120 (4): 944-952. 7. Fath El Rahman RM, Ibrahim YE. Dental Caries Status of Preschool Children in Khartoum Province. IADR/CADR 86th General Session, Toronto, Canada. Scientific Meeting of the Sudanese Section. J Dent Res 2008; 87 (Special issue C): abstract 0029. 8. Lulic-Dukic O, Juric H, Dukic W, Glavina D. Factors Predisposing to Early Childhood Caries (ECC) in Children of Pre-School Age in the City of Zagreb, Croatia. Coll Antropol 2001; 25(1): 297-302. 9. Postma TC, Ayo-Yusuf OA, van Wyk PJ. Socio-demographic correlates of early childhood caries prevalence and severity in a developing country – South Africa. Int Dent J 2008; 58(2): 91-97. 10. Azevedo TDPL, Bezzera ACB, de Toledo OA. Feeding Habits and Severe Early Childhood Caries in Brazilian Preschool Children. Pediatr Dent 2005; 27(1): 28-33. 11. Jin BH, Ma DS, Moon HS, Paik DI, Hahn SH, Horowitz AM. Early childhood caries: prevalence and risk factors in Seoul, Korea. J Public Health Dent 2003, 63(3): 183-8. 12. Nematollahi H, Mehrabkhani M, Esmaily HO. Dental Caries Experience and its Relationship to Socio-Economic Factors in 2-6 year old Kindergarten Children in Birjand – Iran in 2007. J Mash Dent Sch 2009; 32(4): 325-32. 13. Ayhan H. Influencing factors of nursing caries. J Clin Pediatr Dent 1996; 20(4): 313-6. 14. Eronat N, Eden E. A comparative study of some influencing factors of rampant caries or nursing caries in preschool children. J Clin Pediatr Dent 1992; 16 (4): 275-9. 15. Marciel SM, Marcenes W, Watt RG, Sheiham A. The relationship between sweetness preference and dental caries in mother/child pairs from Maringa-Pr, Brazil. Int Dent J 2001; 51: 83-8. 16. Qin M, Li J, Zhang S, Ma W. Risk Factors for Severe Early Childhood Caries in Children Younger Than 4 Years Old in Beijing, China. Pediatr Dent 2008; 30(2): 122-8. 17. Slabsinskiene E, Miciuviene S, Narbutaite J, Vasilianskiene I, Andruskeviciene V, Bendoraitiene EA, Saldunaite K. Severe early childhood caries and behavioral risk factors among 3-year-old children in Lithuania. Medicina (Kaunas) 2010, 46(2): 135-141. 18. De Grauwe A, Aps JKM, Martens LC, Vanobbergen J. Determinants of severe early childhood caries (S-ECC) in a group of inner city children. 7th Congress of the European Academy of Paediatric Dentistry, Barcelona 10th-13th June 2004. Abstract Book.

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DENTAL NANOROBOTS – SMALL INSTRUMENTS WITH LARGE POTENTIAL Ana-Maria Dumitrescu1, Cristina Dascălu2 1Student, Dental Medicine Faculty, "Gr. T. Popa" University of Medicine and Pharmacy Iasi 2Lecturer, Department of Medical Informatics and Biostatistics, "Gr. T. Popa" University of Medicine and Pharmacy Iasi, Romania

ABSTRACT Science of miniaturization (nanotechnology) is manipulating matter at nanometer level. Using nanotechnology, in the latest 10 years a new field of research appeared: dental nanomedicine, which will use new tools, nanorobots. Aim This paper aims to provide the recent information about some application of nanorobots to dental problems, especially in orthodontics. Materials and methods We addressed some queries to the electronic data bases including „Google Scholar”, „Google Books” and MEDLINE, using the key-words: ”nanotechnology”, ”dental nanomedicine”, ”nanodentistry” and ”dental nanorobots”. We have taken into consideration the articles and monographies in the field of nanomedicine and nanotechnology issued in English until the 31st of December 2010. From the collected materials, we have conceived a summary of the data about the design and architecture of nanorobots, as well as their applications in dental nanomedicine. Results The dental nanorobots will be invisible for human eye and could have different shapes as they will have to do different tasks. They will be manufactured out of thousands of mechanical parts, made out of diamondoid materials. The most important part of the architecture of a nanorobot will be the nanocomputer on board which will be under the control of the dentist. The dental robots could accomplish numerous tasks: inducing local anaesthesia, desensitize teeth, correct positioning of periodontal tissue and poorly aligned teeth, restorative dental procedures, and curative preventive procedures at oral cavity level. Though there will be numerous benefits of using nanorobots in dental medicine, some scientists consider that there will be also some risks, including the disappearance of every living being on Earth if the nanorobots will evolve towards the capacity of continuous auto-replication. Conclusion Nanorobots will be the next big treatment revolution in dentistry. Scientists appreciate that the years 2020 will be called “the decade of the medical nanorobots” as in those years these “intelligent” instruments will be at work. The role of the dentist working with such instruments will change, but also the types of the dental problems of the patients who will address to him will change.

Key words: dental nanomedicine, dental nanorobots, applications, benefits, risks

INTRODUCTION that would enable us to manipulate atoms and More than half a century ago, at the annual molecules, thus opening new technological American Physical Society meeting (1959), possibilities. The physicist suggested that the physicist Richard Feynman, Nobel Prize using regular machine tools can produce other winner in Physics, presented his work machine-tools, only smaller, and so on, step “Plenty of Room at the bottom” which dealt by step, till the production of molecular with the matter of manipulating and machines [1]. controlling small scale things, a field which The true founder of nanotechnology was, he thought would have “a great deal of though, Eric Drexler, who published in 1986 technical applications”. He proposed the the book „Engines of Creation. The Coming construction of “submicroscopic computers” Era of Nanotechnology”, in which he

77 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 introduces the molecular technology which he ”nanotechnology”, ”dental nanomedicine”, also calls nanotechnology. He states that in the ”nanodentistry” and ”dental nanorobots”. near future this kind of technology will be We have taken into consideration the articles used to assembly atoms and molecules in order and monographies in the field of to build nanocircuits and nanomachines. “The nanomedicine and nanotechnology issued in way average instruments can build average English until the 31st of December 2010. machines out of compound pieces, molecular Adding to that, the articles quoted in the instruments will create connections between articles and monographies found in the first molecules in order to create pinions, engines, research have been added to the review. From manipulating arms and minute covers that will the collected materials, we have conceived a be assembled into complex machines” [2]. summary of the data about the design and The prefix „nano” refers to the scale of architecture of nanorobots, as well as their these constructions, the word coming from applications in dental nanomedicine. Greek where it means “dwarf”, a nanometer being the billionth part of a meter. The first RESULTS scientist who described the medical The field of dental nanomedicine implies applications of nanotechnology and the use of three classes of molecular nanorobots was Robert Freitas Jr. In an article structures: nanomaterials, non-biological published by the Journal of American Dental nanoparticles, materials and instruments Association, he defined nanomedicine as the based on biotechnology and non-biological “science and technology of diagnosing, instruments including nanorobotics, all for treating and preventing disease and diagnosis and therapy purposes. The most traumatic injury; of relieving pain; and of effective domain of the three classes of the preserving and improving human health, dental nanomedicine technology is considered through the use of nanoscale-structured to be the one of the nanorobotics [4]. materials, biotechnology and genetic The first step of this research field dates engineering, and eventually complex back in the 1980s, when the scanning molecular machine systems and nanorobots”. tunneling microscope and also the atomic In the same article, Freitas introduced the force microscope were invented. Those concept of nanodentistry, which he defines as microscopes enabled the identification for the the science and technology that “will make first time of individual atoms. In the years possible the maintenance of near-perfect oral 2000 the devices necessary for building health through the use of nanomaterials, nanorobots began to be manufactured (micro- biotechnology, including tissue engineering, engines, micro-impellers, micro-pumps, and nanorobotics” [3]. micro-sensors, manipulating micro-arms and In this article we will present the most even molecular computers [4, 5]. In 2008, C. recent data of the medical literature about the Edeler, research scientist of the Department architecture and potential use of nanorobots of Microrobotic Engineering of the in nanodentistry, as well as possible Oldenburg University from Germany advantages and risks connected to their use. announced the creation of a mobile platform where nanorobots are already being MATERIALS AND METHODS manufactured [6]. We have searched the electronic data bases Nanorobots architecture including „Google Scholar”, „Google Books” Medical nanorobots represent and MEDLINE, using the key-words: microscopical objects artificially

