dental news september 2014

Dental News, Volume XXI, Number III, 2014


A strong bond provides confidence and support

• Powerful luting materials

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Effect of Fluoride-Based Prophylactic Agents on Titanium Corrosion

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Special toothpaste and mouthbath with Ems salts for sensitive teeth and denuded toothnecks, irritations ofthe gums, plaque


• firms up the gums and combats dental plaque

• neutralizes acids harmful to the teeth

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• caries prophylaxis

• stimulates salivation

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Bahrain: Awal Pharmacy, East Riffa, Bahrain. Egypt: Sesic, Alexandria. Jordan: Areel for Cosmetics Trading, Amman. Kuwait: Al-Maseela Pharmaceutical Co., Safat. Lebanon: A.M.G. Medical.Jdeideh-Azur Center. Libya: Al Osra, Benghazi. Oman: Ibn Sina Pharmacy L.L.C., Muscat. Qatar: Ahmed Khalil Al Baker & Sons, Doha. Saudi Arabia: Depot Phar-maceutique du Moyen Orient, Jeddah. Sudan: Pharma Care Co, Khartoum. United Arab Emirates: Al Hayat Pharmaceuticals, Sharjah. Yemen: Al Rawdha Trading Group, Sana’a.


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* #The 1 patient-requested

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Helps stop bleeding gums

Adapted from Saxer et al 1994. All interdental spaces from 6+ to +6 were tested at baseline and 4 weeks for bleeding on probing on the right side (buccal) and left side (lingual). Findings were recorded as 0=no bleeding; 1=slight/isolated bleeding; 2=marked bleeding. Mean scores were determined. N=22.Baseline values [Mean SD]: Control (fluoride-containing toothpaste) group 24.75 (6.34); parodontax® group 25.40 (6.80). After 4 weeks: Control (fluoride-containing toothpaste) group 26.00 (9.14); parodontax® group 19.80 (7.38). *parodontax® vs control p<0.05.

Baseline 4 weeks 4 weeksBaseline

Ch

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bas

elin

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edin

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pro

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g in

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aft

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30.00

25.00

20.00

15.00

10.00

5.00

0.00

Reduced bleeding on probing index after 4 weeks with parodontax®9*

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bleeding

Fluoride-containingcontrol toothpaste

parodontax®

In ‘bleeding on probing’ trials over 4 weeks, parodontax® demonstrated significant effects in reducing bleeding gums by 22% (p<0.01)

Bleeding on probing increased after 4 weeks of brushing with the fluoride control toothpaste

(p<0.01 vs. baseline)


OH

/CA

/00/

13/0

03


Adapted from Saxer et al 1994. All interdental spaces from 6+ to +6 were tested at baseline and 4 weeks for bleeding on probing on the right side (buccal) and left side (lingual). Findings were recorded as 0=no bleeding; 1=slight/isolated bleeding; 2=marked bleeding. Mean scores were determined. N=22.Baseline values [Mean SD]: Control (fluoride-containing toothpaste) group 24.75 (6.34); parodontax® group 25.40 (6.80). After 4 weeks: Control (fluoride-containing toothpaste) group 26.00 (9.14); parodontax® group 19.80 (7.38). *parodontax® vs control p<0.05.

Baseline 4 weeks 4 weeksBaseline

Ch

ang

e vs

bas

elin

e in

ble

edin

g

on

pro

bin

g in

dex

aft

er 4

wee

ks

30.00

25.00

20.00

15.00

10.00

5.00

0.00

Reduced bleeding on probing index after 4 weeks with parodontax®9*

22%reduction in

bleeding

Fluoride-containingcontrol toothpaste

parodontax®

In ‘bleeding on probing’ trials over 4 weeks, parodontax® demonstrated significant effects in reducing bleeding gums by 22% (p<0.01)

Bleeding on probing increased after 4 weeks of brushing with the fluoride control toothpaste

(p<0.01 vs. baseline)


OH

/CA

/00/

13/0

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JIDC 2014 - The 24th Jordanian International Dental Conference

October 21 - 24, 2014at the Landmark Hotel in Amman, JORDANEmail: : [email protected] Website: www.jidc2014.jda.org.jo

KDA 2014 - The 18th Kuwait Dental Association Conference

SDA 2014 - The 8thSudanese Dental Association Conference

November 20 - 22, 2014KUWAITEmail: [email protected] Website: www.kda.org.kw

December 2 - 4, 2014SUDANEmail: [email protected] Website: www.sdasudan.org


AIDC 2014 - The 19th Alexandria International Dental Congress

IQDAC 2014 - The 4thInternational Quintessence Dental Arab Congress

SDS 2015 - The 26thSaudi Dental SocietyInternational Dental Conference

DFCIC 2014 - The 6thDental-Facial CosmeticInternational Conference

AEEDC 2015 - The 19thUAE International Dental Conference & Arab Dental Exhibition

October 22 - 24, 2014Alexandria Int’l Dental CongressAlexandria, EGYPTEmail: [email protected] Website: www.aidc-congress.com

October 24 - 25, 2014at the Riyadh Colleges,Riyadh, KSAEmail: [email protected] Website: www.iqdac.org

January 13 - 15, 2015at the Riyadh InternationalConvention & Exhibition Center,Riyadh, KSAEmail: [email protected]: www.sdsam.org

November 14 - 15, 2014at the Jumeirah Beach Hotel,Dubai, UAEEmail: [email protected] Website: www.cappmea.com/aesthetic2014

February 17 - 19, 2015at the Dubai InternationalConventional & Exhibition Center,Dubai, UAEEmail: [email protected] Website: www.aeedc.com


12

Effect of Fluoride-Based Prophylactic Agents on Titanium Corrosion: A Literature Review and Clinical Implications

Dr. Wiam El Ghoul

Dr. Mireille Rahi

Dr. Ghassan Mostapha

[email protected]

[email protected]

Dr. Elias Smaira

Pr. Khaldoun Rifai

AbstractTitanium is known to possess excellent biocom-patibility as a result of corrosion resistance and lack of allergenicity when compared with many other metals. Fluoride is well known as a specific and effective caries prophylactic agent and its systematic application has been recommended widely over recent decades. Nevertheless, high fluoride concentrations impair corrosion resis-tance of titanium. The purpose of this paper is to discuss the current data regarding the influence of fluoride on titanium corrosion process in the last years. These data demonstrate noxious ef-fects induced by high fluoride concentration as well as low PH in the oral cavity. Therefore, such conditions should be considered when prophy-lactic treatment is indicated with patients having dental implants or other dental devices.

KeywordsCorrosion. Dental implants. Titanium alloys. Fluoride prophylactic agents. Titanium oxide layer. Oral cavity.

IntroductionTitanium materials used for dental implants manufacturing are supposed to exhibit high cor-rosion resistance.1,2,3 Corrosion is defined as the process of interac-tion between a solid material and its chemical environment which leads to a loss of substance from the material, roughening of the surface, change in its structural characteristics, weaken-ing of the restoration, loss of structural integrity, liberation of elements from the metal and toxic reactions.1,2,3

Many factors may influence corrosion in the oral environment such as type of materials, pH, temperature, humidity, oxygen and type of

bacteria.4,5,6,7

High metal alloys used in dentistry are so stable chemically that they do not undergo signifi-cant corrosion in the oral environment.2 Most of commercially available implant systems are made of pure titanium or titanium alloy (Ti-6Al-4V).8 Titanium and its alloys provide strength, rigidity, and ductility, similar to those of other dental alloys. Whereas, titanium and its alloy have excellent biocompatibility, low density, low thermal conductibility, good mechanical prop-erties and greater corrosion resistance in saline and acidic environments.9,10,11 Another property of titanium is passivity, which is the formation of a thin layer of oxides TiO2, however this stable oxide layer is not inert to corrosion attack.11,12,13,14

Saliva contains several viruses, bacteria, fungi and food debris. Many Gram+ and Gram- bac-terial species form a major part of the dental plaque around teeth and also colonize mucosal surfaces.2,15,16 These microorganisms affect cor-rosion of metals by forming of organic acids during glycolysis pathways from sugars, which will reduce the pH. A low pH creates a favorable environment for corrosion.2

Moreover, different products used in oral cavity have innumerous substances that can interact with titanium. Fluoride is one of these corrosive chemicals which are present at different concen-trations in toothpastes, mouthwashes, and other sources like tablets, drops or chewing gums due to its evidence-based anticariogenic effect.7,17,18

The increasing use of various titanium-based materials for dental implants and orthodontic brackets raises the question of their corrosion resistance in presence of fluoride ions, which are present in toothpastes and mouth rinses.4,19

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ObjectivesThe aim of this paper was to discuss published data on the role of fluoride on titanium corrosion in oral cavity and its clinical implications.

Materials and methodsSearch strategy: MEDLINE and PubMed searches were performed for articles written in English using the following terms: Corrosion process- Pure and Ti-tanium alloys- Fluoride prophylactic agents- Fluoride corrosion- Titanium oxide layer- Saliva components- Oral cavity. References from 1990 to 2013 were con-sulted and reviewed for appropriate studies.

Results: A total of 39 references were used, focusing on the effect of fluoride prophylactic agents on titanium corrosion, leading to 30 in-vitro studies, 1 in-vivo and 5 literature reviews.

The effect of fluoride on the corrosive processDental use of fluoride has been considered the main method to protect the enamel and to reduce its dissolution; fluoride ions having the ability to interact with the enamel’s hydroxyapatite crystals forming fluorited hydroxyapatite or fluoroapatite. These minerals have greater lattice energy, higher crystallinity, and better resistance to dissolution than hydroxyapatite.19,20 However, corrosion behavior of pure titanium and titanium alloy investigated in artificial saliva are significantly affected by the presence of fluoride ions (added by NaF) as proven by electrochemical methods.4 Fluoride ions are very aggressive on the protective TiO2 film formed on titanium and titanium alloys. They incorporate into the oxide layer TiO2, and cause the breakdown of this protective passive layer.21,22,23 This contributes to the formation of a hydrofluoric acid,24,25,26 which results in morphological variations, such as increasing roughness leading to plaque accumulation3,11,13 and possibly inhibition of osseointegration.2,3 Siirila et al. (1991) reviewed the effect of topical fluoride on titanium and concluded that toothbrushes used in contact with titanium surfaces should be as non-abrasive as possible and that long lasting contamination with topical fluorides should be avoided.27

Licausi et al. (2013) proved that titanium alloys are subjected to different mechanical actions (sliding or fretting), thus resulting in a tribocorrosion system, which is an irreversible material degradation process due to the combined effect of corrosion and wear.10

Commercial dental gels and rinses contain fluoride from 200 to 20,000 ppm, and can affect corrosion behavior of titanium.6,21 Campus et al. (2003) proved that concentration of fluorides in saliva after brushing with toothpaste diminishes, still lower concentrations of fluoride are still found up to 24 hours.28

A critical fluoride concentration exists above which corrosion rates increases.10

Mimura et al. (1996) reported that titanium was not considered to have a high corrosion resistance in the solution containing 500 ppm at pH =4.29

Huang et al. (2002-2003) reported that the protectiveness of TiO2 formed on titanium and titanium alloy is degraded by fluoride ions when NaF concentration exceeds 0,1 % (fluoride ion close to 500 ppm) via the formation of a Ti-F complex compound leading to severe corrosion of metal.30,31

Toniollo et al. (2012) suggested that use of 0,05 % NaF solution on titanium is safe, whereas the 0,2 % NaF solution should be carefully evaluated in regard

to its daily use.7

Fluoride concentration is not the only factor affecting corrosion process. It was also shown that pH value affects negatively this process. Reclaru et al. (1998) found that titanium and titanium alloys tested undergo a corrosive process, as soon as the pH drops below 3.5.32 Nakagawa et al. (1999-2005) revealed that titanium was corroded by existence of a small amount of NaF if pH was considerably low, and that titanium was corroded even at high pH if the NaF concentration was considerably high.6,33

Toniollo et al. (2009) reported that fluoride-containing solutions (pH=7) used as mouthwashes do not damage the surface of cast pure titanium and can be used by patients with titanium-based restorations.5

Lelli et al. (2013) revealed that corrosion of titanium in the solution containing fluoride depends on the concentration of hydrofluoric acid HF. When HF was higher than 30 ppm, the passivation film of the titanium was destroyed.11 Rosalbino et al. (2012) have explained the active behavior for all the titanium alloys in fluoridated acidified saliva due to the presence of significant concentrations of HF that dissolve the spontaneous air-formed oxide film, giving rise to surface activation. However, an increase in stability of the passive oxide layer and consequently a decrease in surface activation are observed for the Ti-1M alloys (M=Ag, Au, Pd, Pt).8

Morphology changes in the surface of titanium were observed following fluoride corrosion. Correa et al. (2009) reported that the process of corrosion by fluoride on commercially pure titanium allowed greater streptocoque mutans adherence than in the absence of corrosion.3 Muguruma et al. (2011) investigated miniscrew implant, they observed pits and cracks formed on implant surfaces after immersion in 0,1 or 0,2 % NaF mouth rinse solutions. However, this should not cause deterioration of their torsional performance.34

Roselino et al. (2007) concluded that prolonged contact with fluoride ions is harmful to mechanical properties of titanium structures.18

To further elucidate the role of fluoride ion concentration on the corrosion behavior of titanium and Ti-6Al-4V implant alloys, when


16

coupled either metal/ceramic or all-ceramic superstructure, Anwar et al. (2011) examined this scenario by different electrochemical methods in artificial saliva solutions: they concluded that increased fluoride concentration leads to a decrease in the corrosion resistance of all tested couples.25

