Content uploaded by Irmina Tahmiscija
Author content
All content in this area was uploaded by Irmina Tahmiscija on Jul 23, 2015
Content may be subject to copyright.
Stomatološki vjesnik
Stomatološki vjesnik
Stomatological review
Stomatological review
Stomatološki vjesnik 2015; 4 (1)
Stomatološki vjesnik
Stomatološki vjesnik 2015; 4 (1)
CONTENTS / SADRŽAJ
ORIGINAL SCIENTIFIC ARTICLES / ORIGINALNI NAUČNI RADOVI
CASE REPORT / PRIKAZ SLUČAJA
K
BOOK REVIEW / PRIKAZ KNJIGE
CLINICAL PARAMETERS OF CHRONIC AND AGGRESSIVE PERIODONTITIS BEFORE AND AFTER INITIAL TREATMENT
Pašić E, Dedić A, Hadžić S, Gojkov-Vukelić M, Hodžić M, Nakaš E
THE RELATIONSHIP BETWEEN PERIODONTAL HEALTH AND DIABETES MELLITUS TYPE 1
Atanasovska-Stojanovska A, Stefanovska E, Popovska M, Muratovska I, Zabokova-Bilbilova E
THE EFFECT OF DIFFERENT CONCENTRATIONS OF CHLORHEXIDINE DIGLUCONATE (0,12% AND 0,2%) IN
DEVELOPMENT OF POSTOPERATIVE SEQUELAE AND INCIDENCE OF WOUND INFECTIONS FOLLOWING
ORAL-SURGICAL PROCEDURES: A PROSPECTIVE CLINICAL STUDY
Šečić S, Prohić S, Komšić S, Vuković A
ACCIDENTAL INJURIES AMONG DENTISTS IN PRIVATE AND PUBLIC DENTAL PRACTICE
Cilović-Lagarija Š, Huseinbegović A, Čavaljuga S, Branković S, Selimović-Dragaš M
EFFECT OF BLOOD CONTAMINATION ON SHEAR BOND STRENGTH OF
ORTHODONTIC BUTTON ATTACHMENT- IN VITRO STUDY
Holcner B, Prohić S, Tiro A, Džemidžić V, Redžepagić Vražalica L, Nakaš E
ASSESSMENT OF ANGIOGENESIS BY ENDOGLIN (CD 105) IN INFLAMED DENTAL PULP
Tahmiščija I, Radović S, Jukić-Krmek S, Konjhodžić-Prcić A, Šečić S, Đapo N
MICROLEAKAGE OF TEMPORARY FILLING MATERIALS
Vinković D, Prskalo K
THE USE OF COLD FLOWABLE GUTTA-PERCHA IN ENDODONTIC THERAPY
orać S, Jakupović S, Konjhodžić-Prcić A, Tahmiščija I, Džanković A, Hasić Branković L
BASICS OF ORTHODONTIC DIAGNOSTICS
Nakaš E, Tiro A, Džemidžić V, Redžepagić-Vražalica L, Ajanović M
3
11
19
27
33
41
47
53
61
Izdavač / Publisher:
Za izdavača / For publisher: Sead Redžepagić
ČLANOVI UREĐIVAČKOG ODBORA / EDITORIAL BOARD :
Glavni urednik / Editor in chief: Sadeta Šečić
Sekretar uređivačkog odbora / Secretary of editorial board: Selma Zukić
Članovi /Members: Sead Redžepagić, Samir Prohić, Muhamed Ajanović, Amira Dedić, Sedin Kobašlija, Tarik Mašić, Amra
Vuković, Enita Nakaš
MEĐUNARODNI UREĐIVAČKI ODBOR / INTERNATIONAL EDITORIAL BOARD:
Anwar Barakat Bataineh (Irbid, Jordan), Jasenka Živko-Babić (Zagreb, Hrvatska), Andrija Petar Bošnjak (Rijeka, Hrvatska),
Hrvoje Brkić (Zagreb , Hrvatska), Dolores Biočina Lukenda (Split, Hrvatska), Davor Katanec (Zagreb, Hrvatska), Šahza Hatibović
Koffman (London Ontario Kanada), Mladen Kuftinec (USA), Darko Macan (Zagreb, Hrvatska), Berislav Perić (Zagreb, Hrvatska),
Tore Solheim (Oslo, Norveška), Dragoslav Stamenković (Beograd, Srbija), Marin Vodanović (Zagreb, Hrvatska)
Lektor za engleski jezik / English language editor: Nermana Bičakčić
Tehničko uređenje / Technical editor: Branislav Trogrančić
Štampa / Printed by: Štamparija Fojnica
Dizajn naslovnice / Cover page design: Lana Malić
Tiraž/ Number of copies:
KONTAKT / CONTACT:
Stomatološki vjesnik
Stomatološki fakultet sa klinikama
Bolnička 4a, 71000 Sarajevo
Bosna i Hercegovina
Telefon: + 387(33)214 294
e-mail: stomatoloskivjesnik@sf.unsa.ba
Web: www.stomatoloskivjesnik.ba
TRANSAKCIJSKI RACUN / TRANSFER ACCOUNT:
33386902296551066
UniCredit Bank dd
Stomatološki fakultet Univerziteta u Sarajevu / Faculty of Dentistry, University of Sarajevo
200
ISSN 0350-5499 UDK 616.31
Svrha i i cilj :
Stomatološki vjesnik je neprofitni naučno stručni časopis koji publicira originalne naučne radove, prikaze slučajeva, pisma uredniku,
savremene perspektive, editorijale, preliminarne komunikacije u oblasti stomatologije i drugih biomedicinskih nauka. Radovi su na
Bosanskom/Hrvatskom/Srpskom jeziku sa naslovom, sažetkom i ključnim riječima bilingvalnim B/H/S i engleskom jeziku. Radovi se
mogu koristiti u edukacijske svrhe bez predhodnog odobrenja, a uz obavezno navođenje izvora. Korištenje cijelih ili dijelova članaka u
komercijalne svrhe nije dozvoljeno bez predhodnog pismenog odobrenja izdavača Autorska prava posjeduje izdavač: Stomatološki
fakultet sa klinikama Univerziteta u Sarajevu.
Aim and Scope:
Stomatološki vijesnik / Stomatological review is a non-profit scientific journal that publishes original articles, case reports, letters to the
editors, current perspectives, editorials, fast-track articles in a field of dentistry and other bio-medical sciences. Papers are in Bosnian/
Croatian/Serbian language with at least title, abstract and key words bilingual in B/C/S and English language. All manuscripts undergo
the peer review process before can be accepted for publishing in Stomatološki vjesnik/ Stomatolgical review. Papers can be used for
educational purposes without prior consent only with adequate citation of the sources. Using whole or parts of articles for commercial
purposes is not permitted without prior written permission of the publisher. Copyright owns the publisher: Faculty of Dentistry with
Clinics, University of Sarajevo.
Časopis Stomatološki vjesnik je oslobođen poreza na promet prema Mišljenju Federalnog ministarstva obrazovanja, nauke, kulture i
sporta br: 04-15-661/2002.
Journal Stomatological review is tax exempt according to the opinion of the Federal Ministry of Education Science Culture and Sports no:
04-15-661/2002.
Printed on acid free paper
Indexed in: (Index Copernicus International), (Directory of Open Access Journal), (Electronishe
Zeitschriftenbibliothek), SJIF (Scientific Journal Impact Factor Value 2.502), EBSCO, HINARI BASE CITEFACTOR
DOAJ, DRJI ORG, EZB, GOOGLE SCHOLAR, ICI, INFOBASE, ONE SEARCH, PUBGET, RESEARCH BIBLE, SIS, SJIF
IIC DOAJ EZB
, , ,
Stomatološki vjesnik
Stomatološki vjesnik 2015; 4 (1)
CONTENTS / SADRŽAJ
ORIGINAL SCIENTIFIC ARTICLES / ORIGINALNI NAUČNI RADOVI
CASE REPORT / PRIKAZ SLUČAJA
K
BOOK REVIEW / PRIKAZ KNJIGE
CLINICAL PARAMETERS OF CHRONIC AND AGGRESSIVE PERIODONTITIS BEFORE AND AFTER INITIAL TREATMENT
Pašić E, Dedić A, Hadžić S, Gojkov-Vukelić M, Hodžić M, Nakaš E
THE RELATIONSHIP BETWEEN PERIODONTAL HEALTH AND DIABETES MELLITUS TYPE 1
Atanasovska-Stojanovska A, Stefanovska E, Popovska M, Muratovska I, Zabokova-Bilbilova E
THE EFFECT OF DIFFERENT CONCENTRATIONS OF CHLORHEXIDINE DIGLUCONATE (0,12% AND 0,2%) IN
DEVELOPMENT OF POSTOPERATIVE SEQUELAE AND INCIDENCE OF WOUND INFECTIONS FOLLOWING
ORAL-SURGICAL PROCEDURES: A PROSPECTIVE CLINICAL STUDY
Šečić S, Prohić S, Komšić S, Vuković A
ACCIDENTAL INJURIES AMONG DENTISTS IN PRIVATE AND PUBLIC DENTAL PRACTICE
Cilović-Lagarija Š, Huseinbegović A, Čavaljuga S, Branković S, Selimović-Dragaš M
EFFECT OF BLOOD CONTAMINATION ON SHEAR BOND STRENGTH OF
ORTHODONTIC BUTTON ATTACHMENT- IN VITRO STUDY
Holcner B, Prohić S, Tiro A, Džemidžić V, Redžepagić Vražalica L, Nakaš E
ASSESSMENT OF ANGIOGENESIS BY ENDOGLIN (CD 105) IN INFLAMED DENTAL PULP
Tahmiščija I, Radović S, Jukić-Krmek S, Konjhodžić-Prcić A, Šečić S, Đapo N
MICROLEAKAGE OF TEMPORARY FILLING MATERIALS
Vinković D, Prskalo K
THE USE OF COLD FLOWABLE GUTTA-PERCHA IN ENDODONTIC THERAPY
orać S, Jakupović S, Konjhodžić-Prcić A, Tahmiščija I, Džanković A, Hasić Branković L
BASICS OF ORTHODONTIC DIAGNOSTICS
Nakaš E, Tiro A, Džemidžić V, Redžepagić-Vražalica L, Ajanović M
3
11
19
27
33
41
47
53
61
Izdavač / Publisher:
Za izdavača / For publisher: Sead Redžepagić
ČLANOVI UREĐIVAČKOG ODBORA / EDITORIAL BOARD :
Glavni urednik / Editor in chief: Sadeta Šečić
Sekretar uređivačkog odbora / Secretary of editorial board: Selma Zukić
Članovi /Members: Sead Redžepagić, Samir Prohić, Muhamed Ajanović, Amira Dedić, Sedin Kobašlija, Tarik Mašić, Amra
Vuković, Enita Nakaš
MEĐUNARODNI UREĐIVAČKI ODBOR / INTERNATIONAL EDITORIAL BOARD:
Anwar Barakat Bataineh (Irbid, Jordan), Jasenka Živko-Babić (Zagreb, Hrvatska), Andrija Petar Bošnjak (Rijeka, Hrvatska),
Hrvoje Brkić (Zagreb , Hrvatska), Dolores Biočina Lukenda (Split, Hrvatska), Davor Katanec (Zagreb, Hrvatska), Šahza Hatibović
Koffman (London Ontario Kanada), Mladen Kuftinec (USA), Darko Macan (Zagreb, Hrvatska), Berislav Perić (Zagreb, Hrvatska),
Tore Solheim (Oslo, Norveška), Dragoslav Stamenković (Beograd, Srbija), Marin Vodanović (Zagreb, Hrvatska)
Lektor za engleski jezik / English language editor: Nermana Bičakčić
Tehničko uređenje / Technical editor: Branislav Trogrančić
Štampa / Printed by: Štamparija Fojnica
Dizajn naslovnice / Cover page design: Lana Malić
Tiraž/ Number of copies:
KONTAKT / CONTACT:
Stomatološki vjesnik
Stomatološki fakultet sa klinikama
Bolnička 4a, 71000 Sarajevo
Bosna i Hercegovina
Telefon: + 387(33)214 294
e-mail: stomatoloskivjesnik@sf.unsa.ba
Web: www.stomatoloskivjesnik.ba
TRANSAKCIJSKI RACUN / TRANSFER ACCOUNT:
33386902296551066
UniCredit Bank dd
Stomatološki fakultet Univerziteta u Sarajevu / Faculty of Dentistry, University of Sarajevo
200
ISSN 0350-5499 UDK 616.31
Svrha i i cilj :
Stomatološki vjesnik je neprofitni naučno stručni časopis koji publicira originalne naučne radove, prikaze slučajeva, pisma uredniku,
savremene perspektive, editorijale, preliminarne komunikacije u oblasti stomatologije i drugih biomedicinskih nauka. Radovi su na
Bosanskom/Hrvatskom/Srpskom jeziku sa naslovom, sažetkom i ključnim riječima bilingvalnim B/H/S i engleskom jeziku. Radovi se
mogu koristiti u edukacijske svrhe bez predhodnog odobrenja, a uz obavezno navođenje izvora. Korištenje cijelih ili dijelova članaka u
komercijalne svrhe nije dozvoljeno bez predhodnog pismenog odobrenja izdavača Autorska prava posjeduje izdavač: Stomatološki
fakultet sa klinikama Univerziteta u Sarajevu.
Aim and Scope:
Stomatološki vijesnik / Stomatological review is a non-profit scientific journal that publishes original articles, case reports, letters to the
editors, current perspectives, editorials, fast-track articles in a field of dentistry and other bio-medical sciences. Papers are in Bosnian/
Croatian/Serbian language with at least title, abstract and key words bilingual in B/C/S and English language. All manuscripts undergo
the peer review process before can be accepted for publishing in Stomatološki vjesnik/ Stomatolgical review. Papers can be used for
educational purposes without prior consent only with adequate citation of the sources. Using whole or parts of articles for commercial
purposes is not permitted without prior written permission of the publisher. Copyright owns the publisher: Faculty of Dentistry with
Clinics, University of Sarajevo.
Časopis Stomatološki vjesnik je oslobođen poreza na promet prema Mišljenju Federalnog ministarstva obrazovanja, nauke, kulture i
sporta br: 04-15-661/2002.
Journal Stomatological review is tax exempt according to the opinion of the Federal Ministry of Education Science Culture and Sports no:
04-15-661/2002.
Printed on acid free paper
Indexed in: (Index Copernicus International), (Directory of Open Access Journal), (Electronishe
Zeitschriftenbibliothek), SJIF (Scientific Journal Impact Factor Value 2.502), EBSCO, HINARI BASE CITEFACTOR
DOAJ, DRJI ORG, EZB, GOOGLE SCHOLAR, ICI, INFOBASE, ONE SEARCH, PUBGET, RESEARCH BIBLE, SIS, SJIF
IIC DOAJ EZB
, , ,
Stomatološki vjesnik 2015; 4 (1) 3
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
CLINICAL PARAMETERS OF CHRONIC
AND AGGRESSIVE PERIODONTITIS
BEFORE AND AFTER INITIAL TREATMENT
1 1 1 1
Pašić E*, Dedić A , Hadžić S , Gojkov-Vukelić M ,
1 2
Hodžić M , Nakaš E
1 Department for Periodontology and Oral Medicine, Faculty of Dentistry,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
2 Department of Orthodontics, Faculty of Dentistry,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Objective: The aim of this study was to determine clinical
response of the periodontal tissue after initial periodontal
treatment in patients with aggressive and chronic periodontitis.
Materials and methods: The study was conducted on 40
periodontal patients who had received no prior treatment, with
the average age of 18 – 50. The first group comprised of 18
patients with aggressive periodontitis. The second group
comprised of 22 patients with chronic periodontitis. The clinical
periodontal exam included the measurement of periodontal
pockets (PD), clinical attachment loss (CAL), sulcus bleeding
index (SBI), plaque index (PI), looseness of teeth and RTG.
Results: According to the results of the t-test, the difference in
average value of dental plaque before the therapy and 30 days
after the therapy is statistically significant at the level of 1%
(p<.01). The t-test for dependent samples showed no statistically
significant difference between the average values of sulcus
bleeding index before the therapy and 30 days after the therapy.
The t-test for dependent samples showed a statistically
significant difference at the level of 1% (p<.01) between the
average values of BOP on the mesial and buccal sides before the
therapy and 30 days after the therapy. On average, in patients with
aggressive periodontitis (AgP) the depth of periodontal pockets
was reduced by 1.18, from a mean of 5.45 to 4.27, while in patients
with chronic periodontitis the depth of periodontal pockets was
reduced by 0.94, from a mean of 4.83 to 3.89.
Conclusion: The results of this study showed an improvement
in clinical periodontal parameters after the initial treatment.
Key words: initial therapy, periodontal clinical parameters,
aggressive periodontitis, chronic periodontitis.
*Corresponding author
Enes Pašić, PhD
Department for Periodontology
and Oral Medicine,
Faculty of Dentistry
University of Sarajevo
Bolnička 4a
71000 Sarajevo
Bosnia and Herzegovina
Phone: +387 33 214 249
Fax: + 387 33 443 395
e-mail:epasic@sf.unsa.ba
Stomatološki vjesnik 2015; 4 (1) 3
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
CLINICAL PARAMETERS OF CHRONIC
AND AGGRESSIVE PERIODONTITIS
BEFORE AND AFTER INITIAL TREATMENT
1 1 1 1
Pašić E*, Dedić A , Hadžić S , Gojkov-Vukelić M ,
1 2
Hodžić M , Nakaš E
1 Department for Periodontology and Oral Medicine, Faculty of Dentistry,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
2 Department of Orthodontics, Faculty of Dentistry,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Objective: The aim of this study was to determine clinical
response of the periodontal tissue after initial periodontal
treatment in patients with aggressive and chronic periodontitis.
Materials and methods: The study was conducted on 40
periodontal patients who had received no prior treatment, with
the average age of 18 – 50. The first group comprised of 18
patients with aggressive periodontitis. The second group
comprised of 22 patients with chronic periodontitis. The clinical
periodontal exam included the measurement of periodontal
pockets (PD), clinical attachment loss (CAL), sulcus bleeding
index (SBI), plaque index (PI), looseness of teeth and RTG.
Results: According to the results of the t-test, the difference in
average value of dental plaque before the therapy and 30 days
after the therapy is statistically significant at the level of 1%
(p<.01). The t-test for dependent samples showed no statistically
significant difference between the average values of sulcus
bleeding index before the therapy and 30 days after the therapy.
The t-test for dependent samples showed a statistically
significant difference at the level of 1% (p<.01) between the
average values of BOP on the mesial and buccal sides before the
therapy and 30 days after the therapy. On average, in patients with
aggressive periodontitis (AgP) the depth of periodontal pockets
was reduced by 1.18, from a mean of 5.45 to 4.27, while in patients
with chronic periodontitis the depth of periodontal pockets was
reduced by 0.94, from a mean of 4.83 to 3.89.
Conclusion: The results of this study showed an improvement
in clinical periodontal parameters after the initial treatment.
Key words: initial therapy, periodontal clinical parameters,
aggressive periodontitis, chronic periodontitis.
*Corresponding author
Enes Pašić, PhD
Department for Periodontology
and Oral Medicine,
Faculty of Dentistry
University of Sarajevo
Bolnička 4a
71000 Sarajevo
Bosnia and Herzegovina
Phone: +387 33 214 249
Fax: + 387 33 443 395
e-mail:epasic@sf.unsa.ba
4
CLINICAL PARAMETERS OF CHRONIC AND AGGRESSIVE PERIODONTITIS BEFORE AND AFTER INITIAL TREATMENT
5
Pašić E, Dedić A, Hadžić S, Gojkov-Vukelić M, Hodžić M, Nakaš E
Introduction
Dental plaque is a complex biofilm accumulated
on the hard and soft tissues in the oral cavity. Oral
flora together with aerobic and anaerobic bacteria is
the primary etiological factor for the development of
caries and periodontal disease. Even though more
than 700 bacterial species are present in dental
plaque, the pattern of initial adhesion of the bacteria
is firstly followed by colonization, and then secon-
dary colonization through interconnection of bacte-
rial species [1].
Adhesion of microorganisms and molecular inter-
actions contribute to the development of plaque and
eventually lead to the diseases such as caries and
periodontal disease. The number of bacteria in the
sub-gingival sulcus is around -
The dominant features of
gingivitis and periodontitis are inflammatory and
immune responses to the microorganisms in plaque.
The inflammatory reaction in the affected periodon-
tal tissue can be seen both clinically and microsco-
pically, and it represents the host response to plaque
microorganisms and their products [2]. Species of
microorganisms do interact, and although some of
these interactions are not pathogenic, they indeed
may affect the course of a disease by increasing the
virulence potential of other microorganisms. Micro-
organisms in periodontal pockets are in the conti-
nuous flow stage, while periodontal destruction may
be the result of a combination of bacterial factors that
change over time. The primary periodontal patho-
gens, mainly anaerobes, are very aggressive patho-
gens. Following a tooth extraction, these microorga-
nisms were still to be found in the oral cavity flora,
mostly on the tongue and in saliva, only in low
concentrations [3]. It is not clear whether the pre-
sence of microorganisms in patients can cause or be
the result of a disease [4]. Many microorganisms that
are considered to be periodontal pathogens are
actually strict anaerobes and, as such, are often lin-
ked to the progression, but not the onset of the
disease. There is a belief nowadays that a periodontal
disease is primarily a poly-bacterial manifestation
linked to the action of certain bacterial pathogens [5].
Despite the existence of a large number of microorga-
nisms found in the periodontal pocket, the following
are considered to be pathogenic: Actinobacillus acti-
3
10 , while in periodon
8
tal pockets it reaches 10 .
nomycetemcomitans, Porphyromonas gingivalis,
Bacteroides forsythus, Prevotella intermedia, Eice-
nella corrodens, Fusobacterium nucleatum i Trepo-
nema denticola [6]. According to the latest findings
by Page, even though the role of the bacteria is crucial,
it is the host factors that determine the presence,
progression and outcome of the disease [7]. The
disease manifests itself through the active and re-
mission phases, therefore a large number of patients
often seem as not been in an active phase of the
disease (which may occur intermittently and irregu-
larly). However, in a small percentage of periodontal
patients, the progression of the disease is frequent
and rapid, while the disease itself responds adversely
to the treatment. As we cannot predict either active
or inactive phase of the disease, the question arises as
to how to distinguish patients at high risk of perio-
dontal disease from those at low risk [8]. Most of the
sub-gingival bacteria are sensitive to the antimicro-
bial effect of the mechanical ultrasonic therapy.
Thorough scraping with an ultrasonic instrument
equally reduces the sub-gingival microfilm as manual
scraping [9]. Mechanical treatment, coupled with the
proper oral hygiene, in most patients can stop and
prevent further los of periodontal attachment and
the progression of periodontal disease [10]. The
purpose of this study was to determine the clinical
response of periodontal tissues after initial perio-
dontal treatment in patients with aggressive and
chronic periodontitis.
Materials and methods
The study included 40 periodontal patients of
both sexes aging from 18 to 50, who had received no
prior treatment and who had been clinically and ra-
diological diagnosed with chronic (CP) and aggres-
sive (AgP) periodontitis with the depth of periodon-
tal pockets of 5 and more millimeters. The patients
were divided into two groups. The first group com-
prised of 18 patients with aggressive periodontitis.
The second group comprised of 22 patients with
chronic periodontitis with the average age of 43.
After the clinical examination, the diagnosis was
confirmed by an RTG analysis of the orthopanto-
mogram (OPG). Patients with systemic diseases were
not included in the study, nor patients who had been
treated during the course of the previous month with
antibiotics and antiseptics having been proved to
have effect on clinical periodontal status. The com-
plete clinical periodontal examination included the
measurement of periodontal pockets (PD), clinical
attachment loss (CAL), sulcus bleeding index (SBI),
plaque index (PI), looseness of teeth and RTG before
and 30 days after the initial treatment. All the
patients in the study went through initial periodontal
treatment. Before the treatment, the patients were
instructed about the methods of the oral hygiene. The
initial periodontal treatment was exclusively
performed with the EMS Mini Piezon ultrasonic
scalar with frequency range of 25 – 32 kHz. The tips
used were the types A, P and sub-gingival PS. For the
statistical data processing, STATA 12 for Windows
and Excel 2007 was used. The average plaque index
(PI), sulcus bleeding index, clinical attachment loss
(CAL) and depth of periodontal pockets for all the
patients, as well as for the patients group based on
their diagnoses, are shown in the graphs (Figure
1,2,3,4,5). The statistical significance of changes in
parameter values before and after the therapy was
calculated by the t-test for dependant samples at the
level of statistical significance of p˂0, 01.
Results
The total number of patients with aggressive
periodontitis (AgP) was 18, while the total number of
patients with chronic periodontitis (CP) was 22. The
mean values of plaque index (PI) for all the patients,
as well as the patients group based on their diag-
noses, are shown in Figure 1. Before the treatment,
higher mean values of plaque index were recorded in
patients with CP than in patients with AgP.
According to the t-test results (Table 1), the
difference in the mean value of plaque index before
and 30 days after the therapy is statistically signi-
ficant at the level of 1% (p<.01), no matter whether
we take all the patients into consideration or sepa-
rate them on the basis of their diagnosis groups.
Generally, 30 days after the therapy, there was a
statistically significant decrease in the mean values of
plaque index, indicating that the therapy was effec-
tive regarding the removal of dental plaque.
The mean values of sulcus bleeding index (SBI)
before the therapy and 30 days after the therapy
(SBI30) are shown in Figure 2. Unlike the previous
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
AgP
0
0,5
1
1,5
2
CP Total
Before the treatment
30 days after the treatment
1,67 1,77 1,73
0,72
0,50 0,60
Figure 1. Mean plaque index (PI) before and 30 days after the treatment
t-test for dependent samples
All patients
AgP
CP
1.102
0.944
1.2727
0.155
0.177
0.194
0.788
0.583
0.861
1.416
1.305
1.411
7.11***
5.329***
6.565***
40
18
22
Diagnosis Mean value Standard
deviation
95% confidence interval
t
Nlower upper
*** Level of statistical significance 1% (p<.01)
Table 1.