78 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 manufactured, endowed with “intelligence”, should probably have a sphere shape, capable of free diffusion inside the human resembling blood cells and leucocytes [10, 4]. body and which can interact with human Martel et al. appreciates that, for a good body cells or can manipulate them, with a movement through the blood flow, the best nanometric resolution (10 -9 m) in order to design shape for medical nanorobots should fulfil tasks in the medical field. As a regular be that of flagellated bacteria [12]. robot, a medical nanorobot can be Dental nanorobots should have a spider manufactured out of thousands of mechanical like body as they need to be quick in fulfilling parts, made out of nanomaterials such as their tasks [13]. They will be manufactured carbon nanotubes, metallic nanoconductors out of diamondoid structures (Fig. 2), and diamondoid materials [4, 7]. Unlike disposed into nanotubes, as the super-sleek regular robots, medical nanorobots will have surfaces should reduce to a minimum the invisible dimensions to the human eye, possibility of activating the immune system respectively from 0.1 to 10 μm, but the of the organism [4, 14, 9, 11, 10]. compound parts will have molecular sizes (1- Diamondoid molecules are circular saturated 10 nm) [4, 7, 8, 9]. hydrocarbons with a diamond like structure. The dental nanorobot (Fig. 1) will have a Diamondoids have unique properties due to nanocomputer on board which will stock and the exceptional atomic structure. They are execute planned missions, will receive and chemically and thermically stable, can self- process signals and external stimuli, will assembly, are more resistant, but lighter than communicate with other nanocomputers and steel [15, 16]. will respond to external control and Fullerenes have also been analysed in view monitoring devices and will possess the of their use in manufacturing dental contextual knowledge in order to ensure the nanorobots, due to their special physical and correct functioning of the nanomechanical chemical properties. They are a class of devices [3, 5]. aromatic carbon compounds, of a somewhat The researchers have taken into account sphere shape in which the carbon bonds form various shapes for the design of medical pentagons and hexagons. The diameter of a nanorobots bearing in mind both the C60 fullerene molecule is of 0.7 nm, and that biomimetism and the place of action. Freitas recommends it as an important member of the considers that intravascular nanorobots nanomaterials family [17].

Fig. 1. The architecture of the dental Fig. 2. The molecular structure of nanorobot (an adaptation of Sujatha et al., diamondoids 2010)

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Once inside the human body, nanorobots suspension containing millions of anesthetic ensure their movement energy not only from dental nanorobots will be applied to the internal sources (such as the energy released patient’s gum. They will reach the pulp in by the radioactive particles attached to the approximately 100 seconds and will interrupt nanorobot body or a solar cell reduced to the traffic of the nervous impulse, under the nanoscale), but also out of external sources control of the dentist through the intermediate (such as the patient's body heat or the of the nanocomputer aboard the nanorobots electrolytes and the metabolism of the [20]. After finishing the oral procedures, the glucose in the blood flow) [18, 13, 11]. dentist will be able to command the According to present day theories, dental nanorobots to redo the nervous traffic of the nanorobots should have at least two means of selected tooth and to exit the tooth the way communication: both with the doctor who they entered [3, 20]. Using anaesthetic coordinates it, and with the other nanorobots nanorobots will have numerous advantages: a he teams up with. Two possible ways of larger comfort for the patient by reducing the communicating between nanorobots are being anxieties and needle phobias, a larger base of considered: either by means of light signals – selection and a quick complete reversible through optical nanosensors [4], or by action, as well as the disappearance of side chemical signals – through chemical effects and complications of the current nanosensors (i.e. nanorobots monitoring anesthesia [3, 21]. glucose level) [19, 13]. Treatment of dentine hypersensitivity As to the possible ways of communication A relatively frequently encountered between nanorobots and the doctor who pathology in dental practice is the dentine coordinates them, research scientists incline hypersensitivity characterized by a diffuse towards acoustic signals, allowing rapid rates symptomatology, slightly painful, caused by of data transfer, or electromagnetic radio the pressure, hydrodinamically transmitted to waves, considered useful in detecting the the pulp, through the dentinal tubes of the current status of the nanorobots inside the exposed dentine. It seems that in this patient [3, 4, 13]. condition, the hypersensitive teeth have a Applications of nanorobots in dental density of dentinal tubes 8 times bigger, and nanomedicine they have a diameter twice the size of dentinal Research scientists appreciate that dental tubes of non-sensitive teeth [13, 20, 8]. nanorobots could accomplish numerous tasks: In the era of nanomedicine, dental inducing local anesthesia, desensitize teeth, nanorobots will selectively and precisely correct positioning of parodontal tissue and occlude the selected dentinal tubes in a few poorly aligned teeth, restorative dental minutes, using biocompatible materials and procedures, and curative preventive offering the patient a quick and permanent procedures at oral cavity level [3, 13, 20]. treatment of the hypersensitivity [20, 13]. Inducing local anaesthesia Orthodontic treatment As local anaesthesia used now in dental Nowadays, orthodontic treatment has a lot medicine is a painful procedure which causes of disadvantages among which the need to the patient discomfort and can be sometimes wear the orthodontic appliance for weeks or accompanied by complications, manu- months being the most important, to which we facturing anaesthetic dental nanorobots will can add the unaesthetic aspect of the smile, as have a large impact on patients as a result of well as the discomfort of the patient in terms the numerous advantages. A colloidal of speaking and eating. In the era of the

80 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 orthodontic nanorobots, they will be able to controlled from a distance and working manipulate directly the parodontal tissues, together will be able to excavate old amalgam including gums, parodontal ligament, restorations and will be used to prepare the cementum and alveolar bone, allowing a quick cavities and restore the teeth with biological and painless straightening, rotating or vertical materials, so that the newly formed teeth positioning within minutes or hours [20, 13]. could not be differentiated from the original Aesthetic dental treatment tooth [13]. Nowadays, aesthetic dental medicine uses Treatment for the oral cancer the tooth implant placed inside the maxillary The fight against the oral cavity cancer bone or the mandibular bone (on the spot of a will be fought with the help of nanomedical former dental root), in order to help replacing destrorobots, which will be nanotechnological one or several missing teeth. This is followed objects capable of researching and destroying by a period of osteo-acceptance and another in due time the presence of the oral cavity metal piece (a prosthetic joint) is attached to cancer. As in oral cavity cancer there are the implant on top of which the doctor can numerous feeding blood vessels, the destrobot place the crown, the bridge or the prosthetic, could penetrate the tumor and could use that will replace the missing tooth (teeth). focalized lasers, microwaves or ultrasonic This restoring technique has a lot of signals in order to attack neoplasm cells advantages, but, on the other side, a lot of which they will destroy without breaking the disadvantages, being a surgical procedure cell wall, as they work by increasing the inducing discomfort to the patient as it pressure or intracellular temperature to high requires several sessions stretched along values [7]. several months, and the implant can be Maintaining an almost perfect oral rejected by the organism. The reconstructive hygiene nanodental techniques will imply genetic This will be possible with the help of engineering procedures, tissue engineering, dentifrobots playing an important part in nanorobotic manufacturing for the growth of preventing cavities and parodontal diseases. a new tooth in vitro, followed by its Their daily application will be used by means installation in the dental alveoli with the help of mouthwash or toothpaste. Being capable of of reconstructive dental nanorobots. The reaching places a tooth brush can’t reach, nanotherapy of complete replacement of the dentifrobots will identify and destroy dentition with biological teeth, including both pathogen bacteria in the subocclusal area mineral and cellular compounds, will have while allowing the harmless bacterial flora the advantage of being possible in the dental from the mouth to develop in a healthy practice in one session [3, 20, 13, 8]. ecosystem. Dentifrobots will patrol all the Reconstructive dental nanorobots will surfaces above and beneath the gums and will maintain the natural tooth and will improve metabolize the rests of organic matter its aesthetic aspect (in terms of color and transforming it into odourless vapours. They texture) and durability by means of replacing will be programmed to avoid the occlusal the upper layers of the enamel with artificial areas and will be deactivated if chewed [13, biocompatible materials, such as sapphire and 20, 21]. As putrefaction is the central diamond, with a hardness of 20-100 times metabolic process involved in the odour of larger than the natural enamel and thus, a the oral cavity, due to their cleaning larger resistance to fracture [13, 20]. The activities, dentifrobots will ensure a numerous reconstructive dental nanorobots, continuous barrier against halitosis [3].

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Benefits vs risks in the use of dental useless gray mass (the so-called gray-goo nanorobots scenario) [25]. Rapid development in the field of nanorobotics in the last two decades has CONCLUSIONS generated controversies over the safety of In the 1950s, nanorobotics was at a their application as well as the toxic effect of fictional stage, now we are at the theoretical the medical nanorobots on the human being stage, but the years 2020 will be called “the or the medium [22] and it seems we are decade of the medical nanorobots”. witnessing the birth of a new discipline: Nanorobots, considered even now as nanoethics [23]. revolutionary instruments are being expected The benefits of using dental nanorobots with a lot of enthusiasm and hopes, but also could be as numerous as there could be with some fear as they will radically change probably as many applications of these the 21st century dental medicine. Once widely minute instruments as there are needs in used, the role of the dentist will change dental medicine. visibly. More than ever, he will have to The possible toxicological risks on the possess technical capabilities and a quick and human body are being also discussed [24], the correct professional judgment. He will have possible disappearance of homo sapiens to treat especially acute facial trauma and rare sapiens if the nanorobots will not be genetic disease with manifestations at the eliminated from the human body, but also the level of the oral cavity. Besides, patients will possible disappearance of the biosphere if the ask for more aesthetic dental treatments. As a nanorobots will evolve towards the capacity result, dental nanorobots, today somewhat of continuous auto-replication, resulting in fictional, will bring significant benefits in oral the appearance of clusters consuming any health, contributing to achieving painless, living creature on Earth, leaving behind a quick and high precision dental treatments.