DiscussionFrom above literature review, it is important to stress that described evidence of fluoride on titanium alloys derives mostly from in-vitro research, which includes oversimplifications in simulating oral environment.13 According to Lopez- Alias et al. (2006), it is difficult to predict the clinical behavior of any alloy from in-vitro studies, since such factors as changes in the quantity and quality of saliva, diet, oral hygiene, polishing of alloy, the amount and distribution of occlusal forces, or brushing with toothpaste can all influence corrosion to varying de-grees.35

On the other hand, choice of materials to be used as suprastructures with tita-nium implants is crucial. Their galvanic corrosion behaviors should be evaluated in order to avoid any corrosive process.2 The concern of reducing implant corrosion might be addressed by different methods such as noble metal alloying additions, especially gold on the corro-sion behavior of titanium; this could be ascribed to an incorporation of noble metal into the passive layer, resulting in increasing its dissolution resistance.8 Nakagawa et al. (2005) concluded that addition of a small amount of Pd or Pt to Ti to create an alloy proved to be very effective in improving the corrosion resistance of titanium in sodium fluoride (NaF) solutions of various concentra-tions up to 2 %.33 Ag and Au have excellent corrosion resistance in many aque-ous solutions, and good in vivo biocompatibility.8

Zhang et al. (2009) clarified that addition of Ag was found to be effective in reducing corrosion current density and increasing the open circuit potential of titanium in artificial saliva environment.36

Shim et al. (2005) reported that Ti-Ag alloys with low Ag content (< 5 %) have better corrosion resistance than pure titanium in artificial saliva.37

Yamazoe et al. (2007) showed that Ti-0,5 Pt, Ti-6 Al- 4N -0,5 Pt, and Ti-6Al-7Nb-0,5 Pt alloys had high corrosion resistance in a fluoride containing envi-ronment and high mechanical strength. Therefore, use fullness of these alloys as new implants or denture base materials was suggested.38 Design and texture of implant surface was also studied. The presence of pores in implant materials may be a source of corrosion problems. Foit and Joska (2013) showed that titanium implants with porosity of 24 and 33% initiated a local attack of the material.39

Moreover, the abnormal electrical currents produced during corrosion can con-vert any metallic implant into an electrode, and the negative impact on the surrounding tissues due to these extreme signals could be an additional cause of poor performance and rejection of implants.Electrical protection of the surfaces of the implants was proposed by Gittens et al. (2011) in order to reduce implant corrosion.15

On the other hand, innovative commercial mouthwashes and toothpastes during the last decade have replaced fluoride with biomimetic hydroxyapatite nanocrystals (CHA) as a remineralizing agent to avoid the effects of fluoride on human health.11

ConclusionThe most favorable suprastructure/implant couple is the one capable of resisting the most extreme conditions that could possibly be en-countered in oral cavity. Most studies were con-ducted in-vitro. Results showed that fluoride–containing products should be controlled and prescribed carefully, since increasing the use of such products can lead to alterations of implants and restoration surfaces, compromising the lon-gevity of the treatment. In fact, fluoride ions seem to exert a negative influence on the cor-rosion resistance of pure titanium and titanium alloy Ti-6Al-4V, especially in the acidic artificial saliva which contained over 0,1% NaF (fluoride ions = 500 ppm). This may cause the breakdown of protective passivation layer that normally ex-ists on titanium and titanium alloys, leading to severe corrosion.20,29,30,31 However, further in-vivo studies are warranted in order to elucidate corrosion resistance of ti-tanium and titanium alloys exposed to fluoride agents in oral cavity.

1. AdyA N, AlAm m, RAviNdRANAth t, mubeeN A, SAlujA b. CoRRo-SioN iN titANium deNtAl implANtS: liteRAtuRe Review. j iNdiAN pRoStho SoC 2005 july;5(3):128-131.2. ChAtuRvedi tp. AN oveRview of the CoRRoSioN ASpeCt of deNtAl implANtS (titANium ANd itS AlloyS). iNdiAN j deNt ReS 2009 jAN-mAR;20(1):91-8.3. CoRReA Cb, piReS jR, feRNANdeS-filho Rb, SARtoRi R, vAz lG. fAtiGue ANd fluoRide CoRRoSioN oN StReptoCoCCuS mutANS AdheR-eNCe to titANium-bASed implANt/CompoNeNt SuRfACeS. j pRoStho 2009;18:382–387.4. miloSev i, KApuN b, Selih vS. the effeCt of fluoRide ioNS oN the CoRRoSioN behAvioR of ti metAl, ANd ti6-Al-7Nb ANd ti-6Al-4v Al-loyS iN ARtifiCiAl SAlivA. ACtA Chim Slov 2013;60(3):543-55.5. toNiollo mb, tioSSi R, mACedo Ap, RodRiGueS RCS, RibeiRo Rf, dA GloRiA m, de mAttoS C. effeCt of fluoRide-CoNtAiNiNG SolutioNS oN the SuRfACe of CASt CommeRCiAlly puRe titANium. bRAz deNt j 2009;20(3):201-4.6. NAKAGAwA m, mAtSuyA S, ShiRAiShi t, ohtA m. effeCt of fluoRide CoNCeNtRAtioN ANd ph oN CoRRoSioN behAvioR of titANium foR deN-tAl uSe. j deNt ReS 1999; SeptembeR, 78(9): 1568-1572.7. toNiollo mb, GAlo R, mACedo Ap, RodRiGueS RCS, RibeiRo Rf, dA GloRiA m, de mAttoS C. effeCt of fluoRide Sodium mouthwASh SolutioNS oN Cpti: evAluAtioN of phySiCoChemiCAl pRopeRtieS. bRAz deNt j 2012 Sept/oCt;23(5):496-501.8. RoSAlbiNo f, delSANte S, boRzoNe G, SCAviNo G. iNflueNCe of Noble metAlS AlloyiNG AdditioNS oN the CoRRoSioN behAviouR of titA-Nium iN A fluoRide-CoNtAiNiNG eNviRoNmeNt. j mAteR SCi mAteR med 2012; 23:1129–1137.9. CANAy S, heReSK N, ulhA AC, bilGiC S. evAluAtioN of titANium iN oRAl CoNditioNS ANd itS eleCtRoChemiCAl CoRRoSioN behAvioR. j oRAl RehAb 1998;25:759–764.10. liCAuSi mp, iGuAz muNoz A, AmiGo boRRAS v. iNflueNCe of the fAbRiCAtioN pRoCeSS ANd fluoRide CoNteNt oN the tRiboCoRRoSioN be-hAvioR of ti6Al4v biomediCAl Alloy iN ARtifiCiAl SAlivA. j meCh behAv biomed mAteR. 2013 ApR;20:137-48.

References

Implant Dentistry

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11. lelli m, mARChiSio o, foltRAN i, GeNoveSi A, moNtebuGNoli G, mARCACCio m, Co-vANi u, RoveRi N. diffeReNt CoRRoSive effeCtS oN hydRoxyApAtite NANoCRyStAlS ANd AmiNe fluoRide-bASed mouthwASheS oN deNtAl titANium bRACKetS: A CompARAtive iN vivo Study. iNt j NANomed 2013;8:307-314.12. fovet y, GAl jy, toumeliN-ChemlA f. iNflueNCe of ph ANd fluoRide CoNCeNtRAtioN oN titANium pASSivAtiNG lAyeR: StAbility of titANium dioxide. tAlANtA 2001 jAN 26;53(5):1053-63.13. fRAGou S. eliAdeS t. effeCt of topiCAl fluoRide AppliCAtioN oN titANium AlloyS: A Review of effeCtS ANd CliNiCAl impliCAtioNS. pediAtR deNt. 2010 mAR-ApR;32(2):99-105.14. peRiNetti G, CoNtARdo l, CeSChi m, ANtoNiolli f, fRANChi l, bACCetti t, di leNARdA R. SuRfACe CoRRoSioN ANd fRACtuRe ReSiStANCe of two NiCKel-titANium-bASed ARChwiReS iN-duCed by fluoRide, ph, ANd theRmoCyCliNG. AN iN vitRo CompARAtive Study. euR j oRtho 2012;34:1-9.15. GitteNS RA, olivARiS RN, tANNeNbAum R, boyAN bd, SCwARtz z. eleCtRiCAl impliCAtioNS of CoRRoSioN foR oSSeoiNteGRAtioN of titANium implANtS. j deNt ReS 2011;90(12):1389-1397.16. fRANCiSCo jAvieR Gil fj, RodRiGuez A, eSpiNAR e, liAmAS jm, pAdulléS e, juáRez A. ef-feCt of oRAl bACteRiA oN the meChANiCAl behAvioR of titANium deNtAl implANtS. iNt j oRAl mAxillofAC implANtS 2012;27:64–68.17. SChiff N, GRoSGoGeAt b, liSSAC m, dAlARd f. iNflueNCe of fluoRide CoNteNt ANd ph oN the CoRRoSioN ReSiStANCe of titANium ANd itS AlloyS. biomAt 2002 mAy;23(9):1995-2002.18. RoSeliNo RAl, NoRieGA jR, dAmetto fR, vAz lG. CompReSSive fAtiGue iN titANium deNtAl implANtS Submitted to fluoRide ioNS ACtioN. j Appl oRAl SCi 2007;15(4):299-304.19. duNCAN tb, duNCAN wK, de bAll S. fluoRide: A Review—pARt ii: topiCAl fluoRideS. miSS deNt ASSoC j 1999:55(1):34-6.20. lee th, huANG tK, liNSy, CheN lK, Chou my, huANG hh. CoRRoSioN ReSiStANCe of diffeReNt NiCKel-titANium ARChwiReS iN ACidiC fluoRide-CoNtAiNiNG ARtifiCiAl SAlivA. ANGle oRthod 2010;80:547–553.21. NoGuti j, de olivieRA f, peReS RC, ClAudiA A, ReNNo m, RibeiRo dA. the Role of fluRiode oN the pRoCeSS of titANium CoRRoSioN iN oRAl CAvity. biomAt 2012;25:859-862.22. KhouRy eS, Abboud m, bASSil-NASSif N, bouSeRhAl j. effeCt of two-yeAR fluoRide deCAy pRoteCtioN pRotoCol oN titANium bRACKetS. iNt oRthod 2011 deC;9(4):432-51.23. SRivAStAvA K, ChANdRA pK, KAmAt N. effeCt of fluoRide mouth RiNSeS oN vARiouS oRthodoNtiC ARChwiRe AlloyS teSted by modified beNdiNG teSt; AN iN vitRo Study. iNdiAN j deNt ReS 2012;23(3):433-434.24. wAlKeR mp, white Rj, KulA KS. effeCt of fluoRide pRophylACtiC AGeNtS oN the me-ChANiCAl pRopeRtieS of NiCKel-titANium-bASed oRthodoNtiC wiReS. Am j oRthod deNtofACiAl oRthop 2005 juNe;127(6):662-9.25. ANwAR em, KheiRAllA lS, tAmmAm Rh. effeCt of fluoRide oN the CoRRoSioN behAvioR of ti ANd ti6Al4v deNtAl implANtS Coupled with diffeReNt SupeRStRuCtuReS. j oRAl implANtol 2011 juN;37(3):309-17.26. mANe pp, pAwAR R, GANiGeR C, phAphe S. effeCt of fluoRide pRophylACtiC AGeNtS oN the SuRfACe topoGRAphy of Niti ANd CuNiti wiReS. j CoNtemp deNt pRACt 2012 mAy 1;13(3):285-8.27. SiiRilA hS, KoNoNeN m. the effeCt of oRAl topiCAl fluoRideS oN the SuRfACe of Com-meRCiAlly puRe titANium. iNt j oRAl mAxillofAC implANtS 1991;6:50-54.28. CAmpuS G, lAllAi mR, CARboNi R. fluoRide CoNCeNtRAtioN iN SAlivA AfteR uSe of oRAl hyGieNe pRoduCtS. CARieS ReS 2003;37:66-70.29. mimuRA h, miyAGAwA y. eleCtRoChemiCAl CoRRoSioN behAvioR of titANium CAStiNGS: pARt 1. effeCtS of deGRee of SuRfACe poliShiNG ANd KiNd of SolutioN. jpN j deNt mAteR dev 1996;15:283-295.30. huANG hh. effeCtS of fluoRide CoNCeNtRAtioN ANd elAStiC teNSile StRAiN oN the CoRRo-SioN ReSiStANCe of CommeRCiAly puRe titANium. biomAt 2002 jAN;23(1):59-63.31. huANG hh. effeCtS of fluoRide ANd AlbumiN CoNCeNtRAtioN oN the CoRRoSioN behAvioR of ti-6Al-4v Alloy. biomAt 2003;24:275-282.32. ReClARu l, meyeR jm. effeCtS of fluoRideS oN titANium ANd otheR deNtAl AlloyS iN deNtiStRy. biomAt 1998 jAN-feb;19(1-3):85-92.33. NAKAGAwA m, mAtoNo y, mAtSuyA S, udoh K, iShiKAwA K. the effeCt of pt ANd pd AlloyiNG AdditioNS oN the CoRRoSioN behAvioR of titANium iN fluoRide-CoNtAiNiNG eNviRoN-meNtS. biomAt 2005;26:2239-2246.34. muGuRumA t, iijimA m, bRANtley wA, KyuNG hm, mizoGuChi i. effeCtS of Sodium fluoRide mouth RiNSeS oN the toRSioNAl pRopeRtieS of miNiSCRew implANtS. Am j oRthod deNtofACiAl oRthop 2011;139(5):588-593.35. lopez-AliAS jf, mARtiNez-GomiS j, ANGlAdA jm, peRAiRe m. ioN ReleASe fRom deNtAl CAStiNG AlloyS AS ASSeSSed by A CoNtiNuouS flow SyStem: NutRitioNAl ANd toxiColoGy impli-CAtioNS. deNt mAteR 2006;22:832-7.36. zhANG bb, zheNG yf, liu y. effeCt of AG oN the CoRRoSioN behAvioR of ti-AG AlloyS iN ARtifiCiAl SAlivA SolutioNS. deNt mAteR 2009;25(5):672-677.37. Shim hm, oh Kt, woo jy, hwANG Cj, Kim KN. CoRRoSioN ReSiStANCe of titANi-um-SilveR AlloyS iN AN ARtifiCiAl SAlivA CoNtAiNiNG fluoRide ioNS. j biomed mAteR ReS b 2005;73:252-257.38. yAmAzoe j, NAKAGAwA m, mAtoNo y, tAKeuChi A, iShiKAwA K. the developmeNt of ti AlloyS foR deNtAl implANt with hiGh CoRRoSioN ReSiStANCe ANd meChANiCAl StReNGth. deNt mAteR j 2007;26:260-267. 39. foit j, joSKA l.. iNflueNCe of poRoSity oN CoRRoSioN behAviouR of ti-39Nb Alloy foR deNtAl AppliCAtioNS. biomed mAteR eNG 2013;23(3):183-95.