T-test for dependent
samples: plaque index
4
CLINICAL PARAMETERS OF CHRONIC AND AGGRESSIVE PERIODONTITIS BEFORE AND AFTER INITIAL TREATMENT
5
Pašić E, Dedić A, Hadžić S, Gojkov-Vukelić M, Hodžić M, Nakaš E
Introduction
Dental plaque is a complex biofilm accumulated
on the hard and soft tissues in the oral cavity. Oral
flora together with aerobic and anaerobic bacteria is
the primary etiological factor for the development of
caries and periodontal disease. Even though more
than 700 bacterial species are present in dental
plaque, the pattern of initial adhesion of the bacteria
is firstly followed by colonization, and then secon-
dary colonization through interconnection of bacte-
rial species [1].
Adhesion of microorganisms and molecular inter-
actions contribute to the development of plaque and
eventually lead to the diseases such as caries and
periodontal disease. The number of bacteria in the
sub-gingival sulcus is around -
The dominant features of
gingivitis and periodontitis are inflammatory and
immune responses to the microorganisms in plaque.
The inflammatory reaction in the affected periodon-
tal tissue can be seen both clinically and microsco-
pically, and it represents the host response to plaque
microorganisms and their products [2]. Species of
microorganisms do interact, and although some of
these interactions are not pathogenic, they indeed
may affect the course of a disease by increasing the
virulence potential of other microorganisms. Micro-
organisms in periodontal pockets are in the conti-
nuous flow stage, while periodontal destruction may
be the result of a combination of bacterial factors that
change over time. The primary periodontal patho-
gens, mainly anaerobes, are very aggressive patho-
gens. Following a tooth extraction, these microorga-
nisms were still to be found in the oral cavity flora,
mostly on the tongue and in saliva, only in low
concentrations [3]. It is not clear whether the pre-
sence of microorganisms in patients can cause or be
the result of a disease [4]. Many microorganisms that
are considered to be periodontal pathogens are
actually strict anaerobes and, as such, are often lin-
ked to the progression, but not the onset of the
disease. There is a belief nowadays that a periodontal
disease is primarily a poly-bacterial manifestation
linked to the action of certain bacterial pathogens [5].
Despite the existence of a large number of microorga-
nisms found in the periodontal pocket, the following
are considered to be pathogenic: Actinobacillus acti-
3
10 , while in periodon
8
tal pockets it reaches 10 .
nomycetemcomitans, Porphyromonas gingivalis,
Bacteroides forsythus, Prevotella intermedia, Eice-
nella corrodens, Fusobacterium nucleatum i Trepo-
nema denticola [6]. According to the latest findings
by Page, even though the role of the bacteria is crucial,
it is the host factors that determine the presence,
progression and outcome of the disease [7]. The
disease manifests itself through the active and re-
mission phases, therefore a large number of patients
often seem as not been in an active phase of the
disease (which may occur intermittently and irregu-
larly). However, in a small percentage of periodontal
patients, the progression of the disease is frequent
and rapid, while the disease itself responds adversely
to the treatment. As we cannot predict either active
or inactive phase of the disease, the question arises as
to how to distinguish patients at high risk of perio-
dontal disease from those at low risk [8]. Most of the
sub-gingival bacteria are sensitive to the antimicro-
bial effect of the mechanical ultrasonic therapy.
Thorough scraping with an ultrasonic instrument
equally reduces the sub-gingival microfilm as manual
scraping [9]. Mechanical treatment, coupled with the
proper oral hygiene, in most patients can stop and
prevent further los of periodontal attachment and
the progression of periodontal disease [10]. The
purpose of this study was to determine the clinical
response of periodontal tissues after initial perio-
dontal treatment in patients with aggressive and
chronic periodontitis.
Materials and methods
The study included 40 periodontal patients of
both sexes aging from 18 to 50, who had received no
prior treatment and who had been clinically and ra-
diological diagnosed with chronic (CP) and aggres-
sive (AgP) periodontitis with the depth of periodon-
tal pockets of 5 and more millimeters. The patients
were divided into two groups. The first group com-
prised of 18 patients with aggressive periodontitis.
The second group comprised of 22 patients with
chronic periodontitis with the average age of 43.
After the clinical examination, the diagnosis was
confirmed by an RTG analysis of the orthopanto-
mogram (OPG). Patients with systemic diseases were
not included in the study, nor patients who had been
treated during the course of the previous month with
antibiotics and antiseptics having been proved to
have effect on clinical periodontal status. The com-
plete clinical periodontal examination included the
measurement of periodontal pockets (PD), clinical
attachment loss (CAL), sulcus bleeding index (SBI),
plaque index (PI), looseness of teeth and RTG before
and 30 days after the initial treatment. All the
patients in the study went through initial periodontal
treatment. Before the treatment, the patients were
instructed about the methods of the oral hygiene. The
initial periodontal treatment was exclusively
performed with the EMS Mini Piezon ultrasonic
scalar with frequency range of 25 – 32 kHz. The tips
used were the types A, P and sub-gingival PS. For the
statistical data processing, STATA 12 for Windows
and Excel 2007 was used. The average plaque index
(PI), sulcus bleeding index, clinical attachment loss
(CAL) and depth of periodontal pockets for all the
patients, as well as for the patients group based on
their diagnoses, are shown in the graphs (Figure
1,2,3,4,5). The statistical significance of changes in
parameter values before and after the therapy was
calculated by the t-test for dependant samples at the
level of statistical significance of p˂0, 01.
Results
The total number of patients with aggressive
periodontitis (AgP) was 18, while the total number of
patients with chronic periodontitis (CP) was 22. The
mean values of plaque index (PI) for all the patients,
as well as the patients group based on their diag-
noses, are shown in Figure 1. Before the treatment,
higher mean values of plaque index were recorded in
patients with CP than in patients with AgP.
According to the t-test results (Table 1), the
difference in the mean value of plaque index before
and 30 days after the therapy is statistically signi-
ficant at the level of 1% (p<.01), no matter whether
we take all the patients into consideration or sepa-
rate them on the basis of their diagnosis groups.
Generally, 30 days after the therapy, there was a
statistically significant decrease in the mean values of
plaque index, indicating that the therapy was effec-
tive regarding the removal of dental plaque.
The mean values of sulcus bleeding index (SBI)
before the therapy and 30 days after the therapy
(SBI30) are shown in Figure 2. Unlike the previous
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
AgP
0
0,5
1
1,5
2
CP Total
Before the treatment
30 days after the treatment
1,67 1,77 1,73
0,72
0,50 0,60
Figure 1. Mean plaque index (PI) before and 30 days after the treatment
t-test for dependent samples
All patients
AgP
CP
1.102
0.944
1.2727
0.155
0.177
0.194
0.788
0.583
0.861
1.416
1.305
1.411
7.11***
5.329***
6.565***
40
18
22
Diagnosis Mean value Standard
deviation
95% confidence interval
t
Nlower upper
*** Level of statistical significance 1% (p<.01)
Table 1.
T-test for dependent
samples: plaque index
Figure 5. Mean depth of periodontal pockets in patients with CP
TotalMesially
0
1
2
3
5
7
4
6
Bucally Distally Palatally
Before the treatment
30 days after the treatment
6,32
3,96 3,41
5,65
4,90
3,33 3,89
2,85
4,51 4,83
Figure 4. Mean depth of periodontal pockets in patients with AgP
TotalMesially
0
1
2
3
5
8
7
4
6
Bucally Distally Palatally
Before the treatment
30 days after the treatment
7,10
4,40 3,91
6,39
5,36
3,55
4,27
3,25
4,95 5,45
Figure 3. Mean clinical attachment loss (CAL) before and 30 days after the treatment
Mesially
0
1
2
3
5
7
4
6
Bucally Distally Palatally
Before the treatment
30 days after the treatment
6,18
4,50
2,05
4,37
4,94
3,87
1,76
3,61
t-test for dependent samples
All patients
AgP
CP
2.00
2.15
1.87
0.211
0.283
0.302
1.579
1.783
1.253
2.421
2.717
4.474
9.455***
7.657***
6.164***
40
18
22
Diagnosis Mean value Standard
error
95% confidence interval
t
Nlower upper
*** Level of statistical significance 1% (p<.01)
Table 2.
T-test for dependent
samples: sulcus
bleeding index
Figure 2. Mean sulcus bleeding index (SBI) before and 30 days after the treatment
AgP
0
0,5
1
1,5
2,5
3,5
2
3
CP Total
Before the treatment
30 days after the treatment
3,33
2,82 3,05
1,17
0,95 1,05
6
CLINICAL PARAMETERS OF CHRONIC AND AGGRESSIVE PERIODONTITIS BEFORE AND AFTER INITIAL TREATMENT
index, the recorded values of SBI were higher in
patients with AgP (3.33) than in patients with CP
(2.82). After the therapy, the mean value of SBI was
lower by 2 (from 3.05 to 1.05) in all patients, by 2.15
(from 3.33 to 1.17) in patients with AgP and by 1.87
(from 2.82 to 0.95) in patients with CP. To determine
a statistical significance of this change the t-test for
dependant samples was used. The t-test for depen-
dant samples indicated that there was a statistically
significant difference between the mean values of
sulcus bleeding index before the therapy and 30 days
after the therapy. Based on the results in Table 2, it
can be concluded that if we were to accept a null
hypothesis of equality between the mean indices
before and after the therapy, the possibility of error
would be less than 1% - i.e. in all patients the value
would be t=9.455; p<.01, in the patients with AgP
t=7.657; p<0.1, and in the patients with CP t=6.164;
p<0.1.
The mean values of clinical attachment loss (CAL)
before and 30 days after the treatment are shown in
Figure 3. 30 days after the treatment the mean values
7
of clinical attachment loss decreased mesially, buc-
cally, distally and palatinal (Figure 3). The greatest
values of clinical attachment were at the mesial site
and the lowest at the palatinal site both before and
after the treatment. Likewise, the greatest clinical
attachment loss of 1.22 occurred at the mesial sites
(from 6.18 to 4.94), while the minimum change of
0.29 in the clinical attachment loss value was noted at
the palatinal sites (from 2.05 to 1.76).
The t-test for dependant samples indicated that
there was a statistically significant difference bet-
ween the mean value of CAL at the mesial and buccal
sites before the treatment and 30 days after the
treatment, at the level of 1% of statistical importance
(p<.01).
Figure 4 shows the average depth of periodontal
pockets in patients with AgP. The average values of
the depth of periodontal pockets in patients with AgP
before and after the treatment (Figure 4) indicate
that the average depth of all periodontal pockets
decreased. Before the treatment, the highest average
depth of periodontal pockets at the mesial sites
measured 7.10, at the distal sites 6.39, and the buccal
sites 4.40, while the lowest average depth was 3.91 at
the palatinal sites. The treatment proved to be
successful since the depth of all periodontal pockets
decreased. On average, in the patients with AgP the
depth of periodontal pockets was reduced by 1.18
(from 5.45 to 4.27).
Figure 5 shows the average depth of periodontal
pockets in patients with CP. The average values of the
depth of periodontal pockets in patients with CP
before and after the treatment (Figure 5) indicate
that the average depth of all periodontal pockets
decreased. Before the treatment, the highest average
depth of periodontal pockets at the mesial sites
measured 6.32, at the distal sites 5.65, and the buccal
sites 3.96, while the lowest average depth was 3.41 at
the palatinal sites. After the treatment, the depth of
all periodontal pockets decreased. On average, in the
patients with chronic periodontitis the depth of
periodontal pockets was reduced by 0.94 (from 4.83
to 3.89).
The t-test for dependent samples indicated that
there was a statistically significant difference
(t=20.798; p<.01) between the average depth of all
periodontal pockets before the treatment and 30
days after the initial treatment.
Pašić E, Dedić A, Hadžić S, Gojkov-Vukelić M, Hodžić M, Nakaš E
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Figure 5. Mean depth of periodontal pockets in patients with CP
TotalMesially
0
1
2
3
5
7
4
6
Bucally Distally Palatally
Before the treatment
30 days after the treatment
6,32
3,96 3,41
5,65
4,90
3,33 3,89
2,85
4,51 4,83
Figure 4. Mean depth of periodontal pockets in patients with AgP
TotalMesially
0
1
2
3
5
8
7
4
6
Bucally Distally Palatally
Before the treatment
30 days after the treatment
7,10
4,40 3,91
6,39
5,36
3,55
4,27
3,25
4,95 5,45
Figure 3. Mean clinical attachment loss (CAL) before and 30 days after the treatment
Mesially
0
1
2
3
5
7
4
6
Bucally Distally Palatally
Before the treatment
30 days after the treatment
6,18
4,50
2,05
4,37
4,94
3,87
1,76
3,61
t-test for dependent samples
All patients
AgP
CP
2.00
2.15
1.87
0.211
0.283
0.302
1.579
1.783
1.253
2.421
2.717
4.474
9.455***
7.657***
6.164***
40
18
22
Diagnosis Mean value Standard
error
95% confidence interval
t
Nlower upper
*** Level of statistical significance 1% (p<.01)
Table 2.
T-test for dependent
samples: sulcus
bleeding index
Figure 2. Mean sulcus bleeding index (SBI) before and 30 days after the treatment
AgP
0
0,5
1
1,5
2,5
3,5
2
3
CP Total
Before the treatment
30 days after the treatment
3,33
2,82 3,05
1,17
0,95 1,05
6
CLINICAL PARAMETERS OF CHRONIC AND AGGRESSIVE PERIODONTITIS BEFORE AND AFTER INITIAL TREATMENT
index, the recorded values of SBI were higher in
patients with AgP (3.33) than in patients with CP
(2.82). After the therapy, the mean value of SBI was
lower by 2 (from 3.05 to 1.05) in all patients, by 2.15
(from 3.33 to 1.17) in patients with AgP and by 1.87
(from 2.82 to 0.95) in patients with CP. To determine
a statistical significance of this change the t-test for
dependant samples was used. The t-test for depen-
dant samples indicated that there was a statistically
significant difference between the mean values of
sulcus bleeding index before the therapy and 30 days
after the therapy. Based on the results in Table 2, it
can be concluded that if we were to accept a null
hypothesis of equality between the mean indices
before and after the therapy, the possibility of error
would be less than 1% - i.e. in all patients the value
would be t=9.455; p<.01, in the patients with AgP
t=7.657; p<0.1, and in the patients with CP t=6.164;
p<0.1.
The mean values of clinical attachment loss (CAL)
before and 30 days after the treatment are shown in
Figure 3. 30 days after the treatment the mean values
7
of clinical attachment loss decreased mesially, buc-
cally, distally and palatinal (Figure 3). The greatest
values of clinical attachment were at the mesial site
and the lowest at the palatinal site both before and
after the treatment. Likewise, the greatest clinical
attachment loss of 1.22 occurred at the mesial sites
(from 6.18 to 4.94), while the minimum change of
0.29 in the clinical attachment loss value was noted at
the palatinal sites (from 2.05 to 1.76).
The t-test for dependant samples indicated that
there was a statistically significant difference bet-
ween the mean value of CAL at the mesial and buccal
sites before the treatment and 30 days after the
treatment, at the level of 1% of statistical importance
(p<.01).
Figure 4 shows the average depth of periodontal
pockets in patients with AgP. The average values of
the depth of periodontal pockets in patients with AgP
before and after the treatment (Figure 4) indicate
that the average depth of all periodontal pockets
decreased. Before the treatment, the highest average
depth of periodontal pockets at the mesial sites
measured 7.10, at the distal sites 6.39, and the buccal
sites 4.40, while the lowest average depth was 3.91 at
the palatinal sites. The treatment proved to be
successful since the depth of all periodontal pockets
decreased. On average, in the patients with AgP the
depth of periodontal pockets was reduced by 1.18
(from 5.45 to 4.27).
Figure 5 shows the average depth of periodontal
pockets in patients with CP. The average values of the
depth of periodontal pockets in patients with CP
before and after the treatment (Figure 5) indicate
that the average depth of all periodontal pockets
decreased. Before the treatment, the highest average
depth of periodontal pockets at the mesial sites
measured 6.32, at the distal sites 5.65, and the buccal
sites 3.96, while the lowest average depth was 3.41 at
the palatinal sites. After the treatment, the depth of
all periodontal pockets decreased. On average, in the
patients with chronic periodontitis the depth of
periodontal pockets was reduced by 0.94 (from 4.83
to 3.89).
The t-test for dependent samples indicated that
there was a statistically significant difference
(t=20.798; p<.01) between the average depth of all
periodontal pockets before the treatment and 30
days after the initial treatment.
Pašić E, Dedić A, Hadžić S, Gojkov-Vukelić M, Hodžić M, Nakaš E
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
9
CLINICAL PARAMETERS OF CHRONIC AND AGGRESSIVE PERIODONTITIS BEFORE AND AFTER INITIAL TREATMENT
8
Discussion
Periodontal disease occurs due to etiological
factors, it causes an immunological reaction and it
interacts with systemic and genetic components in
the body. According to Matthews (2000), bacteria are
the main cause of the disease, while the immune
inflammatory response of the host is responsible for
most of the changes in the periodontal tissue [29]. If
left untreated, the inflammatory process spreads to
all periodontal tissues, leading to anatomical and
functional deterioration of the periodontium. Perio-
dontal treatment aims at restoring anatomical and
functional integrity to the periodontium, removing
all symptoms and creating conditions for the regene-
ration of the periodontal tissues.
This study investigated and compared the clinical
condition of periodontal tissues before and after the
initial treatment in patients with aggressive (AgP)
and chronic periodontitis (CP). The clinical perio-
dontal exam included the measurement of plaque
index (PI), sulcus bleeding index (SBI), periodontal
pockets (PD) and clinical attachment loss (CAL)
before and 30 days after the initial treatment. The
purpose of the plaque index is to help quantitatively
determine and assess the level of oral hygiene in
patients. In our study, we measured the plaque index
in patients with AgP and CP, before the initial and
surgical treatment and 30 days after the treatment.
Higher mean values of plaque index were recorded in
patients with CP (1.77) than in patients with AgP
(1.67), which is in line with what had been previously
reported by Auer et al. (2005), considering the
absence of inflammation and both low frequency of
caries and plaque control index in patients with AgP
[11]. Our findings are consistent with the clinical
picture of aggressive periodontitis, since aggressive
periodontitis has been clinically characterized by
small amounts of sub-gingival plaque and pro-
gressive loss of epithelial attachment causing vertical
bone defects, which is in line with what Lindhe and
Rateitschak found in their study [12, 13]. Higher
mean values of plaque index in patients with chronic
periodontitis (CP) are consistent with the clinical
picture where plaque correlates with the degree of
inflammation and the level of periodontal destruc-
tion, which is characteristic for chronic periodontitis
(CP). 30 days after the treatment there was a sta-
tistically significant decrease (p<.01) in the mean
values of plaque index indicating the success of the
initial treatment in removing plaque no matter whe-
ther the patients were considered as a single group or
separated into diagnostic groups. Higher mean valu-
es of SBI were recorded in patients with AgP (3.33)
than in patients with CP (2.82). After the treatment,
the mean values of SBI were lowered by 2.15 (from
3.33 to 1.17) in patients with AgP, and by 1.87 (from
2.82 to 0.95) in patients with CP. The t-test for depen-
dant samples indicated that there was a statistically
significant difference in the mean values of SBI before
and 30 days after the treatment (p<.01) in patients
with AgP and CP. The study indicated clinical im-
provement in the levels of dental plaque and the
amount of gingival bleeding.
The mean values of CAL were lowered indicating
the success of the initial periodontal treatment. The
findings correspond with the findings from other stu-
dies demonstrating clinical improvement and achie-
ved stability of periodontal disease [14].
The t-test for dependent samples indicated that
there is a statistically significant difference between
the extent of clinical attachment loss mesially and
buccally before and 30 days after the treatment.
There was no difference in the extent of clinical
attachment loss distally and palatinally before and 30
days after the treatment.
The clinical assessment of the initial treatment
was complemented with the measurement of perio-
dontal pocket depths, which could objectively assess
the destruction of the periodontal tissue and the
success of the initial treatment, while residual pocket
depths after the initial treatment have values for
further progression of the disease [15]. Our findings
show that there is a statistically significant corre-
lation between the depth of a periodontal pocket and
a clinical attachment loss before the treatment. The
positive direction of the correlation indicates that the
depth of a periodontal pocket and a clinical attach-
ment loss are directly related – i.e. the greater the
pocket depth, the greater the clinical attachment loss.
The mean value of pocket depth in patients with
AgP was 5.4 mm, and in patients with CP 4, 8 mm. The
patients with AgP had greater pocket depth. The
success of the initial treatment, which was estimated
by a parallel probing before and after the treatment,
varied from one group to another (p < 0,001). The
treatment proved to be effective in decreasing the
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Pašić E, Dedić A, Hadžić S, Gojkov-Vukelić M, Hodžić M, Nakaš E
depth of all periodontal pockets. The depth of the
periodontal pockets in patients with AgP decreased
by 1.18 (from 5.45 to 4.27), while in patients with CP
it decreased by 0.94 (from 4.83 to 3.89). However, the
findings of this study indicate the appropriateness of
initial periodontal treatment. The failure of the
treatment, more often reported in patients with CP,
can be explained by poor motivation for the oral hygi-
ene in patients with mild symptoms of the disease.
In recent years, some studies were conducted to
evaluate the use of slimmer and thinner tips for ultra-
sonic sub-gingival debridement. The advantage of
slimmer tips is that they are thinner than curettes
and they can be more easily inserted into periodontal
pockets. Petersilka et al. (2011) proved that ultra-
sonic scalers are just as effective as hand instruments
in removing sub-gingival biofilm [16].
The study by Tsurumaki et al. (2011) revealed that
at greater probing depths slim ultrasonic scalers
achieved better results than hand instruments [17].
The study by Singh et al. (2012) confirmed that
such scalers removed the bacteria more easily with-
out removing dental cement giving the way to a new
approach in using periodontal instruments [18].
In addition to conducting the ultrasonic treatment
and reducing the sub-gingival biofilm, our goal was to
preserve the dental cement and its function.
Casarini et al. (2009) proved that the removal of
sub-gingival bacterial plaque using initial periodon-
tal treatment was sufficient for healing the perio-
dontal tissue lesions, provided the supra-gingival
deposits were removed regularly [19]. The initial
periodontal treatment improved the clinical picture
of the periodontal tissue and yielded good results in
patients with aggressive and chronic periodontitis,
which would, in turn, lead to remodeling and regene-
ration of all periodontal structures.
Conclusion
The initial periodontal treatment improved the
clinical picture of the periodontal tissue and yielded
good results in patients with aggressive and chronic
periodontitis, which would, in turn, lead to
remodeling and regeneration of all periodontal
structures.
Conflict of interest
The authors declare that they have no conflict of
interest. This study was not sponsored by any exter-
nal organization.
Authors' contributions
Conception and design: PE, DA; Acquisition, ana-
lysis and interpretation of data: PE, GM and HM; Draf-
ting the article PE, HS; Critical Revision of important
intellectual content: PE, HS and NE.
References
1. Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE.
Defining the normal bacterial flora of the oral
cavity. J Clin Microbiol. 2005;43:5721–32.
2. Matthews DC. Periodontal medicine: a new
paradigm. J Can Dent Assoc. 2000 Oct;66(9):488-
91.
3. Van Assche N, , ,
hels W, Quirynen M. Do periodontopathogens
disappear after full-mouth tooth extraction? J
Clin Periodontol. 2009 Dec;36(12):1043-7.
4. Roberts FA, Darveau RP. Beneficial bacteria of the
periodontium. Periodontol 2000. 2002;30:40-50.
5. Socransky SS, Haffajee AD. The bacterial etiology
of destructive periodontal disease: Current con-
cept. J Periodontol. 1992;6:322-31.
6. Haffajee AD, Socransky SS. Microbial etiologic
agents in destructive periodontal diseases. Perio-
dontology 2000;5:78-111.
7. Page RC. The pathobiology of periodontal disea-
ses by affect systemic diseases: Inversion of a pa-
radigm. Annals of Periodontology 1998;3:108-
20.
8. Ivić-Kardum M, Beader N, Štaudt-Škaljac G. Acta
Stomat Croat. 2001;133-136.
9. Lea SC, Felver B, Landini G, Walmsley AD. Three-
dimensional analyses of ultrasonic scaler oscilla-
tions. J Clin Periodontol. 2009;36(1):44-50.
10. Petersilka GJ, Ehmke B, Flemmig TF. Antimicro-
bial effects of mechanical debridement. Perio-
dontol 2000. 2002;28:56-71.
Van Essche M Pauwels M Teug-
9
CLINICAL PARAMETERS OF CHRONIC AND AGGRESSIVE PERIODONTITIS BEFORE AND AFTER INITIAL TREATMENT
8
Discussion
Periodontal disease occurs due to etiological
factors, it causes an immunological reaction and it
interacts with systemic and genetic components in
the body. According to Matthews (2000), bacteria are
the main cause of the disease, while the immune
inflammatory response of the host is responsible for
most of the changes in the periodontal tissue [29]. If
left untreated, the inflammatory process spreads to
all periodontal tissues, leading to anatomical and
functional deterioration of the periodontium. Perio-
dontal treatment aims at restoring anatomical and
functional integrity to the periodontium, removing
all symptoms and creating conditions for the regene-
ration of the periodontal tissues.
This study investigated and compared the clinical
condition of periodontal tissues before and after the
initial treatment in patients with aggressive (AgP)
and chronic periodontitis (CP). The clinical perio-
dontal exam included the measurement of plaque
index (PI), sulcus bleeding index (SBI), periodontal
pockets (PD) and clinical attachment loss (CAL)
before and 30 days after the initial treatment. The
purpose of the plaque index is to help quantitatively
determine and assess the level of oral hygiene in
patients. In our study, we measured the plaque index
in patients with AgP and CP, before the initial and
surgical treatment and 30 days after the treatment.