REFERENCES 1. R. Feynman, There's Plenty of Room at the Bottom. An invitation to Enter a New Field of Physics, http://www.zyvex.com/nanotech/feynman.html 2. K.E. Drexler, Engines of Creation. The Coming Era of Nanotechnology, Anchor Books, New York, 1986 http://e-drexler.com/d/06/00/EOC/EOC_Chapter_1.html 3. R.A. Freitas Jr., Nanodentistry, Journal of American Dental Association, 2000, 131(11): 1559-1565 4. R.A. Freitas Jr., Computational Tasks in Medical Nanorobotics, în M.M. Eshaghian-Wilner (ed.), Bio-inspired and Nano-scale Integrated Computing, John Wiley & Sons, New Jersey, USA, 2009, pp. 391-428 5. R.A. Freitas, Jr., Current Status of Nanomedicine and Medical Nanorobotics, Journal of Computational and Theoretical Nanoscience, 2005, 2: 1-25 6. C. Edeler, I. Meyer, S. Fatikow, Simulation and Measurement of Stick-Slip-Microdrivers for Nanorobots, în Doina Pisla, Marco Ceccarelli, Manfred Husty (eds.), New Trends in Mechanism Science: Analysis and Design, Springer Science +Business Media B.V., 2010, p. 109 7. M.J. Schulz, V.N. Shanov, Y. Yun (Eds.), Nanomedicine Design of Particles, Sensors, Motors, Implants, Robots, and Devices, Artech House, 2009, p. 10 8. S. Gorav, Vasudeva Kamlesh, P. Nidhi, Nanodentistry - the future ahead, BFUDJ, 2010, 1(1):43-45 9. P. Dutta, S. Gupta, Understanding of Nano Science and technology, Global Vision Publishing House, Delhi, India, 2006, pp. 43-44 10. R.A. Freitas, Progress in nanomedicine and medical nanorobotics, în M. Rieth şi W. Schommers (Eds.), Handbook of Theoretical and Computational Nanotechnology, Vol. X, 2005, American Scientific Publishers, pp. 1-54 http://www.nanomedicine.com/Papers/ProgressNM06.pdf

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11. Cavalcanti A, Shirinzadeh B, Zhang M, Kretly LC, Nanorobot Hardware Architecture for Medical Defense, Sensor. 2008, 8:2932-2958 12. Martel S, Mohammadi M, Felfoul O, Lu Z, Poiponneau P. Flagellated Magnetotactic Bacteria as Controlled MRI-trackable Propulsion and Steering Systems for Medical Nanorobots Operating in the Human Microvasculature. Int J Rob Res. 2009; 1; 28(4):571-582. 13. Sujatha V, Suresh M, Mahalaxmi S, Nanorobotics - a futuristic approach, SRM University Journal of Dental Sciences. 2010, 1(1):86-90 14. Xing Z, Dai L. Nanodiamonds for nanomedicine, Nanomedicine, 2009, 4(2):207-218 15. Xue Y, Ali Mansoori G. Self-Assembly of Diamondoid Molecules and Derivatives (MD Simulations and DFT Calculations), Int J Mol Sci. 2010; 11(1): 288–303 16. Zheng B, Lowther JE. Numerical investigations into mechanical properties of hexagonal silicon carbon nanowires and nanotubes. Nanoscale. 2010; 2(9):1733-9. 17. Partha R, Conyers JL. Biomedical applications of functionalized fullerene-based nanomaterials, Int J Nanomedicine. 2009; 4:261-275 18. Hogg T, Freitas RA Jr. Chemical power for microscopic robots in capillaries. Nanomedicine, 2010; 6(2):298-317. 19. Schulz MJ, Shanov VN, Yun Y. (Eds.), Nanomedicine Design of Particles, Sensors, Motors, Implants, Robots, and Devices, Artech House, 2009, p. 10 20. Saravana K.R., Vijayalakshmi R. Nanotechnology in dentistry, Indian Journal of Dental Research, 2006, 17(2):62-65 21. Patil M., Mehta DS, Guvva S. Future impact of nanotechnology on medicine and dentistry, 2008; 12 (2): 34-40 22. Singh Surya, Nalwa HS. Nanotechnology and health safety –toxicity and risk assessments of nanostructured materials on human health, J Nanosci Nanotechnol. 2007; 7(9):3048-3070 23. Leontis VL, Agich GJ. Freitas on disease in nanomedicine: implications for ethics, Nanoethics, 2010, 4:205-214 24. Popov AM, Lozovik YE, Fiorito Silvana, Yahia L’Hocine, Biocompatibility and applications of carbon nanotubes in medical nanorobots, Int J Nanomedicine. 2007; 2(3): 361–372 25. Drexler KE. Engines of Creation: The Coming Era of Nanpotechnology, Anchor Press/Doubleday, New York, 1986, p. 78 http://edrexler.com/d/06/00/EOC/EOC_Chapter_11.html#section01of05

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THE INFLUENCE OF THE ETCHING TIME ON THE ENAMEL HYBRIDIZATION IN PREVENTIVE SEALING. IN VITRO STUDY Cătălina Iulia Săveanu1, Anca Todiraşcu2, Irina Maftei3, Ioan Dănilă4 1Assistant Professor, PhD - Department of Oro-Dental Prevention, Faculty of Dentistry, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania 2Student - Faculty of Dentistry, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania 3PhD - Department of Oro-Dental Prevention, Faculty of Dentistry, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania 4Professor, PhD - Department of Oro-Dental Prevention, Faculty of Dentistry, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania

ABSTRACT Adhesion of dental materials to the dental hard tissue is dependent on a number of factors relating both to the material used and the type of approach to dental substrate. The purpose of this study was to analyze the size of the hybrid layer (HL) in evaluated sealed oclussal surfaces by scanning electron microscopy (SEM). Method: The study was realized in vitro on a sample of 16 human teeth premolars and molars extracted for orthodontic or periodontal reasons. Permission was obtained from an institutional ethical committee of "Gr. T. Popa" University of Medicine and Pharmacy, Iasi and the subjects gave written, informed consent. The teeth were randomly divided into two equal groups (Gr1=etching time 20 seconds and GR2=etching time 60 seconds). The teeth were restored using 3M™ Schotchbond Etch, Single Bond Dental Adhesive System 3MTM, composite resin Concise (3MESPE). The materials were photo activated with halogen source (3M), stored (48h), cut lengthwise (diamond), polished, conditioned (H3PO4-37%-5s) analysed by SEM (TESLA, BS 340), SPSS14.00 statistically analysed (ANOVA, p≤0.05). Results: Analysis of the HL has highlighted differences between groups only in the enamel p=.000 average size HL being Gr.1:17.76 (±6.7)µm;Gr.2:6.36(±2.8)µm. Conclusions: The thickness of hybrid layer related directly proportional with etching time, after 60 second the hybrid layer had a thickness of about three times higher than in the case for 20 seconds demineralization. Key words: resin composite, hybrid layer, enamel etch

Acknowledgements: The research was supported by a CNCSIS grant budget, no.2669/2008- Ideas Competition - Exploratory Research Projects - Ultra structural analyse of dental hard tissue hybridization in the minimal invasive treatment of the dental lesions achieved through mechanical and kinetic treatment with laser.

INTRODUCTION infiltration and polymerization of the The prevention of caries is one of the most materials used. In order to obtain the most simple and cheap methods of dental intimate adhesion between biomaterials and treatment. (American Dental Association). In hard dental structure, we rely on a less this context the methods of primary viscous phase which will penetrate the prevention should be a goal to be attained by previously conditioned hard dental tissues. each practitioner. Adherence of the materials to the dental Usually, the mechanical adhesion of substructures is dependent on a number of composite resins is based on dental tissue factors relating both to the type of material hybridization by means of surface and used as well as to the dental substrate subsurface demineralization, followed by preparation method.