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MiddleEast_ContactHS.pdf 1 12/11/13 11:21 AM


Repair of an Implant-Supported Porcelain-Fused-to-Metal Restoration in Under-Occlusion: A Case Report

Prosthetic Dentistry

20

Dr. Norma Ziadeh

Dr. Danielle El Hakim

[email protected]

[email protected]

AbstractThis paper presents an indirect intraoral repair procedure that may be used to overcome an under-occlusion defect on an implant-support-ed porcelain-fused-to-metal (PFM) fixed partial denture. In the present technique, onlay ceramic restorations were adhesively bonded to the orig-inal PFM. The reparation was quick, relatively affordable and easier than removing the bridge and making a new one. This procedure provided good aesthetic and functional results.

IntroductionFracture of porcelain is a frequent mechanical complication in implant-supported prosthesis. The reparation can present difficult challenges to the practitioner. Due to the brittle nature of the porcelain and its fabrication process requir-ing firing, new porcelain can hardly be added to an existing restoration intra-orally.1 Intra-oral repair options provide the possibility of repairing the porcelain in the patient’s mouth preventing replacement of the complete restorations.1,3

Repair alternatives are classified in two catego-ries: the direct and the indirect techniques.4 In the direct technique, composite resin is applied directly to the fractured restoration with the aim to reestablish function and aesthetics. Several articles2-4 have been published describing the in-direct technique whereby the remainder of the restoration is prepared and a lab-fabricated res-toration is cemented or bonded on the remain-ing substrate. This technique is more appropriate for large fractured surfaces, in posterior areas with heavy functional load, or where aesthetic result is important; however, it requires a second appointment.2-4

No previous publications have reported the use of this approach to adjust the occlusal plane. This paper describes an indirect intraoral repair technique for an implant-supported porcelain-fused-to-metal fixed partial denture in under-occlusion. CAD/CAM onlay ceramic restorations were used to treat the defect.

Case-reportA 45-year old woman came to the dental of-fice complaining of unaesthetic smile and poor chewing ability on the left side. Clinical exami-nation revealed a disharmony of the occlusal plane, poor restorations, missing teeth and a 4 unit implant-supported PFM bridge in the lower left area in under-occlusion (fig 1).

Fig 1

Fig.1: Clinical view showing the under-occlusion in the lower left mandible.

Radiographic examination (fig 2) showed the presence of radiolucency around one implant (the third most distal) and an unfamiliar screw element in the last implant all this with good

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Fig 2

Fig.2: Initial radiographic examination. Note the presence of radiolucency around the third most distal implant and an unfamiliar screw element in the most distal implant. (right to the photo)

Fig.3: Preparation of the ceramic. A 1 mm depth and 1.5 mm height with fine grit 25micron rounded shoulder burs.

Fig.4: Provisional restoration from wax up

clinical and radiographic adaptation of the prosthesis. Probing of the third implant was executed, of 5mm depth, no pus or bleeding signs were found around it. A slight redness on the gingival margins around the implants due to plaque retention caused by poor mouth hygiene.

Fig 3

A full-mouth rehabilitation was indicated, changing all the deteriorated resto-rations and crowns, placing implants in edentulous areas, to adjust the occlusal plane including 2 implants in upper maxilla facing the 4 unit implant supported PFM’s. The patient was informed about his problem and treatment alternatives; After all options discussion, a deep scaling of the implant surface in question was implemented and an indirect repair was decided without removing the existing 4-element restoration. Since removal of the bridge could potentially result in deterioration of the abutments especially the most distal one where an unknown metallic screw is used to fix the abutment, which may lead to loosing the last implant as well as the implant with bone resorption and the inability to place 2 other implants in this site because of the insufficient bone height above the inferior dental nerve.

Repair techniqueStudy casts were mounted in articulator and a full wax-up was carried out to evaluate the height or space to be corrected. Buccal, palatal, mesial and distal preparations of 1 mm depth and 1.5 mm height were created using fine grit 25 micron burs (Komet Dental, Lemgo, Germany) to prevent cracks in the prepared ceramic. With the occlusal present defect, no occlusal reduction was needed (fig 3). A provisional restoration was made using a silicon key as mold copying the morphology of the wax-up. The temporary used between the two appointments (fig 4) helped in testing the new occlusion.A one-step polyether impression (ImpregumTM PentaTM medium-bodied and ImpregumTM GarantTM L DuoSoftTM light-bodied consistency) (3M ESPE, Ger-many) in custom tray was taken for the fabrication of the master cast. Bite

Fig 4

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registration, shade selection was done to match the new onlays with the exist-ing bridge.The plaster cast was scanned with the indirect in lab technique and CAD/CAM onlays were milled (IPS e.max CAD, Ivoclar Vivadent, Schaan, Liechtenstein). The onlays were tried in mouth and checked for marginal adaptation and final outcome prior to bonding.Internal surfaces of the IPS e.max onlays were etched with 9.5% hydrofluoric acid for 20 seconds. For control of the oral cavity humidity and patient protec-tion due to the inherent risks of the hydrofluoric acid, field isolation was ob-tained with the aid of a rubber dam, a lip expander and the use of a protection eyewear. The prepared surface of the feldspathic restoration was etched for 2 minutes with the same acid (fig 5). After rinsing with water for 30s and drying the ceramics with an air stream, a one bottle silane coupling agent (Monobond S, Ivoclar Vivadent, Schaan, Liechtenstein) was applied on both surfaces, left undisturbed for 1 minute and then air dried.

Fig.5: Use of a rubber dam for etching and bonding

Fig.6: Final occlusal view, onlays bonded

Figure 7: Radiographic examination and clinical view after 2 years.

Fig 5

Finally, the ceramic onlays were adhesively bonded to the prepared surface using the dual-curing luting composite, Variolinc N (Ivoclar Vivadent, Schaan, Liechtenstein), and the interface margin was polished (fig 6). At the end of the bonding session, occlusal contact points were verified with 12 Microns articulating paper (Arti-fol, Bausch, Koln, Germany), for any occlusal or lateral prematurity contacts, to achieve a harmonic distribution of the occlusion. After the contacts adjustments a ceramic polishing kit (Komet Dental, Düssel-dorf, Germany) was used with 3 progressive granulometries and a polishing paste (Inten-sive Unigloss Paste, Intensiv, Montagnola, Switzerland)

Fig 6

Fig 7

After 6 months of treatment, the full-mouth re-habilitation was completed and the patient re-established function and esthetics. The comfort in chewing food was expressed by the patient in the one-year follow up. The prosthesis has been in the mouth for 2 years (fig 7), and no visible alterations have been observed so far.

Discussion Other treatment modalities could have been considered in this case; Total replacement of the bridge or, even more, replacement of the defect-ed implant(s). This would have made the treat-ment extremely expensive and time-consuming, besides leaving the patient vulnerable to a more complicated situation. The CAD/CAM restorations allow less stress on the ceramic to ceramic interface and more ac-curacy of fit. IPS e. max CAD is a high-strength


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lithium-disilicate-based glass ceramic with high edge stability. With strength of 360 to 400 MPa, the material is suited to the fabrication of fully anatomical and partially reduced anterior and posterior crowns.10

When repair of ceramic restorations is considered, a strong and durable bond between the crown and repairing ceramic must be achieved. A strong resin bond relies on micromechanical interlocking and chemical bonding to the si-lanized ceramic and bridge surfaces, which requires roughening (HF) and clean-ing for adequate surface activation.4

Several considerations should be accounted for when choosing the material of the repair onlay restorations. Feldspathic ceramics, used as veneering porcelain in PFM restorations and lithium disilicate onlays are both glass-ceramic materi-als3 allowing etching process. Ceramic-ceramic compatibility is important for enhanced esthetic outcome and better bond. Successful material combinations should have close thermal expansion coefficients to avoid any thermal stresses that may lead to a future cracking or debonding. It is known that lithium disili-cate is a brittle material but it gets its strength when bonded correctly. Many studies were published describing how to prepare the surface of a frac-tured restoration for intraoral repair.1-4 For glass-ceramic surfaces, the use of silane seems to be essential, whereas an appropriate etching and a mechanical treatment depend on the kind of the ceramic.Hydrofluoric (HF) etching can achieve a proper surface roughness, because the glassy matrix is selectively removed and crystalline structure is exposed.3-7 For instance, with the lithium disilicate, 9,5% HF acid applied for only 20 seconds is successful to provide a proper etch, while for the feldspathic ceramic,8,9 a 2-2.5 minutes is needed (9,5% HF). Intraoral use of hydrofluoric acid is controversial because of its hazardous properties.1,3,4 Therefore, clinicians should never use it without a rubber dam and eyewear protection.Chemical bonding is achieved by application of a silane.3-6,11 Silane solutions are bifunctional molecules that bond silicone dioxide (SiO2) with hydroxyl groups on the ceramic surface and silane is a crutial agent for a satisfying resin bond to glass ceramics; it has also a functional group that co-polymerizes with the organic matrix of the resin. Additionally, silanization increases the wettability of the bonded surface. As a general rule, for most systems, fresh chemically active silane (one to two coats) should be applied and allowed to dry for a minimum of 30 seconds to 1 minute in room temperature followed by a gentle warm-air drying (for 60 seconds). To be noted that extended time of silanized ceramic could lead to losing the bonding properties by chemical transformation of si-lane into siloxane (inactive saturated formula).

VariolinkN is a dual-curing luting composite product for adhesive luting of glass-ceramic, lithium disilicate and composite restorations. It is composite resin cement,5 with modified formula and has the advantages of high strength, high adhesion, low solubility, and aesthetic results. This allows it to be used with brittle, esthetic restoration types such as glass-ceramics and indirect composite or in cases where retention is critical.

The ultimate success and longevity of intraoral porcelain reparations is a multi-factor chain. The extent of the repair, occlusal forces applied on it, and the patient’s oral habits, oral hygiene, and esthetic demands are some of the fac-tors that might contribute to the survival of the reparation. The use of a rubber dam is essential to provide adequate isolation for the adhesive steps, and the

occlusion must be carefully adjusted after the bonding. This technique was never described in the litterature.

ConclusionThe replacement of a multi-unit implant sup-ported bridge with under-occlusion problem may not necessarily be the most suitable solu-tion because of added cost, chair time required and related removal complications. Indirect intraoral reparation using ceramic onlays res-torations may offer appropriate therapeutic alternative with short-term clinical success. Fur-ther clinical cases and long term follow up are needed in order to implement this technique as a long term solution for under-occlusion metal ceramic prosthesis.

References

1. ozCAN m. evAluAtioN of AlteRNAtive iNtRA-oRAl RepAiR teChNiqueS foR fRACtuRed CeRAmiC-fuSed-to-metAl ReStoRAtioNS. j oRAl RehAbil 2003; 30:194-203.2. GAliAtSAtoS AA. AN iNdiReCt RepAiR teChNique foR fRACtuRed met-Al-CeRAmiC ReStoRAtioNS: A CliNiCAl RepoRt. j pRoSthet deNt 2005; 93:321-323.3. KimmiCh m, StAppeRt Cfj. iNtRAoRAl tReAtmeNt of veNeeRiNG poR-CelAiN ChippiNG of fixed deNtAl ReStoRAtioNS. A Review ANd CliNiCAl AppliCAtioN. j Am deNt ASSoC 2013; 144:31-44.4. hAmmoud bd, Swift jR ej, bRACKett ww. iNtRAoRAl RepAiR of fRACtuRed CeRAmiC ReStoRAtioNS. j Compil 2009; 21:275-284.5. blAtz mb, SAdAN AS, KeRN m. ReSiN-CeRAmiC boNdiNG: A Review of the liteRAtuRe. j pRoSthet deNt 2003; 89:268–274.6. Alex G. pRepARiNG poRCelAiN SuRfACeS foR optimAl boNdiNG. Com-peNd CoNtiN eduC deNt 2008;29:324–335.7.vidotti hA, GARCiA Rp, CoNti pCR, peReiRA jR, vAlle Ald. iNflu-eNCe of low CoNCeNtRAtioN ACid tReAtmeNt oN lithium diSiliCAte CoRe/veNeeR CeRAmiC boNd StReNGth. j CliN exp deNt. 2013; 5:157-162.8. SANtoS jR GC, SANtoS mjmC, RizKAllA AS. AdheSive CemeNtAtioN of etChAble CeRAmiC eSthetiC ReStoRAtioNS. j CAN deNt ASSoC 2009; 75:379-384.9. SoAReS Cj, SoAReS pv, peReiRA jC, foNSeCA Rb. SuRfACe tReAtmeNt pRotoColS iN the CemeNtAtioN pRoCeSS of CeRAmiC ANd lAboRAtoRy-pRoCeSSed CompoSite ReStoRAtioNS: A liteRAtuRe Review. j eSthetReStoR deNt 2005; 17:224-235.10. ReiCh S, fiSCheR S, SobottA b, KlAppeR hu, GozdowSKi S. A pRe-limiNARy Study oN the ShoRt-teRm effiCACy of ChAiRSide ComputeR-Aided deSiGN/ComputeR-ASSiSted mANufACtuRiNG- GeNeRAted poSteRioR lithium diSiliCAte CRowNS. iNt j pRoSthodoNt. 2010 mAy-juN; 23(3):214-6.11. Culp l, mClAReN eA. lithium diSiliCAte: the ReStoRAtive mAteRiAl of multiple optioNS. CompeNdCoNtiNeduC deNt 2010; 31:716-725.