Higher mean values of plaque index were recorded in
patients with CP (1.77) than in patients with AgP
(1.67), which is in line with what had been previously
reported by Auer et al. (2005), considering the
absence of inflammation and both low frequency of
caries and plaque control index in patients with AgP
[11]. Our findings are consistent with the clinical
picture of aggressive periodontitis, since aggressive
periodontitis has been clinically characterized by
small amounts of sub-gingival plaque and pro-
gressive loss of epithelial attachment causing vertical
bone defects, which is in line with what Lindhe and
Rateitschak found in their study [12, 13]. Higher
mean values of plaque index in patients with chronic
periodontitis (CP) are consistent with the clinical
picture where plaque correlates with the degree of
inflammation and the level of periodontal destruc-
tion, which is characteristic for chronic periodontitis
(CP). 30 days after the treatment there was a sta-
tistically significant decrease (p<.01) in the mean
values of plaque index indicating the success of the
initial treatment in removing plaque no matter whe-
ther the patients were considered as a single group or
separated into diagnostic groups. Higher mean valu-
es of SBI were recorded in patients with AgP (3.33)
than in patients with CP (2.82). After the treatment,
the mean values of SBI were lowered by 2.15 (from
3.33 to 1.17) in patients with AgP, and by 1.87 (from
2.82 to 0.95) in patients with CP. The t-test for depen-
dant samples indicated that there was a statistically
significant difference in the mean values of SBI before
and 30 days after the treatment (p<.01) in patients
with AgP and CP. The study indicated clinical im-
provement in the levels of dental plaque and the
amount of gingival bleeding.
The mean values of CAL were lowered indicating
the success of the initial periodontal treatment. The
findings correspond with the findings from other stu-
dies demonstrating clinical improvement and achie-
ved stability of periodontal disease [14].
The t-test for dependent samples indicated that
there is a statistically significant difference between
the extent of clinical attachment loss mesially and
buccally before and 30 days after the treatment.
There was no difference in the extent of clinical
attachment loss distally and palatinally before and 30
days after the treatment.
The clinical assessment of the initial treatment
was complemented with the measurement of perio-
dontal pocket depths, which could objectively assess
the destruction of the periodontal tissue and the
success of the initial treatment, while residual pocket
depths after the initial treatment have values for
further progression of the disease [15]. Our findings
show that there is a statistically significant corre-
lation between the depth of a periodontal pocket and
a clinical attachment loss before the treatment. The
positive direction of the correlation indicates that the
depth of a periodontal pocket and a clinical attach-
ment loss are directly related – i.e. the greater the
pocket depth, the greater the clinical attachment loss.
The mean value of pocket depth in patients with
AgP was 5.4 mm, and in patients with CP 4, 8 mm. The
patients with AgP had greater pocket depth. The
success of the initial treatment, which was estimated
by a parallel probing before and after the treatment,
varied from one group to another (p < 0,001). The
treatment proved to be effective in decreasing the
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Pašić E, Dedić A, Hadžić S, Gojkov-Vukelić M, Hodžić M, Nakaš E
depth of all periodontal pockets. The depth of the
periodontal pockets in patients with AgP decreased
by 1.18 (from 5.45 to 4.27), while in patients with CP
it decreased by 0.94 (from 4.83 to 3.89). However, the
findings of this study indicate the appropriateness of
initial periodontal treatment. The failure of the
treatment, more often reported in patients with CP,
can be explained by poor motivation for the oral hygi-
ene in patients with mild symptoms of the disease.
In recent years, some studies were conducted to
evaluate the use of slimmer and thinner tips for ultra-
sonic sub-gingival debridement. The advantage of
slimmer tips is that they are thinner than curettes
and they can be more easily inserted into periodontal
pockets. Petersilka et al. (2011) proved that ultra-
sonic scalers are just as effective as hand instruments
in removing sub-gingival biofilm [16].
The study by Tsurumaki et al. (2011) revealed that
at greater probing depths slim ultrasonic scalers
achieved better results than hand instruments [17].
The study by Singh et al. (2012) confirmed that
such scalers removed the bacteria more easily with-
out removing dental cement giving the way to a new
approach in using periodontal instruments [18].
In addition to conducting the ultrasonic treatment
and reducing the sub-gingival biofilm, our goal was to
preserve the dental cement and its function.
Casarini et al. (2009) proved that the removal of
sub-gingival bacterial plaque using initial periodon-
tal treatment was sufficient for healing the perio-
dontal tissue lesions, provided the supra-gingival
deposits were removed regularly [19]. The initial
periodontal treatment improved the clinical picture
of the periodontal tissue and yielded good results in
patients with aggressive and chronic periodontitis,
which would, in turn, lead to remodeling and regene-
ration of all periodontal structures.
Conclusion
The initial periodontal treatment improved the
clinical picture of the periodontal tissue and yielded
good results in patients with aggressive and chronic
periodontitis, which would, in turn, lead to
remodeling and regeneration of all periodontal
structures.
Conflict of interest
The authors declare that they have no conflict of
interest. This study was not sponsored by any exter-
nal organization.
Authors' contributions
Conception and design: PE, DA; Acquisition, ana-
lysis and interpretation of data: PE, GM and HM; Draf-
ting the article PE, HS; Critical Revision of important
intellectual content: PE, HS and NE.
References
1. Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE.
Defining the normal bacterial flora of the oral
cavity. J Clin Microbiol. 2005;43:5721–32.
2. Matthews DC. Periodontal medicine: a new
paradigm. J Can Dent Assoc. 2000 Oct;66(9):488-
91.
3. Van Assche N, , ,
hels W, Quirynen M. Do periodontopathogens
disappear after full-mouth tooth extraction? J
Clin Periodontol. 2009 Dec;36(12):1043-7.
4. Roberts FA, Darveau RP. Beneficial bacteria of the
periodontium. Periodontol 2000. 2002;30:40-50.
5. Socransky SS, Haffajee AD. The bacterial etiology
of destructive periodontal disease: Current con-
cept. J Periodontol. 1992;6:322-31.
6. Haffajee AD, Socransky SS. Microbial etiologic
agents in destructive periodontal diseases. Perio-
dontology 2000;5:78-111.
7. Page RC. The pathobiology of periodontal disea-
ses by affect systemic diseases: Inversion of a pa-
radigm. Annals of Periodontology 1998;3:108-
20.
8. Ivić-Kardum M, Beader N, Štaudt-Škaljac G. Acta
Stomat Croat. 2001;133-136.
9. Lea SC, Felver B, Landini G, Walmsley AD. Three-
dimensional analyses of ultrasonic scaler oscilla-
tions. J Clin Periodontol. 2009;36(1):44-50.
10. Petersilka GJ, Ehmke B, Flemmig TF. Antimicro-
bial effects of mechanical debridement. Perio-
dontol 2000. 2002;28:56-71.
Van Essche M Pauwels M Teug-
10 11
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
THE RELATIONSHIP BETWEEN
PERIODONTAL HEALTH AND
DIABETES MELLITUS TYPE 1
1 1
Atanasovska-Stojanovska A*, Stefanovska E ,
1 2 3
Popovska M , Muratovska I , Zabokova-Bilbilova E
1 Department of Periodontology and Oral Pathology,
University Dental Clinical Centre "St. Pantelejmon", Faculty of Dentistry,
University "Ss. Cyril and Methodius", Skopje, Republic of Macedonia
2 Department of Cariology and Endodontology,
University Dental Clinical Centre "St. Pantelejmon", Faculty of Dentistry,
University "Ss. Cyril and Methodius", Skopje, Republic of Macedonia
3 Department of Pediatric and Preventive Dentistry,
University Dental Clinical Centre "St. Pantelejmon", Faculty of Dentistry,
University "Ss. Cyril and Methodius", Skopje, Republic of Macedonia
ABSTRACT
Evidence consistently shows that diabetes is a risk factor for
increased prevalence of gingivitis and periodontitis. The aim of the
present study is to explore the relationship between diabetes
mellitus type 1 and periodontal health status so as to indicate the
most present sub-gingival bacterial species detected at these
subjects. Periodontal health of 30 participants suffering from type-
1 diabetes mellitus was measured by the DPI, IGI, PPD and CAL and
compared with 30 healthy patients. The most common periodontal
pathogens in sub-gingival plaque were determined with
Polymerase chain reaction (PCR). Data and statistical analysis were
performed using SPSS, version (7.0). DPI, IGI, PPD and CAL scores
showing higher values at subgroups of patients with diabetes type
1 in comparison with healthy patients but also with statistically
significant differences (p≤ 0.05) among all examined groups. The
most present bacterial species detected from sub-gingival dental
plaque in patients who suffer from diabetes mellitus type 1 were
with statistically significant differences (p≤ 0.05) in comparison
with healthy patients.
Periodontal indexes were prevalent and more severe in people
suffering from diabetes than in those without it. Patients suffering
from diabetes are at higher risk to have periodontitis. Education
about oral health and periodontal treatments should be mandatory
for all patients with DM.
Key words: diabetes mellitus, oral health, periodontitis.
*Corresponding author
Atanasovska-Stojanovska A.
Department of Periodontology
and Oral Pathology,
University Dental Clinical
Centre "St. Pantelejmon",
Faculty of Dentistry,
University "Ss. Cyril and Methodius",
Vodnjanska 17
1000 Skopje
Republic of Macedonia
CLINICAL PARAMETERS OF CHRONIC AND AGGRESSIVE PERIODONTITIS BEFORE AND AFTER INITIAL TREATMENT
11. Aurer A, Roguljić M, Jorgić-Srdjak K. Comparison
of the success of initial at those suffering from
aggressive and chronic parodontitis. Acta Sto-
matol Croat. 2005;39(1):29-34.
12. Wolf HF, Rateitschak – Plüss EM, Rateitschak KH.
Parodontology – Stomatology atlas. Naklada Slap.
3. Re-worked and widened Croatian edition.
Zagreb, 2009
13. Lindhe J, Lang NP, Karring T. Clinic parodontology
and dental implantology. Nakladni zavod Globus.
5. English edition. Zagreb, 2010
14. He L, Li P, Sha YQ. Correlation between sulfide
levels in periodontal pocket of periodontitis pati-
ents and periodontal clinical parameters. Zhong-
hua Kou Qiang Yi Xue Za Zhi. 2006 Apr; 41(4):
209-11.
15. Van der Weijden GA, Timmerman MF. A systema-
tic review on the clinical efficacy of subgingival
debriment of chronic periodontitis. J Clin Perio-
dontol 2002;29: 55-71.
16. Petersilka GJ. Subgingival air-polishing in the
treatment of periodontal biofilm infections. Pe-
riodontol 2000. 2011;55(1):124-42.
17. Tsurumaki JN, Souto BH, Oliveira GJ, Sampaio JE,
Marcantonio JE, Marcantonio RA. Effect of instru-
mentation using curettes, piezoelectric ultraso-
nic scaler and Er,Cr:YSGG laser on the morpho-
logy and adhesion of blood components on root
surfaces: a SEM study. Braz Dent J. 2011;22(3):
185-92.
18. Singh S, Uppoor A, Nayak D. A comparative eva-
luation of the efficacy of manual, magnetostric-
tive and piezoelectric ultrasonic instruments--an
in vitro profilometric and SEM study. J Appl Oral
Sci. 2012;20(1):21-6.
19. Casarin RCV, Ribeiro FV, Sallum AV, Sallum EA,
Nociti FH, Casati MZ. Root Surface defect
produced by hand instruments and ultraconic
scaler with different power settings: an in vitro
study. Braz Dent J. 2009;20(1):58-63.
10 11
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
THE RELATIONSHIP BETWEEN
PERIODONTAL HEALTH AND
DIABETES MELLITUS TYPE 1
1 1
Atanasovska-Stojanovska A*, Stefanovska E ,
1 2 3
Popovska M , Muratovska I , Zabokova-Bilbilova E
1 Department of Periodontology and Oral Pathology,
University Dental Clinical Centre "St. Pantelejmon", Faculty of Dentistry,
University "Ss. Cyril and Methodius", Skopje, Republic of Macedonia
2 Department of Cariology and Endodontology,
University Dental Clinical Centre "St. Pantelejmon", Faculty of Dentistry,
University "Ss. Cyril and Methodius", Skopje, Republic of Macedonia
3 Department of Pediatric and Preventive Dentistry,
University Dental Clinical Centre "St. Pantelejmon", Faculty of Dentistry,
University "Ss. Cyril and Methodius", Skopje, Republic of Macedonia
ABSTRACT
Evidence consistently shows that diabetes is a risk factor for
increased prevalence of gingivitis and periodontitis. The aim of the
present study is to explore the relationship between diabetes
mellitus type 1 and periodontal health status so as to indicate the
most present sub-gingival bacterial species detected at these
subjects. Periodontal health of 30 participants suffering from type-
1 diabetes mellitus was measured by the DPI, IGI, PPD and CAL and
compared with 30 healthy patients. The most common periodontal
pathogens in sub-gingival plaque were determined with
Polymerase chain reaction (PCR). Data and statistical analysis were
performed using SPSS, version (7.0). DPI, IGI, PPD and CAL scores
showing higher values at subgroups of patients with diabetes type
1 in comparison with healthy patients but also with statistically
significant differences (p≤ 0.05) among all examined groups. The
most present bacterial species detected from sub-gingival dental
plaque in patients who suffer from diabetes mellitus type 1 were
with statistically significant differences (p≤ 0.05) in comparison
with healthy patients.
Periodontal indexes were prevalent and more severe in people
suffering from diabetes than in those without it. Patients suffering
from diabetes are at higher risk to have periodontitis. Education
about oral health and periodontal treatments should be mandatory
for all patients with DM.
Key words: diabetes mellitus, oral health, periodontitis.
*Corresponding author
Atanasovska-Stojanovska A.
Department of Periodontology
and Oral Pathology,
University Dental Clinical
Centre "St. Pantelejmon",
Faculty of Dentistry,
University "Ss. Cyril and Methodius",
Vodnjanska 17
1000 Skopje
Republic of Macedonia
CLINICAL PARAMETERS OF CHRONIC AND AGGRESSIVE PERIODONTITIS BEFORE AND AFTER INITIAL TREATMENT
11. Aurer A, Roguljić M, Jorgić-Srdjak K. Comparison
of the success of initial at those suffering from
aggressive and chronic parodontitis. Acta Sto-
matol Croat. 2005;39(1):29-34.
12. Wolf HF, Rateitschak – Plüss EM, Rateitschak KH.
Parodontology – Stomatology atlas. Naklada Slap.
3. Re-worked and widened Croatian edition.
Zagreb, 2009
13. Lindhe J, Lang NP, Karring T. Clinic parodontology
and dental implantology. Nakladni zavod Globus.
5. English edition. Zagreb, 2010
14. He L, Li P, Sha YQ. Correlation between sulfide
levels in periodontal pocket of periodontitis pati-
ents and periodontal clinical parameters. Zhong-
hua Kou Qiang Yi Xue Za Zhi. 2006 Apr; 41(4):
209-11.
15. Van der Weijden GA, Timmerman MF. A systema-
tic review on the clinical efficacy of subgingival
debriment of chronic periodontitis. J Clin Perio-
dontol 2002;29: 55-71.
16. Petersilka GJ. Subgingival air-polishing in the
treatment of periodontal biofilm infections. Pe-
riodontol 2000. 2011;55(1):124-42.
17. Tsurumaki JN, Souto BH, Oliveira GJ, Sampaio JE,
Marcantonio JE, Marcantonio RA. Effect of instru-
mentation using curettes, piezoelectric ultraso-
nic scaler and Er,Cr:YSGG laser on the morpho-
logy and adhesion of blood components on root
surfaces: a SEM study. Braz Dent J. 2011;22(3):
185-92.
18. Singh S, Uppoor A, Nayak D. A comparative eva-
luation of the efficacy of manual, magnetostric-
tive and piezoelectric ultrasonic instruments--an
in vitro profilometric and SEM study. J Appl Oral
Sci. 2012;20(1):21-6.
19. Casarin RCV, Ribeiro FV, Sallum AV, Sallum EA,
Nociti FH, Casati MZ. Root Surface defect
produced by hand instruments and ultraconic
scaler with different power settings: an in vitro
study. Braz Dent J. 2009;20(1):58-63.
12 13
THE RELATIONSHIP BETWEEN PERIODONTAL HEALTH AND DIABETES MELLITUS TYPE 1 Atanasovska-Stojanovska A, Stefanovska E, Popovska M, Muratovska I, Zabokova-Bilbilova E
an important risk factor, not only for the onset but
also for progression of the disease [3].
Individuals suffering from diabetes are up to 3 ti-
mes more likely to have gum attachment loss and
bone loss than those non-diabetics [4].
Many studies have reported on the correlation
between various diabetes-related factors including
HbA1c and duration of diabetes, and periodontal
health. In the US National Health and Nutrition Exa-
mination Survey (NHANES) III, adults with an HbA1c
level of >9% had significantly higher prevalence of
severe periodontitis than those without diabetes
[12].
The most of them evaluating the relation between
periodontitis and the duration of diabetes and have
reported that the prevalence of periodontitis increa-
sed with the duration of diabetes [13, 14].
There were 41 cross-sectional studies (with re-
sults from 37 showing a relationship) and seven
prospective studies (with results from all seven
showing a relationship). In a subsequent review, Tay-
lor and Borgnakke [2], identified 17 cross-sectional
articles that were published in the English language
between 2000 and 2007. The results from 13 of them
supported the conclusion that periodontitis is more
prevalent and severe in patients suffering from dia-
betes mellitus than in patients without diabetes
mellitus. Therefore, the results from 57 out of 65
studies support this association.
There are 80 000 people suffering from diabetes
in Macedonia, 1800 of type 1 where insufficient se-
cretion of insulin occurs at latest until the age of 25.
The aim of the present study was to evaluate the
periodontal status and oral health status in adoles-
cents suffering from type 1 diabetes related to meta-
bolic control of the disease compared to healthy in-
dividuals of the same age, as well as the percentage of
the most common periodontal pathogens in sub-
gingival plaque at diabetic type 1 patients and heal-
thy patients.
Material and Methods
A descriptive cross-sectional study approved by
the Ethical Committee from the Faculty of Medicine
was conducted during 6 months, consisting of 30
diabetes type 1 affected individuals, aging from 14 to
24. All the subjects received information about the
questionnaire and the clinical examination, and they
signed an agreement (for those under 18 years,
parent or guardian signed the agreement). The ques-
tionnaire, the samples and the examinations were
taken at The University Clinic of Endocrinology,
Diabetes and Metabolic Disorders, Skopje and
Department of Oral Pathology and Periodontology,
University Dental Clinic Skopje in Macedonia.
The control group consisted of 30 randomly selec-
ted healthy individuals of the same age.
Type 1 diabetic patients were divided in two main
subgroups depending on the therapy:
• Subgroup 1, consisted of 15 individuals taking
multiple injection basal/bolus insulin therapy.
• Subgroup 2, consisted of 15 individuals taking
therapy with insulin infusion (insulin pump) over
the minimum period of 2 years.
Criteria for individual selection:
• individuals with diabetes type 1 (minimum two
years) at the age 14-24
• individuals at the age 14-24 without any type of
chronic disease, healthy patients
Criteria for individual excluding:
• type 2 diabetes
• acute inflammatory diseases
• autoimmune diseases
• malignant diseases
• antibiotic therapy (tetracycline)
• therapy with corticosteroids
• immune suppression therapy in the last 6 months
• history of any general disease which violets
functions of immune system
• present acute necrotizing ulcerative gingivitis
• current or former smokers
Periodontal status and oral health status were de-
termined by applying index of gingival inflammation
(IGI) according to Loe Silness, index of dental plaque
IDP according to Silness Loe, measurements of
periodontal pocket depth (PPD), and measurement
of clinical attachment loss (CAL).
The most common periodontal pathogens in sub-
gingival plaque at diabetes type 1 patients were
determined with Polymerase chain reaction (PCR). It
is a powerful and sensitive technique for DNA ampli-
fication from biological material (dental plaque,
inflamed gingival tissue, gingival fluid or saliva).
These samples are containing DNA of the infecting
microorganisms used to determine the most preva-
lent periopathogenic bacteria species.
Sub-gingival dental plaque was collected using a
sterilized paper point from mesial and distal side on
six teeth in the mouth (16, 21, 24, 36. 41, 44).
Parodontose plus test (GeniID GmbH, Straßberg-
Germany) reverse hybridization kit was used for the
detection of periodontal marker of bacteria species:
Actinobacillus actinomycetemcomitans, Porphyro-
monas gingivalis, Prevotella intermedia, Tannerella
forsythia and Treponema denticola,
Data and statistical Analyses were performed
using SPSS, version (7.0). (The case-control analysis
focused on the association between periodontitis
and diabetes.
Results
DPI values at Healthy patients, Diabetes type1-
patients with insulin pump and Diabetes type
1patients with conservative insulin therapy showed
in Table 1. Dental plaque index scores shows higher
values at subgroups diabetes type 1 patients
compared to healthy patients and with statistically
significant differences (p≤ 0.05).
Table 2 shows IGI values at Healthy patients,
Diabetes type1 with insulin pump and Diabetes type
1 with conservative insulin therapy. Gingival in-
flammation index scores shows higher values at sub-
groups diabetes type 1 patients compared to healthy
patients and statistically significant differences (p≤
0.05).
Table 3 shows PPD values at Healthy patients,
Diabetes type1 with insulin pump and Diabetes type
1 with conservative insulin therapy
Both groups of diabetes type 1 patients' marked
higher scores in comparison to healthy patients and
statistically significant differences (p≤ 0.05).
CAL scores shows higher values at subgroups dia-
betes type 1 patients compared to healthy patients
and statistically significant differences (p≤ 0.05),
among all examined groups (Table 4).
Table 5 shows the pathogenic bacteria detected in
patients suffering from diabetes and the control
group. Healthy patients had only the presence of
Treponema denticolla and it is significantly more
frequent in patients suffering from diabetes. Other
pathogenic bacteria are not detected in healthy
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Introduction
Periodontal disease is a chronic inflammatory
condition characterized by destruction of the perio-
dontal tissues and resulting in loss of connective
tissue attachment, loss of alveolar bone, and the for-
mation of pathological pockets around the diseased
teeth. Some level of periodontal disease has been
found in most populations studied and is responsible
for substantial portion of the tooth loss in adulthood
[1, 2].
Diabetes is the most common endocrine disorder
and by the year 2010 it was estimated that more than
200 million people worldwide would have DM and
300 million will subsequently have the disease by
2025 [3].
There are three general categories of diabetes: a)
Type 1, which is the result of an absolute insulin
deficiency in the body; b) Type 2, which is caused by
an insulin secretory defect and insulin resistance;
and c) gestational diabetes, which occurs during
pregnancy and is due to abnormal glucose tolerance
[4].
Type 1 diabetes which accounts for only 5–10% of
those suffering from diabetes, previously encom-
passed by the terms insulin-dependent diabetes,
type I diabetes, or juvenile-onset diabetes, results
from a cellular-mediated autoimmune destruction of
the β-cells of the pancreas [5]. Long-term complica-
tions may occur in both type 1 and type 2 diabetes [6].
Periodontitis has been identified as the sixth
complication of diabetes. Advanced glycation end-
products, altered lipid mechanisms, oxidative stress,
and systemically elevated cytokine levels in patients
suffering from diabetes and periodontitis suggest
that dental and medical care providers should coor-
dinate therapies [7, 8].
The prevalence of periodontitis is higher and its
symptoms are more severe in individuals suffering
from diabetes in comparison with those non-diabe-
tics [9, 10]. The influence of diabetes on oral health
conditions has been well documented. Frequently
observed oral conditions in diabetic patients include
dental caries, xerostomia (dry mouth), tooth loss,
gingivitis, cheilitis, increase of glucose level in saliva,
and periodontitis [11].
Bacterial plaque is the main etiologic agent, al-
though it is the host immune response that causes pe-
riodontal tissue destruction. Diabetes is considered
12 13
THE RELATIONSHIP BETWEEN PERIODONTAL HEALTH AND DIABETES MELLITUS TYPE 1 Atanasovska-Stojanovska A, Stefanovska E, Popovska M, Muratovska I, Zabokova-Bilbilova E
an important risk factor, not only for the onset but
also for progression of the disease [3].
Individuals suffering from diabetes are up to 3 ti-
mes more likely to have gum attachment loss and
bone loss than those non-diabetics [4].
Many studies have reported on the correlation
between various diabetes-related factors including
HbA1c and duration of diabetes, and periodontal
health. In the US National Health and Nutrition Exa-
mination Survey (NHANES) III, adults with an HbA1c
level of >9% had significantly higher prevalence of
severe periodontitis than those without diabetes
[12].
The most of them evaluating the relation between
periodontitis and the duration of diabetes and have
reported that the prevalence of periodontitis increa-
sed with the duration of diabetes [13, 14].
There were 41 cross-sectional studies (with re-
sults from 37 showing a relationship) and seven
prospective studies (with results from all seven
showing a relationship). In a subsequent review, Tay-
lor and Borgnakke [2], identified 17 cross-sectional
articles that were published in the English language
between 2000 and 2007. The results from 13 of them
supported the conclusion that periodontitis is more
prevalent and severe in patients suffering from dia-
betes mellitus than in patients without diabetes
mellitus. Therefore, the results from 57 out of 65
studies support this association.
There are 80 000 people suffering from diabetes
in Macedonia, 1800 of type 1 where insufficient se-
cretion of insulin occurs at latest until the age of 25.
The aim of the present study was to evaluate the
periodontal status and oral health status in adoles-
cents suffering from type 1 diabetes related to meta-
bolic control of the disease compared to healthy in-
dividuals of the same age, as well as the percentage of
the most common periodontal pathogens in sub-
gingival plaque at diabetic type 1 patients and heal-
thy patients.
Material and Methods
A descriptive cross-sectional study approved by
the Ethical Committee from the Faculty of Medicine
was conducted during 6 months, consisting of 30
diabetes type 1 affected individuals, aging from 14 to
24. All the subjects received information about the
questionnaire and the clinical examination, and they
signed an agreement (for those under 18 years,
parent or guardian signed the agreement). The ques-
tionnaire, the samples and the examinations were
taken at The University Clinic of Endocrinology,
Diabetes and Metabolic Disorders, Skopje and
Department of Oral Pathology and Periodontology,
University Dental Clinic Skopje in Macedonia.
The control group consisted of 30 randomly selec-
ted healthy individuals of the same age.
Type 1 diabetic patients were divided in two main
subgroups depending on the therapy:
• Subgroup 1, consisted of 15 individuals taking
multiple injection basal/bolus insulin therapy.
• Subgroup 2, consisted of 15 individuals taking
therapy with insulin infusion (insulin pump) over
the minimum period of 2 years.