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The purpose of this study was SEM material used was Concise 3M ESPE. evaluation (Scanning Electron Microscopy) of The samples were longitudinally enamel hybridization in preventive sealing sectioned-from mesial to distal-with diamond 0 when two different conditioning agents are disks, washed with 90 alcohol, processed, used. Null hypothesis is that the size of the polished with paper discs 400,600,1200 and hybrid layer does not differ significantly among 2400 grit SiC, with rubber points and abrasive the studied groups. The reason we chose to test pastes 6, 3, 1 and 0.25 µm under continuous the sealant’s adhesion to enamel when using irrigation. The samples were demineralised two different etching methods was the literary with H3PO4 35% for 4 seconds and washed controversy on the etching times and the desire with distilled water for 2 minutes [1]. to establish a possible correlation between the Prepared teeth were preserved in saline duration of acid application and the degree of solution in labelled bottles (up to 48 hours). sealant-enamel micro-leakage. Analysis of the samples was done by SEM (JEOLJSM Japan 6390). The hybrid layer MATERIAL AND METHODS (HL) thickness was measured in at least three The study included 16 human premolar different areas and an average was made for and molar teeth, freshly extracted due to each sample. The type of this study was orthodontic or periodontal reasons, after experimental SEM. Comparative analysis was obtaining the patient’s informed consent. The performed using Analysis of Variance test study followed the protocol approved by the (ANOVA), setting a 5% confidence interval. "Gr. T. Popa" UMPh Iasi ethics committee. The groups analysed were: GR.1: 8; SE ™ The teeth were mechanically brushed with a (60sec), ASBP, Concise ™ and Gr.2: 8; SE non-fluoridated abrasive paste, washed with ™ (20sec), ASBP, Concise™ . running water, stored in 0.5% chloramine 0 solution at 4 C. The samples were divided RESULTS randomly into two equal groups (N = 8) and The analysis of the hybrid layer in the two sealed according to protocol by applying two studied groups revealed statistically different etching times GR1=60seconds and significant differences p ≤ 0.05, with an GR2 = 20 seconds. Adhesion was achieved average of 17.761 µm for group A and 6.364 with etch and rinse adhesive system IS = µm for group B. Differences were recorded Schotchbond Etch ™ (3M ™), ASBP=Adper both between groups and in the same group, Single Bond Plus (3M ESPE). The sealing even in the same samples (Table 1, 2, 3, 4).

Sample D SH µm GR.1 D SH µm GR.2 M-GR.1 M-GR.2 Point 1 2 3 1 2 3 1 10,259 11,562 15,379 12,4 5,292 4,864 8,605 6,253 2 25,535 15,459 17,779 19,591 1,111 1,488 0,964 1,187 3 24,501 26,585 28,185 26,423 8,486 4,151 10,672 7,769 4 22,788 22,788 23,840 23,130 6,607 10,571 9,156 8,778 5 9,034 11,365 14,424 11,607 8,355 8,487 12,406 9,749 6 8,412 14,476 12,118 11,668 7,879 5,143 6,831 6,617 7 12,753 30,404 34,704 25,953 8,871 7,322 5,543 7,245 8 11,470 10,066 12,440 11,320 4,112 1,851 3,993 3,318 M 17,761 6,364

D= size; SH= hybrid layer; µm =micrometers M= mean Table 1. Results of quantitative analysis of the hybrid layer in the studied groups

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Levene Statistic df1 df2 Sig. 16.699 1 14 .001 Table 2. Statistical analysis in the groups studied

95% Confidence Std. Interval for Mean N Mean Std. Error Min Max Deviation Lower Upper Bound Bound GROUP A 8 17.76150 6.756344 2.388728 12.11305 23.40995 11.320 26.423 GROUP B 8 6.36450 2.833261 1.001709 3.99583 8.73317 1.187 9.749 Total 16 12.06300 7.725695 1.931424 7.94627 16.17973 1.187 26.423 Table 3. Descriptive statistics

Sum of Squares df Mean Square F Sig.

Between Groups 519.566 1 519.566 19.360 .001 Within Groups 375.729 14 26.838

Total 895.295 15

Table 4. ANOVA in the groups studied

A. B. Fig. 1. SEM appearance of the enamel hybrid layer in preventive sealing with Concise White Sealant (3M ESPE): A. Group 1 - 60 seconds etching time revealed penetration of sealant to the bottom of the fissure and the formation of an optimal hybrid layer; B. Group 2 - 20 seconds etching time revealed penetration of sealant to the bottom of the fissure but with marginal gap DISCUSSION crystals prisms with the development of Enamel etching in the protocol of the new microtags and macrotags [5], raising the free adhesive techniques [2, 3] aims to provide an energy on the enamel surface, which optimal impregnation of its surface with facilitates the filling of the demineralized area adhesive monomer and consists of: removal with adhesive [6, 7] and ensuring wider of plaque, removal of remaining dentinal contact surface between enamel and resin [8, debris, creating micro-retentions in the form 9]. All these objectives are aimed at achieving of crypts [4] by: partial and preferential effective hybridization of the enamel by a dissolution of prismatic and between mineral maximum monomer infiltration [10].

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The hybrid layer dimension can be influenced by the orientation of the crystals towards the conditioned surface (Fig. 2, 3, 4). There are three types of enamel [6, 11]: Type I - with interprismatic enamel demine- ralization in the form of a "bird's nest"; it is the most common type and it affects the body of the prism; peripheral prisms remain approximately integral, especially in the case of a longer etching time- 45 seconds opposed to 30 seconds [12] Optimal micro retentive relief (type I) was obtained only when the enamel was conditioning in a parallel direction to the Fig. 2. A-SEMX800 -enamel interprismatic axis of the prism, the acid attack perpendicular areas –after demineralization with H3PO4 to it, sometimes proving to be totally inefficient. 35%, for 1 minute [Iulia Săveanu].

A B Fig. 3. SEM enamel between prisms areas- after demineralization with H3PO4 35%, for 30 seconds A. SEMX4000; B. SEMX10000. We can observe the places where the material can penetrate to form resin microtags [Iulia Săveanu].

A) B) Fig. 4 A)-SEMX1000- enamel interprismatic areas- after etching with 35% orthophosphoric acid for 60 seconds, B)-SEMX4000-[Iulia Săveanu]. Type II - enamel with accentuated the centre of the prism remaining intact; with peripheral between prisms demineralization, a lower frequency [12, 13]. This morphology

87 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 offers retention only in the between prisms surface, allowing the penetration of a low areas, where the adhesive will penetrate and viscosity resin up to a depth of 30-50 μm. through the resin polymerization it will form This etching will induce an adherence of macrotags. Type III - enamel in which coexist about 20 MPa [17]. both demineralization types, resulting an amorphous irregular surface after etching CONCLUSIONS with H3PO4 37% for 15 seconds [12, 13]. SEM objectively reflects the adhesion of Other electron microscopy studies the sealing material to the enamel. Hybrid revealed that an etching performed for 15 layer size varies both between groups and in seconds is as effective as one performed for the same group, even in the same samples. 60 seconds [14, 15], the attack mode of the The thickness of the hybrid layer formed enamel was unchanged by the action time between enamel and sealant is directly except for the depth around the enamel proportional to the etching time; after 60 prisms, but the adhesion strength was not seconds the hybrid layer has three times the affected by the depth of demineralization, thickness of the one formed by a 20 seconds aspect illustrated in a in vitro study [7]. That demineralization. The etching time influences study highlights the fact that the adherence of the dimension of the HL in favour of the the composite resin is not significantly samples that were demineralised for 60 influenced by the type of acid used- 19.7 MPa seconds. for 35% orthophosphoric acid and 18.6 MPa for 10% maleic acid in microfilled ACKNOWLEDGEMENTS composites - but it is influenced by the type The research was supported by a CNCSIS and composition of the restorative materials grant budget, no.2669/2008 - Ideas even if they are of the same class Competition-Exploratory Research Projects - (composites). Also, other laboratory studies Ultra structural analyse of dental hard tissue [14, 16] demonstrated similar results in terms hybridization in the minimal invasive of adherence and micro-leakage for an acid treatment of the dental lesions achieved etching of 15 or 60 seconds. 37% through mechanical and kinetic treatment orthophosphoric acid etching for 15 seconds with laser will lead to micro-spaces on the enamel

REFERENCES 1. Joseph VP, Rossouw PE, Basson NJ. “Some sealants seal a scanning electron microscopy (SEM) investigation” Am J Orthod Dentofacial Orthop 1994; 105:362-368. 2. Buonocuore MG, Matsui A, Gwinnett AJ “Penetration of resin dental materials into enamel surfaces with reference to bonding” Arch Oral Biol 1968;13:61-70. 3. Macri Soraia, Mariane Goncalves, Tomio Nonaka, Jaime Maia dos Santos, “ Scanning Electron Microscopy Evaluation of the Interface of Three Adhesive Systems”, Braz Dent J (2002) 13(1):33-38 ISSN 0103-6440. 4. Ngo, H, Mount GJ, Peters MCRB“A study of glass ionomer cement and its interface with the enamel and dentin using a low-temperature, high resolution scanning electron microscope technique”, Quintesence International 1997;, 28; 63-69. 5. Gwinnett A.J., Matsui A. “A study of enamel adhesives. The physical realationship between enamel and adhesive” Arch Oral Bioal 1967;12:1615-1620. 6. Gwinnett AJ “Histologic changes in human enamel following treatment with acidic adhesive conditioning agents” Arch Oral Biol 1971; 16:731-738. 7. Retief DH “Effect of conditioning the enamel surface with phosphoric acid” J Dent Res