28

Dr. Parmanand DhanrajaniOral surgeon

Dr. Gregory BellamyChief dental officer

HCF Dental CentreSydney, Australia

[email protected]

Despite numerous attempts to clarify the role of third molars in causing late anterior crowding, the issue remains controversial. This has been ex-tensively reviewed in the literature with different conclusions.1,2 Moreover, orthodontic patients and their parents are often concerned that third molars will threaten the stability of orthodontic results, and frequently cite the eruption of third molars as causing redevelopment of their maloc-clusion in the form of anterior crowding.3

Being in the field of oral surgeon for more than two decades it becomes difficult to answer pa-tient as to whether the wisdom teeth will cause crowding of anterior teeth or not.Recently my colleague referred a 22 years old young man for the removal of left both upper and lower third molars due to crowding on the left side, the patient complaint was of left ante-rior crowding.The patient reported a history of orthodontic treatment, his right upper and lower third mo-lars were removed 3 years previously. On examination, 28 and 38 were impacted and he had crowding of anterior teeth on left side more on lower jaw (fig 1). Orthopantomogram

Role of Erupting Third Molars in Causing Dental Crowding

References

1. SidlAuSKAS A, tRAKiNieNe G. effeCt of the loweR thiRd molARS oN the loweR deNtAl ARCh CRowdiNG. StomAtoloGijA, bAltiC deNtAl ANd mAxillofACiAl jouRNAl 2006; 8:80-84.2. liNdAueR Sj, lASKiN dm, tufeKCi e, tAyloR RS, CuShiNG bj, beSt Am. oRthodoNtiStS ANd SuRGeoNS opiNioNS oN the Role of thiRd mo-lARS AS A CAuSe of deNtAl CRowdiNG. Am j oRthod deNtofAC oRthop. 2007; 132:43-48.3. tufeCKi e, SveNSK d, KAlluNKi j, huGGARe j, liNdAueR Sj, lASKiN dm. opiNioNS of AmeRiCAN ANd SwediSh oRthodoNtiStS About the Role of eRuptiNG thiRd molARS AS A CAuSe of deNtAl CRowdiNG. ANGle oRthod. 2009; 1139-1142.

Fig 1

Fig.1: Orthopantomogram showing impacted left lower third molars with anterior crowding

Fig.2: Photograph showing anterior crowding on left side

showed mesioangular 38 and impacted 28 high (fig 2). Patient had the 18 and 48 removed after orthodontic treatment but did not have the 28 and 38 removed until he was referred again this time.Clinical and orthopantomogram findings were very suggestive of erupting third molars having a definitive role in causing anterior crowding. Al-though this is a single case but we cannot ignore the finding of these clinical implications.We leave to clinicians to decide whether to re-move, prophylactically, erupting third molars af-ter orthodontic treatment.

Fig 2

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1 CompleteSeNSItIVItY tootHpASte

Adapted from Tai et al, 2006.4 Randomised, double-blind, controlled clinical study of 95 volunteers given NovaMin® containing dentifrice or placebo control (non-aqueous dentifrice containing no NovaMin®) for 6 weeks. All subjects received supragingival prophylaxis and polishing and were instructed in brushing technique.4 *GBI scale ranges from 0–3.

Significant reduction in gingival bleeding index (GBI) over 6 weeks with a NovaMin® containing dentifrice4

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References:1. Du MQ et al. Am J Dent 2008; 21(4): 210−214. 2. Pradeep AR et al. J Periodontol 2010; 81(8): 1167−1113. 3. Salian S et al. J Clin Dent 2010; 21(3): 82-87. Prepared November 2011, Z-11-496. 4. Tai BJ et al. J Clin Periodontol 2006; 33: 86-91. 5. Devi MA et al. Int J Clin Dent Sci 2011; 2: 46-49. 6. GSK data on file (study 23690684) 7. LaTorre G, Greenspan DC. J Clin Dent 2010; 21(3): 72-76. 8. Edgar WM. Br Dent J 1992; 172(8): 305-312. 9. Burwell A et al. J Clin Dent 2010; 21(Spec Iss): 66–71. 10. Efflandt SE et al. J Mater Sci Mater Med 2002; 26(6): 557-565. 11. de Aza DN et al. J Mat Sci: Mat in Med 1996; 399–402. 12. Arcos D et al. A J Biomed Mater Res 2003; 65: 344–351. 13. Earl J et al. J Clin Dent 2011; 22[Spec Iss]: 62-67. (A) 14. Parkinson C et al. J Clin Dent 2011; 22(Spec Issue): 74-81. 15. West NX et al. J Clin Dent 2011; 22(Spec Iss): 82-89. 16. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 68-73. (B) 17. Wang Z et al. J Dent 2010; 38: 400−410. 18. “Dentifrices” Encyclopedia of Chemical Technology 4th ed. vol 7, pp. 1023-1030, by Morton Poder Consumer Products Development Resources Inc. 19. van der Weijen GA and Hioe KPK. J Ciul Periodontal 2005; 32 (Supp 1.6): 214-228. Date of Preparation: July 2013, Code: CHSAU/CHSENO/0008/13

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30

The effect of aging and thermocycling on adhesive bonding to fluorosed enamel

Dr. Wafa H. Alajam,BDS, MDSc, PhD.

Assistant Professor, Department of Restorative Dental sciences, College

of Dentistry, King Khalid University, Abha, KSA

Dr. Khalid M. Abdelaziz,BDS, MDSc, PhD.

Associate Professor in Dental Biomaterials, Department of Restorative Dental sciences,

College of Dentistry, King Khalid University, Abha, KSA

Dr. Mohamed M. Almoaleem,BDS, MDSc, PhD.

Assistant Professor, Department of Prosthodontics,

College of Dentistry, Jazan University, Jazan, KSA

[email protected]

Abstract

BackgroundAdhesive bonding to tooth surfaces could be affected by aging and structural abnormalities of tooth tissues. This study evaluated the shear bond strength of 2 contemporary adhesives to fluorosed tooth enamel following wet aging and thermocycling.

Materials and MethodsTwo groups (n=40 each) of extracted premolars were respectively selected with mild and mod-erate fluorosis. Another 40 premolars with no fluorosis served as control. Cylinders of nano-filled composite were bonded in two subgroups onto buccal enamel of all teeth using AdperTM Single Bond 2 (ASB) and Adper Prompt L-Pop (ALP) adhesive systems (n= 20 each). Before testing the shear bond strength of all groups, 10 specimens from each of their subgroups were subjected to 6 months of wet aging in distilled water at 37±1oC and thermocycling at 5, 37 and 60oC with 30s dwelling time for 5000 cycles (Class 1). The other 10 were tested after 24h of wet storage with no thermocycling (Class 2). Both one-way ANOVA and Tukey’s comparisons (α =0.05) were then used to statistically analyze the collected data. The fracture surfaces of all specimens were also inspected to determine the common mode of bond failure.

ResultsNo differences were detected between bonding values of both adhesives to normal and fluo-rosed enamel (P>0.05). Wet aging and thermo-cycling has no effect (P>0.05) on the bonding values. The reported bond failures were mainly belonged to admixed and adhesive modes.

ConclusionBoth ASB and ALP adhesives provide compa-rable bonding values to normal and fluorosed tooth enamel. Wet aging and thermocycling have no adverse effect on the adhesive bond-ing to tooth enamel with different degrees of fluorosis.

KeywordsAdhesive bonding, aging, enamel, fluorosis, thermocycling.

IntroductionThe esthetic perception of teeth is seriously affected in presence of dental fluorosis.1 This condition usually alters the normal structure of tooth enamel that, in some instances, requires dental intervention to restore teeth esthetic and function.2 The restoration process mostly utilizes resin composites that normally retain micro-mechanically to the etched enamel surfaces,3,4 in spite of the expected difficulty to etch the hy-permineralized, fluorosed enamel.5,6

Originally, the standard 15-60s enamel etch-ing7,8 looks not enough to provide an accept-able shear bond strength of resin composites to fluorosed teeth enamel.2,3,9 However, grinding some of surface enamel improves the bonding values.10 Sometime ago, dental manufacturers introduced a variety of self-etch, 1 and 2- step adhesives aiming to reduce the number of ap-plication steps and to save the operators’ time accordingly. However, the performance of these adhesives in presence of fluorosed enamel still not affirmed yet.11-14 Shida et al.15 reported that water fluoridation has an adverse influence on the etching efficacy of the self-etching adhe-sives. More researchers correlated the noted reduction in the bond strength of these to the

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severity of enamel fluorosis,16 although others deduced no difference in the bond strength to normal or fluorosed enamel surfaces.17 To date, a contradiction is obvious between the results of some studies. Some studies10,18 showed better bonding of acid-etch adhesive systems to fluorosed enamel in comparison to self-etching adhesive. Other investigators19 encoun-tered the reverse results as the 2-step self-etching adhesives provided higher bond strength values to fluorosed enamel than that obtained by the other types of adhesives. Moreover, no study concerned about the effect of aging and thermocycling on the bond strength of contemporary adhesive to the fluo-rosed enamel of patients in endemic areas like Saudi Arabia. Depending on the proceedings, this in vitro study aims to evaluate the shear bond strength of both total and self-etching dental adhesives to enamel sur-faces with mild and moderate fluorosis following wet aging.

Materials and methodsTwo groups of extracted premolars with mild and moderate fluorosis (n=40 each) were selected for this in vitro study. Another 40 premolars with no fluorosis served as control. All teeth were collected out of Saudi orthodontic patients by 2 investigators following the clinical criteria of Thystrup and Fejer-skov.20 Teeth scored 0 were considered normal, while those scored 1-3 and 4-6 were respectively classified as mildly and moderately-fluorosed (Table 1). After cutting their roots off, selected teeth were embedded horizontally into auto-polymerizing acrylic resin blocks (Meliodent, Heraeus Kulzer, Hanau, Ger-many) with their buccal surfaces up. The exposed buccal surfaces together with the acrylic top surfaces were then flattened up using 220-800 grit sandpaper discs (Wetordry, 3M Collision Repair, St. Paul, MN, USA). Cylinders of nano-filled composite restorative (Filtek Z350, 3M ESPE, St. Paul, MN, USA) were incrementally-built-up in a rubber mold, 3mm in both diameter and height, and bonded to the prepared buccal surfaces of teeth in each group using either a total or a self-etching adhesive system (n= 20 each) .

In subgroup 1, an Adper Single Bond 2 (ASB) ad-hesive (3M ESPE, St. Paul, MN, USA) was rubbed in 2 coats against the buccal enamel surfaces following a standardized 15s etching (Scotch-bond etchant, 3M ESPE, St. Paul, MN, USA). The adhesive material was left undisturbed for 15s, air thinned, and light cured (LEDition, Ivoclar Vivadent, Schaan, Liechtenstein) for 15 more seconds before building the composite cylinders up. The single-step Adper Prompt L-Pop (ALP) (3M ESPE, St. Paul, MN, USA) self-etching adhe-sive system was used to bond composite cylin-ders to the non-etched enamel surfaces in sub-group 2. Pouches contents were mixed together for 5s with aid of the supplied brush. The mixed material was then rubbed onto enamel surfaces in 2 coats. The material was left in contact with enamel without disturbance for 15s, air thinned and cured for another 15s. Before testing the shear bond strength of all groups, 10 specimens from each of their subgroups were subjected to 6 months of wet storage in distilled water at 37±1oC and thermocycling at 5, 37and 60oC with 30s dwelling time for 5000 cycles (Class 1). The other 10 were tested after 24h of wet stor-age with no thermocycling (Class 2).The shear bond strength of all test specimens was tested on a universal testing machine (WP 300 universal material tester, G.N.U.T Geräte-bau GmbH, Fahrenberg, Germany) running at a

No fluorosis

TFI scores

0

1-3

4-6

7-9

Clinical findings

Normal enamel translucency following prolonged drying

Smooth surface enamel usually shows pronounced lines or areas of opacities. Similar areas of opacities are notable on the occlusal surface and accompa-nied sometimes with worn areas circumscribed by a rim of opaque enamel.

Marked opacity or chalky-white appearance of enamel is obvious on smooth tooth surfaces. Opacity of occlusal enamel is usually accompanied with pro-nounced attrition or pitting 2-3mm in diameter.

Loss of outermost smooth surface enamel involving ≥ ½ of entire surface. Marked occlusal attrition and deviation from normal tooth configuration are obvious. A cervical rim of normal enamel is usually noticed.