Criteria for individual selection:
• individuals with diabetes type 1 (minimum two
years) at the age 14-24
• individuals at the age 14-24 without any type of
chronic disease, healthy patients
Criteria for individual excluding:
• type 2 diabetes
• acute inflammatory diseases
• autoimmune diseases
• malignant diseases
• antibiotic therapy (tetracycline)
• therapy with corticosteroids
• immune suppression therapy in the last 6 months
• history of any general disease which violets
functions of immune system
• present acute necrotizing ulcerative gingivitis
• current or former smokers
Periodontal status and oral health status were de-
termined by applying index of gingival inflammation
(IGI) according to Loe Silness, index of dental plaque
IDP according to Silness Loe, measurements of
periodontal pocket depth (PPD), and measurement
of clinical attachment loss (CAL).
The most common periodontal pathogens in sub-
gingival plaque at diabetes type 1 patients were
determined with Polymerase chain reaction (PCR). It
is a powerful and sensitive technique for DNA ampli-
fication from biological material (dental plaque,
inflamed gingival tissue, gingival fluid or saliva).
These samples are containing DNA of the infecting
microorganisms used to determine the most preva-
lent periopathogenic bacteria species.
Sub-gingival dental plaque was collected using a
sterilized paper point from mesial and distal side on
six teeth in the mouth (16, 21, 24, 36. 41, 44).
Parodontose plus test (GeniID GmbH, Straßberg-
Germany) reverse hybridization kit was used for the
detection of periodontal marker of bacteria species:
Actinobacillus actinomycetemcomitans, Porphyro-
monas gingivalis, Prevotella intermedia, Tannerella
forsythia and Treponema denticola,
Data and statistical Analyses were performed
using SPSS, version (7.0). (The case-control analysis
focused on the association between periodontitis
and diabetes.
Results
DPI values at Healthy patients, Diabetes type1-
patients with insulin pump and Diabetes type
1patients with conservative insulin therapy showed
in Table 1. Dental plaque index scores shows higher
values at subgroups diabetes type 1 patients
compared to healthy patients and with statistically
significant differences (p≤ 0.05).
Table 2 shows IGI values at Healthy patients,
Diabetes type1 with insulin pump and Diabetes type
1 with conservative insulin therapy. Gingival in-
flammation index scores shows higher values at sub-
groups diabetes type 1 patients compared to healthy
patients and statistically significant differences (p≤
0.05).
Table 3 shows PPD values at Healthy patients,
Diabetes type1 with insulin pump and Diabetes type
1 with conservative insulin therapy
Both groups of diabetes type 1 patients' marked
higher scores in comparison to healthy patients and
statistically significant differences (p≤ 0.05).
CAL scores shows higher values at subgroups dia-
betes type 1 patients compared to healthy patients
and statistically significant differences (p≤ 0.05),
among all examined groups (Table 4).
Table 5 shows the pathogenic bacteria detected in
patients suffering from diabetes and the control
group. Healthy patients had only the presence of
Treponema denticolla and it is significantly more
frequent in patients suffering from diabetes. Other
pathogenic bacteria are not detected in healthy
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Introduction
Periodontal disease is a chronic inflammatory
condition characterized by destruction of the perio-
dontal tissues and resulting in loss of connective
tissue attachment, loss of alveolar bone, and the for-
mation of pathological pockets around the diseased
teeth. Some level of periodontal disease has been
found in most populations studied and is responsible
for substantial portion of the tooth loss in adulthood
[1, 2].
Diabetes is the most common endocrine disorder
and by the year 2010 it was estimated that more than
200 million people worldwide would have DM and
300 million will subsequently have the disease by
2025 [3].
There are three general categories of diabetes: a)
Type 1, which is the result of an absolute insulin
deficiency in the body; b) Type 2, which is caused by
an insulin secretory defect and insulin resistance;
and c) gestational diabetes, which occurs during
pregnancy and is due to abnormal glucose tolerance
[4].
Type 1 diabetes which accounts for only 5–10% of
those suffering from diabetes, previously encom-
passed by the terms insulin-dependent diabetes,
type I diabetes, or juvenile-onset diabetes, results
from a cellular-mediated autoimmune destruction of
the β-cells of the pancreas [5]. Long-term complica-
tions may occur in both type 1 and type 2 diabetes [6].
Periodontitis has been identified as the sixth
complication of diabetes. Advanced glycation end-
products, altered lipid mechanisms, oxidative stress,
and systemically elevated cytokine levels in patients
suffering from diabetes and periodontitis suggest
that dental and medical care providers should coor-
dinate therapies [7, 8].
The prevalence of periodontitis is higher and its
symptoms are more severe in individuals suffering
from diabetes in comparison with those non-diabe-
tics [9, 10]. The influence of diabetes on oral health
conditions has been well documented. Frequently
observed oral conditions in diabetic patients include
dental caries, xerostomia (dry mouth), tooth loss,
gingivitis, cheilitis, increase of glucose level in saliva,
and periodontitis [11].
Bacterial plaque is the main etiologic agent, al-
though it is the host immune response that causes pe-
riodontal tissue destruction. Diabetes is considered
14
Diabetes type 1 with conservative
insulin therapy (3)
Diabetes type 1 with conservative
insulin therapy (3)
Diabetes type1 with insulin pump(2)
Diabetes type1 with insulin pump(2)
Healthy (1)
Healthy (1)
DPI
IGI
mean
1,38000
2,33333
2,62666
mean
1,720000
2,406667
2,666667
SD
0,345768
0,482059
0,413118
SD
0,379473
0,502091
0,411733
p
(1/2) 0,000132
(1/3) 0,000125
p
(1/2) 0,00152
(1/3) 0,00014
N
30
15
15
N
30
15
15
Tukey HSD test; variable: marked differences are significant at p < ,05000
Tukey HSD test; variable: IGI (marked differences are significant at p < ,05000
Table 1.
DPI values at Healthy patients,
Diabetes type1-patients with
insulin pump and Diabetes
type 1 patients with
conservative insulin therapy
Table 2.
IGI values at Healthy patients,
Diabetes type1 with insulin
pump and Diabetes type 1
with conservative insulin
therapy
Analysis of Variance=26, 76 p=0, 000000
Healthy/Diabetes type 1 with insulin pump p=0, 000132
Healthy/Diabetes type 1 with conservative insulin therapy p=0, 000125
Analysis of Variance=14, 16 p=0, 00003
Healthy/Diabetes type 1 with insulin pump p=0, 0015
Healthy/Diabetes type 1 with conservative insulin therapy p=0, 00014
15
THE RELATIONSHIP BETWEEN PERIODONTAL HEALTH AND DIABETES MELLITUS TYPE 1 Atanasovska-Stojanovska A, Stefanovska E, Popovska M, Muratovska I, Zabokova-Bilbilova E
patients, and the differences are statistically signi-
ficant.
Table 6 shows the average values of Hb A1C which
is an indicator of the success of the regulation of
blood glucose in diabetic patients. There are not
statistically significant correlation between HbA1c
and analyzed indexes in two examined group of
diabetic patients, those with different ways of
metabolic control of the disease.
The way in which glycaemia is regulated is highly
associated with the level of glycemic hemoglobin
HbA1c, which is an indicator for a long term regu-
lation of glycaemia. It allows you to measure high
values of glucose over a period of 30-60 days. It is
used for short-term fluctuations in blood sugar level.
Discussion
Diabetics have 15 times more loss of attachment
and alveolar bone. Aggressive periodontitis occurs
much earlier in diabetics 27% aging from 15-19
years. Faster is exacerbation of periodontitis during
longitudinal study with poorly controlled type 1 DM
HbAC1> 9 vs. well controlled HbAC1 <7. Patients had
twice more chances to get worsening of HbA1c over
2-3 years when severe periodontitis was present at
baseline.
Patients with poorly controlled type 1 diabetes
mellitus with elevated blood glucose and HbA1c
levels have severe form of periodontitis. Good
metabolic control in type 1 DM reduces susceptibility
to infection and has great importance for preventing
periodontitis in these patients. A recent review of 55
studies involving individuals suffering from diabetes
found consistent evidence of greater periodontitis:
prevalence, incidence, severity, extent and progres-
sion.
Dose-response relationship - as glycemic control
worsens, periodontitis worsens. Diabetes reflects on
saliva production. Decreased level of saliva leads to
caries, dry oral mycosis and ulcerous inflammations.
It also causes problems with food intake, sense of
taste and swallowing. The advanced form of
periodontitis further affects the level of blood
glucose in individuals with or without diabetes, and
is associated with higher risk of developing diabetes.
Reduction in the level of HbA1c shortly after perio-
dontal treatment is equivalent to adding of second
drug in pharmacological regime of diabetes. If this
reduction is extended in the long run, it would reduce
the mobility and morbidity caused by diabetes. In
type 1 diabetes additional antibiotic therapy has
great benefit, while in type 2 professional mechanical
debridement and effective homecare are sufficient.
Toxins produced by the bacteria in plaque
irritate/ulcerate the gingiva. The toxins stimulate
chronic inflammatory response in which body turns
to itself thus leading tissues and bone to break down
and be destroyed. Diabetes is a chronic disease with
epidemic proportions, its complications significantly
contribute to the quality of life, longevity and finan-
cial balance. There are 346 million people in the
world suffering from diabetes currently, with
progression to 439 million by 2030 (WHO 2011).
Every 10 seconds in the world: two people develop
diabetes, 1 person dies. There are large number of
undiagnosed cases. Many of them are at constant risk
for their health. All these things require multidisci-
plinary approach from our side. Diabetes mellitus is a
chronic state of hyperglycemia with metabolic dis-
orders in carbohydrates, lipids and proteins caused
by partial or total lack of insulin or combined with
insulin resistance.
There are growing scientific evidence that syste-
mic inflammation is a result of infiltration of oral
microorganisms and their virulence factors in
circulation.
Evidence for that are elevated values of CRP and
markers of oxidative stress in blood.
It adversely affects diabetes control (HbA1c),
complications and function of B-cells of the pancreas
– resistance to insulin and developing type 2 DM.
Reduced function of polymorphonuclear leukocytes,
abnormalities in metabolism of collagen formation
AGE (AGE advanced glycation end products) that
stimulate inflammatory tissue destruction in
inflammatory cells and production of oxygen free
radicals, which have an additional effect on stability
of collagen and vascular integrity.
AGF attached receptor monocytes and macro-
phages result in increased secretion of IL -1 and TNF
ALPHA leading to increased susceptibility to perio-
dontal tissue destruction, loss of attachment and
alveolar bone.
Pro-inflammatory cytokines (IL-1, IL-6, TNF-A)
and prostaglandins (PgE2) accumulate in the gum
tissues in active periodontitis at extraordinary levels
and can enter the circulation.
Are there a growing number of pathogenic bacte-
ria under the influence of diabetes? There are thin
capillary vessels, impaired function of leukocytes,
decreased production of collagen and thus reduced
regeneration of tissue and poorly healing wounds,
increased activity of MSEs.
Since there are conflicting reports in the litera-
ture, the aim of this study was to analyze the perio-
dontal disease in adolescents with type 1 diabetes
mellitus. A dental study was carried out on 30
adolescents aging from 14-24 years with type 1 DM
(with insulin pump and with conservative insulin
therapy) in comparison with a 15 non-DM group as
control group. Periodontitis is a complex multifactor
disease. It can especially cause a problem for adoles-
cents with DM. Inadequate oral hygiene is respon-
sible for high oral debris in case of diabetic adoles-
cents, being in correlation with the status of perio-
dontium. A doubt exists suspecting that the link
between diabetes and periodontal disease may be
bidirectional; the body's response to periodontal
pathogens may be exacerbated in individuals with
diabetes and pro inflammatory cytokines produced
by gingival tissues during chronic periodontal infec-
tion may gain access to the bloodstream leading to in-
creased insulin resistance and poor glycaemic con-
trol [10].
The intensity of gingivitis and periodontitis, as
well as the increased alveolar bone loss was more
prevalent and more severe in diabetic adolescents
than in healthy individuals. Many papers on the sub-
ject have outlined that the inclination, extent, severi-
ty and development of periodontal disease are signi-
ficantly increased in case of patients suffering from
diabetes. According to them, periodontal disease is
one of the most prevalent and rapidly progressive
complications of DM in case of adults [15, 16].
The oral hygiene (OHI-S), especially the debris
index was worse in case of diabetic individuals than
in case of the control persons and correlation was
found between the intensity of gingivitis and perio-
dontitis and on the oral hygiene. In our study DPI and
IGI were much higher in case of diabetic patients than
in case of metabolically healthy persons (p< 0. 05)
(Table1, Table 2). The authors received the same
results for diabetic adolescents.
It is in accordance with De Pommereu et al. [17]
and Lalla at all [18], who found more serious gin-
givitis in diabetics than in control persons, although
plaque scores were the same in both groups. Sappala
et al. [19], has shown that adults with Type 1 diabetes
mellitus have higher degree of attachment loss and
bone loss than control subjects' group under similar
dental plaque conditions.
Another aspect of the rela-
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
14
Diabetes type 1 with conservative
insulin therapy (3)
Diabetes type 1 with conservative
insulin therapy (3)
Diabetes type1 with insulin pump(2)
Diabetes type1 with insulin pump(2)
Healthy (1)
Healthy (1)
DPI
IGI
mean
1,38000
2,33333
2,62666
mean
1,720000
2,406667
2,666667
SD
0,345768
0,482059
0,413118
SD
0,379473
0,502091
0,411733
p
(1/2) 0,000132
(1/3) 0,000125
p
(1/2) 0,00152
(1/3) 0,00014
N
30
15
15
N
30
15
15
Tukey HSD test; variable: marked differences are significant at p < ,05000
Tukey HSD test; variable: IGI (marked differences are significant at p < ,05000
Table 1.
DPI values at Healthy patients,
Diabetes type1-patients with
insulin pump and Diabetes
type 1 patients with
conservative insulin therapy
Table 2.
IGI values at Healthy patients,
Diabetes type1 with insulin
pump and Diabetes type 1
with conservative insulin
therapy
Analysis of Variance=26, 76 p=0, 000000
Healthy/Diabetes type 1 with insulin pump p=0, 000132
Healthy/Diabetes type 1 with conservative insulin therapy p=0, 000125
Analysis of Variance=14, 16 p=0, 00003
Healthy/Diabetes type 1 with insulin pump p=0, 0015
Healthy/Diabetes type 1 with conservative insulin therapy p=0, 00014
15
THE RELATIONSHIP BETWEEN PERIODONTAL HEALTH AND DIABETES MELLITUS TYPE 1 Atanasovska-Stojanovska A, Stefanovska E, Popovska M, Muratovska I, Zabokova-Bilbilova E
patients, and the differences are statistically signi-
ficant.
Table 6 shows the average values of Hb A1C which
is an indicator of the success of the regulation of
blood glucose in diabetic patients. There are not
statistically significant correlation between HbA1c
and analyzed indexes in two examined group of
diabetic patients, those with different ways of
metabolic control of the disease.
The way in which glycaemia is regulated is highly
associated with the level of glycemic hemoglobin
HbA1c, which is an indicator for a long term regu-
lation of glycaemia. It allows you to measure high
values of glucose over a period of 30-60 days. It is
used for short-term fluctuations in blood sugar level.
Discussion
Diabetics have 15 times more loss of attachment
and alveolar bone. Aggressive periodontitis occurs
much earlier in diabetics 27% aging from 15-19
years. Faster is exacerbation of periodontitis during
longitudinal study with poorly controlled type 1 DM
HbAC1> 9 vs. well controlled HbAC1 <7. Patients had
twice more chances to get worsening of HbA1c over
2-3 years when severe periodontitis was present at
baseline.
Patients with poorly controlled type 1 diabetes
mellitus with elevated blood glucose and HbA1c
levels have severe form of periodontitis. Good
metabolic control in type 1 DM reduces susceptibility
to infection and has great importance for preventing
periodontitis in these patients. A recent review of 55
studies involving individuals suffering from diabetes
found consistent evidence of greater periodontitis:
prevalence, incidence, severity, extent and progres-
sion.
Dose-response relationship - as glycemic control
worsens, periodontitis worsens. Diabetes reflects on
saliva production. Decreased level of saliva leads to
caries, dry oral mycosis and ulcerous inflammations.
It also causes problems with food intake, sense of
taste and swallowing. The advanced form of
periodontitis further affects the level of blood
glucose in individuals with or without diabetes, and
is associated with higher risk of developing diabetes.
Reduction in the level of HbA1c shortly after perio-
dontal treatment is equivalent to adding of second
drug in pharmacological regime of diabetes. If this
reduction is extended in the long run, it would reduce
the mobility and morbidity caused by diabetes. In
type 1 diabetes additional antibiotic therapy has
great benefit, while in type 2 professional mechanical
debridement and effective homecare are sufficient.
Toxins produced by the bacteria in plaque
irritate/ulcerate the gingiva. The toxins stimulate
chronic inflammatory response in which body turns
to itself thus leading tissues and bone to break down
and be destroyed. Diabetes is a chronic disease with
epidemic proportions, its complications significantly
contribute to the quality of life, longevity and finan-
cial balance. There are 346 million people in the
world suffering from diabetes currently, with
progression to 439 million by 2030 (WHO 2011).
Every 10 seconds in the world: two people develop
diabetes, 1 person dies. There are large number of
undiagnosed cases. Many of them are at constant risk
for their health. All these things require multidisci-
plinary approach from our side. Diabetes mellitus is a
chronic state of hyperglycemia with metabolic dis-
orders in carbohydrates, lipids and proteins caused
by partial or total lack of insulin or combined with
insulin resistance.
There are growing scientific evidence that syste-
mic inflammation is a result of infiltration of oral
microorganisms and their virulence factors in
circulation.
Evidence for that are elevated values of CRP and
markers of oxidative stress in blood.
It adversely affects diabetes control (HbA1c),
complications and function of B-cells of the pancreas
– resistance to insulin and developing type 2 DM.
Reduced function of polymorphonuclear leukocytes,
abnormalities in metabolism of collagen formation
AGE (AGE advanced glycation end products) that
stimulate inflammatory tissue destruction in
inflammatory cells and production of oxygen free
radicals, which have an additional effect on stability
of collagen and vascular integrity.
AGF attached receptor monocytes and macro-
phages result in increased secretion of IL -1 and TNF
ALPHA leading to increased susceptibility to perio-
dontal tissue destruction, loss of attachment and
alveolar bone.
Pro-inflammatory cytokines (IL-1, IL-6, TNF-A)
and prostaglandins (PgE2) accumulate in the gum
tissues in active periodontitis at extraordinary levels
and can enter the circulation.
Are there a growing number of pathogenic bacte-
ria under the influence of diabetes? There are thin
capillary vessels, impaired function of leukocytes,
decreased production of collagen and thus reduced
regeneration of tissue and poorly healing wounds,
increased activity of MSEs.
Since there are conflicting reports in the litera-
ture, the aim of this study was to analyze the perio-
dontal disease in adolescents with type 1 diabetes
mellitus. A dental study was carried out on 30
adolescents aging from 14-24 years with type 1 DM
(with insulin pump and with conservative insulin
therapy) in comparison with a 15 non-DM group as
control group. Periodontitis is a complex multifactor
disease. It can especially cause a problem for adoles-
cents with DM. Inadequate oral hygiene is respon-
sible for high oral debris in case of diabetic adoles-
cents, being in correlation with the status of perio-
dontium. A doubt exists suspecting that the link
between diabetes and periodontal disease may be
bidirectional; the body's response to periodontal
pathogens may be exacerbated in individuals with
diabetes and pro inflammatory cytokines produced
by gingival tissues during chronic periodontal infec-
tion may gain access to the bloodstream leading to in-
creased insulin resistance and poor glycaemic con-
trol [10].
The intensity of gingivitis and periodontitis, as
well as the increased alveolar bone loss was more
prevalent and more severe in diabetic adolescents
than in healthy individuals. Many papers on the sub-
ject have outlined that the inclination, extent, severi-
ty and development of periodontal disease are signi-
ficantly increased in case of patients suffering from
diabetes. According to them, periodontal disease is
one of the most prevalent and rapidly progressive
complications of DM in case of adults [15, 16].
The oral hygiene (OHI-S), especially the debris
index was worse in case of diabetic individuals than
in case of the control persons and correlation was
found between the intensity of gingivitis and perio-
dontitis and on the oral hygiene. In our study DPI and
IGI were much higher in case of diabetic patients than
in case of metabolically healthy persons (p< 0. 05)
(Table1, Table 2). The authors received the same
results for diabetic adolescents.
It is in accordance with De Pommereu et al. [17]
and Lalla at all [18], who found more serious gin-
givitis in diabetics than in control persons, although
plaque scores were the same in both groups. Sappala
et al. [19], has shown that adults with Type 1 diabetes
mellitus have higher degree of attachment loss and
bone loss than control subjects' group under similar
dental plaque conditions.
Another aspect of the rela-
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Diabetes type 1 with conservative
insulin therapy (3)
Diabetes type 1 with conservative
insulin therapy (3)
Diabetes type1 with insulin pump(2)
Diabetes type1 with insulin pump(2)
Healthy (1)
Healthy (1)
PPD
CAL
mean
1,18000
4,19333
4,48000
mean
1,240000
3,826667
4,400000
SD
1,266491
0,786009
0,708318
SD
0,031935
0,831064
0,595219
p
(1/2) 0,00012
(1/3) 0,662233
p
(1/2) 0,00012
(1/3) 0,00012
N
30
15
15
N
30
15
15
Tukey HSD test; variable: marked differences are significant at p < ,05000
Tukey HSD test; variable: KGA Marked differences are significant at p < ,05000
Table 3.
PPD values at Healthy patients,
Diabetes type1 with insulin
pump and Diabetes type 1 with
conservative insulin therapy
Table 4.
CAL values at Healthy patients,
Diabetes type1 with insulin
pump and Diabetes type 1
with conservative insulin
therapy
Analysis of Variance=46, 3 p=0, 000000
Healthy/Diabetes type 1 with insulin pump p=0, 000125
Healthy/Diabetes type 1 with conservative insulin therapy p=0, 000125
Analysis of Variance=49, 2 p=0, 000000
Healthy/Diabetes type 1 with insulin pump p=0, 000125
Healthy/Diabetes type 1 with conservative insulin therapy p=0, 000125 T=1, 32 p=0,19 p>0,05
17
THE RELATIONSHIP BETWEEN PERIODONTAL HEALTH AND DIABETES MELLITUS TYPE 1
tionship between diabetes mellitus and periodontitis
was presented in a series of studies in which resear
chers examined the oral manifestations of diabetes in
childrenand adolescents. In one, Lalla and colleagues
examined 350 children and adolescents with
diabetes mellitus and 350 children and adolescents
without diabetes mellitus (all 6-18 years of age).
They used three definitions of periodontal
disease, which incorporated attachment loss, gingi-
val bleeding or both. With use of multiple regression
analysis to account for a variety of variables, the inve-
stigators observed greater prevalence of periodontal
disease and tissue inflammation in children with
diabetes mellitus than in children without diabetes.
Also, in our study t
-
[20]
he mean values of CAL and PPD
were higher in case of diabetic patients than in case of
those non diabetic, with no significant differences
among the subgroups of diabetic patients ( insulin
pump and conservative insulin therapy, p<0.05)
(Table 3, Table 4).
It was recognized that periodontal disease was
more prevalent and more severe in people with dia-
betes than in people without diabetes, researchers
sought specific biological mechanism to explain the
association [21, 22]. Diabetes is believed to promote
periodontitis through an exaggerated inflammatory
response to the periodontal microflora. The most
present bacterial species detected from sub-gingival
dental plaque in patients who have diabetes mellitus
type 1 were Treponema denticolla (45%) and Tane-
rella forsitus (31%), whereas at healthy patient only
Treponema denticolla (4%)
Studies of gingivitis in humans with or without
type 1 diabetes have shown that both diabetic and
nondiabetic subjects react to experimental plaque
accumulation with gingival inflammation. However,
subjects with type 1 diabetes develop an earlier and
more severe local inflammatory response to a
comparable bacterial challenge [23].
That proves the fact that impaired immune res-
ponse, different bacterial microflora and collagen
metabolism are involved in the pathogenesis of
diabetic periodontal disease.
Periodontitis is a clinical complication of diabetes
mellitus. Furthermore, approximately 30 % of people
with diabetes mellitus have undiagnosed diabetes
mellitus. Therefore, the dental office is a health care
site that can help to identify undiagnosed diabetes
mellitus, which can lead to better care management
of diabetic patients.
In a 2008 article, Taylor and Borgnakke [24]
identified periodontal disease as a possible risk fac-
tor for poor metabolic control in people with diabetes
mellitus. This bidirectional relationship between
(Table 5) was detected.
16 Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
periodontal disease and diabetes mellitus makes
diabetes a disorder of importance to dentists and
dental hygienists and to patients seen in the dental
office.
Frequent dental treatments may help maintain
good oral health. Treatment is especially crucial at
the onset of the disease. Dental care at the early
stages of the disease, reducing susceptibility to infec-
tion, is also significant for the prevention of perio-
dontal disease in case of adolescents with type 1
diabetes mellitus. Patients should also be checked
regularly for bleeding gums or inflammation in order
to prevent the alveolar bone loss, which leads to
irreversible changes of periodontium.
The education of patients on proper home oral
care is the basic method for periodontal health.
Conclusion
Patients suffering from diabetes mellitus have
significantly higher values for indices such as gingival
inflammation, dental plaque, clinical attachment loss
and depth of the periodontal pocket, which are indi-
cators of the gingival and periodontal health.
This brings us to the conclusion that patients suffe-
ring from diabetes have a greater presence of gingi-
vitis and periodontitis in comparison to population
without diabetes at the same age.
Between the two groups of patients suffering from
diabetes divided by the method of blood glucose
control, there were no significant differences, leading
to the conclusion that we cannot give preference to
any one of them in terms of better prevention of
gingivitis and periodontitis. Significantly, presence of
more periopatogens in patients suffering from
diabetes only confirms weak regulation of the immu-
ne system being proven in these patients and thus
requiring additional antibiotic treatment to be
recommended.
А programs designed to promote prevention and
treatment of periodontitis with strictly set protocols
is required for patients suffering from diabetes
mellitus.
References
1. Amos A, McCarty D, Zimmet P. The rising global
burden of diabetes and its complications, estima-
tes and projections to the year 2010. Diabetic Med
1997; 14: S1-S85.
Atanasovska-Stojanovska A, Stefanovska E, Popovska M, Muratovska I, Zabokova-Bilbilova E
Bacterial species
HbA1c patients with insulin pump vs. HbA1c patients with conservative insulin th
p
Table 5.