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1973;52:333-341. 8. Swift J. Edward, “Bonding systems for restorative materials – a comprehensive review”, Pediatr. Dent. 199;, 20:2,80-84,. 9. Swift J. Edward, “The effect of sealants on dental caries: a review, JADA 1988;9(2):57-60. 10. Nakabayashi N, Pashley DH Tokyo, “Hybridization of dental hard tissue” Quintessence International, 1998. 11. Silverstone LM, Saxton CA, Dogon IL, Fejerskov, “Variation in the pattern of acid etching of human dental enamel examinated by scanning electron microscopy”. Caries Res 1975;9:373-387. 12. Liciane RRS, Costa, Ii-sei Watanabe, Marcelo Fava, “Three-Dimensional Aspects of Etched Enamel in Non-Erupted Deciduous Teeth”, Braz Dent J 1998;, 9(2):95-100 ISSN 0103-6440. 13. Fava Marcelo, Ii-Sei Watanabe, Elavio Fava, “Observations on etched enamel in non-erupted deciduous molars: a scanning electron microscopy”, Rev Odontol Univ. Sao Paolo 1997;.11(3): 157- 160:. 14. Barkmeier WW, Shaffer SE, Gwinnett AJ, “Effects of 15 vs 60 second enamel acid conditioning on adhesion and morphology” Oper Dent 1986;11:111-116. 15. Gilpatrick RO, Ross JA, Simonsen RJ,”Resin to enamel bond strnths with various etching times” Quintesence International 1991;22:47-49. 16. Nordenvall K-J, Brannstrom M, Malmgren O, “Etching of deciduous teeth and zoung and old permanent teeth. A comparison between 15 and 60 seconds of etching” Am J Orthod 1980;19:36-38. 17. Mount GJ, “An atlas of glass-ionomer cements. A clinical’s guide” 3rd edn, London: Martin Dunitz Ltd, 2002.

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STUDY ON THE FREQUENCY OF ENDOCRINE DISORDERS IN CHILDREN AND TEENAGERS

Adriana Bălan, Marinela Păsăreanu, Ana Petcu, Veronica Șerban Pintiliciuc “Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania Faculty of Dental Medicine, Department of Pediatric Dentistry

ABSTRACT Aim The purpose of the study was to evaluate the frequency of endocrine disorders in children and teenagers in Moldova county where the presence of major cranio-maxillo-facial disturbances related to endocrine disorders is a well-known reality. The importance of these results relies in the future management of these diseases both clinical and therapeutic. Materials and Methods In the analytic process of observation and care, we used primarily statistical data from a group of 404 patients (children and teenagers), 157 boys and 247 girls aged between 3.6 and 18.5 years, admitted in the Endocrinology Clinic at St. Spiridon University Hospital, Iasi. Every investigated subject was attributed a recording chart with personal data, name, age, sex, and the residence area. Results and Discussion Specific for the analysed group of patients was the great prevalence of Turner Syndrome, followed by pituitary dwarfism and other growth disorders. Nevertheless there also were patients with Klinefelter Syndrome, gonadal disgenesias or congenital mix oedema. This is why further research in other regional hospitals is needed, in order to elucidate possible zonal characteristics (endemic) of various endocrine disorders. On the other hand, genetic and endocrine syndromes seriously affect the patients' oral health, especially the cranio-maxillo-facial growth in children. Conclusions This high prevalence identified in this region can be explained by a better coordination in the identification and treatment of the children, as a result of a sustained clinical program established by the Endocrinology Clinic, the Human Genetic Centre and other paediatric medicine clinics. The identified disorders imply a careful clinical management performed by both the endocrinologist and the paediatric dentist.

Key words: endocrine diseases, children frequency.

INTRODUCTION maxillo-facial disorders in genetic and The progresses made in the last decades in endocrine syndromes [3]. medical fundamental research determined radical changes in all the fields of medical OBJECTIVES practice [1]. This is also true for dental The purpose of the study was to evaluate medicine, in which the interest of the the frequency of endocrine disorders in scientists extends beyond the field of children and teenagers in Moldova County, dentistry, seeking collaboration with other the presence of major cranio-maxillo-facial specialties [2]. One can participate in this disturbances in endocrine disorders being a situation to the complex evaluation well-known reality. concerning the implication of dismorphogenetic phenotypes, not only from MATERIALS AND METHODS the dental specific entities point of view, but 404 recording charts of patients (children also in the identification and definition of the and teenagers, 157 boys and 247 girls, aged deficient factors involved in the cranio- between 3.6 and 18.5 years old), from the

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Endocrinology Clinic of Iasi, “Sf. Spirion” mixedema (3.46%). Considering the Universitary Hospital have been assessed. correlation between hypopituitarism Every investigated subject had a recording (idiopathic or secondary) and hypostature, chart, with personal data, name, age, sex and although pituitary hormones may be deficient, the residence area in which he or she lived. usually there should be an isolated deficiency in growth hormone [4]. In relation to the RESULTS AND DISCUSSION hypothyroidism (congenital or juvenile), Graph 1 indicates the frequency of thyroid hormone deficiency is most often different endocrine disorders. Details on sex secondary to a primary disease of the thyroid and residence area of subjects are presented and less commonly associated with in tables 1 and 2. From all the patients with hypothalamic and/or pituitary insufficiency endocrine disorders, the absolute frequency [4, 5]. and percentage of the cases is represented by In what concerns the environmental the Turner syndrome (31.68%), followed by implications, our results show higher levels of almost equal percentages of the pituitary affectation for urban areas patients (16.83%) dwarfism cases (22.26%), and short stature in comparison with those from rural areas and growth disorders (22.77%). In a third (14.85%) for the Turner syndrome, while the position with a frequency of 12.37% is pituitary dwarfism shows a different ratio, another genetic endocrine disease – the rural areas children being more affected Klinefelter syndrome, followed by other (12.87%) than those from urban areas gonad disgenesias (7.42%) and congenital (9.40%) (Table 1, 2).

M F TOTAL Diagnostic n % n % n % Hypopituitarism 49 12,12 41 10,14 90 22,26 Turner Syndrome - 128 31,68 128 31,68 Klinefelter Syndrome 50 12,37 - 50 12,37 Congenital Hypothyroidism 4 0,99 10 2,47 14 3,46 Other gonad disgenesias - 30 7,42 30 7,42 Hypostature and other growth disorders 54 13,36 38 9,40 92 22,77 TOTAL 157 38,86 247 61,14 404 100 Tabel 1. Absolute and percent frequencies of cases relative to sex and diagnosis

Fig. 2. Diagnostic structure relative to Fig. 2. Diagnostic structure relative to sex ecologic origin Based on the different counties, in our shows the highest values (41.33%) followed region, during this period the Iasi county by Vaslui and Suceava counties (14.10% and

91 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 respectively 14.85%), Botosani county Vrancea (2.47%). Insignificant percentage is (8.16%), Bacau and Neamt counties (7.29% represented by other counties of the country and respectively 6.68%). On the last places (Table 3). are situated Galati county (2.72%) and

U R TOTAL Diagnosis n % n % n % Hypopituitarism 38 9,40 52 12,87 90 22,27 Turner Syndrome 68 16,83 60 14,85 128 31,68 Klinefelter Syndrome 29 7,18 21 5,20 50 12,38 Congenital Hypothyroidism 4 0,99 10 2,48 14 3,47 Other gonadic disginesias 17 4,21 13 3,22 30 7,43 Hipostature and Growth disorders 38 9,40 54 13,37 92 22,77 TOTAL 194 48,01 210 51,99 404 100 Tabel 2. Absolute and percent frequencies of cases relative to ecologic origin

M F TOTAL County n % n % n % IS 62 15,34 105 25,99 167 41,33 VS 23 5,69 34 8,41 57 14,10 SV 22 5,45 38 9,40 60 14,85 BT 19 4,70 14 3,46 33 8,16 BC 14 3,46 18 4,46 32 7,92 NT 9 2,22 18 4,46 27 6,68 GL 4 0,99 7 1,73 11 2,72 VN 4 0.99 6 1,48 10 2,47 CT - 1 0,24 1 0,24 I.L - 1 0,24 1 0,24 DB - 1 0,24 1 0.24 BN - 1 0,24 1 0,24 PH - 1 0,24 1 0.24 HD 1 0,24 - 1 0,24 TL 1 0,24 - 1 0,24 TOTAL 159 39,35 245 60,65 404 100 Tabel 3. Absolute and percent frequencies of cases relative to sex and demographic origin treatment of the children, as a result of a sustained program established between Endocrinology Clinic, the Human Genetic Centre and the territorial medical centres, as well as other social and economic factors that permit a better access in an University Clinic. A research in other hospitals is needed to elucidate the zonal characteristics of endocrine disorders.

Fig. 3. Territorial distribution of cases with CONCLUSIONS endocrinopathies Based on the observations made in this The higher values for Iasi county and for research we can draw the following those around, can be explained by a better conclusions: coordination in the identification and 1. The most frequent endocrine disorders in

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this study are the Turner syndrome and coordination in the identification and pituitary dwarfism, closely followed by treatment of the children, as a result of a short stature and other growth disorders. sustained program established between the 2. The pituitary dwarfism and the short Endocrinology Clinic, the Human Genetic stature have a higher frequency in the rural Centre and the territorial dispensaries. areas than in the urban areas, an inverse 4. A study on the frequency of endocrine ratio being observed for Turner syndrome disorders in the other hospitals in Moldova and Klinefelter syndrome. and other regions of the country is needed 3. The higher values for Iasi county and for to elucidate the zonal characteristics of those around, can be explained by a better endocrine disorders.