Type of fluorosis

Table 1. Clinical findings of teeth with different degrees of fluorosis

Mild fluorosis

Moderate fluorosis

Sever fluorosis

• TFI= Thystrup and Fejerskov index20



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crosshead speed of 0.5 mm/min. All specimens were mounted horizontally in a specially-designed metal jig. A knife-edged rod attached to the moving upper member of the testing machine aided in stressing the enamel-composite adhe-sive junction. The maximum force at fracture was recorded for each specimen and the shear bond strength was then calculated in reference to the bonded surface area. The recorded bond strength data were then analyzed statistically using both one-way ANOVA and Tukey’s HSD comparisons (α =0.05) to stand on the significance of differences detected between different classes of test specimens. The fracture surfaces of each specimen were inspected at X10 (A. Kruss Optronic GmbH, Hamburg, Germany) under low angle illumination in order to categorize the mode of bond failure. The adhesive type of bond failure was recorded when a complete separation was detected at either adhesive-tooth or adhesive-composite interface, while the cohesive one was recorded when the separation was entirely detected within composite or enamel bulk. The admixed type of bond failure was recorded when the debonding pattern showed signs of both previously described adhesive and cohesive failures. To confirm the recorded findings, a further instrumental assessment of some frac-ture surfaces belonging to the 3 different categories of bond failure was carried out using scanning electron microscope (SEM) (JEOL, JCM-5000, NeoScope, JEOL Ltd, Tokyo, Japan) at X100 original magnification.

ResultsShear bond strength data are summarized in Table 2. The initial statistical testing of the collected shear bond strength data indicated some differences

No aging

No aging

Moderately-fluorosed enamel

ASB ALP

Moderately-fluorosed enamel

ASB ALP

Mildly-fluorosed enamel

ASB ALP

Mildly-fluorosed enamel

ASB ALP

Normal enamel

ASB ALP

Normal enamel

ASB ALP

16.16± 0.65(control)

400

60

402040

AdhesiveCohesiveAdmixed

AdhesiveCohesiveAdmixed

15.73± 0.98

601030

700

30

14.14± 0.85#$

50050

400

60

16.45± 0.55 15.55± 1.93 14.98± 0.73

16.82± 3.34(control)

400

60

501040

16.99± 3.36

50050

50050

16.30± 1.17

50050

30070

16.72± 1.24 15.89± 1.87 14.16± 0.52#$

Grouping

Grouping

Table 2. Shear bond strength values (MPa) to normal and fluorosed tooth enamel

Table 3. Incidence (%) of different modes of bond failure

Aging andthermocycling

Aging andthermocycling

• ASB = Adper Single Bond 2, ALP= Adper Prompt L-Pop• # Significantly different from ALP bonded to normal enamel with no aging (control). (Tukey’s comparisons, P= 0.03474 and 0.03835)• $ Significantly different from ALP bonded to mildly-fluorosed enamel with no aging. (Tukey’s comparisons, P= 0.01786 and 0.01986)

• ASB = Adper Single Bond 2, ALP= Adper Prompt L-Pop

Failuremode

between the 12 tested classes of specimens (ANOVA, P= 0.001086). Further analysis using Tukey’s comparisons showed that most of the tested classes have no differences either from the controls or between each other (P> 0.05). Considering each group of specimens, no dif-ference was noticed between bond strengths of both adhesives to normal and mildly-fluo-rosed enamel surfaces (Groups 1 and 2) even when aging and thermocyling were considered. However in group 3 (Moderately-fluorosed enamel), both the non- aged ASB and the aged ALP classes of specimens showed lower bond strength values when compared with ALP con-trol class (ALP bonded to normal enamel with no aging) (Tukey’s comparisons, P= 0.03474 and 0.03835), although they were not different from each other (Tukey’s comparisons, P=1). The same 2 classes also showed lower bond strength values than that recorded for the non-aged ALP class of specimens of group 2 (ALP bonded to mildly-fluorosed enamel with no aging) (Tukey’s comparisons, P= 0.01786 and 0.01986) .



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36

Inspection of fracture surfaces (Table3) indicated that both adhesive and ad-mixed types are the commonly detected modes of bond failure for specimens bonded with either ASB or ALP in all groups and subjected to no aging. On the other hand, subjecting the bonded specimens to wet aging and thermocycling helped the adhesive mode of bond failure to be dominant on expense of the admixed one. The SEM images also confirmed that most of the bond failures belonged to the admixed and adhesive modes (Figures 1-4), although very few surfaces showed evidence of cohesive failure within the composite body (Figure 5).

DiscussionFluorosis of tooth enamel is usually associated with histologic changes that re-flect on the normal tooth esthetic.1 Adhesive bonding of composite restorative is considered a time-saving approach to restore the fluortic defects,2 in spite of the known difficulties of enamel etching.21,18 This fact displays evident con-troversies about the bonding performance of different types of contemporary adhesive systems to fluorotic enamel.3,5,6,21 Accordingly, this in vitro study was designed to evaluate the bonding values of a total-etch, 2-step and 1-step, self-etching adhesives before and after wet storage and thermocycling.For standardization, the selection of fluorosed teeth was done according to the detected clinical characteristics following the modified Thylstrup and Fejerskov index20 shown in Table 1. On the other hand, testing the shear bond strength was found to have close proximity to the actual dislodging forces that normally act on adhesive veneers. The outer 0.5 mm of mid-labial enamel surface was ground away creating flat enamel surfaces in order to mimic the clinical prepa-ration characteristics for veneering restoration, and to help standardize and measure the bonding surface area.In disagreement with Weerasinghe et al.,21 results of this study showed no differences in the bonding values of the selected adhesives to normal and

Fig 1

Fig 3

Fig 4

Fig 5

Fig 2

Fig. 1: Admix mode of bond failure of Adper Single Bond 2 in non-aged normal enamel specimen.

Fig. 3: Admix mode of bond failure of Adper Single Bond 2 in aged moderately-fluorosed enamel speci-men.

Fig. 4: Adhesive mode of bond failure of Adper Prompt L-Pop in aged moderately-fluorosed enamel specimen.

Fig. 5: Cohesive mode of bond failure (composite bulk) of Adper Single Bond 2 in non-aged mild-fluorosed enamel specimen.

Fig. 2: Admix mode of bond failure of Adper Single Bond 2 in aged mildy-fluorosed enamel specimen.

fluorosed enamel surfaces (Table 1). This find-ing could be related to the enamel’s preparation procedure done at the time of bonding. The grinding and flattening of enamel helps, in some way, get rid of the enamel layer that normally resists etching due to its abnormal structure. In spite of the detected non-meaningful differ-ences, the two adhesive systems, ASB and ALP, showed no logical differences when bonded to



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CS81003D DN:Layout 1 07/08/2014 14:15 Page 1

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enamel surfaces with mild and moderate fluorosis (Table 2). These data indi-cated that the investigated self-etching adhesive system is as effective as those utilizing phosphoric acid etching and come, accordingly, in coincidence with those of Pashley and Tay, and Tay et al.,22,23 They postulated that the sever-ity of etching does not affect the values of adhesive bond strength to tooth enamel, although this thought is currently in conflict with the deduction of Ateyah and Akpata.6 Some investigators24 believe that the lower acidity (higher pH) of self-etch adhesive in comparison to the commonly used 35% phos-phoric acid etchant (pH=0.7) could suppress their etching power. Therefore, this study utilized a self-etch adhesive with comparable acidity (pH=0.8-0.9) to that of regular etchants and this could be attributed to its efficient bonding to tooth enamel.24,25 In contrary, Ostby et al.25 noticed acceptable bonding of the self-etch adhesives with higher pH (2.7) to tooth enamel and deduced minimal importance of this factor accordingly.An additional debate over the performance of different adhesive systems bonding to fluorotic enamel was also noticed between some previous studies. Waidyasekera et al.26 reported higher bond strength of self-etching adhesives to fluorosed tooth tissues in comparison to total-etch adhesives, while Ertu-grul et al.27 stated that the use of etch-and-rinse dentin bonding technique produced higher bond strengths of the resin composite tested to fluorotic and nonfluorotic enamel compared to self-etching techniques. As the restoration ages in service, the bond quality usually shows a sort of de-terioration as a result of the mechanical and thermal stresses that continuously develop at the bonding interfaces.28 Both water storage and thermocycling are procedures usually used to simulate clinical aging. In this study and in agree-ment with Khoroushi and Rafiei,29 5000 cycles of thermocycling at 5, 37 and 60oC together with 6 months aging in wet environment had no significant effect on the recorded shear bond strength data (Table 2); although the mode of bond failure has obviously altered in response (Table 3). The reported bond failures respectively showed admix and adhesive characteristics, with the ad-hesive mode becoming dominant among aged samples. Accordingly, further photo-micro-graphical studies are required to clarify the effect of aging on the interfacial junction between resin adhesive and fluorosed tooth enamel.

ConclusionBoth Adper Single Bond 2 and Adper Prompt L-Pop adhesive systems provided comparable bonding values to normal and fluorosed tooth enamel. Wet aging and thermocycling have no adverse effect on the adhesive bonding to tooth enamel with different degrees of fluorosis.

References

1. lAwSoN j, wARReN jj, levy Sm, bRoffitt b, biShARA Se. RelAtive eSthetiC impoRtANCe of oRthodoNtiC ANd ColoR AbNoRmAlitieS. ANGle oRthod 2008; 78(5):889–94.2. Al-SuGAiR mh, AKpAtA eS. effeCt of fluoRoSiS oN etChiNG of humAN eNAmel. j oRAl RehAbil 1999; 26(6): 521–8.3. AdANiR N, tüRKKAhRAmAN h, GüNGöR Ay. effeCtS of fluoRoSiS ANd bleAChiNG oN SheAR boNd StReNGthS of oRthodoNtiC bRACKetS. euR j deNt 2007; 1(4): 230–5.4. buoNoCoRe mG. A Simple method of iNCReASiNG the AdheSioN of ACRyliC filliNG mAteRiAlS to eNAmel SuRfACeS. j deNt ReS 1955; 34(6): 849–53. 5. opiNyA GN, pAmeijeR Ch. teNSile boNd StReNGth of fluoRoSed KeNyAN teeth uSiNG the ACid etCh teChNique. iNt deNt j 1986; 36(4): 225–9. 6. AteyAh N, AKpAtA e. fACtoRS AffeCtiNG SheAR boNd StReNGth of CompoSite ReSiN to fluoRoSed humAN eNAmel. opeR deNt 2000; 25(3): 216-22.7. Retief dh, woodS e, jAmiSoN hC. effeCt of CAvoSuRfACe tReAtmeNt oN mARGiNAl leAKAGe iN ClASS v CompoSite ReSiN ReStoRAtioNS. j pRoSthet deNt 1982; 47(5): 496-501.