Percentage distribution of the
subgingival microflora in patient
with Diabetes type 1, both
subgroups (with insulin pump
and with conservative insulin
therapy) and healthy patients
Table 6.
T-test for Independent Samples
Note: Variables were treated as
independent samples
Actinobacillus actinomycetemmcomitans
Porfiromonas gingivalis
Prevotella intermedia
Tanerella forsitus
Treponema denticolla
5
15
14
31
45
4,44
19,26
11,62
15,17
8,29
0,04
0,00001
0,007
0,00009
0,004
4
Diabetes mellitus
type 1 (%)
Mean HbA1c patients with insulin pump
Mean HbA1c patients with conservative insulin therapy
t-value
df
p
Valid N
Std. Dev. patients with insulin pump
Std. Dev. with conservative insulin therapy
Pearson Chi
square
Healthy
patients (%)
7,452941
8,282353
-1,32658
32,0
0,194038
17,0
1,700043
1,937858
Diabetes type 1 with conservative
insulin therapy (3)
Diabetes type 1 with conservative
insulin therapy (3)
Diabetes type1 with insulin pump(2)
Diabetes type1 with insulin pump(2)
Healthy (1)
Healthy (1)
PPD
CAL
mean
1,18000
4,19333
4,48000
mean
1,240000
3,826667
4,400000
SD
1,266491
0,786009
0,708318
SD
0,031935
0,831064
0,595219
p
(1/2) 0,00012
(1/3) 0,662233
p
(1/2) 0,00012
(1/3) 0,00012
N
30
15
15
N
30
15
15
Tukey HSD test; variable: marked differences are significant at p < ,05000
Tukey HSD test; variable: KGA Marked differences are significant at p < ,05000
Table 3.
PPD values at Healthy patients,
Diabetes type1 with insulin
pump and Diabetes type 1 with
conservative insulin therapy
Table 4.
CAL values at Healthy patients,
Diabetes type1 with insulin
pump and Diabetes type 1
with conservative insulin
therapy
Analysis of Variance=46, 3 p=0, 000000
Healthy/Diabetes type 1 with insulin pump p=0, 000125
Healthy/Diabetes type 1 with conservative insulin therapy p=0, 000125
Analysis of Variance=49, 2 p=0, 000000
Healthy/Diabetes type 1 with insulin pump p=0, 000125
Healthy/Diabetes type 1 with conservative insulin therapy p=0, 000125 T=1, 32 p=0,19 p>0,05
17
THE RELATIONSHIP BETWEEN PERIODONTAL HEALTH AND DIABETES MELLITUS TYPE 1
tionship between diabetes mellitus and periodontitis
was presented in a series of studies in which resear
chers examined the oral manifestations of diabetes in
childrenand adolescents. In one, Lalla and colleagues
examined 350 children and adolescents with
diabetes mellitus and 350 children and adolescents
without diabetes mellitus (all 6-18 years of age).
They used three definitions of periodontal
disease, which incorporated attachment loss, gingi-
val bleeding or both. With use of multiple regression
analysis to account for a variety of variables, the inve-
stigators observed greater prevalence of periodontal
disease and tissue inflammation in children with
diabetes mellitus than in children without diabetes.
Also, in our study t
-
[20]
he mean values of CAL and PPD
were higher in case of diabetic patients than in case of
those non diabetic, with no significant differences
among the subgroups of diabetic patients ( insulin
pump and conservative insulin therapy, p<0.05)
(Table 3, Table 4).
It was recognized that periodontal disease was
more prevalent and more severe in people with dia-
betes than in people without diabetes, researchers
sought specific biological mechanism to explain the
association [21, 22]. Diabetes is believed to promote
periodontitis through an exaggerated inflammatory
response to the periodontal microflora. The most
present bacterial species detected from sub-gingival
dental plaque in patients who have diabetes mellitus
type 1 were Treponema denticolla (45%) and Tane-
rella forsitus (31%), whereas at healthy patient only
Treponema denticolla (4%)
Studies of gingivitis in humans with or without
type 1 diabetes have shown that both diabetic and
nondiabetic subjects react to experimental plaque
accumulation with gingival inflammation. However,
subjects with type 1 diabetes develop an earlier and
more severe local inflammatory response to a
comparable bacterial challenge [23].
That proves the fact that impaired immune res-
ponse, different bacterial microflora and collagen
metabolism are involved in the pathogenesis of
diabetic periodontal disease.
Periodontitis is a clinical complication of diabetes
mellitus. Furthermore, approximately 30 % of people
with diabetes mellitus have undiagnosed diabetes
mellitus. Therefore, the dental office is a health care
site that can help to identify undiagnosed diabetes
mellitus, which can lead to better care management
of diabetic patients.
In a 2008 article, Taylor and Borgnakke [24]
identified periodontal disease as a possible risk fac-
tor for poor metabolic control in people with diabetes
mellitus. This bidirectional relationship between
(Table 5) was detected.
16 Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
periodontal disease and diabetes mellitus makes
diabetes a disorder of importance to dentists and
dental hygienists and to patients seen in the dental
office.
Frequent dental treatments may help maintain
good oral health. Treatment is especially crucial at
the onset of the disease. Dental care at the early
stages of the disease, reducing susceptibility to infec-
tion, is also significant for the prevention of perio-
dontal disease in case of adolescents with type 1
diabetes mellitus. Patients should also be checked
regularly for bleeding gums or inflammation in order
to prevent the alveolar bone loss, which leads to
irreversible changes of periodontium.
The education of patients on proper home oral
care is the basic method for periodontal health.
Conclusion
Patients suffering from diabetes mellitus have
significantly higher values for indices such as gingival
inflammation, dental plaque, clinical attachment loss
and depth of the periodontal pocket, which are indi-
cators of the gingival and periodontal health.
This brings us to the conclusion that patients suffe-
ring from diabetes have a greater presence of gingi-
vitis and periodontitis in comparison to population
without diabetes at the same age.
Between the two groups of patients suffering from
diabetes divided by the method of blood glucose
control, there were no significant differences, leading
to the conclusion that we cannot give preference to
any one of them in terms of better prevention of
gingivitis and periodontitis. Significantly, presence of
more periopatogens in patients suffering from
diabetes only confirms weak regulation of the immu-
ne system being proven in these patients and thus
requiring additional antibiotic treatment to be
recommended.
А programs designed to promote prevention and
treatment of periodontitis with strictly set protocols
is required for patients suffering from diabetes
mellitus.
References
1. Amos A, McCarty D, Zimmet P. The rising global
burden of diabetes and its complications, estima-
tes and projections to the year 2010. Diabetic Med
1997; 14: S1-S85.
Atanasovska-Stojanovska A, Stefanovska E, Popovska M, Muratovska I, Zabokova-Bilbilova E
Bacterial species
HbA1c patients with insulin pump vs. HbA1c patients with conservative insulin th
p
Table 5.
Percentage distribution of the
subgingival microflora in patient
with Diabetes type 1, both
subgroups (with insulin pump
and with conservative insulin
therapy) and healthy patients
Table 6.
T-test for Independent Samples
Note: Variables were treated as
independent samples
Actinobacillus actinomycetemmcomitans
Porfiromonas gingivalis
Prevotella intermedia
Tanerella forsitus
Treponema denticolla
5
15
14
31
45
4,44
19,26
11,62
15,17
8,29
0,04
0,00001
0,007
0,00009
0,004
4
Diabetes mellitus
type 1 (%)
Mean HbA1c patients with insulin pump
Mean HbA1c patients with conservative insulin therapy
t-value
df
p
Valid N
Std. Dev. patients with insulin pump
Std. Dev. with conservative insulin therapy
Pearson Chi
square
Healthy
patients (%)
7,452941
8,282353
-1,32658
32,0
0,194038
17,0
1,700043
1,937858
18 19
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
2. Taylor GW. The effects of periodontal treatment on
diabetes. The Journal of the American Dental
Association 2003; 134:41-48.
3. Silva JA, Lorencini M, Reis JR, Carvalho HF, Cagnon
VH, Stach-Machado DR. The influence of type I
diabetes mellitus in periodontal disease induced
changes of the gingival epithelium and connective
tissue. Tissue Cell 2008 Aug; 40(4):283-92.
4. Eisenberg S. Educational resources on diabetes
mellitus. JADA 134(1):59.
5. Morton T, Gandara B. Oral Health and Diabetes.
Interprofessional Coordination of Patient-
Centered Care Diabetes Spectrum November
2011; 24(4):191-192.
6. Orlando VA, Johnson LR, Wilson AR, Maahs DM,
Wadwa RP, Bishop FK, Dong F, Morrato EH: Oral
health knowledge and behaviours among adoles-
cents with type 1 diabetes. Int J Dent 2010; doi:
10.1155/2010/942124.
7. The Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus: Diagnosis and
classification of diabetes mellitus Diabetes Care.
Jan 2009; 32 (Suppl 1): 62–67.
8. Shay K. Infectious complications of dental and
periodontal diseases in the elderly population.
Clinical Infectious Diseases 2002; 34(9):1215-
1223.
9. Marigo L, Cerreto R, Giuliani M, Somma F, Lajolo C,
Cordaro M. Diabetes mellitus: biochemical, histo-
logical and microbiological aspects in periodontal
disease. Eur Rev Med Pharmacol Sci 2011; 15(7):
751-758.
THE RELATIONSHIP BETWEEN PERIODONTAL HEALTH AND DIABETES MELLITUS TYPE 1 ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
THE EFFECT OF DIFFERENT CONCENTRATIONS OF
CHLORHEXIDINE DIGLUCONATE (0,12% AND 0,2%)
IN DEVELOPMENT OF POSTOPERATIVE SEQUELAE
AND INCIDENCE OF WOUND INFECTIONS
FOLLOWING ORAL-SURGICAL PROCEDURES:
A PROSPECTIVE CLINICAL STUDY
11 1 2
Šečić S* , Prohić S , Komšić S , Vuković A
1 Department of Oral Surgery, Faculty of Dentistry, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
2 Department of Dental Morphology, Anthropology and Forensics,
Faculty of Dentistry, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Objective: The aim of the research is to evaluate the clinical
effect of different concentrations of chlorhexidine digluconate
(0.12% and 0.2%) on development of postoperative sequelae
(pain, edema and trismus) and incidence of surgical wound
infections in oral-surgical procedures.
Materials and Methods: The total of 480 patients was
included in prospective, randomized clinical study. Patients were
randomly divided into control group and two clinical-
experimental groups: the first group used 0.12% chlorhexidine
mouthwash and the second group 0.2% chlorhexidine
mouthwash 7 days postoperatively.
Results: A total of 480 patients were included in this study:
267 females and 213 males, gender ratio 1:1, 25 in favor of
females. The age ranges from 18 to 60 years with an average of ±
SD= 32 ± 9 years. The incidence of postoperative wound infection
was 5% (n=24; %=5) in control, 3,125% in experimental group 1
(n=15; %=3,125) and 1,875% in experimental group 2 (n=9;
%=1,875). Chlorhexidine digluconate did not show statistically
significant clinical effects on development of postoperative
sequalae following oral-surgical procedures (p>0, 05).
Conclusion: Chlorhexidine is a potent antiseptic that can be
used in order to control postoperative sequalae and complica-
tions in oral surgery. It has proven as safe and efficient in reducing
the risk of oral-surgical wound infections. The authors recom-
mend its use in preoperative and postoperative wound care
management in oral-surgical procedures.
Key words: chlorhexidine digluconate, oral-surgical procedu-
res, postoperative sequelae, surgical wound infection.
*Corresponding author
Sadeta Šečić, DDS, PhD
Department of Oral Surgery
Faculty of Dentistry
University of Sarajevo
Bolnička 4a
71000 Sarajevo
Bosnia and Herzegovina
Phone: +387 33 214 249
e-mail: sadetas@gnet.ba
18 19
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
2. Taylor GW. The effects of periodontal treatment on
diabetes. The Journal of the American Dental
Association 2003; 134:41-48.
3. Silva JA, Lorencini M, Reis JR, Carvalho HF, Cagnon
VH, Stach-Machado DR. The influence of type I
diabetes mellitus in periodontal disease induced
changes of the gingival epithelium and connective
tissue. Tissue Cell 2008 Aug; 40(4):283-92.
4. Eisenberg S. Educational resources on diabetes
mellitus. JADA 134(1):59.
5. Morton T, Gandara B. Oral Health and Diabetes.
Interprofessional Coordination of Patient-
Centered Care Diabetes Spectrum November
2011; 24(4):191-192.
6. Orlando VA, Johnson LR, Wilson AR, Maahs DM,
Wadwa RP, Bishop FK, Dong F, Morrato EH: Oral
health knowledge and behaviours among adoles-
cents with type 1 diabetes. Int J Dent 2010; doi:
10.1155/2010/942124.
7. The Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus: Diagnosis and
classification of diabetes mellitus Diabetes Care.
Jan 2009; 32 (Suppl 1): 62–67.
8. Shay K. Infectious complications of dental and
periodontal diseases in the elderly population.
Clinical Infectious Diseases 2002; 34(9):1215-
1223.
9. Marigo L, Cerreto R, Giuliani M, Somma F, Lajolo C,
Cordaro M. Diabetes mellitus: biochemical, histo-
logical and microbiological aspects in periodontal
disease. Eur Rev Med Pharmacol Sci 2011; 15(7):
751-758.
THE RELATIONSHIP BETWEEN PERIODONTAL HEALTH AND DIABETES MELLITUS TYPE 1 ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
THE EFFECT OF DIFFERENT CONCENTRATIONS OF
CHLORHEXIDINE DIGLUCONATE (0,12% AND 0,2%)
IN DEVELOPMENT OF POSTOPERATIVE SEQUELAE
AND INCIDENCE OF WOUND INFECTIONS
FOLLOWING ORAL-SURGICAL PROCEDURES:
A PROSPECTIVE CLINICAL STUDY
11 1 2
Šečić S* , Prohić S , Komšić S , Vuković A
1 Department of Oral Surgery, Faculty of Dentistry, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
2 Department of Dental Morphology, Anthropology and Forensics,
Faculty of Dentistry, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Objective: The aim of the research is to evaluate the clinical
effect of different concentrations of chlorhexidine digluconate
(0.12% and 0.2%) on development of postoperative sequelae
(pain, edema and trismus) and incidence of surgical wound
infections in oral-surgical procedures.
Materials and Methods: The total of 480 patients was
included in prospective, randomized clinical study. Patients were
randomly divided into control group and two clinical-
experimental groups: the first group used 0.12% chlorhexidine
mouthwash and the second group 0.2% chlorhexidine
mouthwash 7 days postoperatively.
Results: A total of 480 patients were included in this study:
267 females and 213 males, gender ratio 1:1, 25 in favor of
females. The age ranges from 18 to 60 years with an average of ±
SD= 32 ± 9 years. The incidence of postoperative wound infection
was 5% (n=24; %=5) in control, 3,125% in experimental group 1
(n=15; %=3,125) and 1,875% in experimental group 2 (n=9;
%=1,875). Chlorhexidine digluconate did not show statistically
significant clinical effects on development of postoperative
sequalae following oral-surgical procedures (p>0, 05).
Conclusion: Chlorhexidine is a potent antiseptic that can be
used in order to control postoperative sequalae and complica-
tions in oral surgery. It has proven as safe and efficient in reducing
the risk of oral-surgical wound infections. The authors recom-
mend its use in preoperative and postoperative wound care
management in oral-surgical procedures.
Key words: chlorhexidine digluconate, oral-surgical procedu-
res, postoperative sequelae, surgical wound infection.
*Corresponding author
Sadeta Šečić, DDS, PhD
Department of Oral Surgery
Faculty of Dentistry
University of Sarajevo
Bolnička 4a
71000 Sarajevo
Bosnia and Herzegovina
Phone: +387 33 214 249
e-mail: sadetas@gnet.ba
20 21
THE EFFECT OF DIFFERENT CONCENTRATIONS OF CHLORHEXIDINE DIGLUCONATE (0,12% AND 0,2%) IN DEVELOPMENT OF POSTOPERATIVE SEQUELAE AND INCIDENCE OF WOUND INFECTIONS FOLLOWING ORAL-SURGICAL PROCEDURES: A PROSPECTIVE CLINICAL STUDY
Šečić S, Prohić S, Komšić S, Vuković A
Introduction
Chlorhexidine digluconate is a cationic bisbigua-
nid, colorless and odorless aqueous solution, mode-
rately soluble. The bactericidal effect is based on the
disruption of the integrity of cell membranes by inhi-
biting the enzyme systems and coagulation of proto-
plasm. After entering into the cell, it causes precipi-
tation of the cytoplasm thus preventing vital function
of the microorganism. Adsorption of active substance
to the cell surface is dependent on the current con-
centration, the type of microorganism and the pH
value. In lower concentrations it dissolves and
coagulates cytoplasmic constituents with the inac-
tivation of the enzyme, therefore exhibits bacterio-
static effects [1]. Differences in the sensitivity of
microorganisms are attributed to the different
possibilities of adsorption on the cell wall. It works
with an immediate bactericidal action and the pro-
longed bacteriostatic effects can persist for several
hours due to the adsorption onto the pellicle-coated
enamel surface [2].
Chlorhexidine digluconate has broad antibacte-
rial spectrum. Its effect depends on the concentra-
tion. It has bactericidal effect in particular against
gram-positive micro-organisms
. A weaker effect is on gram-negative bacteria
and fungi, for which significantly higher concentra-
tion (10 to more than 73 It
shows good adhesion to the mucosa and the tooth
surface, and does not interfere with the exchange of
substances. The molecules of chlorhexidine are posi-
tively charged, and with cationic appeal they exhibit
great affinity to the negatively charged cell mem-
branes such as membranes of streptococci and lacto-
bacilli. Enamel, gingiva and oral mucosa are also
negatively charged, which means that chlorhexidine
shows affinity to these structures. Thus, in these
areas the active substance reservoirs are formed
(about 30% of the used quantity) being gradually
released after administration of extending the appli-
ed antimicrobial agents [3].
Chlorhexidine is often used as an active ingredient
in mouthwash designed to reduce dental plaque and
oral bacteria. There are oral pathologic conditions in
which the maintenance of oral hygiene with twice a
day use of 0.12% chlorhexidine gluconate solution is
required for healing and regeneration of the oral tis-
sues [4]. Numerous studies investigated its benefits
in concentrations ≥
1 µg/l
is required μg/ml) [1].
in oral surgery (prevention of alveolar osteitis) [5-8],
dental-alveolar traumatology (management of trau-
matic dental injuries and controlling inflammatory
resorption in delayed transplantation of teeth) [9,10]
and dental implantology (enhancement of the
successful osseointegration of implants and treat-
ment of periimplantitis) [11,12].The clinical efficacy
of the application of chlorhexidine as a component of
oral rinses is well documented by many clinical
studies summarized by review articles [13].
The effect in clinical practice is reflected in the
application during the preoperative preparation of
patients who are scheduled for surgery in order to act
on the prevention of postoperative sequelae such as
swelling, trismus and pain. These are the sequelae
that may occur as a result of infection development.
Therefore the application of various concentrations
of chlorhexidine digluconate in correlation with sur-
gery outcomes, represents the subject of this
research.
The aim of the research is to evaluate the clinical
effect of different concentrations of chlorhexidine
digluconate (0.12% and 0.2%) on development of
postoperative sequelae (pain, edema and trismus)
and incidence on oral-surgical procedures.
Material and Methods
The study is conducted at the Department of Oral
Surgery, Faculty of Dentistry in Sarajevo. The patients
were from standard casuistry of Clinic for Oral Sur-
gery with indication for certain operative procedu-
res, including: enucleatio cystis radicularis maxillae/
mandibulae in totto, enucleatio cystis residualis,
enucleatio cystis e retentione, resectio apicis dentis,
extractio dentis, extractio dentis operativa, nivelatio
processus alveolaris maxillae/mandibulae, excisio
mucosae oris. Each surgical procedure involves a
group of 60 patients of both genders, aging from 18-
60 years with no systemic disease, meaning that the
research included 480 patients in total.
Diagnostic examination of patients included me-
dical history, clinical and radiographic examination,
laboratory blood tests and an internist preparation if
needed. After informing patients about medical
procedure, patients signed the consent. All surgical
procedures were performed under local anesthesia
Lidocain 2% Adrenaline 1:80000(Alkaloid®, Skopje,
Republic of Macedonia) in the same operating room
under the same conditions, by two different sur-
geons. Oral surgical procedures were performed
according to current operational protocols at
Department and the Clinic for Oral Surgery. Detailed
instructions on the postoperative course were given
to all patients with clear explanations on how and
how often you the proposed irrigation of surgical
wound with solution of chlorhexidine should be
performed.
Patients were randomly divided into control
groups and two clinical-experimental groups: the
first group used 0.12% chlorhexidine mouthwash
and the second group 0.2% chlorhexidine mouth-
wash 7 days postoperatively. All patients were invited
for regular check-ups so that postoperative sequelae
(pain, swelling, trismus), complications and wound
infections could be evaluated.
Pain was evaluated daily on a visual analogue
scale (VAS) of 0 (no pain) to 10 (worst pain) during
the first post-operative week. The edema was measu-
red on the face with following points: mandibular
angle, lateral cantus, base of nasal wing, nasal commi-
sures and pogonion. Trismus was measured as maxi-
mal inter-incisal distance.
Details of the surgery and the postoperative
recovery were entered into the operating protocol of
the Clinic, and later were entered into a database that
was specially created for this study with all necessary
variables that were monitored in the study. Data were
processed and analyzed in statistical software SPSS
20.0 (SPSS Inc, Chicago, Il, USA). The data were
statistically analyzed by T-test of independent
samples and the comparison between the groups was
made using the Chi-squared test. P-value lower than
0, 05 was considered to be statistically significant.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Results
A total of 480 patients were included in this study:
267 females and 213 males, gender ratio being 1:1,
25 in favor of females. The age ranges from 18 to 60
years with mean age of ± SD= 32 ± 9 years.
The pain in control group and both experimental
groups was highest at the first postoperative day and
then decreasing through postoperative period. The
lowest was recorded the seventh postoperative day
(Figure 1). The mean postoperative pain in control
group is ± SD=4, 04±2, 59. In experimental group 1
the mean is ± SD = 4, 02±3, 62, and in experimental
group 2 ± SD= 3, 62±2, 42 respectively. The pain in
experimental groups was lower compared to the
control group (p>0, 05).
The highest values of edema were recorded on the
second postoperative day (control and experimental
group 1) and third postoperative day (experimental
group 2) (Figure 2). The edema in control group
ranged from 3 (first postoperative day) to 58 (second
postoperative day) with mean value of ± SD = 33,
43±18, 40. The edema in experimental group 1
ranged from 4 (first postoperative day) to 59 (third
postoperative day) with mean value of ± SD = 32, 71 ±
18, 43. The edema in experimental group 2 ranged
from 5 (first postoperative day) to 57 (second
postope-rative day) with mean value of ± SD = 33, 43
± 17, 64. There is no statistical significance in inciden-
ce of edema in control and experimental groups (p>0,
05).
Trismus was the most pronounced in second post-
operative day. The values of inter-incisal distance on
the seventh postoperative day reached almost pre-
operative values (Figure 3). The maximal inter-inci-
sal distance was in range from 45mm (preoperative)
to 25mm (second and third postoperative day) in
Figure 1.
Evaluation of pain on VAS
in first postoperative week
Evaluation of pain (on VAS)
Control group
Experimental group 1
Experimental group 2
1
0
1
2
3
4
5
6
7
8
9
2 3 4 5 6 7
Postoperative day
The level of pain
20 21
THE EFFECT OF DIFFERENT CONCENTRATIONS OF CHLORHEXIDINE DIGLUCONATE (0,12% AND 0,2%) IN DEVELOPMENT OF POSTOPERATIVE SEQUELAE AND INCIDENCE OF WOUND INFECTIONS FOLLOWING ORAL-SURGICAL PROCEDURES: A PROSPECTIVE CLINICAL STUDY
Šečić S, Prohić S, Komšić S, Vuković A
Introduction
Chlorhexidine digluconate is a cationic bisbigua-
nid, colorless and odorless aqueous solution, mode-
rately soluble. The bactericidal effect is based on the
disruption of the integrity of cell membranes by inhi-
biting the enzyme systems and coagulation of proto-
plasm. After entering into the cell, it causes precipi-
tation of the cytoplasm thus preventing vital function
of the microorganism. Adsorption of active substance
to the cell surface is dependent on the current con-
centration, the type of microorganism and the pH
value. In lower concentrations it dissolves and
coagulates cytoplasmic constituents with the inac-
tivation of the enzyme, therefore exhibits bacterio-
static effects [1]. Differences in the sensitivity of
microorganisms are attributed to the different
possibilities of adsorption on the cell wall. It works
with an immediate bactericidal action and the pro-
longed bacteriostatic effects can persist for several
hours due to the adsorption onto the pellicle-coated
enamel surface [2].
Chlorhexidine digluconate has broad antibacte-
rial spectrum. Its effect depends on the concentra-
tion. It has bactericidal effect in particular against
gram-positive micro-organisms
. A weaker effect is on gram-negative bacteria
and fungi, for which significantly higher concentra-
tion (10 to more than 73 It
shows good adhesion to the mucosa and the tooth
surface, and does not interfere with the exchange of
substances. The molecules of chlorhexidine are posi-
tively charged, and with cationic appeal they exhibit
great affinity to the negatively charged cell mem-
branes such as membranes of streptococci and lacto-
bacilli. Enamel, gingiva and oral mucosa are also
negatively charged, which means that chlorhexidine
shows affinity to these structures. Thus, in these
areas the active substance reservoirs are formed
(about 30% of the used quantity) being gradually
released after administration of extending the appli-
ed antimicrobial agents [3].
Chlorhexidine is often used as an active ingredient
in mouthwash designed to reduce dental plaque and
oral bacteria. There are oral pathologic conditions in
which the maintenance of oral hygiene with twice a
day use of 0.12% chlorhexidine gluconate solution is
required for healing and regeneration of the oral tis-
sues [4]. Numerous studies investigated its benefits
in concentrations ≥
1 µg/l
is required μg/ml) [1].
in oral surgery (prevention of alveolar osteitis) [5-8],
dental-alveolar traumatology (management of trau-
matic dental injuries and controlling inflammatory
resorption in delayed transplantation of teeth) [9,10]
and dental implantology (enhancement of the
successful osseointegration of implants and treat-
ment of periimplantitis) [11,12].The clinical efficacy
of the application of chlorhexidine as a component of
oral rinses is well documented by many clinical
studies summarized by review articles [13].