REFERENCES 1. Maxim A, Pasareanu M, Balan A, Armencea B. Paedodontics. Ed. Contact International, 1999. 2. Zbranca E, Mogos V, Galesanu C, Vulpoi C. Endocrinologie clinica. Ed. Cutia Pandorei, Vaslui, 1997. 3. Williams W. Textbook of Endocrinology. 8th Edition, ed. by JD Wilson, DN Foster, WB Saunders Co. 1992. 4. Angus CC, Richard PW, Handbook of Pediatric Dentistry, Mosby, 2003. 5. Koch G, Poulsen S,Modeer Th, Rasmussen P, Pedodontics – A Clinical Approach, Munksgaard, 1997.

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STUDY REGARDING THE ASSESSMENT OF ENAMEL MICROHARDNESS IN INCIPIENT CARIOUS LESIONS TREATED BY ICON METHOD Galina Pancu, Sorin Andrian, Gianina Iovan, Angela Ghiorghe, Claudiu Topoliceanu, Antonia Moldovanu, Andrei Georgescu, Ion Pancu, Simona Stoleriu Dental Medicine School, „Gr. T. Popa” U.M.Ph., Department of Odontology and Periodontology, Cariology and Restorative Dentistry, Iasi, Romania,

ABSTRACT Sealing or infiltrating dental hard tissues are modern methods in conservative treatment of early carious lesions. One of the most actual methods for the conservative therapy of incipient dental caries is based on local use of sealing and infiltrating agents. This study assesses the enamel microhardness comparing artificial carious lesions treated by ICON method and carious lesions treated by fluorisation with microhardness of similar untreated surfaces. The highest values of microhardness were obtained for enamel demineralised surfaces treated with ICON. The ICON method conducts to the formation of harder enamel surfaces, able to resist to further acid attacks.

׃Key words: artificial caries, infiltration method ICON, enamel conservative treatment

INTRODUCTION localised on smooth surfaces (buccal, oral, The actual methods for the treatment of approximal). incipient caries do not always succeed to stop The aim of our research was to determine their evolution [1, 2]. The reason for failure is the microhardness of untreated demineralised represented by the lack of patient compliance to enamel surfaces with microhardness of enamel dentist indications related to hygiene and surfaces with artificial dental caries, treated fluorisation protocols. In this context a high with ICON method or by fluor remineralisation. percent of uncavitated enamel caries transforms in cavitary dental caries. In incipient carious MATERIALS AND METHODS lesions the enamel demineralisation progress The study included 10 teeth (bicusps or below subsurface layer, forming a porous layer molars), healthy, extracted for orthodontic or that allows diffusion of cariogenic acids. In this periodontal reasons. Teeth were cut stage minerals are removed favouring the dental longitudinal with diamond discs. The slices caries progression. In the first stage of enamel were polished with carborundum paper (100- caries is important to apply some efficient 4000) under water cooling. The polishing was therapeutically measures to stop further finished with 0,05 polish and diamond paste evolution of cariogenic processes. The ICON no. 3 and no. 1, using a device Buehler, infiltration method was introduced by prof. H. model Minimet. The samples were cleaned Meyer-Luckel& Dr. Sebastian Paris and with ethanol and washed three times for 5 developed by DMG. ICON method uses a minutes with distilled water [13, 14]. The composite resin with high viscosity that sections were immersed in a demineralisation infiltrates (maximum 800 µm) dental caries solution (2,2 mM CaCl₂, 2,2 mM KH₂PO₄,

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0,05 M acetic acid, pH 4,4) for 120 hours. optic stereomicroscope than included in After demineralisation stage sections were autopolimerisable resin. The indentations of imersed in water for 24 hours. Finally the Vicker hardness were measured and assessed sections were divided in three study groups: with Optic Microscope Neophot 21. The Study group I- Icon, Study group II- Fluor, measures of Vickers hardness were realised Control group III- untreated enamel surfaces. with a special device for microhardness  Group I Icon – 10 sections with artificial testing with a squared diamond head with caries submitted to infiltration with Icon, angle 136º. This device includes an optic accordingly to producer indications; microscope with high resolution and contrast.  Group II Fluor – 10 sections with artificial The device, produced by VEB Zeiss Jena is caries submitted to remineralisation with used with Optic Microscope Neophot Bifluorid 12. measuring hardness of different structure  Group III (control) – 10 sections with components. The indentations were untreated artificial caries. performed with a loading 100g and at least The protocol for Icon technique: A 15% 40μm minimal distance between indentations. hydrochloric gel is used to remove the The number of indentations varied “pseudointact” surface and open the pore accordingly to enamel and dentine thickness. system of the incipient lesion body (Icon-Etch, The criteria for accepting indentations 2 min).Washed (30 sec.), air-dried (30 sec.) (indentation geometry) include sharpness on After rinsing the area is dried with ethanol diagonal edges and uniform aspect [2, 12]. (Icon Dry 30 sec.) followed by dry air (30 sec). To identify and control parameters that Then, the infiltrant is applied and allowed to influence statistical measures, the penetrate the lesion pores by capillary action composition and orientation of pressure head for 3 minutes. Any excess material is removed taken in account. with dental floss, and the infiltrant is light The VHN values are presented in tables cured from three angles for 40 seconds. A below. The mean values and standard second layer of infiltrant is applied for 1 variation were calculated both for IL and minute, and light cured for 40 seconds. VHN. Test Kappa was used to establish The sections were initially examined with safety coefficients for IL reading.

Microhardness values (VHN) Surfaces 1 2 3 4 5 6 7 8 9 10 Indent. No. 221 176 98 208 198 226 219 211 98 146 10 165 89 105 198 234 142 92 231 241 168 10 Study Group I 189 247 124 176 208 98 169 171 187 158 10 (ICON) 165 109 217 97 167 211 145 192 192 99 10 231 223 229 194 158 229 201 145 67 231 10 107 102 44 68 76 78 69 71 62 78 10 92 91 118 43 108 91 94 97 99 107 10 Study group II 118 98 125 98 82 67 85 89 64 68 10 (Bifluorid) 87 50 109 77 91 87 66 56 92 94 10 42 76 74 40 96 61 89 67 78 84 10 37 42 44 31 29 28 32 42 29 34 10 32 31 18 43 38 31 44 37 29 27 10 Study group III 28 28 25 29 32 28 28 39 34 31 10 (untreated) 24 30 39 37 41 37 36 26 42 44 10 42 27 44 40 36 41 29 37 28 24 10 Table 1. Micro-Vickers hardness test values

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t Test. Independent samples - Group Statistics LOT N Mean Std. Dev Std. Error Mean Lot Icon 5 194.20 30.842 13.793 Hardness Surface 1 Lot Martor 5 32.60 7.127 3.187 Lot Icon 5 168.80 69.009 30.862 Hardness Surface 2 Lot Martor 5 31.60 6.025 2.694 Lot Icon 5 154.60 63.303 28.310 Hardness Surface 3 Lot Martor 5 34.00 11.853 5.301 Lot Icon 5 174.60 44.898 20.079 Hardness Surface 4 Lot Martor 5 36.00 5.916 2.646 Lot Icon 5 193.00 30.952 13.842 Hardness Surface 5 Lot Martor 5 35.20 4.764 2.131 Table 2. Icon lot–control lot Surfaces 1-5

RESULTS The values of enamel microhardness associated with artificial dental caries varied in the range 246-67 VHN for lot I (Icon infiltration method), 125-40 VHN for lot II (fluorisation method) and between 44-24 VHN for lot III (control lot- untreated demineralised enamel surfaces).

Independent Samples Test t-test for Equality of Means Levene's Test for Equality of 95% Confidence Variances Interval of the Difference p. (2- Mean Std. Error F Sig. t Df Lower Upper tailed) Difference Difference Equal variances 12.807 .007 11.415 8 .000 161.600 14.156 128.956 194.244 assumed Hardn.Surf.1 Equal variances 11.415 4.426 .000 161.600 14.156 123.744 199.456 not assumed Equal variances 15.188 .005 4.429 8 .002 137.200 30.979 65.762 208.638 assumed Hardn.Surf.2 Equal variances 4.429 4.061 .011 137.200 30.979 51.695 222.705 not assumed Equal variances 35.718 .000 4.187 8 .003 120.600 28.802 54.182 187.018 assumed Hardn.Surf.3 Equal variances 4.187 4.280 .012 120.600 28.802 42.655 198.545 not assumed Equal variances 4.210 .074 6.844 8 .000 138.600 20.252 91.898 185.302 assumed Hardn.Surf.4 Equal variances 6.844 4.139 .002 138.600 20.252 83.107 194.093 not assumed Equal variances 9.734 .014 11.267 8 .000 157.800 14.005 125.504 190.096 assumed Hardn.Surf.5 Equal variances 11.267 4.189 .000 157.800 14.005 119.600 196.000 not assumed Table 3.