8. bARKmeieR ww, ShAffeR Se, GwiNNett Aj. effeCtS of 15 vS 60 SeCoNd eNAmel ACid CoNditioNiNG oN AdheSioN ANd moRpholoGy. opeR deNt 1986; 11(3): 111-69. GuNGoR Ay, tuRKKAhRAmAN h, AdANiR N, AlKiS h. effeCtS of fluoRoSiS ANd Self etChiNG pRimeRS oN SheAR boNd StReNGthS of oRth-odoNtiC bRACKetS. euR j deNt 2009; 3(3): 173–7.10. eRmiS Rb, de muNCK j, CARdoSo mv, CoutiNho e, vAN lANduyt Kl, poiteviN A, lAmbReChtS p, vAN meeRbeeK b. boNdiNG to GRouNd veRSuS uNGRouNd eNAmel iN fluoRoSed teeth. deNt mAteR 2007; 23(10): 1250-5. 11. bouillAGuet S, GySi p, wAtAhA jC, CiuCChi b, CAttANi m, GodiN Ch, meyeR jm. boNd StReNGth of CompoSite to deNtiN uSiNG CoN-veNtioNAl, oNe-Step ANd Self-etChiNG AdheSive SyStemS. j deNt 2001; 29(1): 55–61.12. vAN meeRbeeK b, vARGAS m, iNoue S, yoShidA y, peumANS m, lAmbReChtS p, vANheRle G. AdheSiveS ANd CemeNtS to pRomote pReS-eRvAtioN deNtiStRy. CAvex pRoduCtS 2001; SupplemeNt 6: 119–44. AvAilAble At: http://www.CAvex.Nl/eN/quAdRANt/CASuS-A-ReSeARCh/ReSeARCh/437. 13. Swift ej jR. deNtiN/eNAmel AdheSiveS: Review of the liteRAtuRe. pediAtR deNt 2002; 24(5): 456-61.14. toRii y, itou K, hiKASA R, iwAtA S, NiShitANi y. eNAmel teNSile boNd StReNGth ANd moRpholoGy of ReSiN-eNAmel iNteRfACe CReAted by ACid etChiNG SyStem with oR without moiStuRe ANd Self-etChiNG pRim-iNG SyStem. j oRAl RehAbil 2002; 29(6): 528-33.15. ShidA K, KitASAKo y, buRRow mf, tAGAmi j. miCRo-SheAR boNd StReNGthS ANd etChiNG effiCACy of A two-Step Self-etChiNG AdheSive SyStem to fluoRoSed ANd NoN-fluoRoSed eNAmel . euR j oRAl SCi 2009; 117(2): 182–6. 16. Neme Al, evANS db, mAxSoN bb. evAluAtioN of deNtAl AdheSive SyStemS with AmAlGAm ANd ReSiN CompoSite ReStoRAtioNS: CompARiSoN of miCRoleAKAGe ANd boNd StReNGth ReSultS. opeR deNt 2000; 25(6): 512–9.17. RAtNAweeRA pm, NiKAido t, weeRASiNGhe d, wettASiNGhe KA, miuRA h, tAGAmi j. miCRo-SheAR boNd StReNGth of two All-iN-oNe AdheSive SyStemS to uNGRouNd fluoRoSed eNAmel. deNt mAteR j 2007; 26(3): 355-60.18. toRReS-GAlleGoS i, mARtiNez-CAStAñoN GA, loyolA-RodRiGuez jp, pAtiño-mARiN N, eNCiNAS A, Ruiz f, ANuSAviCe K. effeCtiveNeSS of boNdiNG ReSiN-bASed CompoSite to heAlthy ANd fluoRotiC eNAmel uSiNG totAl-etCh ANd two Self-etCh AdheSive SyStemS. deNt mAteR j 2012; 31(6): 1021–7.19. wAidyASeKeRA pG, NiKAido t, weeRASiNGhe dd, tAGAmi j. boNd-iNG of ACid-etCh ANd Self-etCh AdheSiveS to humAN fluoRoSed deNtiNe. j deNt 2007; 35(12): 915-22.20. thylStRup A, fejeRSKov o. CliNiCAl AppeARANCe of deNtAl fluoRo-SiS iN peRmANeNt teeth iN RelAtioN to hiStoloGiC ChANGeS. CommuNity deNt oRAl epidemiol 1978; 6(6): 315-28. 21. weeRASiNGhe dS, NiKAido t, wettASiNGhe KA, AbAyAKooN jb, AGAmi j. miCRo-SheAR boNd StReNGth ANd moRpholoGiCAl ANAlySiS of A Self-etChiNG pRimeR AdheSive SyStem to fluoRoSed eNAmel. j deNt 2005; 33(5): 419-26.22. pAShley dh, tAy fR. AGGReSSiveNeSS of CoNtempoRARy Self-etChiNG AdheSiveS. pARt ii. etChiNG effeCtS oN uNGRouNd eNAmel. deNt mAteR 2001; 17(5): 430–44.23. tAy fR, pAShley dh, KiNG Nm, CARvAlho Rm, tSAi j, lAi SC, mARqueziNi l jR. AGGReSSiveNeSS of Self-etChiNG AdheSiveS oN uN-GRouNd eNAmel. opeR deNt 2004; 29(3):309–16.24. SuyAmA y, lühRS AK, de muNCK j, miNe A, poiteviN A, yAmAdA t, vAN meeRbeeK b, CARdoSo mv. poteNtiAl SmeAR lAyeR iNteRfeR-eNCe with boNdiNG of Self-etChiNG AdheSiveS to deNtiN. j AdheS deNt. 2013; 15(4): 317-24.25. oStby Aw, biShARA Se, deNehy Ge, lAffooN jf, wARReN jj. effeCt of Self-etChANt ph oN the SheAR boNd StReNGth of oRthodoNtiC bRACKetS. Am j oRthod deNtofACiAl oRthop. 2008; 134(2): 203-8. 26. wAidyASeKeRA pG, NiKAido t, weeRASiNGhe dd, tAGAmi j. boNd-iNG of ACid-etCh ANd Self-etCh AdheSiveS to humAN fluoRoSed deNtiNe. j deNt 2007; 35(12): 915-22. 27. eRtuGRul f, tüRKüN m, tüRKüN lS, tomAN m, CAl e. boNd StReNGth of diffeReNt deNtiN boNdiNG SyStemS to fluoRotiC eNAmel. j AdheS deNt 2009; 11(4): 299-303.28. yuN x, li w, liNG C, foK A. effeCt of ARtifiCiAl AGiNG oN the boNd duRAbility of fiSSuRe SeAlANtS. j AdheS deNt 2013;15 (3): 251-8.29. KhoRouShi m, RAfiei e. effeCt of theRmoCyCliNG ANd wAteR StoR-AGe oN boNd loNGevity of two Self-etCh AdheSiveS. GeN deNt 2013; 61(3): 39-44.



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Oral Ulcers in Infants and Children Part II: Treatment

40

Oral Pathology

AbstractMany treatments have been advocated for oral ulcers. These may be preventive, symptomatic and etiologic. They may be local or systemic and based upon antiseptics, antibiotics, corticosteroids, antirheumatics, anti-inflammatory, hormone therapy, antiviral, colchicine, thalidomide, interferon, hyaluronic acid, laser, cautery, cryotherapy, bioadhesives, homeopathy, vitamins as well as sundry other management strategies and combinations of various medications.Systemic treatment may be appropriate for severe and resistant cases.

KeywordsPreventive treatment, symptomatic treatment, laser treatment and etiologic treatment.

IntroductionMost injuries to the oral mucosa are painful and are a common reason for patients to choose self-treatment or to seek professional dental help.Whether caused by mucosal trauma or common aphthous ulcer, these benign lesions are source of acute pain that can disturb daily activities.Many products are available for the treatment of oral soreness. Over-the-counter products in-dicated for oral ulcers include different formula-tions and different active compounds.1

Modalities of treatment

a. Preventive treatmentIt consists to prevent the appearance of the ul-cer, especially traumatic ulcer, like:- Using film cover. (Fig.1)- Hydration of the cotton roll before removing it.- Taking care when you put the suction tip.- Advise patient with alveolar nerve block anal-gesia to stop eating and sleeping for two hours, and for children who did analgesia for the first time to be for two hours under supervision of an adult.

b. Symptomatic treatmentSymptomatic treatment is a must even if we are searching for the etiology of ulcers. It consists simply in reducing, even disappearance of symp-toms, mainly pain. It can be local or systemic.

Local treatmentIt consists to cover the ulcer like putting gel which sticks to it and to get it to adhere firmly: this gel should form a protective layer over the ulcer to help make it comfortable2 (Fig.2).Usually, the treatment should be instaured 15 minutes before any painful situation like eating

Dr. Sawsan Nasreddine, BDS, DESS Pediatric

Dentistry, DESS Public Health Dentistry, Department of

Public Health Dentistry.

Dr. Antoine Cassia,Dr. Chir. Dent., Dr. Sc. Odont.,

DUPRMF, Associate Professor and Former Chairperson,

Department of Oral Pathology and Diagnosis, Director of

LASER Unit.

Lebanese University School of Dentistry, Beirut.

[email protected]

a

b

Fig.1-a: traumatic ulcer related to radiographic film

Fig. 1-b: film cover

Fig 1


42

Oral Pathology

or speaking by applying on dried lesions (3 to 5 times daily), or according to the manufacturer.

Gel and paste

Dental adhesive paste- Solcoseryl® active ingredients:. Calf blood extract protein-free 2.125mg. Lauromacrogol 400 10mg/g

Dental analgesic paste mainly anesthetic- Emla® 5% cream contains two amide-type lo-cal anesthetics, lidocaine 2.5% and prilocaine 2.5% (Fig.3).Prilocaine and lidocaine are classified as amide-type local anesthetics for which serious adverse effects include methemoglobinemia. Although the hydrolyzed metabolites of prilocaine (o-tolu-idine) and lidocaine (2,6-xylidine) have been sus-pected to induce methemoglobinemia. When the parent compounds (prilocaine and lidocaine) were incubated with human liver microsomes (HLM), methemoglobin (Met-Hb) formation was lower than when the hydrolyzed metabo-lites were incubated with HLM.3

- Medijel® gel active ingredients:. lidocaine hydrochloride and aminoacridine hy-drochloride.. Apply Medijel to the painful area.

0 up to 3 months or < 5 kg

Maximum total dose of Emla cream

Maximum application area

Maximum application time

1 g 10 cm2 1 hour

10 g 100 cm2 4 hours

2 g 20 cm2 4 hours

20 g 200 cm2 4 hours

Age and body weight requirements

3 up to 12 months and > 5 kg

1 to 6 years and > 10 kg

7 to 12 years and > 20kg

Fig.3 maximum prescription of Emla 5% cream related to age and body weight requirements as recommended by manufacturer.

Fig 2

Fig 3


44

Oral Pathology

- Orabase® product characteristics:. 20% benzocaine.. Orabase® gives maximum strength pain relief for canker.

- Ginvapast® components consist of calcium glu-conate, cetylpyridinium chloride and procaine hydrochloride.

We can do our own “cocktail” by mixing dental adhesive paste with dental analgesic paste like:Solcoseryl® + Emla® 5% or Orabase® + Solco-seryl®

Dental anti-inflammatory paste- Kenalog® in Orabase (AIS)Kenalog (triamcinolone acetonide 1mg/g) in Orabase 0.1%. It is the theoretical advantage of incorporating a corticosteroid in an adhesive base.4 The active ingredient of Kenalog in Orabase for mouth ulcers relieves pain by reducing the swell-ing around the ulcer and it speeds up the heal-ing process.The treatment is effective because the active ingredient is a unique paste - Orabase - which keeps the medicine in direct contact with the ulcer. Orabase also helps to prevent the pain be-cause it covers the ulcer, protecting the tender exposed nerves from further irritation.

- Pyralvex® Although it is neither a paste nor a gel it con-tains a few ingredients; however there are two main ingredients: They are the rhubarb extract and salicylic acid. The rhubarb extract is a genuine (natural) ex-tract while the salicylic acid is an acid similar to aspirin.

- Pansoral®

Pansoral contains cetalkonium chloride 0.1mg/g and choline salicylate 87mg/g

- Dologel®

Dologel contains Choline Salicylate and Lido-caine Hydrochloride. (AI)Dosage: 8.7% gel: Apply as directedContraindication: children <12years.

Patch- RemeSense®

It’s a patch active ingredients:. Hyaluronic acid: helps to reform oral tissues. Bark extract of the red mangrove: forms an im-pervious protective layer over the affected area. Cellulose: creates a strong barrierThe patch automatically dissolves after a few hours.

- Urgo® active ingredients: Ibuprofen.

Mouthwash• Protective action- Aloclair®

Aloclair contains the film-forming agent, polyvi-nylpyrrolidone.Dosage and administration:. Fill the measuring cap provided to the 5 ml or 10 ml indicator mark.. Rinse the mouth with the liquid for at least 60 seconds.. Gargle and spit out.. Use as needed, up to 3-4 times a day.. May be used by children who are old enough to follow the instructions.

• Sodium bicarbonate diluted in warm water

• Analgesic and antiseptic- Trachisan® (chlorhexidine gluconate, lidocaine hydrochloride)

• Antiseptic - Eludril®

Eludril mouthwash contains two active ingre-dients, chlorhexidine gluconate at 0.20% and chlorbutanol hemihydrate.

- Paroex® (chlorhexidine gluconate 0.12%)

- Cariax® (chlorhexidine gluconate 0.12%, so-dium fluoride)Alcohol-free mouthwashes will generally be more comfortable for the patient to use.5

Systemic treatmentAntipyretics/AnalgesicsParacetamol/Acetaminophen: 30mg/kg/d every 4 hours- Panadol® 125mg/5ml


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- Adol® 250mg/5ml

Systemic antibiotics can be used to prevent secondary infectious.4

Other modalities have been used with some success: excision with primary clo-sure, cryosurgery, and topical application of tetracycline followed by cortisone ointment and injection of cortisone directly into the lesion in combination with systemic administration of cortisone.6

Laser treatment Laser technology in pediatric dentistry is a viable treatment modality for chil-dren and adolescents. The laser can be thought of as an alternative instrument that sometimes completes and, at other times, substitutes for the traditional techniques.Because of their well documented surgical and clinical advantages, lasers are commonly used on soft tissues in oral pathology.The laser offers a minimally painful treatment option that allows fast healing. Different laser wavelengths can be used with sub-ablative power both to de-toxify and dehydrate the ulcer as well as to induce analgesic and bio-stimulat-ing effects.7

Different wavelengths interact differently with a variety of chromophores (e.g. hemoglobin, water, hydroxyapatite) contained in several types of target tis-sues (e.g. mucosa); therefore, the choice of laser is regulated by the different optical affinity and coefficient of absorption of the tissues for each particular wavelength.Thus, lasers are classified according to their use on the soft tissues exclusively, on soft and hard tissues.7

The low level laser therapy or ‘soft laser therapy’ is effective for some specific applications in dentistry such as in treatment of ulcers. Along with the primary benefit of being nonsurgical, it promotes tissue healing and reduces edema, inflammation and pain. 810, 940 and 980 nm diode laser can be used for the treatment of minor aphthous ulcers and herpetiform aphthous ulcers; both be-ing clinical variants of aphthous ulcers.8

The wound should be cleaned and dried prior to application. At first, laser should be applied in the center of the lesion, in a punctual manner and scan-ning along lesion at a distance of 5mm, with 2 J/cm² and move to the edges of the wound in a circular scanning manner with 2 to 4 J/cm², according to the extension of the lesion.9

Application frequency: 2-3 applications weekly, with a 24-hour interval, until improvement of painful symptomatology and total tissue repair (Fig.3).

b

Fig. 3-a,b: Banding laser (courtesy Oral pathology and Oral diagnosis depart-ment – LU)

Fig. 4-a, Aphthous ulcer can be irritating to patient and can delay treatment.b, ulcer was exposed to laser erbium.c, post operation vision. Courtesy Oral pathology and Oral diagnosis department – UL.

Fig 3

The performance therapy of laser consists in banding laser. Banding laser consist on the elaboration of a protective layer on the surface of a lesion related to thermal energy (Ray 2005).