The effect in clinical practice is reflected in the
application during the preoperative preparation of
patients who are scheduled for surgery in order to act
on the prevention of postoperative sequelae such as
swelling, trismus and pain. These are the sequelae
that may occur as a result of infection development.
Therefore the application of various concentrations
of chlorhexidine digluconate in correlation with sur-
gery outcomes, represents the subject of this
research.
The aim of the research is to evaluate the clinical
effect of different concentrations of chlorhexidine
digluconate (0.12% and 0.2%) on development of
postoperative sequelae (pain, edema and trismus)
and incidence on oral-surgical procedures.
Material and Methods
The study is conducted at the Department of Oral
Surgery, Faculty of Dentistry in Sarajevo. The patients
were from standard casuistry of Clinic for Oral Sur-
gery with indication for certain operative procedu-
res, including: enucleatio cystis radicularis maxillae/
mandibulae in totto, enucleatio cystis residualis,
enucleatio cystis e retentione, resectio apicis dentis,
extractio dentis, extractio dentis operativa, nivelatio
processus alveolaris maxillae/mandibulae, excisio
mucosae oris. Each surgical procedure involves a
group of 60 patients of both genders, aging from 18-
60 years with no systemic disease, meaning that the
research included 480 patients in total.
Diagnostic examination of patients included me-
dical history, clinical and radiographic examination,
laboratory blood tests and an internist preparation if
needed. After informing patients about medical
procedure, patients signed the consent. All surgical
procedures were performed under local anesthesia
Lidocain 2% Adrenaline 1:80000(Alkaloid®, Skopje,
Republic of Macedonia) in the same operating room
under the same conditions, by two different sur-
geons. Oral surgical procedures were performed
according to current operational protocols at
Department and the Clinic for Oral Surgery. Detailed
instructions on the postoperative course were given
to all patients with clear explanations on how and
how often you the proposed irrigation of surgical
wound with solution of chlorhexidine should be
performed.
Patients were randomly divided into control
groups and two clinical-experimental groups: the
first group used 0.12% chlorhexidine mouthwash
and the second group 0.2% chlorhexidine mouth-
wash 7 days postoperatively. All patients were invited
for regular check-ups so that postoperative sequelae
(pain, swelling, trismus), complications and wound
infections could be evaluated.
Pain was evaluated daily on a visual analogue
scale (VAS) of 0 (no pain) to 10 (worst pain) during
the first post-operative week. The edema was measu-
red on the face with following points: mandibular
angle, lateral cantus, base of nasal wing, nasal commi-
sures and pogonion. Trismus was measured as maxi-
mal inter-incisal distance.
Details of the surgery and the postoperative
recovery were entered into the operating protocol of
the Clinic, and later were entered into a database that
was specially created for this study with all necessary
variables that were monitored in the study. Data were
processed and analyzed in statistical software SPSS
20.0 (SPSS Inc, Chicago, Il, USA). The data were
statistically analyzed by T-test of independent
samples and the comparison between the groups was
made using the Chi-squared test. P-value lower than
0, 05 was considered to be statistically significant.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Results
A total of 480 patients were included in this study:
267 females and 213 males, gender ratio being 1:1,
25 in favor of females. The age ranges from 18 to 60
years with mean age of ± SD= 32 ± 9 years.
The pain in control group and both experimental
groups was highest at the first postoperative day and
then decreasing through postoperative period. The
lowest was recorded the seventh postoperative day
(Figure 1). The mean postoperative pain in control
group is ± SD=4, 04±2, 59. In experimental group 1
the mean is ± SD = 4, 02±3, 62, and in experimental
group 2 ± SD= 3, 62±2, 42 respectively. The pain in
experimental groups was lower compared to the
control group (p>0, 05).
The highest values of edema were recorded on the
second postoperative day (control and experimental
group 1) and third postoperative day (experimental
group 2) (Figure 2). The edema in control group
ranged from 3 (first postoperative day) to 58 (second
postoperative day) with mean value of ± SD = 33,
43±18, 40. The edema in experimental group 1
ranged from 4 (first postoperative day) to 59 (third
postoperative day) with mean value of ± SD = 32, 71 ±
18, 43. The edema in experimental group 2 ranged
from 5 (first postoperative day) to 57 (second
postope-rative day) with mean value of ± SD = 33, 43
± 17, 64. There is no statistical significance in inciden-
ce of edema in control and experimental groups (p>0,
05).
Trismus was the most pronounced in second post-
operative day. The values of inter-incisal distance on
the seventh postoperative day reached almost pre-
operative values (Figure 3). The maximal inter-inci-
sal distance was in range from 45mm (preoperative)
to 25mm (second and third postoperative day) in
Figure 1.
Evaluation of pain on VAS
in first postoperative week
Evaluation of pain (on VAS)
Control group
Experimental group 1
Experimental group 2
1
0
1
2
3
4
5
6
7
8
9
2 3 4 5 6 7
Postoperative day
The level of pain
22 23
Šečić S, Prohić S, Komšić S, Vuković A
control group, with mean ±SD= 32, 43mm±7,17mm.
The maximal inter-incisal distance in experimental
group 1 was in range from 47mm (preoperative) to
19mm (third postoperative day) with mean value of ±
SD= 31,71mm± 9,44mm. The maximal inter-incisal
distance in experimental group 2 was in range from
44mm (preoperative) to 22mm (third postoperative
day) with mean value of ±SD= 31, 43mm±7,87mm.
There is no statistical significance in development of
trismus in control and experimental groups (p>0,
05).
The incidence of postoperative wound infection
was 5% (n=24; %=5) in control, 3,125% in experi-
mental group 1 (n=15; %=3,125) and 1,875% in
experimental group 2 (n=9; %=1,875). There is sta-
tistical significance in incidence of postoperative
infection between control and experimental groups
(p<0, 05) (Figure 4).
Discussion
The infection of surgical wounds is not uncommon
in surgical practice and can complicate even the best
performed procedure. It is the most common nosoco-
mial infection in patients undergoing surgery [14]
with the estimated incidence of 1% do 30% [15]. The
surgical wound infection interferes with the normal
healing process and can lead to many complications
with different clinical outcomes. Although majority
of these infections are self-limited and easily treated
with antibiotics and local measures, due to proximity
of vital structures and the development of antibiotic-
resistant bacteria, they can lead to life-threatening
infections of head and neck, especially in medically
compromised patients. Therefore, minimizing the
risk of surgical infection is an important aspect of
postoperative treatment of patients. However, there
are many reports considering the emerging antibio-
tic-resistant microorganisms that can aggravate the
treatment and affect the ultimate outcome, which
further complicates the management of postoperati-
ve infections. Therefore, current trends are directed
towards alternative means, in particular, antiseptics.
Preoperative use of antiseptics is performed in
order to reduce the microorganisms in the area of the
surgical incision and can be extended during post-
operative period in order to minimize the risk of sur-
gical wound infection. Chlorhexidine gluconate
(0.12%) is often recommended as a mouth rinse to
reduce the number of surface microorganisms in the
surgical field, and its use may be continued during the
postoperative healing stage [16, 17]. Antiseptics
need not be omitted from the therapeutic armamen-
tarium of wound care. In patients and wound types
with high risk of infection, antiseptics may be used to
prevent wound infection that would have deleterious
effects on wound healing. Antiseptics present advan-
tages over topical antibiotics, since they do not cause
the emergence of drug-resistant bacteria and have
broader antimicrobial spectrum and lower sensiti-
zation rates [18].
The results of our study suggest that the rinsing
with chlorhexidine reduces the level of bacterial con-
tamination, thus decreasing the incidence of post-
operative sequelae after surgical procedures. There
is a statistically significant reduction of postoperative
surgical wound infection in patients where chlor-
hexidine was used. These findings are in accordance
with Kosutic et al, whose results also showed statisti-
cally significant reduction of bacterial counts during
oral and maxillofacial procedures in which antisep-
tics are used to wash the oral cavity preoperatively. In
his study, chlorhexidine showed its superiority and is
recommended for procedures lasting more than 1
hour [19]. Furthermore, the preoperative rinsing can
influence the prevalence of bacteremia following
dental extractions. A randomized, controlled clinical
trial indicates that preoperative mouth-rinsing with
chlorhexidine before dental extraction reduces the
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
incidence of postoperative bacteremia [20]. There-
fore, the authors recommend the use of chlorhexi-
dine mouthwash before dental extractions.
Our results did not show chlorhexidine-gluconate
as mouth rinse decreases the pain after surgical pro-
cedures (p>0, 05). This is contrary to the results of
Haraji et al [21]. In double-blind split-mouth rando-
mized clinical trial the intra-alveolar application of
0,2% bio-adhesive chlorhexidine gel reduced the
incidence of alveolar osteitis and relieved postsur-
gical pain [21]. Abu-Mustafa compared the effect of
intra-alveolar 0.2 % chlorohexidine bio-adhesive gel
versus 0.12% chlorohexidine rinse in reducing alveo-
lar osteitis following molar teeth extractions. Accor-
ding to his results, 0.2% chlorhexidine gel showed
insignificant less occurrence of alveolar osteitis when
compared to 0.12 % chlorhexidine rinse [5]. Also,
there is no significant differences in clinical effects of
1% and 0.2% chlorhexidine gel [8]. Results of these
studies indicate that the effectiveness of chlorhexi-
dine is not dependent on concentration or the me-
thod of application. On the other side, our findings
suggest that the patients with higher chlorhexidine
concentrations developed less pronounced postope-
rative sequelae. However, these results were not sta-
tistically significant.
The results of our study suggest that chlorhexi-
dine is a potent antiseptic that can be used in order to
control postoperative sequalae and complications in
oral surgery. More favorable postoperative recovery
was detected in experimental groups with chlorhexi-
dine rinsing, compared to the control group. These
results are in accordance with findings of Lambert et
al, since they reported six-fold differences in fre-
quency of infectious complications of dental implants
in patients when chlorhexidine was used as mouth
rinse in perioperative period [22].
Chlorhexidine has minimal side-effects, and can
be used for a longer period of time. Some reported
side effects of chlorhexidine are: mouth irritation,
tooth staining, dry mouth, decreased taste sensation,
desquamation of the oral mucosa and swelling of the
parotid gland. Most of adverse effects (taste change
and staining) are resolved easily by subjects' discon-
tinuing mouth rinse use and receiving dental pro-
phylaxis [23].
However, the use of chlorhexidine on wounds
should be careful and rational. Results of series of
animal and human in-vitro studies showed that anti-
septics are toxic also against human cells essential to
THE EFFECT OF DIFFERENT CONCENTRATIONS OF CHLORHEXIDINE DIGLUCONATE (0,12% AND 0,2%) IN DEVELOPMENT OF POSTOPERATIVE SEQUELAE AND INCIDENCE OF WOUND INFECTIONS FOLLOWING ORAL-SURGICAL PROCEDURES: A PROSPECTIVE CLINICAL STUDY
Figure 3.
Evaluation of trismus
(as maximal interincisal
distance in mm) in first
postoperative week
Figure 4.
Incidence of postoperative wound infection
Figure 2.
Evaluation of facial
edema (in mm) in first
postoperative week
Evaluation of trismus
Evaluation of edema Incidence of postoperative wound infection
Frequency of cases
Control group
Experimental group 1
Experimental group 2
Control group
Experimental group 1
Experimental group 2
1
1
0
5
10
15
20
25
30
35
40
45
50
0
10
20
30
40
50
60
70
2
2
3
3
4
4
5
5
6
6
7
7
Postoperative day
Postoperative day
Maximal interincisal range (in mm) Edema (in mm)
0
5
10
15
20
25
30
Control
group
Experimental
group 1
Experimental
group 2
22 23
Šečić S, Prohić S, Komšić S, Vuković A
control group, with mean ±SD= 32, 43mm±7,17mm.
The maximal inter-incisal distance in experimental
group 1 was in range from 47mm (preoperative) to
19mm (third postoperative day) with mean value of ±
SD= 31,71mm± 9,44mm. The maximal inter-incisal
distance in experimental group 2 was in range from
44mm (preoperative) to 22mm (third postoperative
day) with mean value of ±SD= 31, 43mm±7,87mm.
There is no statistical significance in development of
trismus in control and experimental groups (p>0,
05).
The incidence of postoperative wound infection
was 5% (n=24; %=5) in control, 3,125% in experi-
mental group 1 (n=15; %=3,125) and 1,875% in
experimental group 2 (n=9; %=1,875). There is sta-
tistical significance in incidence of postoperative
infection between control and experimental groups
(p<0, 05) (Figure 4).
Discussion
The infection of surgical wounds is not uncommon
in surgical practice and can complicate even the best
performed procedure. It is the most common nosoco-
mial infection in patients undergoing surgery [14]
with the estimated incidence of 1% do 30% [15]. The
surgical wound infection interferes with the normal
healing process and can lead to many complications
with different clinical outcomes. Although majority
of these infections are self-limited and easily treated
with antibiotics and local measures, due to proximity
of vital structures and the development of antibiotic-
resistant bacteria, they can lead to life-threatening
infections of head and neck, especially in medically
compromised patients. Therefore, minimizing the
risk of surgical infection is an important aspect of
postoperative treatment of patients. However, there
are many reports considering the emerging antibio-
tic-resistant microorganisms that can aggravate the
treatment and affect the ultimate outcome, which
further complicates the management of postoperati-
ve infections. Therefore, current trends are directed
towards alternative means, in particular, antiseptics.
Preoperative use of antiseptics is performed in
order to reduce the microorganisms in the area of the
surgical incision and can be extended during post-
operative period in order to minimize the risk of sur-
gical wound infection. Chlorhexidine gluconate
(0.12%) is often recommended as a mouth rinse to
reduce the number of surface microorganisms in the
surgical field, and its use may be continued during the
postoperative healing stage [16, 17]. Antiseptics
need not be omitted from the therapeutic armamen-
tarium of wound care. In patients and wound types
with high risk of infection, antiseptics may be used to
prevent wound infection that would have deleterious
effects on wound healing. Antiseptics present advan-
tages over topical antibiotics, since they do not cause
the emergence of drug-resistant bacteria and have
broader antimicrobial spectrum and lower sensiti-
zation rates [18].
The results of our study suggest that the rinsing
with chlorhexidine reduces the level of bacterial con-
tamination, thus decreasing the incidence of post-
operative sequelae after surgical procedures. There
is a statistically significant reduction of postoperative
surgical wound infection in patients where chlor-
hexidine was used. These findings are in accordance
with Kosutic et al, whose results also showed statisti-
cally significant reduction of bacterial counts during
oral and maxillofacial procedures in which antisep-
tics are used to wash the oral cavity preoperatively. In
his study, chlorhexidine showed its superiority and is
recommended for procedures lasting more than 1
hour [19]. Furthermore, the preoperative rinsing can
influence the prevalence of bacteremia following
dental extractions. A randomized, controlled clinical
trial indicates that preoperative mouth-rinsing with
chlorhexidine before dental extraction reduces the
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
incidence of postoperative bacteremia [20]. There-
fore, the authors recommend the use of chlorhexi-
dine mouthwash before dental extractions.
Our results did not show chlorhexidine-gluconate
as mouth rinse decreases the pain after surgical pro-
cedures (p>0, 05). This is contrary to the results of
Haraji et al [21]. In double-blind split-mouth rando-
mized clinical trial the intra-alveolar application of
0,2% bio-adhesive chlorhexidine gel reduced the
incidence of alveolar osteitis and relieved postsur-
gical pain [21]. Abu-Mustafa compared the effect of
intra-alveolar 0.2 % chlorohexidine bio-adhesive gel
versus 0.12% chlorohexidine rinse in reducing alveo-
lar osteitis following molar teeth extractions. Accor-
ding to his results, 0.2% chlorhexidine gel showed
insignificant less occurrence of alveolar osteitis when
compared to 0.12 % chlorhexidine rinse [5]. Also,
there is no significant differences in clinical effects of
1% and 0.2% chlorhexidine gel [8]. Results of these
studies indicate that the effectiveness of chlorhexi-
dine is not dependent on concentration or the me-
thod of application. On the other side, our findings
suggest that the patients with higher chlorhexidine
concentrations developed less pronounced postope-
rative sequelae. However, these results were not sta-
tistically significant.
The results of our study suggest that chlorhexi-
dine is a potent antiseptic that can be used in order to
control postoperative sequalae and complications in
oral surgery. More favorable postoperative recovery
was detected in experimental groups with chlorhexi-
dine rinsing, compared to the control group. These
results are in accordance with findings of Lambert et
al, since they reported six-fold differences in fre-
quency of infectious complications of dental implants
in patients when chlorhexidine was used as mouth
rinse in perioperative period [22].
Chlorhexidine has minimal side-effects, and can
be used for a longer period of time. Some reported
side effects of chlorhexidine are: mouth irritation,
tooth staining, dry mouth, decreased taste sensation,
desquamation of the oral mucosa and swelling of the
parotid gland. Most of adverse effects (taste change
and staining) are resolved easily by subjects' discon-
tinuing mouth rinse use and receiving dental pro-
phylaxis [23].
However, the use of chlorhexidine on wounds
should be careful and rational. Results of series of
animal and human in-vitro studies showed that anti-
septics are toxic also against human cells essential to
THE EFFECT OF DIFFERENT CONCENTRATIONS OF CHLORHEXIDINE DIGLUCONATE (0,12% AND 0,2%) IN DEVELOPMENT OF POSTOPERATIVE SEQUELAE AND INCIDENCE OF WOUND INFECTIONS FOLLOWING ORAL-SURGICAL PROCEDURES: A PROSPECTIVE CLINICAL STUDY
Figure 3.
Evaluation of trismus
(as maximal interincisal
distance in mm) in first
postoperative week
Figure 4.
Incidence of postoperative wound infection
Figure 2.
Evaluation of facial
edema (in mm) in first
postoperative week
Evaluation of trismus
Evaluation of edema Incidence of postoperative wound infection
Frequency of cases
Control group
Experimental group 1
Experimental group 2
Control group
Experimental group 1
Experimental group 2
1
1
0
5
10
15
20
25
30
35
40
45
50
0
10
20
30
40
50
60
70
2
2
3
3
4
4
5
5
6
6
7
7
Postoperative day
Postoperative day
Maximal interincisal range (in mm) Edema (in mm)
0
5
10
15
20
25
30
Control
group
Experimental
group 1
Experimental
group 2
24 25
Šečić S, Prohić S, Komšić S, Vuković A
the wound healing response [24-28]. But it seems
that in human subjects in vivo pronounced cytotoxi-
city was not confirmed. In the majority of clinical
trials, antiseptics appear to be safe and were not
found to negatively influence wound healing. The
effect of chlorhexidine on healing of surgical site
should be further elucidated. Efforts to develop
superior antiseptic formulations are likely to and
should continue [18].
Conclusion
Chlorhexidine is a potent antiseptic that can be
used in order to control postoperative sequalae and
complications in oral surgery. It has proven as safe
and efficient in reducing the risk of oral-surgical
wound infections. The authors recommend its use in
preoperative and postoperative wound care manage-
ment in oral-surgical procedures.
Acknowledgments
The permission and financial support of the
Federal Ministry of Education and Science are
acknowledged. Technical and administrative sup-
ports of Faculty of Dentistry, University of Sarajevo,
Bosnia and Herzegovina are highly appreciated and
acknowledged.
Declaration of interests
All authors clearly state that there is no conflict of
interest for any person or institution included in this
research project.
References
1. Leikin, Jerrold B.; Paloucek, Frank P., eds. (2008),
Chlorhexidine Gluconate, Poisoning and Toxico-
logy Handbook (4th ed.), Informa, pp. 183–184.
2. Jenkins S, Addy M, Wade W (August 1988). The
mechanism of action of chlorhexidine. A study of
plaque growth on enamel inserts in vivo. J. Clin.
Periodontol. 15 (7): 415–24.
3. Tervit C, Paquette L, Torneck CD, Basrani B,
Friedman S. Proportion of healed teeth with
apical periodontitis medicated with two percent
chlorhexidine gluconate liquid: a case-series
study. J Endod. 2009 Sep;35(9):1182-5. doi:
10.1016/j.joen.2009.05.010. Epub 2009 Jun 28.
4. Olsson H, Asklow B, Johansson E, Slotte C. Rinsing
with alcohol-free or alcohol-based chlorhexidine
solutions after periodontalsurgery. A double-
blind, randomized, cross-over, pilot study. Swed
Dent J. 2012;36(2):91-9.
5. Abu-Mustafa NA, Algahtani A, Abu-Nasna M,
Alhokail A, Aladsani A. A randomized clinical trial
compared the effect of intra-alveolar 0.2 % Chlo-
rohexidine bio-adhesive gel versus 0.12% Chlo-
rohexidine rinse in reducing alveolar osteitis
following molar teeth extractions. Med Oral Patol
Oral Cir Bucal. 2015 Jan 1;20(1):e82-7.
6. Torres-Lagares D, Gutierrez-Perez JL, Infante-
Cossio P, Garcia-Calderon M, Romero-Ruiz MM,
Serrera-Figallo MA. Randomized, double-blind
study on effectiveness of intra-alveolar chlorhexi-
dine gel in reducing the incidence of alveolar
osteitis in mandibular third molar surgery. Int J
Oral Maxillofac Surg. 2006;35:348-51.
7. Haraji A, Rakhshan V. Single-dose intra-alveolar
chlorhexidine gel application, easier surgeries,
and younger ages are associated with reduced
dry socket risk. J Oral Maxillofac Surg. 2014;
72(2):259-65.
8. Rodriguez-Perez M, Bravo-Perez M, Sanchez-
Lopez JD, Munoz-Soto E, Romero-Olid MN, Baca-
Garcia P. Effectiveness of 1% versus 0.2% chlor-
hexidine gels in reducing alveolar osteitis from
mandibular third molar surgery: a randomized,
double-blind clinical trial. Med Oral Patol Oral Cir
Bucal. 2013;18(4):e693-700.
9. Zadik Y. Algorithm of first-aid management of
dental trauma for medics and corpsmen. Dent
Traumatol 24 (6): 698–701.
10. American Academy of Paediatric Dentistry. Gui-
deline on Management of Acute Dental Trauma:
Reference Manual. Clinical Guidelines. 34 (6):
230- 238.
11. De Waal YC, Raghoebar GM, Huddleston Slater JJ,
Meijer HJ, Winkel EG, van Winkelhoff AJ. Implant
decontamination during surgical peri-implantitis
treatment: a randomized, double-blind, placebo-
controlled trial. J ClinPeriodontol. 2013 Feb;
40(2): 186-95. doi: 10.1111/jcpe.12034. Epub
2012 Dec 4.
12. Kim JE, Kim HY, Huh JB, Lee jY, Shin SW. A Two-
stage Surgical Approach to the Treatment of
Severe Peri-implant Defect: A 30-month Clinical
Follow-up Report. J Oral Implantol. 2012 Oct 30.
13. Lang N, Brecx MC. Chlorhexidine digluconate-an
agent for chemical plaque control and prevention
of gingival inflammation. Journal of Periodontal
Research 21: 74–89.
14. Brachman PS et al. Nosocomial surgical infec-
tions: incidence and costs. Clin North Am 1980;
60: 15-25.
15. Susarla SM, Sharaf B, Dodson TB. Do antibiotics
reduce the frequency of surgical site infections
after impacted mandibular third molar surgery?
Oral MaxillofacSurgClin North Am. 2011 Nov;
23(4):541-6, vi. doi: 10.1016/j.coms.2011.
07.007.
16. Martin MV, Nind D. Use of chlorhexidine gluco-
nate for pre-operative disinfection of apicectomy
sites. British Dental Journal 1987; 162: 459–461.
17. Tsesis I, Fuss Z, Lin S, Tilinger G, Peled M. Analysis
of postoperative symptoms following surgical
endodontic treatment. Quintessence Internatio-
nal 2003; 34: 756–760.
18. Drosou A, Falabella A, Kirsner R. Antiseptics on
Wounds: An Area of Controversy. Wounds. 2003;
15(5)
19. Kosutic D, Uglesic V, Perkovic D, Persic Z, Solman
L, Lupi-Ferandin S, Knezevic P, Sokler K, Knezevic
G. Preoperative antiseptics in clean/contami-
nated maxillofacial and oral surgery: prospective
randomized study. Int J Oral Maxillofac Surg. 2009
Feb;38(2):160-5. doi: 10.1016/j.ijom.2008.11.
023. Epub 2009 Jan 22.
20. Tomas I, Alvarez M, Limeres J, Tomas M, Medina J,
Otero JL, Diz P. Effect of chlorhexidine mouthwash
on the risk of postextraction bacteremia. Infect
Control HospEpidemiol. 2007 May;28(5):577-
82. Epub 2007 Apr 5.
21. Haraji A, Rakhsan V, Khamverdi N, Alishahi HK.
Effects of intra-alveolar placement of 0.2% chlor-
hexidine bioadhesive gel on dry socket incidence
and postsurgical pain: a double-blind split-mouth
randomized controlled clinical trial. J Orofac Pain.
2013 Summer;27(3):256-62. doi: 10.11607/
jop.1142.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
22. Lambert PM, Morris HF, Ochi S. The influence of
0.12% chlorhexidine digluconate rinses on the
incidence of infectious complications and
implant success. J Oral Maxillofac Surg. 1997
Dec;55(12 Suppl 5):25-30.
23. McCoy LC, Wehler CJ, Rich SE, Miller DR, Jones JA.
Adverse events associated with chlorhexidine
use: results from the Department of Veterans
Affairs Dental Diabetes Study. J Am Dent Assoc.
2008 Feb;139(2):178-83.
24. Dundappa J, Kanteshwari K. Comparative evalu-
ation of effects of chlorhexidine and tetracycline
on neutrophil viability and functions in vitro. J
Indian SocPeriodontol. 2012 Jul;16(3):342-9.
doi: 10.4103/0972-124X.100908.
25. Lee TH, Hu CC, Lee SS, Chou MY, Chang YC. Cyto-
toxicity of chlorhexidine on human osteoblastic
cells is related to intracellular glutathione levels.