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Statistical analysis: hypothesis is that there are no significant The aim of research is to establish if mean statistically differences between scores for all values of microhardness for all three groups three groups. We are interested if there are present significant differences between them. significant differences between the mean This is research hypothesis. The null values of study groups.

Group Statistics LOT N Mean Std. Deviation Std. Error Mean Lot Bifluorid 5 89.20 29.098 13.013 Hardn.Surf.1 Lot Control 5 32.60 7.127 3.187 Lot Bifluorid 5 83.40 21.138 9.453 Hardn.Surf.2 Lot Control 5 31.60 6.025 2.694 Lot Bifluorid 5 94.00 34.139 15.268 Hardn.Surf.3 Lot Control 5 34.00 11.853 5.301 Lot Bifluorid 5 65.20 24.243 10.842 Hardn.Surf.4 Lot Control 5 36.00 5.916 2.646 Lot Bifluorid 5 90.60 12.442 5.564 Hardn.Surf.5 Lot Control 5 35.20 4.764 2.131 Table 4. Bifluorid Lot–Control Lot Surfaces 1-5

Independent Samples Test

Levene's t-test for Equality of Means Test for 95% Confidence Equality of Interval of the Variances Difference p. (2- Mean Std. Error F Sig. t df tailed) Difference Difference Lower Upper Hardn.Surf.1 Equal variances 2.730 .137 4.225 8 .003 56.600 13.398 25.705 87.495 assumed Equal variances 4.225 4.478 .011 56.600 13.398 20.917 92.283 not assumed Hardn.Surf.2 Equal variances 5.752 .043 5.270 8 .001 51.800 9.830 29.133 74.467 assumed Equal variances 5.270 4.646 .004 51.800 9.830 25.942 77.658 not assumed Hardn.Surf.3 Equal variances 8.060 .022 3.712 8 .006 60.000 16.162 22.731 97.269 assumed Equal variances 3.712 4.951 .014 60.000 16.162 18.330 101.670 not assumed Hardn.Surf.4 Equal variances 6.936 .030 2.617 8 .031 29.200 11.160 3.466 54.934 assumed Equal variances 2.617 4.475 .053 29.200 11.160 -.530 58.930 not assumed Hardn.Surf.5 Equal variances 2.920 .126 9.298 8 .000 55.400 5.958 41.660 69.140 assumed Equal variances 9.298 5.148 .000 55.400 5.958 40.216 70.584 not assumed Table 5.

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LOT N Mean Std. Deviation Std. Error Mean Lot Icon 5 194.20 30.842 13.793 Hardn.Surf.1 Lot Bifluorid 5 89.20 29.098 13.013 Lot Icon 5 168.80 69.009 30.862 Hardn.Surf.2 Lot Bifluorid 5 83.40 21.138 9.453 Lot Icon 5 154.60 63.303 28.310 Hardn.Surf.3 Lot Bifluorid 5 94.00 34.139 15.268 Lot Icon 5 174.60 44.898 20.079 Hardn.Surf.4 Lot Bifluorid 5 65.20 24.243 10.842 Lot Icon 5 193.00 30.952 13.842 Hardn.Surf.5 Lot Bifluorid 5 90.60 12.442 5.564 Table 6. Icon Lot–Bifluorid Lot Surfaces 1-5 The mean values of microhardness, for is higher than 0.05, variants are equal and the control group are lower than mean values of results of test t is presented on first range. For study groups. all five surfaces the results are statistically The results presented in table 2 show that significant. Similar results appear for the mean values of microhardness in control other lots (coefficient p is marked with red in group are lower comparing with ICON group. below tables). If probability associated with Levene test

Independent Samples Test

Levene's t-test for Equality of Means Test for 95% Confidence Equality of Interval of the Variances Difference p. (2- Mean Std. Error F Sig. t df tailed) Difference Difference Lower Upper Equal variances .322 .586 5.537 8 .001 105.000 18.963 61.272 148.728 Hardn. assumed Surf.1 Equal variances 5.537 7.973 .001 105.000 18.963 61.246 148.754 not assumed Equal variances 7.981 .022 2.646 8 .029 85.400 32.277 10.969 159.831 Hardn. assumed Surf.4 Equal variances 2.646 4.744 .048 85.400 32.277 1.065 169.735 not assumed Equal variances 7.934 .023 1.884 8 .096 60.600 32.165 -13.572 134.772 Hardn. assumed Surf. 3 Equal variances 1.884 6.145 .107 60.600 32.165 -17.655 138.855 not assumed Equal variances .768 .406 4.794 8 .001 109.400 22.819 56.780 162.020 Hardn. assumed Surf.4 Equal variances 4.794 6.150 .003 109.400 22.819 53.892 164.908 not assumed Equal variances 4.380 .070 6.864 8 .000 102.400 14.918 67.998 136.802 Hardn. assumed Surf.5 Equal variances 6.864 5.260 .001 102.400 14.918 64.614 140.186 not assumed Table 7.

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Fig. 1. Mean variation of microhardness for all study groups

DISCUSSIONS The values of enamel microhardness One of the most recent methods for associated with arificial dental caries varied conservative therapy of incipient caries is in the range 246-67 VHN for lot I (Icon represented by local application of sealing infiltration method), 125-40 VHN for lot II agents with role of infiltrating hard dental (fluorisation method) and between 44-24 tissues [1, 4, 5, 10]. The composition, mode VHN for lot III (control lot- untreated of action and efficiency is a complex study demineralised enamel surfaces). The Icon subject [7, 8]. An important problem is method is simple to use and avoid the represented by search of agents that can sacrifice of healthy tissue. The Icon method is establish normal parameters of enamel prisms microinvasive because of the removal of network and dentine structures for an external intact enamel layer to favour better optimum esthetic effect and adequate penetration of infiltrating resin. This method resistance o dental structures [3]. For therapy is adequate to treat only dental caries of incipient dental caries there are two groups extended to external third of dentine (D1). of therapeutical agents:  Agents that influence enamel CONCLUSIONS mineralisation (remake missing ions from The values of microhardness for enamel enamel prisms) [10]; surfaces with artificial dental caries treated  Agents that impair the absorption of with Icon method were significantly higher cariogenic substances (acids, toxines, comparing with untreated demineralised metabolites) on dental hard structures: enamel surfaces. The Icon method can sealants, infiltrating agents, hydrophobe prevent the progression of lesion body and layers [11]. the increase of dental tissues hardness and The infiltrating technique represents a new resistance to acid attacks. The results of our concept that can be used for therapy of D1 study can be associated with therapeutically incipient dental caries, as a microinvasive success of Icon method in the therapy of technique associated with lack of pain. uncavitated incipient enamel caries.

REFERENCES 1. Andrian Sorin Tratamentul minim invaziv al cariei dentare, Editura, Princeps Edit, Iaşi 2002: 94-95. 2. Maria del Pilar Gutiérrez-Salazar, Jorge Reyes-Gasga Microduritatea şi compoziţia chimică a dinţilor umani, Materials Research, 2003, vol 6(3) 367-373. 3. Căruntu I.D. Histologia sistemului stomatognat, Ed., Apolonia, 2001: 43-67. 4. Paris S, Meyer-Lueckel H, Kielbassa AM. Resin infiltration of natural caries lesions. J Dent Res.

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2007;86 (7):662-666. 5. Meyer-Lueckel H, Paris S. Improved resin infiltration of natural caries lesions. J Dent Res. 2008;87(12): 112-116. 6. Gray GB, Shellis P. Infiltration of resin into white spot caries-like lesions of enamel: an in vitro study. Eur J Prosthodont Restor Dent. 2002;10(1): 27-32. 7. Garcia-Godoy F, Summitt JB, Donly KJ. Caries progression of white spot lesions sealed with an unfilled resin. J Clin Pediatr Dent. 1997;21(2):141-143. 8. Reyes-Gasga J., Alcantara-Rodriguez C.M., Gonzalez-Trejo A.M., Madrigal-Colin, A. Microhardness and chemical composition of human tooth. Acta Microscopica, Acta Microscopica, 1997, 6 :24-38, 9. Meredith, N.; Sherriff, M.; Setchell, D.J.; Swanson, S.A. Vikers measurement of the microhardness and Young’s modulus of human enamel and dentine using an indendation technicue.. Archs, Oral Biol. 1996, 41: 539-545. 10. Pancu G., Lăcătuşu Șt., Andrian S., Ghiorghe A., Pancu I., Terapia cariei de smalţ necavitare prin utilizarea tehnicilor minim invazive ; Al X-lea curs naţional de stomatologie generală. Tehnici moderne de diagnostic şi tratament în stomatologie generală. Piatra Neamt, 2-4.07.2004. 11. Pancu G., Lăcătuşu Șt., Andrian S., Iovan G., Ghiorghe A., Stoleriu S., Terapia cariilor incipiente de smalţ prin metoda remineralizării profunde cu Enamel-Ermetizant. Zilele Facultăţii de Medicină Dentară., Supl. lucr. Martie 2006, 135-141. 12. Wilson, T.G.; Love, B. Microhardness and chemical composition of human tooth. Am. J. Orth. and Dentofacial Orthop, 1995, 107: 379-381, 13. Gaspersic, D. J. Microhardness and chemical composition of human tooth. Oral Pathol. Med., 1995, 24:153-158. 14. Kodaka, T.; Debari, K.; Yamada, M.; Kuroiwa, M. Microhardness and chemical composition of human tooth. Caries Res., 199,. 26:139-141 .