The erbium family is certainly the most impor-tant for its versatility in application. The erbium family includes the erbium-chromium-doped yt-trium scandium gallium garnet (Er,Cr:YSGG) and the erbium-doped yttrium aluminum garnet (Er:YAG) lasers.The wavelengths of the two erbium lasers have a lot of clinical overlap in their application but with a more superficial interaction for the Er:YAG, which is primarily absorbed by the wa-ter.7 In cases where higher energies are required, amplifiers have to be employed.10 The erbium la-sers are indicated in soft tissue treatment when the tissue is lightly vascularized.7 In medical applications, and especially in dentist-ry, the Erbium lasers represent highly developed commercial lasers with very high yield and ef-ficiency in tissue removal.10 (Fig.4-a,b,c).

Fig 4a

b

c

a

46

Oral Pathology


47

Oral Pathology

Biopsy must precede laser therapy when there has been an ulcerated area for more than two or three weeks or there is doubt regarding the diagnosis.9

Etiologic treatmentIt is necessary to eliminate all diseases that can be accompa-nied by Crohn’s disease and Behçet’s syndrome. We should try to treat the etiology of the ulcer in that case, the treatment is related to each kind of lesion and eventually underlying systemic disease.

In case of:

Recurrent aphthous ulcersThe course of these ulcers varies from few days to over 2 weeks, but usually their duration is of the order of 10 days. Minor aphthae heal without scar formation.11,12

Major aphthous ulcers are difficult to treat. The patients of-ten have had these non healing ulcers for months.5 They can persist for ≥ 6 weeks and commonly leave scars.12 It requires good oral hygiene. Systemic corticosteroids only in most se-vere cases.13,14 Herpetiform ulcer seems to respond best to tetracycline mouthwash.14

- Ask the patient to change his toothpaste to another one without SLS (Sodium Lauryl Sulfate) when recurrent aphthous ulcers are suspected to relate to SLS components as:. Pronamel (Sensodyne). Orosafe junior. Oral Balance (Biotène)

- Ask the patient blood test if anemia is suspected. Folic acid. Ferritin. Vitamin B12

Primary herpetic gingivostomatitisNormally, the primary herpes simplex infection is self-limiting and the child will recover within 10 days. Children having these lesions decrease their food intake, and it is advisable to adopt a support therapy, which should include:- increase the liquid’s intake- the use of dietary supplements- highly nutritious cold liquid diet 15,16

Systemic antibiotics can be used to prevent secondary infec-tions.6 In severe cases, hospitalization and/or the use of antiviral agents are necessary.16

Active ingredients: - Acyclovir 2 used 3 times per day as:. Zovirax® cream 5%

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. Cyclovax® cream 5%

. Supraviron®

- Valacyclovir used 3 times per day as:. Valatex® (maximum dose is 1000mg 3 times daily)Valacyclovir is an oral antiviral drug which is ac-tive against the herpes viruses. It is used to treat infections with shingles (herpes zoster), and chickenpox (varicella zoster). It belongs to a class of drugs called nucleoside analogs that mimic one of the building blocks of DNA. It stops the spread of herpes virus in the body by prevent-ing the replication of viral DNA that is necessary for viruses to multiply. Valacyclovir, therefore, is active against the same viruses as acyclovir, but Valacyclovir has a longer duration of action than acyclovir, and, therefore, can be taken fewer times each day. Valacyclovir was approved for use by the FDA in 1995.

Traumatic ulcerMost traumatic ulcers heal within 10 days. Oc-

49

Oral Pathology


casionally, however, a lesion persists for some weeks because of continued traumatic insults or continued irritation by the oral liquids or because of the development of a secondary infection.5

Parents should be warned and children reminded not to bite their lips after mandibular block anaesthesia.14 We should remove the cause of the ulcer in case of denture, orthodontic treatment or a tic.

Factitious ulceration (self-inflicted oral lesions)Frequently the diagnosis can be confirmed only by discrete observation after admission to hospital. The patient’s family doctor should be told of the need for specialist psychiatric accessment.2

No local anesthesia is used as the patient’s pain perception is altered.Non-contingent reinforcement therapy is successfully used to reduce self in-flicted oral lesion.17

Viral and bacterial infections Varicella (chickenpox)The virus is extremely contagious and is generally contracted as a childhood infection between 18 months and 5 years of age. The virus is effectively spread by direct contact and even as an airborne infection. The infection generally resolves within 2 weeks.18 Analgesic and antipyretic are often beneficial and refer the patient.

50

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HerpanginaThe systemic symptoms resolve within few days and the oral ulcers usually take seven to ten days to heal.In patients with atypical presentations, laboratory confirmation may be re-quired:- Viral cultures from early vesicular lesions or stool specimen analysis are the best techniques in patients with only oral lesions. Viral cultures of the ulcerative lesions will usually be negative.- Serological tests for rising enterovirus antibody titers between the acute and convalescent stages can be done to confirm the diagnosis in questionable cas-es.In most cases, the infection is self-limiting and without complications. Therapy for these patients is directed toward symptomatic relief. Non-aspirin antipyret-ics and topical anesthetics are often beneficial19 and the patient should be re-ferred.

Hand, foot and mouth diseaseSerological confirmation of the diagnosis is possible but rarely necessary as the history, especially of other cases. The disease typically resolves within a week.2 Culture of cutaneous lesions is best for hand, foot and mouth disease.19 Anal-gesic and antipyretic are usually prescribed and refer the patient.

Oral Pathology

Tuberculosis ulcerDiagnosis is confirmed by biopsy, chest radiog-raphy and a specimen of sputum. Myobacterial infection is confirmed by culture.Oral lesions clear up rapidly if vigorous multi drug chemotherapy is given for the pulmonary infection. No local treatment is required,2 the patient should be referred.

Malignant ulcersSquamous cell carcinomaTreatmentRare in children, the detection of this type of ul-cer is important because the tumor has a good prognosis if accessible and diagnosed at an early stage. Health professional should educate patients to recognize suspicious lesions and to know the risk factors. A biopsy (or second opinion) should obtain for suspicious lesions and ulcers that persist after the removal of possible causal agents, as these

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are the only reliable methods for establishing a definite diagnosis.4

Indications for biopsy of an oral ulcer:- Of unknown origin that remains without signs of healing after 2 weeks.- Of probable known aetiology (after clinical examination and diagnostic tests) that do not respond to appropriate treatment after 2 weeks- Believed to be caused by precipitant factors, which do not show signs of heal-ing 2 weeks after removal of these factors.4

In small ulcers (<5mm in diameter) an excisional biopsy is recommended (in-cluding 2mm of perilesional tissue), whereas in larger ulcers (>5mm in diam-eter) an incisional biopsy is preferred.The specimen must include part of the ulcer and the perilesional tissue, includ-ing the unaffected surrounding epithelium. The centre of the ulcer alone usu-ally does not show diagnostic features. Scalpel or punch biopsies are preferred; other techniques (e.g. lasers, electrical scalpels) are not recommended.4

ConclusionIt is essential to review the patient to assess his progress and response to any treatment instituted. It is important that patients are aware of the limitations of treatment.20

An ulcer without pain can be a chronic ulcer, a healing ulcer or a malignant ulcer. A painful ulcer is usually benign.

Aphthous X

X

X X

X

X

X

X

XX

XX

X

XX

X

X

X

X

X

X

X

Varicella

Recurrent Aphthous

Herpangina

Traumatic

Hand, Foot and Mouth

Primary herpetic gingivostomatitis

Tuberculosis

Squamous cell carcinoma

Preventive Symptomatic Etiologic Hospitalization Refer thepatient

1. deSCRoix v., CoudeRt A.e., viGé A., duRANt j.p., toueNAy S., mollA m., pompiGNoll m., miSSiKA p., AllAeRt f.A. effiCACy of topiCAl 1% lidoCAïNe iN the SymptomAtiC tReAtmeNt of pAiN ASSoCiAted with oRAl muCoSAl tRAumA oR miNoR oRAl AphthouS ulCeR: A RANdomized, double-bliNd, plACebo-CoNtRolled, pARAllel-GRoup, SiNGle-doSe Study. jouRNAl of oRofACiAl pAiN. 2011, vol.25, NbR 4:327-332.2. CAwSoN R.A., odell e.w. diSeASeS of the oRAl muCoSA: iNtRoduCtioN ANd muCoSAl iNfeCtioNS. oRAl pAthol-oGy ANd oRAl mediCiNe. 8th editioN, 2008: 206-216.3. hiGuChi R., fuKAmi t., NAKAjimA m., yoKoi t. pRiloCAiNe- ANd lidoCAiNe-iNduCed methemoGlobiNemiA iS CAuSed by humAN CARboxyleSteRASe-, Cyp2e1-, ANd Cyp3A4-mediAted metAboliC ACtivAtioN. juN 2013, 41(6):1220-304. fiShmAN S.l., NiSeNGARd R.j., bloziS G.G. GeNeRAlized Red CoNditioNS ANd multiple ulCeRAtioNS diffeReNtiAl

diAGNoSiS of oRAl leSioNS. uSA, moSby, 4th editioN, 1991:83-87 5. muNoz-CoRCueRA m., eSpARzA-Gomez G., GoNzAlez-moleS m.A., bASCoNeS-mARtiNez A. oRAl ulCeRS: CliNiCAl ASpeCtS. A tool foR deRmAtoloGiStS. pARt ii. ChRoNiC ulCeRS CliNiCAl ANd expeRimeNtAl deRmAtoloGy. 2009, 34:456-4616. wood N.K., GoAz p.w. diffeReNtiAl diAGNoSiS of oRAl leSioNS. uSA, moSby, 4th editioN, 1991:195-2217. olivi G., mARGoliS f.S., GeNoveSe m.d. pediAtRiC lASeR deNtiStRy, A uSeR’S Guide. ChiCAGo, quiNteSSeNCe publiShiNG Co,2011,15-26 8. thARwANi b. uSe of Soft lASeR theRApy iN tReAtmeNt of Aph-thouS ulCeRS. GuideNt, youR Guide oN the pAth of deNtiStRy. deC 2012:109-111 9. bRuGNeRA A. jR, GARRiNi doS SANtoS A. e. C., boloGNA e. b., piNheiRo lAdAlARdo th. Ch. C. G. AtlAS of lASeR theRApy Applied to CliNiCAl deNtiStRy, ChiCAGo, quiNteSSeNCe editoRA, 2006:34-3510. moRitz A. oRAl lASeR AppliCAtioN. beRliN, quiNteSSeNz veRlAGS-Gmbh, 2006:52-88 11. field e.A., AllAN R.b. Review ARtiCle: oRAl ulCeRAtioN, Aetio-pAthoGeNeSiS, CliNiCAl diAGNoSiS ANd mANAGemeNt iN the GAStRoiNteSti-NAl CliNiC. AlimeNt phARmACol theR. 2003, 18:942-962.12. muNoz-CoRCueRA m., eSpARzA-Gomez G., GoNzAlez-moleS m.A., bASCoNeS-mARtiNez A. oRAl ulCeRS: CliNiCAl ASpeCtS. A tool foR deRmAtoloGiStS. pARt i. ACute ulCeRS, CliNiCAl ANd expeRimeNtAl deRmAtoloGy. 2009, 34:289-29413. m. m. S. NiCo, A. e. bRito, l. e. A. m. mARtiNS, p. boGGio ANd S. v. louReNCo

oRAl ulCeRS iN AN immuNoSuppReSSed 5-yeAR-old boy CliNiCAl ANd ex-peRimeNtAl deRmAtoloGy. 2008, 33:367-36814. CAmeRoN A.C., widmeR R.p. pediAtRiC oRAl mediCiNe ANd pAthol-oGy; ulCeRAtive ANd veSiCulobullouS leSioNS. hANdbooK of pediAtRiC deNtiStRy. ediNbuRGh, moSby, 3Rd editioN, 2008:177-18015. SCully C., felix d.h. oRAl mediCiNe-updAte foR the deNtAl pRAC-titioNeR AphthouS ANd otheR CommoN ulCeRS bRitiSh deNtAl jouRNAl. 2005, vol.199, No 5:259-26416. KoCh G., poulSeN S. oRAl muCouS leSioNS ANd miNoR oRAl SuR-GeRy. pediAtRiC deNtiStRy (A CliNiCAl AppRoACh). CopeNhAGeN, muNKS-GAARd, 2Nd editioN, 2009:298-30717. mediNA A. C., SoGbe R., Gomez-Rey A.m., mAtA m. fACtitiAl oRAl leSioNS iN AN AutiStiC pAediAtRiC pAtieNt iNteRNAtioNAl jouRNAl of pAediAtRiC deNtiStRy. 2003, 13:130-13718. SällbeRG m. oRAl viRAl iNfeCtioNS of ChildReN. peRiodoNtoloGy 2000, 2009, vol.49:87-9519. lewiS m. heRpANGiNA: AN eNteRoviRAl febRile ASSoCiAted veSiCulo-bullouS diSeASe. oKlAhomA deNtAl ASSoCiAtioN jouRNAl. mARCh 2008:32-3420. tAlACKo A.A., GoRdoN A.K., AlfRed m.j. the pAtieNt with Re-CuRReNt oRAl ulCeRAtioN. AuStRAliAN deNtAl jouRNAl. 2010, 55 (1 Suppl):14-22

References

Oral Pathology


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May 29 - 31, 2014 USJ Dental SchoolBeirut, Lebanon

54

More Pictures Available Onwww.facebook.com/dentalnews1

2014

11e JournéesOdontologiques

Picture of the Audience during the oPening ceremony

Monsieur le Recteur,Messieurs les ministres et députés,Chers invités et collègues

Je tiens à remercier, le Recteur et les vice-recteurs pour leur appui incon-ditionnel à l’organisation de ces journées, les présidents de l’ordre, les doyens et directeurs, pour leur présence avec nous. Je souhaite la bienvenue dans notre pays, aux doyens des Facultés de chirurgie dentaire des pays arabes, aux conférenciers spécialistes étrang-ers venus très nombreux pour participer à la réussite de notre congrès biannuel: les 11èmes journées odontologiques et j’espère, au-delà des préoccupations d’ordre professionnel, qu’ils emporteront du pays des cèdres un souvenir agréable.Nous en sommes à la 11ème édition des Journées Odontologiques, la première ayant eu lieu en 1991 au sortir de la guerre. Si cette tradition des journées s’est perpétuée, c’est d’abord parce qu’elle a su rester fidèle à ses principes fondateurs: assurer grâce à la participation des praticiens libanais une mise à jour de l’exercice de la profession.Bien que fortement impliquée dans les préparatifs du congrès, je ne peux que souligner la très grande qualité du programme scientifique, la variété des thématiques, l’ampleur de l’exposition. Le président du comité d’organisation a rappelé l’importance de la formation continue. Je vais aborder les activités de la Faculté qui n’a pas arrêté de se développer depuis 1919 date de la création de l’école dentaire. Nous avons actuellement 450 étudiants: entre le doctorat d’exercice, les Masters spécialisation et recherche et le Doctorat. Mal-gré le nombre important de praticiens au Liban, nous avons remarqué

que l’attrait qu’exerce la profession sur les jeunes libanais augmente toujours.Pour terminer, je voudrais saluer l’engagement du conseil de Faculté, des enseignants et du personnel, remercier le comité d’organisation et son président le Dr Ghassan Yared, qui témoigne de son dévouement pour la Faculté et pour la pro-fession. À vous toutes et tous, praticiens étrangers et libanais, je voudrais vous sou-haiter de tout coeur trois belles journées sur ce campus centenaire des sciences médicales et infirmières.