IntEndod J. 2010;43:430–5,
26. Almazin SM, Dziak R, Andreana S, Ciancio SG. The
effect of doxycycline hyclate, chlorhexidine gluco-
nate, and minocycline hydrochloride on osteo-
blastic proliferation and differentiation in vitro. J
Periodontol. 2009 Jun;80(6):999-1005. doi:
10.1902/jop.2009.080574.
27. Flemingson, Emmadi P, Ambalavanan N, Rama-
krishnan T, Vijayalakshmi R. Effect of three com-
mercial mouth rinses on cultured human gingival
fibroblast: an in vitro study. Indian J Dent Res.
2008 Jan-Mar;19(1):29-35.
28. Tsourounakis I, Palaiologou-Gallis AA, Stoute D,
Maney P, lallier TE. Effect of essential oil and
chlorhexidine mouthwashes on gingival fibro-
blast survival and migration. J Periodontol. 2013
Aug;84(8):1211-20. doi: 10.1902/jop.2012.
120312. Epub 2012 Oct 29.
THE EFFECT OF DIFFERENT CONCENTRATIONS OF CHLORHEXIDINE DIGLUCONATE (0,12% AND 0,2%) IN DEVELOPMENT OF POSTOPERATIVE SEQUELAE AND INCIDENCE OF WOUND INFECTIONS FOLLOWING ORAL-SURGICAL PROCEDURES: A PROSPECTIVE CLINICAL STUDY
24 25
Šečić S, Prohić S, Komšić S, Vuković A
the wound healing response [24-28]. But it seems
that in human subjects in vivo pronounced cytotoxi-
city was not confirmed. In the majority of clinical
trials, antiseptics appear to be safe and were not
found to negatively influence wound healing. The
effect of chlorhexidine on healing of surgical site
should be further elucidated. Efforts to develop
superior antiseptic formulations are likely to and
should continue [18].
Conclusion
Chlorhexidine is a potent antiseptic that can be
used in order to control postoperative sequalae and
complications in oral surgery. It has proven as safe
and efficient in reducing the risk of oral-surgical
wound infections. The authors recommend its use in
preoperative and postoperative wound care manage-
ment in oral-surgical procedures.
Acknowledgments
The permission and financial support of the
Federal Ministry of Education and Science are
acknowledged. Technical and administrative sup-
ports of Faculty of Dentistry, University of Sarajevo,
Bosnia and Herzegovina are highly appreciated and
acknowledged.
Declaration of interests
All authors clearly state that there is no conflict of
interest for any person or institution included in this
research project.
References
1. Leikin, Jerrold B.; Paloucek, Frank P., eds. (2008),
Chlorhexidine Gluconate, Poisoning and Toxico-
logy Handbook (4th ed.), Informa, pp. 183–184.
2. Jenkins S, Addy M, Wade W (August 1988). The
mechanism of action of chlorhexidine. A study of
plaque growth on enamel inserts in vivo. J. Clin.
Periodontol. 15 (7): 415–24.
3. Tervit C, Paquette L, Torneck CD, Basrani B,
Friedman S. Proportion of healed teeth with
apical periodontitis medicated with two percent
chlorhexidine gluconate liquid: a case-series
study. J Endod. 2009 Sep;35(9):1182-5. doi:
10.1016/j.joen.2009.05.010. Epub 2009 Jun 28.
4. Olsson H, Asklow B, Johansson E, Slotte C. Rinsing
with alcohol-free or alcohol-based chlorhexidine
solutions after periodontalsurgery. A double-
blind, randomized, cross-over, pilot study. Swed
Dent J. 2012;36(2):91-9.
5. Abu-Mustafa NA, Algahtani A, Abu-Nasna M,
Alhokail A, Aladsani A. A randomized clinical trial
compared the effect of intra-alveolar 0.2 % Chlo-
rohexidine bio-adhesive gel versus 0.12% Chlo-
rohexidine rinse in reducing alveolar osteitis
following molar teeth extractions. Med Oral Patol
Oral Cir Bucal. 2015 Jan 1;20(1):e82-7.
6. Torres-Lagares D, Gutierrez-Perez JL, Infante-
Cossio P, Garcia-Calderon M, Romero-Ruiz MM,
Serrera-Figallo MA. Randomized, double-blind
study on effectiveness of intra-alveolar chlorhexi-
dine gel in reducing the incidence of alveolar
osteitis in mandibular third molar surgery. Int J
Oral Maxillofac Surg. 2006;35:348-51.
7. Haraji A, Rakhshan V. Single-dose intra-alveolar
chlorhexidine gel application, easier surgeries,
and younger ages are associated with reduced
dry socket risk. J Oral Maxillofac Surg. 2014;
72(2):259-65.
8. Rodriguez-Perez M, Bravo-Perez M, Sanchez-
Lopez JD, Munoz-Soto E, Romero-Olid MN, Baca-
Garcia P. Effectiveness of 1% versus 0.2% chlor-
hexidine gels in reducing alveolar osteitis from
mandibular third molar surgery: a randomized,
double-blind clinical trial. Med Oral Patol Oral Cir
Bucal. 2013;18(4):e693-700.
9. Zadik Y. Algorithm of first-aid management of
dental trauma for medics and corpsmen. Dent
Traumatol 24 (6): 698–701.
10. American Academy of Paediatric Dentistry. Gui-
deline on Management of Acute Dental Trauma:
Reference Manual. Clinical Guidelines. 34 (6):
230- 238.
11. De Waal YC, Raghoebar GM, Huddleston Slater JJ,
Meijer HJ, Winkel EG, van Winkelhoff AJ. Implant
decontamination during surgical peri-implantitis
treatment: a randomized, double-blind, placebo-
controlled trial. J ClinPeriodontol. 2013 Feb;
40(2): 186-95. doi: 10.1111/jcpe.12034. Epub
2012 Dec 4.
12. Kim JE, Kim HY, Huh JB, Lee jY, Shin SW. A Two-
stage Surgical Approach to the Treatment of
Severe Peri-implant Defect: A 30-month Clinical
Follow-up Report. J Oral Implantol. 2012 Oct 30.
13. Lang N, Brecx MC. Chlorhexidine digluconate-an
agent for chemical plaque control and prevention
of gingival inflammation. Journal of Periodontal
Research 21: 74–89.
14. Brachman PS et al. Nosocomial surgical infec-
tions: incidence and costs. Clin North Am 1980;
60: 15-25.
15. Susarla SM, Sharaf B, Dodson TB. Do antibiotics
reduce the frequency of surgical site infections
after impacted mandibular third molar surgery?
Oral MaxillofacSurgClin North Am. 2011 Nov;
23(4):541-6, vi. doi: 10.1016/j.coms.2011.
07.007.
16. Martin MV, Nind D. Use of chlorhexidine gluco-
nate for pre-operative disinfection of apicectomy
sites. British Dental Journal 1987; 162: 459–461.
17. Tsesis I, Fuss Z, Lin S, Tilinger G, Peled M. Analysis
of postoperative symptoms following surgical
endodontic treatment. Quintessence Internatio-
nal 2003; 34: 756–760.
18. Drosou A, Falabella A, Kirsner R. Antiseptics on
Wounds: An Area of Controversy. Wounds. 2003;
15(5)
19. Kosutic D, Uglesic V, Perkovic D, Persic Z, Solman
L, Lupi-Ferandin S, Knezevic P, Sokler K, Knezevic
G. Preoperative antiseptics in clean/contami-
nated maxillofacial and oral surgery: prospective
randomized study. Int J Oral Maxillofac Surg. 2009
Feb;38(2):160-5. doi: 10.1016/j.ijom.2008.11.
023. Epub 2009 Jan 22.
20. Tomas I, Alvarez M, Limeres J, Tomas M, Medina J,
Otero JL, Diz P. Effect of chlorhexidine mouthwash
on the risk of postextraction bacteremia. Infect
Control HospEpidemiol. 2007 May;28(5):577-
82. Epub 2007 Apr 5.
21. Haraji A, Rakhsan V, Khamverdi N, Alishahi HK.
Effects of intra-alveolar placement of 0.2% chlor-
hexidine bioadhesive gel on dry socket incidence
and postsurgical pain: a double-blind split-mouth
randomized controlled clinical trial. J Orofac Pain.
2013 Summer;27(3):256-62. doi: 10.11607/
jop.1142.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
22. Lambert PM, Morris HF, Ochi S. The influence of
0.12% chlorhexidine digluconate rinses on the
incidence of infectious complications and
implant success. J Oral Maxillofac Surg. 1997
Dec;55(12 Suppl 5):25-30.
23. McCoy LC, Wehler CJ, Rich SE, Miller DR, Jones JA.
Adverse events associated with chlorhexidine
use: results from the Department of Veterans
Affairs Dental Diabetes Study. J Am Dent Assoc.
2008 Feb;139(2):178-83.
24. Dundappa J, Kanteshwari K. Comparative evalu-
ation of effects of chlorhexidine and tetracycline
on neutrophil viability and functions in vitro. J
Indian SocPeriodontol. 2012 Jul;16(3):342-9.
doi: 10.4103/0972-124X.100908.
25. Lee TH, Hu CC, Lee SS, Chou MY, Chang YC. Cyto-
toxicity of chlorhexidine on human osteoblastic
cells is related to intracellular glutathione levels.
IntEndod J. 2010;43:430–5,
26. Almazin SM, Dziak R, Andreana S, Ciancio SG. The
effect of doxycycline hyclate, chlorhexidine gluco-
nate, and minocycline hydrochloride on osteo-
blastic proliferation and differentiation in vitro. J
Periodontol. 2009 Jun;80(6):999-1005. doi:
10.1902/jop.2009.080574.
27. Flemingson, Emmadi P, Ambalavanan N, Rama-
krishnan T, Vijayalakshmi R. Effect of three com-
mercial mouth rinses on cultured human gingival
fibroblast: an in vitro study. Indian J Dent Res.
2008 Jan-Mar;19(1):29-35.
28. Tsourounakis I, Palaiologou-Gallis AA, Stoute D,
Maney P, lallier TE. Effect of essential oil and
chlorhexidine mouthwashes on gingival fibro-
blast survival and migration. J Periodontol. 2013
Aug;84(8):1211-20. doi: 10.1902/jop.2012.
120312. Epub 2012 Oct 29.
THE EFFECT OF DIFFERENT CONCENTRATIONS OF CHLORHEXIDINE DIGLUCONATE (0,12% AND 0,2%) IN DEVELOPMENT OF POSTOPERATIVE SEQUELAE AND INCIDENCE OF WOUND INFECTIONS FOLLOWING ORAL-SURGICAL PROCEDURES: A PROSPECTIVE CLINICAL STUDY
27
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
ACCIDENTAL INJURIES AMONG
DENTISTS IN PRIVATE AND PUBLIC
DENTAL PRACTICE
1 2 3
Cilović-Lagarija Š*, Huseinbegović A , Čavaljuga S ,
4 2
Branković S , Selimović-Dragaš M
1 Institute for Public Health FB&H, Sarajevo, Bosnia and Herzegovina
2 Department of Pedodontics , Faculty of Dentistry, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
3 Department of Epidemiology and Biostatistics, Faculty of Medicine,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
4 Faculty of Health Studies, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
ABSTRACT
Accidental injuries have a significant role in spreading the
infection in each dental office.
The aim of this study was to assess the prevalence of
accidental injuries among dentists in public and private health
care sector in Canton Sarajevo.
Method: A total of 271 dentists were included in the study, of
which 147 were employed in public health care centers and 124 in
private sector. For the research purpose a self-administered
questionnaire was designed, with questions pertaining to
frequency and type of accidental injuries and exposures to blood
and body fluids, as well as relating to use of infection precautions
measures. The questionnaire was anonymous with no personal
data included, as well as self-reporting. Participants were fully
informed about the design and purpose of the study and were
asked to sign a written information consent form.
Results: showed that in the last twelve months 22.9% of
dentists have had accidental injuries with needle, 18.5% had a
contact with patients' blood through damaged skin and 32.8%
dentists experienced patients' blood having sprayed into their eye
or other mucous membrane. Far greater proportion of accidental
injuries happened to dentists employed in private dental offices
than in those in public sector.
Conclusion: Due to the fact that accidental injuries ultimately
can lead to fatal diseases, it is necessary to work on the continuous
education of dentists and dental students about infection control
measures in the dental office.
Key words: injuries, dentist.
*Corresponding author
Šeila Cilović-Lagarija, DMD
Institute for Public Health FB&H,
M. Tita 9
71000 Sarajevo
Bosnia and Herzegovina
e-mail: seila.cilovic@gmail.com,
s.cilovic@zzjzfbih.ba
Phone: +38761291022
Stomatološki vjesnik 2015; 4 (1)
27
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
ACCIDENTAL INJURIES AMONG
DENTISTS IN PRIVATE AND PUBLIC
DENTAL PRACTICE
1 2 3
Cilović-Lagarija Š*, Huseinbegović A , Čavaljuga S ,
4 2
Branković S , Selimović-Dragaš M
1 Institute for Public Health FB&H, Sarajevo, Bosnia and Herzegovina
2 Department of Pedodontics , Faculty of Dentistry, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
3 Department of Epidemiology and Biostatistics, Faculty of Medicine,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
4 Faculty of Health Studies, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
ABSTRACT
Accidental injuries have a significant role in spreading the
infection in each dental office.
The aim of this study was to assess the prevalence of
accidental injuries among dentists in public and private health
care sector in Canton Sarajevo.
Method: A total of 271 dentists were included in the study, of
which 147 were employed in public health care centers and 124 in
private sector. For the research purpose a self-administered
questionnaire was designed, with questions pertaining to
frequency and type of accidental injuries and exposures to blood
and body fluids, as well as relating to use of infection precautions
measures. The questionnaire was anonymous with no personal
data included, as well as self-reporting. Participants were fully
informed about the design and purpose of the study and were
asked to sign a written information consent form.
Results: showed that in the last twelve months 22.9% of
dentists have had accidental injuries with needle, 18.5% had a
contact with patients' blood through damaged skin and 32.8%
dentists experienced patients' blood having sprayed into their eye
or other mucous membrane. Far greater proportion of accidental
injuries happened to dentists employed in private dental offices
than in those in public sector.
Conclusion: Due to the fact that accidental injuries ultimately
can lead to fatal diseases, it is necessary to work on the continuous
education of dentists and dental students about infection control
measures in the dental office.
Key words: injuries, dentist.
*Corresponding author
Šeila Cilović-Lagarija, DMD
Institute for Public Health FB&H,
M. Tita 9
71000 Sarajevo
Bosnia and Herzegovina
e-mail: seila.cilovic@gmail.com,
s.cilovic@zzjzfbih.ba
Phone: +38761291022
Stomatološki vjesnik 2015; 4 (1)
28
Needle injury
Injury with the sharp object
Contact with patients blood through damaged skin
Blood sprayes into eye or other mucous membrane
Needle injury
Injury with the sharp object
Contact with patients blood through damaged skin
Blood sprayes into eye or other mucous membrane
22,9 (62)
35,4 (96)
18,5 (50)
32,8 (89)
19,0 (28)
27,9 (41)
17,0 (25)
26,5 (39)
8,9 (24)
7,4 (20)
11,4 (31)
6,6 (18)
p=0,002*
p=0,007*
p=0,132
p=0,014*
68,3 (185)
57,2 (155)
70,1 (190)
60,5 (164)
27,4 (34)
44,4 (55)
20,2 (25)
40,3 (50)
Type of occupational accident
Type of occupational accident
Yes
% (number)
Public sector
% (number)
No
% (number)
Private sector
% (number)
No answer
% (number)
Statistical
significance
Table 1.
Incidence of occupational
accidents in the last twelve
months (n=271)
Table 2.
Incidence of occupational
accidents in the last twelve
months according to
work place
29
ACCIDENTAL INJURIES AMONG DENTISTS IN PRIVATE AND PUBLIC DENTAL PRACTICE Cilović-Lagarija Š, Huseinbegović A, Čavaljuga S, Branković S, Selimović-Dragaš M
Introduction
Exposure to blood or potentially infective body
fluids represents potential risk and danger to the
health care workers [1]. This is of special concern for
the dentists and dental medicine students because of
the nature of their work, since most of the time they
are in contact with patients' saliva or blood. These
injuries occur most often when needles are used for
local anesthesia administration or during needle
recapping after use, as well as during suturing and
other procedures in the operating room.
Injuries caused by infected needles or sharp
objects in dental offices are associated with more
than 20 blood-borne diseases, but those of primary
significance to dental health care workers are infec-
tion with Hepatitis-B virus (HBV), Hepatitis-C virus
(HCV) and Human immunodeficiency virus (HIV).
The World Health Organization estimates the global
burden of disease from occupational exposure to be
40% of the hepatitis B and C infections and 2.5% of
the HIV infections among health care workers as
attributable to exposures at work [2].
Compared to many other healthcare settings, den-
tal professionals are at higher risk of acquiring infec-
tions due to the fact that dentists work in a limited-
access and restricted-visibility field and frequently
use sharp devices [3].
Lack of knowledge of blood-borne diseases and
failure to apply infection control measures favor the
spread of pathogens. Additionally, lack of experience
in performing the procedures, poor practice by not
complying with infection control precautions and
poor risk perception concerning the consequences of
needle stick injury, warns us of the need to identifying
all relevant factors associated with this problem and
the need for more education in this area, in order to
protect dental care workers from unnecessary risks
[4].
Taking into consideration the risk of transmission
of blood-borne pathogens among dental staff, Cen-
ters for Disease Control and Prevention (CDC) have
implemented a doctrine of protection in Dental Prac-
tice which demands protection of dentists and the
patients in a way that each patient should be treated
as potentially infected, because patients with blood-
borne infections can be asymptomatic or unaware
that they pose a risk in the dental practice [5].
Methodology
The aim of this study was to assess the occurrence
of accidental injuries among dentists in public and
private health care sector in Canton Sarajevo. This
was a cross-sectional study conducted during May
and July, 2012. A stratified sample was made of 271
dentists in total, of which 147 were employed in
public health care centers and 124 in private sector
respectively.
For the research purpose a self-administered
questionnaire was designed, with questions pertain-
ing to frequency and type of accidental injuries and
exposures to blood and body fluids, as well as relating
to use of infection precautions measures.
A questionnaire for collecting data from health
care providers at health facilities, published in World
Health Organization guideline "HIV testing, treat-
ment and prevention: generic tools for operational
research" was used as a basis for formulating re-
search questions [6]. The questions concerning the
risk of infection were adjusted for the purpose of this
research.
The questionnaire was anonymous with no perso-
nal data included, as well as self-reporting. In order to
maintain anonymity of the participants, they were
instructed to return the filled in form in an unmarked
envelope. Clearance of study protocol was obtained
from each institution in which this study was carried
out. Participants were fully informed about the
design and purpose of the study and were asked to
sign a written information consent form.
Statistical analysis of data
Descriptive statistics was used to explain basic
features of data in the study (demographical and
employment characteristic of the participants, con-
tact with the possible infectious material and educa-
tion about infection control during the undergradua-
te study).The statistical significance of differences
between the two groups (public and private dentists)
was tested using chi-square test (for categorical va-
riables) and independent samples t test and ANOVA
for comparison of means in various subgroups (den-
tists who use different kind of self-protection equip-
ment). Data analysis was performed with the statis-
tical program R where statistical level of significance
was set at p≤ 0, 05.
Results
The overall response rate was 100%.
All 271 participants in this research were dentists
from Canton Sarajevo of which 28% (76) were male
and 72% (195) female.
More than a half of participating dentists were
employed in public health care institutions, namely
54.2% (147), while 45.8% (124) of dentists were
employed in private sector. Out of total sample of
participants, the largest group was that aging from 21
to 33 years, i.e. 41.3% (112), while 35.1% (95) were
in the group aging from 34 to 46 years and 18.1%
(49) dentist aging from 47 to 59 years respectively.
Large percentage of dentists in this research had
less than ten years of work experience 65.8% (177)
while only 6.3% (17) of dentist had over thirty-one
years of work experience.
As for the frequency of work related accidental
injuries and implementation of infection precaution
measures, results show that in the last twelve months
22.9% of dentists have had accidental injuries with
needle, 18.5% had a contact with patients' blood
through damaged skin and 32.8% dentist have
experienced patients' blood sprayed into their eye or
other mucous membrane. (Table 1).
Comparing the results between two groups, i.e.
dentists in private and public sector, it has been
shown that accidental injuries that have possibility of
spreading the infection happened more frequently
among dentist that work in the private sector during
last twelve months.
Chi-square test have shown that statistically lar-
ger proportion of accidental needle injuries happen
in private sector - 27,4% (χ2=12,875, df=2, p=0,002),
also injury with the sharp object - 44,4% (χ2=9,864,
df=2, p=0,007) and accidents concerning exposure to
blood sprayed into eye or other mucous membrane
40,3% (χ2=8,537, df=2, p=0,014) (Table 2).
Concerning use of basic measures, namely use of
protective equipment, for preventing work place
accidents that pose a risk of blood-bourn pathogen
transmission through contact with patients' blood or
with body fluids, results showed that 85.6%(232)
dentists always wear protective gloves, 73.1% (198)
wear medical protective mask, while 21.4%(58)
dentists never use medical safety glasses (Table 3.).
Differences in the responses of dentists in the
public and private sectors related to the proportion
of respondents who always use protective measures,
were tested with Chi-square test. Compared to doc-
tors who work in the public sector, significantly
higher number of doctors employed in the private
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
28
Needle injury
Injury with the sharp object
Contact with patients blood through damaged skin
Blood sprayes into eye or other mucous membrane
Needle injury
Injury with the sharp object
Contact with patients blood through damaged skin
Blood sprayes into eye or other mucous membrane
22,9 (62)
35,4 (96)
18,5 (50)
32,8 (89)
19,0 (28)
27,9 (41)
17,0 (25)
26,5 (39)
8,9 (24)
7,4 (20)
11,4 (31)
6,6 (18)
p=0,002*
p=0,007*
p=0,132
p=0,014*
68,3 (185)
57,2 (155)
70,1 (190)
60,5 (164)
27,4 (34)
44,4 (55)
20,2 (25)
40,3 (50)
Type of occupational accident
Type of occupational accident
Yes
% (number)
Public sector
% (number)
No
% (number)
Private sector
% (number)
No answer
% (number)
Statistical
significance
Table 1.
Incidence of occupational
accidents in the last twelve
months (n=271)
Table 2.
Incidence of occupational
accidents in the last twelve
months according to
work place
29
ACCIDENTAL INJURIES AMONG DENTISTS IN PRIVATE AND PUBLIC DENTAL PRACTICE Cilović-Lagarija Š, Huseinbegović A, Čavaljuga S, Branković S, Selimović-Dragaš M
Introduction
Exposure to blood or potentially infective body
fluids represents potential risk and danger to the
health care workers [1]. This is of special concern for
the dentists and dental medicine students because of
the nature of their work, since most of the time they
are in contact with patients' saliva or blood. These
injuries occur most often when needles are used for
local anesthesia administration or during needle
recapping after use, as well as during suturing and
other procedures in the operating room.
Injuries caused by infected needles or sharp
objects in dental offices are associated with more
than 20 blood-borne diseases, but those of primary
significance to dental health care workers are infec-
tion with Hepatitis-B virus (HBV), Hepatitis-C virus
(HCV) and Human immunodeficiency virus (HIV).
The World Health Organization estimates the global
burden of disease from occupational exposure to be
40% of the hepatitis B and C infections and 2.5% of
the HIV infections among health care workers as
attributable to exposures at work [2].
Compared to many other healthcare settings, den-
tal professionals are at higher risk of acquiring infec-
tions due to the fact that dentists work in a limited-
access and restricted-visibility field and frequently
use sharp devices [3].
Lack of knowledge of blood-borne diseases and
failure to apply infection control measures favor the
spread of pathogens. Additionally, lack of experience
in performing the procedures, poor practice by not
complying with infection control precautions and
poor risk perception concerning the consequences of
needle stick injury, warns us of the need to identifying
all relevant factors associated with this problem and
the need for more education in this area, in order to
protect dental care workers from unnecessary risks
[4].
Taking into consideration the risk of transmission
of blood-borne pathogens among dental staff, Cen-
ters for Disease Control and Prevention (CDC) have
implemented a doctrine of protection in Dental Prac-
tice which demands protection of dentists and the
patients in a way that each patient should be treated
as potentially infected, because patients with blood-
borne infections can be asymptomatic or unaware
that they pose a risk in the dental practice [5].
Methodology
The aim of this study was to assess the occurrence
of accidental injuries among dentists in public and
private health care sector in Canton Sarajevo. This
was a cross-sectional study conducted during May
and July, 2012. A stratified sample was made of 271
dentists in total, of which 147 were employed in
public health care centers and 124 in private sector
respectively.
For the research purpose a self-administered
questionnaire was designed, with questions pertain-
ing to frequency and type of accidental injuries and
exposures to blood and body fluids, as well as relating
to use of infection precautions measures.
A questionnaire for collecting data from health
care providers at health facilities, published in World
Health Organization guideline "HIV testing, treat-
ment and prevention: generic tools for operational
research" was used as a basis for formulating re-
search questions [6]. The questions concerning the
risk of infection were adjusted for the purpose of this
research.
The questionnaire was anonymous with no perso-
nal data included, as well as self-reporting. In order to
maintain anonymity of the participants, they were
instructed to return the filled in form in an unmarked
envelope. Clearance of study protocol was obtained
from each institution in which this study was carried
out. Participants were fully informed about the
design and purpose of the study and were asked to
sign a written information consent form.
Statistical analysis of data
Descriptive statistics was used to explain basic
features of data in the study (demographical and
employment characteristic of the participants, con-
tact with the possible infectious material and educa-
tion about infection control during the undergradua-
te study).The statistical significance of differences
between the two groups (public and private dentists)
was tested using chi-square test (for categorical va-
riables) and independent samples t test and ANOVA
for comparison of means in various subgroups (den-
tists who use different kind of self-protection equip-
ment). Data analysis was performed with the statis-
tical program R where statistical level of significance
was set at p≤ 0, 05.
Results
The overall response rate was 100%.
All 271 participants in this research were dentists
from Canton Sarajevo of which 28% (76) were male
and 72% (195) female.
More than a half of participating dentists were
employed in public health care institutions, namely
54.2% (147), while 45.8% (124) of dentists were
employed in private sector. Out of total sample of
participants, the largest group was that aging from 21
to 33 years, i.e. 41.3% (112), while 35.1% (95) were
in the group aging from 34 to 46 years and 18.1%
(49) dentist aging from 47 to 59 years respectively.