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MODIFICATION OF SALIVARY PROTEINS, GLUCOSE AND CALCIUM LEVEL IN GENERAL DISEASES Bogdan Petru Bulancea 1, Maria Ursache 2 1PhD Student, Department of Prosthetic Dentistry, Faculty of Dental Medicine, ”Gr. T. Popa” University of Medicine and Pharmacy Iasi, Romania 2Professor, Department of Prosthetic Dentistry, Faculty of Dental Medicine, ”Gr. T. Popa” University of Medicine and Pharmacy Iasi, Romania

ABSTRACT Biochemical analysis of the inorganic salivary compounds can serve as indicators of salivary gland modifications during some general diseases, with repercussions on the cariogenic risk. The aim of the study was to evaluate the modification of some salivary parameters in different conditions of general affection (high blood pressure associated with diabetes and radiotherapy). Materials and methods The study was conducted on 65 patients aged between 65 to 80 years old. The values of total salivary proteins, salivary glucose and calcium- Ca2+, that could influence the occurrence of some oral cavity modifications, as a result of the pre-existing systemic pathology, were determined. Results The study showed that there are no significant variations of total proteins at the studied patients. We found elevated salivary glucose levels in patients with high blood pressure associated with diabetes and an increase of calcium concentration in patients which received radiotherapy. Conclusion The presence of high blood pressure associated with diabetes, and the radiation treatment affects quality of oral fluid.

Key words: total salivary proteins, salivary glucose, salivary calcium, general diseases

INTRODUCTION disease. Changes in salivary or crevicular fluid In this study we evaluated the modification proteins concentration are in tight correlation of some salivary parameters in different with dental-periodontal disorders encountered conditions of general affection. at the third age. Significant flow rate decrease can be the reason for the ductal reabsorption MATERIALS AND METHOD decrease of salivary electrolytes. Biochemical The study was conducted on 65 patients analysis of the inorganic salivary compounds aged between 65 to 80 years old, selected can serve as indicators of salivary gland from the Oral and Maxillofacial Surgery modifications during some general diseases, Clinic and the Odontology-Periodontology with repercussions on the cariogenic risk. Clinic in the Dental Medicine Faculty, Utility of saliva in diagnosis of the oral University of Medicine and Pharmacy “Gr. T. cavity disorders, cariogenic risk and Popa” Iasi, as well as from the Medical Clinic monitoring oral pathology and carious of CFR Hospital Iasi, and the Oncology activity is an area subjected to active Clinic of “Sf. Spiridon” Hospital Iasi during investigation, favouring a proper diagnostic, 2005-2009. but also the monitoring of the disease Of the total, 27 individuals had general condition. Salivary modifications can be the affections - high blood pressure associated most common oral manifestations in systemic with diabetes and 23 followed cervical-facial

101 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 radiotherapy for oral and maxillofacial Total proteins concentration in the saliva is neoplasms. Patients were grouped into three low in patients with low stimulated salivary clusters: flow either by administration of  Cluster A: n=15 patients with a cardiovascular drugs or in those with satisfactory general condition (control radiotherapy. Total proteins concentration group) correlates directly with salivary amylase  Cluster B: n=27 patients with mentioned concentration. Salivary protein secretion is systemic disorders, resulting in mainly regulated by the sympathetic nervous quantitative and qualitative changes of system, exemplified through the production salivary biochemical parameters of amylase by the acinar cells and lysozyme  Cluster C: n=23 patients with cervical- secretion by the ductal cells [1, 2, 3]. Major facial radiotherapy salivary proteins, including amylase and Among the total group of patients, 29 were lysozyme, are synthetized and secreted women, of which 18 in cluster B (patients through a process controlled by beta with general disorders), 4 in cluster C (after adrenergic activity. TP mean values radiotherapy) and 7 in the control group. registered in our study were MTP= 1.506 for In all studied clusters, we determined the the control group, MTP=1.600 for the value of total salivary proteins, salivary systemically affected patients and MTP=1.233 glucose and a mineral (calcium-Ca2+) that post-radiotherapy. Furthermore, glucose could possibly influence the occurrence of levels displayed comparative higher levels some oral cavity modifications, as a result of within the diabetic patients than the control the pre-existing systemic pathology. group (Table 3). Results were processed and statically Calcium values determined in the saliva analysed. The ANOVA and Newman-Keuls for the three studied clusters show significant tests were used for statistical analysis. variations of the variables (Table 5). Comparative analysis of salivary calcium RESULTS AND DISCUSSIONS values indicates the presence of significantly There have not been reported any lower values in patients with cervical-facial significant alterations among the TP values in radiotherapy compared to control group. the saliva within the studied clusters (p=0.29), The highest values of salivary Ca were as can be seen in table I and table II. Patients registered in patients with systemic disorders with general diseases have higher values of (diabetes, HBP). TP compared to the patients in other clusters.

Average Group Average Std.dev Std.err Min Max 95% -95% Control group 1.506 1.400 1.610 0.198 0.050 1.10 1.80 General diseases 1.600 1.177 2.023 1.133 0.207 0.00 4.00 (HBP, diabetes) Radiotherapy 1.233 1.177 1.290 0.114 0.027 1.10 1.40 Table 1. Statistic Indicators of total salivary proteins in g/L

Salivary total proteins ANOVA test F p Df=2 (95%CI) 1.232112 0,298832 Table 2. ANOVA test of total salivary proteins

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Average glucose in Average Group Std.dev Std.er Min Max saliva -95% -95% Control group 1.34 1.13 1.55 0.39 0.10 0.70 1.90 HBP, Diabetes 5.35 4.04 6.65 3.51 0.64 1.00 12.00 Radiotherapy 1.21 1.01 1.42 0.26 0.01 0.57 1.77 Table 3. Statistic indicators of the saliva glucose levels in mg%

Salivary glucose ANOVA Test F p (95%CI) 20.50411 0.000045 Table 4. Salivary glucose values/ risk factors

Group Average Average Std. Std. Min. Max. Ca 95% -95% dev Err. Control group 1.60 1.39 1.81 0.40 0.10 0.88 2.05 HBP, diabetes 4.15 2.43 5.87 2.70 0.78 0.91 7.86

Radiotherapy 0.88 0.87 0.89 0.03 0.01 0.83 0.92 Table 5. Statistic indicators of Ca values in saliva (mmol/L) In patients with parasympathetic of the water amount in saliva concomitant modifications through p-adrenergic with the affection of the parotid glands. stimulation, concentration of Ca, in the unstimulated saliva varies inversely with the CONCLUSIONS flow rate [4, 7]. Significant flow rate decrease Our results reemphasis that biochemical can be the reason for the ductal reabsorption analysis of the inorganic salivary compounds decrease of salivary electrolytes. Calcium may be useful in recording salivary gland concentration varies with type and time of the modifications during some general diseases. stimuli, salivary flow and time of the day. Electrolytes are considered oral markers in Increase of saliva amounts can lead to some general diseases. elevation of calcium concentration [8]. In Variation of these inorganic compounds in patients with radiotherapy, increase of the the saliva has repercussions on the protective calcium concentration is explained through effect of saliva against cariogenic microbial reduction of the water quantity in saliva due agents and can eventually determine the to salivary gland dysfunction through increase of cariogenic risk. irradiation. Serous-mucous submandibular Because in diabetic patients the high blood glands, which secrete most of the calcium, are glucose levels play an important role in less radiosensitive than the parotid glands [5, developing carious lesions, dental 6]. After complete irradiation, salivary management has to be individualized for the calcium concentration begins to gradually patient, has to include frequent dental visits decrease, due to reversion back to normal of associated to periodical evaluation on diet and the salivary pH and amount, 3 months after medication. radiotherapy. Laboratory tests used for salivary glucose Salivary mean calcium concentrations in level, total proteins as well as salivary patients with radiotherapy have very low mineral substances evaluation, are especially values (0.88) compared to those within useful when combined with data on the food systemically affected individuals cluster regime and physical exam. Vitamin and (4.15), probably explained through decrease mineral substances level mainly reflect the

103 Romanian Journal of Oral Rehabilitation Vol. 3, No. 4, December 2011 recent and not the long term intake. of oral fluid this is reflected by changes in the In some patients with general diseases levels of minerals (calcium), total proteins or (HBP, diabetes) or following radiotherapy salivary glucose. treatment is a noticeable change in the quality

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