Pr. Nada NaamanDoyen de la Faculté de Medecine Dentaire

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The Power of 2.


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Prs: KtAmish, Abdelmoneim, osmAn, AbiAd, segAAn

Prs: mAAlouf, hArdAn, dietshi, younis, bouKArAmPrs: sAder, megArbAne, bAdAwi, AzAr, mr. AbelA, hAge, moKbel

Pictures from theoPening ceremony

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dr. yAred, dr. mouKArzel,rector dr. dAKKAsh

dr. fAdi KArAm, President elie mAAlouf, dr. AmmAr houry, dr. nizAr KAdy

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Pr. zbouny, mr. bArAKA, mr. genini, dr. KAmAchi

dr. zArAzir, dr. dib, Pr. mhAnnA, dr. stemPf,mr. KhAttAr

Pr. hArdAn, dr. mAciel Jr,dr. Abi sleimAn

dr. Khoury, Pr. doumit, dr. mzAwAK dr. sAmAhA, dr. hAddAd, dr. dAmien

Pr. tAwil, deAn behbehAni

Pr. zbouny, mr. bArAKA, mr. genini, dr. KAmAchi

dr. sAmAhA, dr. hAddAd, dr. dAmien

Pr. tAwil, deAn behbehAni

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dr. AJAy JuneJA, dr. mAciel Juniormr. dAniel, dr. nAsser, President sAKer

Pictures from theexhibition floor

dr. AJAy JuneJA, dr. mAciel Junior


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More Info Available OnJune 14, 2014 London, UK www.ivoclarvivadent.com

MONOLITHICRESTORATIONCONCEPTS65

Ivoclar Vivadent hosts the 2nd International Expert Symposium in LondonEndorsed by the King’s College London Dental Institute, Ivoclar Vivadent hosted the International Expert Symposium ‘The Quality of Esthetics’ in London. World-renowned specialists discussed the latest materials and advanced clinical concepts to an audience of 750 delegates on 14th June 2014.

Robert Ganley, CEO of Ivoclar Vivadent AG and Darryl Muff, Managing Director Ivoclar Vivadent Ltd. UK & Ireland opened proceedings with a welcoming ad-dress, highlighting their commitment to connect with clinicians and technicians through the continued dissemination of knowledge and education.Dr James Russell and Rob Lynock (UK) looked at ethics in esthetics, illustrating how through close teamwork the clinician and technician can ensure patients are provided with highly esthetic restorations, whilst ensuring minimal prepara-tion and preserving the tooth’s healthy structure. Bart van Meerbeek (Belgium) discussed research into the most effective bonding approach, concluding that in most cases a combination of the self-etch approach and the etch & rinse ap-proach is necessary, even though the self-etch approach is often regarded as the most effective, with its ease-of-use and low-failure rate.Dr Eric van Dooren (Belgium) and technician Murilo Calgaro (Brazil) discussed the general principles of ingot and shade selection with the IPS e.max system, placing great emphasis on lithium discillicate (LS2) with low translucency (LT) and medium opacity (MO) ingots for optimal, esthetic results, whilst technician Michele Temperani (Italy) discussed all-ceramics and CAD/CAM technology as an ideal combination for greater esthetic success.Dr Markus Lenhard (Switzerland) demonstrated how Tetric EvoCeram Bulk Fill layering technique has revolutionised composite restorations to make proce-dures quicker and simpler. Van P. Thompson (USA) discussed monolithic crown CAD/CAM materials, looking at silicate and oxide ceramics, the problems of cone cracks and radial fractures, and why Zirconia has become the material of choice.

Focusing on ultra-thin ceramic restorations, Dr Stefan Koubi (France) emphasised that keeping some of the dyschromia and working closely with the technician to achieve the ideal colour match was key. Supporting this, Dr Rafael Pi-ñeiro Sande (Spain) stressed that diagnosis is most important part of treatment when aiming for the best esthetic results, whilst Oliver Brix (Germany) demonstrated the experience with the IPS e.max system, exploring the limits in in-novative dental design and how to work with nature. Prof Daniel Edelhoff (Germany) concluded the programme by looking at how to solve the problem of accelerated tooth wear due to den-tine exposure, before Josef Richter, Chief Sales Officer of Ivoclar Vivadent AG, closed the Sym-posium by announcing Madrid, Spain, as the next venue for the 2016 Expert Symposium.

More Pictures Available OnJune 17 - 19, 2014 World Trade Center, Dubai, UAE www.facebook.com/dentalnews1

APDC2014 36th ASIA PACIFIC

DENTAL CONGRESS

dr. AishA sultAn surrounded by the rePresentAtives of the APdf

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His Highness Sheikh Hamdan Bin Rashid Al Maktoum.Deputy Ruler of Dubai, Minister of Finance and President of Dubai Health Authority.

Excellencies,Distinguished guests,

Peace and Allah’s mercy and blessing be upon you.

Since its establishment in 1981, the Emirates Medical Association has always been a strong supporter of the health sector in UAE. It helped provide everything that serves this sector through the dissemination of health awareness among the people and keeping up the dental com-munity with all that is new in the field of dentistry.

And the Dental Society as an active member of the Emirates Medical Association have worked hard during the past 30 years of its existence in organizing and promoting dozens of scientific conferences in the dif-ferent fields of dentistry across the country. Many of these events were organized in association with various international dental societies mak-ing UAE a favorable world destination for scientific gatherings.

Your Highness,Dear guests,

To be “number one” has become a state motto and our leadership has set the goal to be number one in everything we do. Our duty as mem-bers of the dental community in UAE is to fulfil the vision of our beloved country in attracting international dental associations and federations to join us in the global promotion of dental health education. To bring

this goal into reality, 4 years ago, the Dental Society of the Emirates Medical Association submitted its proposal to host the 36th Asia Pacific Dental Congress 2014. Several other member nations of the Asia Pacific Dental Federation have joined the race and after a lengthy screening and inspecting process, UAE was granted the honor of hosting this congress here in Dubai. It is the first time for the Asia Pacific Dental Congress to come to this part of Asia since its inauguration in Ja-pan in 1955. From the time it was officially declared as host nation, efforts from all Dental Society members, government agen-cies, academic institutions and private sec-tors in the country have come together to help bring this event into success. Today the name of UAE will be carved in gold as the first state in the Middle East and Gulf region to host this event and for the First Emirati Lady Dentist to become the President of the Asia Pacific Dental Congress for the cycle 2014 – 2015.

Dr. Aisha SultanPresident of theAsia Pacific Dental Federation


Dental News, Volume XXI, Number II, 2014

flAg holders during the oPening ceremony

dr. AlorAyedh, dr. debAybo, dr. zAKiA, dr. dib, Pr. shAmmery, dr. Jishi, dr. KowAsh

meeting of the delegAtes of the AsiA PAcific dentAl federAtion

68 APDC2014 36th ASIA PACIFIC

DENTAL CONGRESS

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hAnding the troPhy to dr. AishA sultAn

dr. AishA sultAn surrounded by her worKing teAm At the ministry of heAlth

dr. christiAn mAKAry receiving the letter of APPreciAtion from dr. mohAmmed KoleylAt

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APDC2014 36th ASIA PACIFIC

DENTAL CONGRESS


French laboratory - www.itena-clinical.com

REFLECTYSAnterior and posterior nanohybrid light-cured composite material

n True mimesisn Exceptional aesthetic quality after polishingn Low polymerization shrinkage:

better marginal adaptationn Easy handling of the material,

does not stick to instrumentsn 16 shades available supplied in syringe format,

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Nature finally matched!Reflectys, true reflection of natural teeth

ITENA_double page_REFLECTYS_210X297_10_07_13_V1.indd 1 02/05/2014 09:02

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CM

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Dental News - 6th DFCIC.pdf 1 06/08/2014 17:16:15

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The new KaVo Design Edition pink orchid adds color to your office. It lets you design not only the upholstery of your new KaVo ESTETICA E70 or E80 treatment center in a refreshingly young and trendy pink, but also adds extra flair through accessories of the same color for the arm system.Show your colors, be strikingly different, and make your new KaVo ESTETICA E70 and E80 unit and your new KaVo PHYSIO® Evo dentist chair the absolute eye-catchers of your office. website: www.kavo.com

KaVo Design Edition pink orchid: Refreshing, bright and beautiful, you’ll fall in love with it!

Medesy is hugely investing in new technologically advanced machineries therefore a bigger factory became a must: during August 2014 Medesy moved to the new factory, where they have installed some last generation machineries and internalized the artisanal works that until now were made by Medesy’s artisans in their own small factories. This way Medesy will increase its monitoring during all phases of production, assuring you the production of highest quality instruments as well as fastest deliveries.The new building, in an area of 20.000 sqm, is divided into production area and administration area. There is an area dedicated to the exhibition room, to host seminars and as a lounge for our guests and employees.The move into the new building is another milestone in Medesy›s history and a valuable commitment to the production location in north-Italywebsite: www.medesy.it

Medesy: Move into the new factory

Reflectys is one of the bestselling products of the French laboratory, ITENA CLINICAL. This anterior and posterior nanohybrid light-cured composite is recommended for all classes & cavities. Confident of the products performance, ITENA had a clinical evaluation performed by the independent American organization, Dental Advisor; which provides objective clinical reports. It was tested by 24 consultants on a variety of factors: aesthetics, non-stickiness to instruments, finishing & packaging.Reflectys received a 91% clinical rating after 740 uses; thereby giving it a great score of 4 ½ stars. Its polishing properties and its universal use were particularly appreciated. The composite is available in 16 shades that can be mixed including two opaque shades, enamel and incisal shades, and a pedo shade. Sold in syringe or capsules, Reflectys is also available in a flowable version - ideal for areas with difficult access thanks to an excellent thixotropy.website: www.itena-clinical.com

ITENA Clinical’s nanohybrid composite Reflectys


78

The extreme precision required for today’s dental technologies would not be possible without safe and reliable modelling resins. The self-curing modelling resin GC Pattern Resin LS has been popular for many years due to its ease of handling and low shrinkage giving extremely precise castings. GC Pattern Resin LS is a product that handles impeccably and is always dimensionally accurate. It is highly appreciated by both dentists and lab technicians. It is perfect for the brush technique. The fact that the material can be precisely applied with a brush simplifies handling, gives you total control over the final outcome and enables you to apply the material incrementally, exactly where you want it. Each freshly applied layer adheres strongly to already polymerized material. What is more, the brush technique is particularly cost effective because only the required amount of material is used.website: www.gc-dental.com

GC Pattern Resin LS Precise dimensional stability for each work step

The Bluephase Style curing light from Ivoclar Vivadent won the bronze medal at one of the most prestigious design competitions in the medical technology industry.With the bronze award of the esteemed «Medical Design Excellence Awards 2014», the polymerization light holds one of the top positions in the category «Dental Instruments, Equipment and Supplies». Criteria for the assessment of the product features were the degree of technological innovation, design and development progress. Furthermore, the patient and the economic benefits as well as the contribution to the health system were considered.website: www.ivoclarvivadent.com

The Bluephase Style polymerization light from Ivoclar Vivadent wins the bronze award

A-dec has launched a simple online, interactive design tool, ‘Inspire Me’. Simply follow the prompts and design your improved surgery. Select your chair model from their range of dental chairs designed to meet every budget, including the premium A-dec 500, the world’s most comfortable dental chair and A-dec 400, the newest addition which combines style with form and function at a beautiful price. Next, choose your delivery system from the innovative range of options, which include the industry’s most reliable air-driven component and the unique 12’oclock delivery options.Add cabinetry to suit the way you work and upholstery from a range of 40 colours to complete the look.A little inspiration to help you dream big.website: www.a-dec.com

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Dental News, Volume XXI, Number I, 2014

dental news september 2014

Documents

dental news

powerful luting materials

wide collection

dental crowdingoral

usj dental school

asia pacific dental

kavo dental gmbh arjaan

different demands