Large percentage of dentists in this research had
less than ten years of work experience 65.8% (177)
while only 6.3% (17) of dentist had over thirty-one
years of work experience.
As for the frequency of work related accidental
injuries and implementation of infection precaution
measures, results show that in the last twelve months
22.9% of dentists have had accidental injuries with
needle, 18.5% had a contact with patients' blood
through damaged skin and 32.8% dentist have
experienced patients' blood sprayed into their eye or
other mucous membrane. (Table 1).
Comparing the results between two groups, i.e.
dentists in private and public sector, it has been
shown that accidental injuries that have possibility of
spreading the infection happened more frequently
among dentist that work in the private sector during
last twelve months.
Chi-square test have shown that statistically lar-
ger proportion of accidental needle injuries happen
in private sector - 27,4% (χ2=12,875, df=2, p=0,002),
also injury with the sharp object - 44,4% (χ2=9,864,
df=2, p=0,007) and accidents concerning exposure to
blood sprayed into eye or other mucous membrane
40,3% (χ2=8,537, df=2, p=0,014) (Table 2).
Concerning use of basic measures, namely use of
protective equipment, for preventing work place
accidents that pose a risk of blood-bourn pathogen
transmission through contact with patients' blood or
with body fluids, results showed that 85.6%(232)
dentists always wear protective gloves, 73.1% (198)
wear medical protective mask, while 21.4%(58)
dentists never use medical safety glasses (Table 3.).
Differences in the responses of dentists in the
public and private sectors related to the proportion
of respondents who always use protective measures,
were tested with Chi-square test. Compared to doc-
tors who work in the public sector, significantly
higher number of doctors employed in the private
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
31
ACCIDENTAL INJURIES AMONG DENTISTS IN PRIVATE AND PUBLIC DENTAL PRACTICE Cilović-Lagarija Š, Huseinbegović A, Čavaljuga S, Branković S, Selimović-Dragaš M
2
sector wear a mask, 81,5%(χ=14,500, df=3,
p=0,002), whereas dentists employed in the public
sector more often use medical safety glasses as a
measure of protection in the workplace - 27,2% (χ2 =
18.022, df = 3, p = 0.000) (Table 4).
Discussion
Accidental injuries among dental health care
workers increase the risk of infection. Research
shows that the average risk of HIV infection after a
single needle stick or cut exposure to infected blood
is 0.3% (1:300). The risk after exposure of the eyes,
nose and mouth to HIV-infected blood is estimated to
be, on average 0.1% (1:100), while the risk after
exposure of non-intact skin to HIV-infected blood is
estimated to less than 0.1% [7]. When it comes to
other blood-transmitted diseases, the risk of trans-
mission of infection from an infected patient to health
care worker after a needle injury is 3-10% for hepa-
titis B and 3% for hepatitis C [8].
Results of the study "Research on HIV stigma and
discrimination among health care workers in the
public and private health sector in Bosnia and Herze-
govina" showed that the most frequent accident that
happen while working with patients is the exposure
to patient's blood through damaged skin (35.1%),
and a needle stick injury (30,6%) [9]. Study con-
ducted among dentists in the Sarajevo Canton, shows
a slightly lower proportion of accidents in the work-
place which occurred during last 12 months and they
are as follows: 22.9% of dentists had a needle stick
injury accident and 18.5 % have been exposed to
patient's blood through damaged skin.
Results of a study conducted in Germany among
doctors and dental students, confirmed professional
experience as a significant factor contributing to the
reduced injury with a sharp object and needle. The
results showed that dental students have twice the
number of injuries in relation to the dentists with
more or less than 10 years of service, while 54.3% of
participants had in their professional career at least
one injury with a sharp object or needle [10].
Results of a study conducted among 434 dentists
in Taiwan showed significantly higher proportion of
accidents in comparison to the results of a study on
accidental injuries in dental practice in Sarajevo Can-
ton. Even 23% of respondents had more than one
needle or sharp object injury per week. Of the total
number of injuries, the majority of the answer, i.e.
31%, was that the injury happened while working
with patients, 28% while recapping the needle, 25%
while trying to take instruments and 10% while
trying to exchange instruments [11].
Even 68% dentists in Korea had 5-10 needle or a
sharp object injures in the last year [12], which, in
comparison with a survey of accidental injuries in
dental practice in the Sarajevo Canton, is a far greater
frequency of accidents.
In a study conducted among dentist in Sarajevo
Canton, result analysis showed significantly more
accidents among employees in the private sector, so
needle injury happened to 27,4% of them, injury with
a sharp object to 44,4% and exposure to blood of the
patient through the eye or other mucous tissues to
40,03% of dentists. Relatively large number of acci-
dents in private practice, in relation to the public
sector, could be explained by the fact that a significant
number of private dental offices do not employ dental
assistants, which enlarges dentist's scope of work
and results in greater risk of accidental injury.
Conclusion
Accidental injuries have a significant role in
spreading the infection in each dental office. Results
of the study showed a far greater proportion of
accidental injuries in dentists employed in private
dental offices, rather than in the public sector. In
comparison to other countries, there are a far smaller
proportion of accidental injuries. Due to the fact that
these accidents ultimately can lead to fatal diseases, it
is necessary to work on the continuous education of
dentists and dental students on infection control
measures in the dental office.
References
1. Farsi D, Zare M.A, Hassani S.A, Abbasi S, Emami-
naini A, Hafezimoghadam P, Rezai M. Prevalence
of occupational exposure to blood and body
secretions and its related effective factors among
health care workers of three Emergency Depar-
tments in Tehran. J Res Med Sci. 2012;17(7):
656–661.
2. Shah R, Mehta HK, Fancy M, Nayak S, Donga BN.
Knowledge and awareness regarding needle stick
injuries among health care workers in tertiary
care hospital in Ahmedabad, Gujarat. Nat J Com
Med. 2010;1:93-6.
3. , Gambhir RS, Singh S, Gill S, Singh A.
Knowledge, awareness and practice regarding
needle stick injuries in dental profession in India:
A systematic review. Niger Med J. 2013 ;54(6):
365-70.
4. Norsayani MY, Noor Hassim I. Study on incidence
of needle stick injury and factors associated with
this problem among medical students. J Occup
Health. 2003;45(3):172-8.
5. Topić B. i sur. Oralna medicina. Sarajevo: Faculty
of Dentistry University in Sarajevo; 2001
6. Obermeyer CM, Bott S, Carrieri P, Parsons M,
Pulerwitz J, Rutenberg N, Sarna A. HIV testing,
treatment and prevention: generic tools for
operational research, Geneva: World Health
Organization; 2009.
7. CDC. Exposure to Blood. What healthcare
Personnel Need to Know; 2003.
8. Heymann DL, editor. Control of Communicable
Diseases Manual. 18th ed. Baltimore: United
Book Press; 2004.
9. Bojanić J. Stojisavljević S. Jokić I. Imamović E.
Šiljak S. Jandrić LJ. Research on HIV stigma and
discrimination between health care providers in
public and private health care sector in BiH. Banja
Luka; Institute for public health RS: 2011
10. Wicker S, Rabenau HF. Occupational exposures to
blood-borne viruses among German dental
professionals and students in a clinical setting.
International Archives of Occupational and
Environmental Health. 2010;83(1):77-83.
11. Cheng HC, Su CY, Yen AMF, Huang CF. Factors
Affecting Occupational Exposure to Needle stick
and Sharps Injuries among Dentists in Taiwan: A
Nationwide Survey PLoS One. 2012; 7(4):
e34911. available at 10.1371/journal.pone.
0034911.
12. Park JC, Choi SH, Kim YT, Kim SJ, Kang HJ, Lee JH,
Shin SC, Cha YJ, Knowledge and attitudes of
Korean dentists towards human immuno-
deficiency virus/acquired immune deficiency
syndrome. J Periodontal Implant Sci. 2011; 41(1):
3–9.
Kapoor V
30 Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Gloves
Double gloves
Medical protective mask
Medical safety glasses
Public Sector
Private Sector
Statistical significance
12,5 (34)
38,4 (104)
22,1 (60)
47,6 (129)
1,8 (5)
38,0 (103)
2,2 (6)
21,4 (58)
86,4 (127)
84,7 (105)
p=0,059
-
18,1 (49)
2,6 (7)
3,7 (10)
27,2 (40)
27,4 (34)
p=0,000*
85,6 (232)
5,5 (15)
73,1 (198)
27,3 (74)
66,0 (97)
81,5 (101)
p=0,002*
Protective equipment
Work place
Sometime
% (number)
Never
% (number)
Gloves
% (number)
Always
% (number)
Medical
protective mask
% (number)
No answer
% (number)
Medical
safety glasses
% (number)
Table 3.
Use of protection by
dentists exposed to
occupational injuries
Table 4.
Proportion of respondents
that always use medical
safety protection
31
ACCIDENTAL INJURIES AMONG DENTISTS IN PRIVATE AND PUBLIC DENTAL PRACTICE Cilović-Lagarija Š, Huseinbegović A, Čavaljuga S, Branković S, Selimović-Dragaš M
2
sector wear a mask, 81,5%(χ=14,500, df=3,
p=0,002), whereas dentists employed in the public
sector more often use medical safety glasses as a
measure of protection in the workplace - 27,2% (χ2 =
18.022, df = 3, p = 0.000) (Table 4).
Discussion
Accidental injuries among dental health care
workers increase the risk of infection. Research
shows that the average risk of HIV infection after a
single needle stick or cut exposure to infected blood
is 0.3% (1:300). The risk after exposure of the eyes,
nose and mouth to HIV-infected blood is estimated to
be, on average 0.1% (1:100), while the risk after
exposure of non-intact skin to HIV-infected blood is
estimated to less than 0.1% [7]. When it comes to
other blood-transmitted diseases, the risk of trans-
mission of infection from an infected patient to health
care worker after a needle injury is 3-10% for hepa-
titis B and 3% for hepatitis C [8].
Results of the study "Research on HIV stigma and
discrimination among health care workers in the
public and private health sector in Bosnia and Herze-
govina" showed that the most frequent accident that
happen while working with patients is the exposure
to patient's blood through damaged skin (35.1%),
and a needle stick injury (30,6%) [9]. Study con-
ducted among dentists in the Sarajevo Canton, shows
a slightly lower proportion of accidents in the work-
place which occurred during last 12 months and they
are as follows: 22.9% of dentists had a needle stick
injury accident and 18.5 % have been exposed to
patient's blood through damaged skin.
Results of a study conducted in Germany among
doctors and dental students, confirmed professional
experience as a significant factor contributing to the
reduced injury with a sharp object and needle. The
results showed that dental students have twice the
number of injuries in relation to the dentists with
more or less than 10 years of service, while 54.3% of
participants had in their professional career at least
one injury with a sharp object or needle [10].
Results of a study conducted among 434 dentists
in Taiwan showed significantly higher proportion of
accidents in comparison to the results of a study on
accidental injuries in dental practice in Sarajevo Can-
ton. Even 23% of respondents had more than one
needle or sharp object injury per week. Of the total
number of injuries, the majority of the answer, i.e.
31%, was that the injury happened while working
with patients, 28% while recapping the needle, 25%
while trying to take instruments and 10% while
trying to exchange instruments [11].
Even 68% dentists in Korea had 5-10 needle or a
sharp object injures in the last year [12], which, in
comparison with a survey of accidental injuries in
dental practice in the Sarajevo Canton, is a far greater
frequency of accidents.
In a study conducted among dentist in Sarajevo
Canton, result analysis showed significantly more
accidents among employees in the private sector, so
needle injury happened to 27,4% of them, injury with
a sharp object to 44,4% and exposure to blood of the
patient through the eye or other mucous tissues to
40,03% of dentists. Relatively large number of acci-
dents in private practice, in relation to the public
sector, could be explained by the fact that a significant
number of private dental offices do not employ dental
assistants, which enlarges dentist's scope of work
and results in greater risk of accidental injury.
Conclusion
Accidental injuries have a significant role in
spreading the infection in each dental office. Results
of the study showed a far greater proportion of
accidental injuries in dentists employed in private
dental offices, rather than in the public sector. In
comparison to other countries, there are a far smaller
proportion of accidental injuries. Due to the fact that
these accidents ultimately can lead to fatal diseases, it
is necessary to work on the continuous education of
dentists and dental students on infection control
measures in the dental office.
References
1. Farsi D, Zare M.A, Hassani S.A, Abbasi S, Emami-
naini A, Hafezimoghadam P, Rezai M. Prevalence
of occupational exposure to blood and body
secretions and its related effective factors among
health care workers of three Emergency Depar-
tments in Tehran. J Res Med Sci. 2012;17(7):
656–661.
2. Shah R, Mehta HK, Fancy M, Nayak S, Donga BN.
Knowledge and awareness regarding needle stick
injuries among health care workers in tertiary
care hospital in Ahmedabad, Gujarat. Nat J Com
Med. 2010;1:93-6.
3. , Gambhir RS, Singh S, Gill S, Singh A.
Knowledge, awareness and practice regarding
needle stick injuries in dental profession in India:
A systematic review. Niger Med J. 2013 ;54(6):
365-70.
4. Norsayani MY, Noor Hassim I. Study on incidence
of needle stick injury and factors associated with
this problem among medical students. J Occup
Health. 2003;45(3):172-8.
5. Topić B. i sur. Oralna medicina. Sarajevo: Faculty
of Dentistry University in Sarajevo; 2001
6. Obermeyer CM, Bott S, Carrieri P, Parsons M,
Pulerwitz J, Rutenberg N, Sarna A. HIV testing,
treatment and prevention: generic tools for
operational research, Geneva: World Health
Organization; 2009.
7. CDC. Exposure to Blood. What healthcare
Personnel Need to Know; 2003.
8. Heymann DL, editor. Control of Communicable
Diseases Manual. 18th ed. Baltimore: United
Book Press; 2004.
9. Bojanić J. Stojisavljević S. Jokić I. Imamović E.
Šiljak S. Jandrić LJ. Research on HIV stigma and
discrimination between health care providers in
public and private health care sector in BiH. Banja
Luka; Institute for public health RS: 2011
10. Wicker S, Rabenau HF. Occupational exposures to
blood-borne viruses among German dental
professionals and students in a clinical setting.
International Archives of Occupational and
Environmental Health. 2010;83(1):77-83.
11. Cheng HC, Su CY, Yen AMF, Huang CF. Factors
Affecting Occupational Exposure to Needle stick
and Sharps Injuries among Dentists in Taiwan: A
Nationwide Survey PLoS One. 2012; 7(4):
e34911. available at 10.1371/journal.pone.
0034911.
12. Park JC, Choi SH, Kim YT, Kim SJ, Kang HJ, Lee JH,
Shin SC, Cha YJ, Knowledge and attitudes of
Korean dentists towards human immuno-
deficiency virus/acquired immune deficiency
syndrome. J Periodontal Implant Sci. 2011; 41(1):
3–9.
Kapoor V
30 Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Gloves
Double gloves
Medical protective mask
Medical safety glasses
Public Sector
Private Sector
Statistical significance
12,5 (34)
38,4 (104)
22,1 (60)
47,6 (129)
1,8 (5)
38,0 (103)
2,2 (6)
21,4 (58)
86,4 (127)
84,7 (105)
p=0,059
-
18,1 (49)
2,6 (7)
3,7 (10)
27,2 (40)
27,4 (34)
p=0,000*
85,6 (232)
5,5 (15)
73,1 (198)
27,3 (74)
66,0 (97)
81,5 (101)
p=0,002*
Protective equipment
Work place
Sometime
% (number)
Never
% (number)
Gloves
% (number)
Always
% (number)
Medical
protective mask
% (number)
No answer
% (number)
Medical
safety glasses
% (number)
Table 3.
Use of protection by
dentists exposed to
occupational injuries
Table 4.
Proportion of respondents
that always use medical
safety protection
33Stomatološki vjesnik 2015; 4 (1)
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
EFFECT OF BLOOD CONTAMINATION
ON SHEAR BOND STRENGTH OF
ORTHODONTIC BUTTON ATTACHMENT
- IN VITRO STUDY
1 2 1
Holcner B* , Prohić S , Tiro A1, Džemidžić V ,
1 1
Redžepagić Vražalica L , Nakaš E
1 Department of Orthodontics, Faculty of Dentistry, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
2 Deparment of Oral Surgery, Faculty of Dentistry, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
ABSTRACT
The goal of this research was to determine effect of the blood
contamination on the bond strength of orthodontic attachments
and tooth.
Materials and methods: This research was conducted on 120
extracted human premolars with preserved vestibular surface.
The samples were classified into 6 experimental groups based on
used adhesives, and presence of blood contamination on etched
surface. As an attachment we used circular shape attachment
with chain, 4 mm diameter and a reticulate mashed base.
Results: Results of the study are indicating that there is a
statistically significant difference in the bonding strength
between blood contaminated enamel and attachment compared
to bonding strength between uncontaminated enamel and
attachment.
Three different adhesive materials showed no statistically
significant difference in the bonding strength between enamel
and attachment, in both cases - within the group without
contamination as well as within the group containing
contamination of blood enamel.
Key words: Blood contamination, shear bond strenght,
orthodontic attachments.
Conclusion: There is a difference in the bonding strength
between enamel and attachment in different conditions of
contamination, for all three tested adhesive materials. There is no
statistically significant difference in the bonding strength
between the enamel and attachment which would be caused by a
type of adhesive used in this study.
*Corresponding author
Bojan Holcner
Department of Orthodontics,
Faculty of Dentistry,
University of Sarajevo,
Bolnička 4a,
71000 Sarajevo,
Bosnia and Herzegovina
Phone:+38733214249
e-mail:bholcner@gmail.com
33Stomatološki vjesnik 2015; 4 (1)
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
EFFECT OF BLOOD CONTAMINATION
ON SHEAR BOND STRENGTH OF
ORTHODONTIC BUTTON ATTACHMENT
- IN VITRO STUDY
1 2 1
Holcner B* , Prohić S , Tiro A1, Džemidžić V ,
1 1
Redžepagić Vražalica L , Nakaš E
1 Department of Orthodontics, Faculty of Dentistry, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
2 Deparment of Oral Surgery, Faculty of Dentistry, University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
ABSTRACT
The goal of this research was to determine effect of the blood
contamination on the bond strength of orthodontic attachments
and tooth.
Materials and methods: This research was conducted on 120
extracted human premolars with preserved vestibular surface.
The samples were classified into 6 experimental groups based on
used adhesives, and presence of blood contamination on etched
surface. As an attachment we used circular shape attachment
with chain, 4 mm diameter and a reticulate mashed base.
Results: Results of the study are indicating that there is a
statistically significant difference in the bonding strength
between blood contaminated enamel and attachment compared
to bonding strength between uncontaminated enamel and
attachment.
Three different adhesive materials showed no statistically
significant difference in the bonding strength between enamel
and attachment, in both cases - within the group without
contamination as well as within the group containing
contamination of blood enamel.
Key words: Blood contamination, shear bond strenght,
orthodontic attachments.
Conclusion: There is a difference in the bonding strength
between enamel and attachment in different conditions of
contamination, for all three tested adhesive materials. There is no
statistically significant difference in the bonding strength
between the enamel and attachment which would be caused by a
type of adhesive used in this study.
*Corresponding author
Bojan Holcner
Department of Orthodontics,
Faculty of Dentistry,
University of Sarajevo,
Bolnička 4a,
71000 Sarajevo,
Bosnia and Herzegovina
Phone:+38733214249
e-mail:bholcner@gmail.com
Ormco Enlight LC®
without blood contamination (n=20)
Dentaurum Contec LC®
without blood contamination (n=20)
3M Transbond XT+SEP ®
without blood contamination (n=20)
Ormco Enlight LC®
with blood contamination (n=20)
Dentaurum Contec LC®
with blood contamination (n=20)
3MTransbondXT+SEP®
with blood contamination (n=20)
36,39±9,82
35,81±7,98
36,20±11,05
8,90±2,94
6,32±1,63
8,86±1,90
22,40
18,22
25,24
6,70
3,71
4,34
13,70
22,30
18,00
1,20
1,80
2,70
95,00
95,00
107,00
25,30
12,00
17,40
Group
The force (N)
95%
Reliability
interval
SD Minimum Maximum
Table 1.
Values of bonding
strength between
enamel and attachment
for each group
35
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
EFFECT OF BLOOD CONTAMINATION ON SHEAR BOND STRENGTH OF ORTHODONTIC BUTTON ATTACHMENT- IN VITRO STUDY
34
Holcner B, Prohić S, Tiro A, Džemidžić V, Redžepagić Vražalica L, Nakaš E
Introduction
Buoncore was first one to performe conditioning
of enamel with phosphoric acid in order to obtain
micro-retention of adhesives within the cavity of the
tooth [1].
Using epoxy resins Newman (1965) emphasis on
direct bonding of brackets, which from that point
becomes widely applied and involves bonding
brackets to previously prepared vestibular surfaces
of the teeth [2].
Impacted canines are according to Pec present
within 2-3% of the general population. Most impac-
ted canines are located palatally while impact rate of
the vestibular canines is from 2 to 3 times less often
[3].
The plan of treatment for retained impacted
canines is projected individually and it's based on
thoroughly conducted orthodontic diagnostic proto-
col. During the orthodontic-surgical therapeutic
protocol it's mandatory to bond attachment to a
surgically shown and previously prepared tooth and
dental arch - as well as it is to have secured position
for retained teeth.
Bonding strength (Shear Bond Strength - SBS)
between attachment and teeth is affect by: enamel
and its variations [4, 5, 6], methods of preparation of
the enamel [7, 8, 9, 10], base orthodontic attachment
[11, 12, 13, 14], types of adhesives [15, 16, 17, 18] and
light sources for polymerization [19, 20, 21].
Objectives of this study were to evaluate the shear
bond strength of connection between attachment
and enamel according to the type of used adhesive
material and exam the shear bond strength of enamel
and attachment under condition of contamination of
the enamel surface.
Materials and Methods
This study was carried out at the Department for
Orthodontics, Faculty of Dentistry in Sarajevo and it
was approved by Ethics Committee. Experimental
materials for this research were extracted human
first premolars with intact vestibular surface. After
extraction, the teeth were stored in saline solution.
The sample contained 120 teeth which were divided
in 6 experimental groups based on used adhesives –
®
3M Unitec Transbond Xt LC+ SEP , Dentaurum Contec
®®
LC i Ormco Enlight LC , and enamel contamination.
As an attachment we used circular shape attachment
with chain, 4 mm diameter and a reticulatar mesh
base. (Figure 1,2). Application of adhesive was done
according to one of the siz following protocols:
Protocol I: 3M Unitec Transbond Xt LC+ A self-etch
®
acidic primer , (3M/ESPE), was placed on the ena-
mel, gently dried with air for 5 seconds. attachments
were bonded and light cured for 10 seconds with LED
Light (5 seconde from each side).
Protocol II: The enamel surface was contaminated
with human blood, after which 3M Unitec Transbond
®
Xt LC+ A self-etch acidic primer , (3M/ESPE) was
applied on the contaminated surface; the brackets
were then bonded and light cured as in protocol I
Protocol III: 37% phosphoric acid was applied for
30 seconds, rinised with watar and air dried, after
®
that Dentaurum Contec LC primer was placed on the
enamel for 20 seconds and light cured for 20 seconds
. attachments were then bonded with Dentaurum
Contect adhesive and light cured for 15 seconds from
each side.
Protocol IV: 37% phosphoric acid was applied for
30 seconds, rinised with watar and air dried. The
enamel surface was contaminated with human blood,
®
after that Dentaurum Contec LC primer was placed
on the enamel for 20 seconds and light cured for 20
seconds. Attachments were then bonded with Denta-
urum Contect adhesive and light cured for 15 seconds
from each side.
Protocol V: 37% phosphoric acid was applied for
30 seconds, rinised with watar and air dried, after
that Ortho solo bond-a® was placed on the enamel
for 20 seconds and light cured for 20 seconds.
Attachments were then bonded with Ormco Enlight
®
LC and light cured for 10 seconds with Led light.
Protocol VI: 37% phosphoric acid was applied for
30 seconds, rinised with watar and air dried. The
enamel surface was contaminated with human blood
®
for 10 seconds, after that Ormco Enlight LC , was
applied on the contaminated surface; the brackets
were then bonded and light cured as in protocol V.
After bonding the teeth were stored in the
physiological saline solution at 37 ° C in an incubator
®
IVOCLAR CULTURE for 24 hours to obtain full
polimerisation of adhesives.
Test of the bonding strength between attachment
and chains for the tooth was carried out at Faculty of
Mechanical Engineering, University of Sarajevo using
digital testing machine from The Zwick Company, Ulm
- Germany.
Results
We examined effects of the preparation of the
enamel surface and the way type of adhesive material
influences on fluctuations in the bonding strength
between enamel and attachment by using the
analysis of variance models (ANOVA).
Average values that were obtained together with
standard deviations and different ranges of values for
each group are shown in Table 1.
As independent variables in the analysis there are
six experimental groups of teeth treated by various
methods of setting attachment. Graphic Figure 1
shows the locations of six points representing the
average value of the force in relation to different
Figure 1.
Attachment, button-chain
Figure 2.
Bonded attachment, button-chain
Ormco Enlight LC®
without blood contamination (n=20)
Dentaurum Contec LC®
without blood contamination (n=20)
3M Transbond XT+SEP ®
without blood contamination (n=20)
Ormco Enlight LC®
with blood contamination (n=20)
Dentaurum Contec LC®
with blood contamination (n=20)
3MTransbondXT+SEP®
with blood contamination (n=20)
36,39±9,82
35,81±7,98
36,20±11,05
8,90±2,94
6,32±1,63
8,86±1,90
22,40
18,22
25,24
6,70
3,71
4,34
13,70
22,30
18,00
1,20
1,80
2,70
95,00
95,00
107,00
25,30
12,00
17,40
Group
The force (N)
95%
Reliability
interval
SD Minimum Maximum
Table 1.
Values of bonding
strength between
enamel and attachment
for each group
35
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
EFFECT OF BLOOD CONTAMINATION ON SHEAR BOND STRENGTH OF ORTHODONTIC BUTTON ATTACHMENT- IN VITRO STUDY
34
Holcner B, Prohić S, Tiro A, Džemidžić V, Redžepagić Vražalica L, Nakaš E
Introduction
Buoncore was first one to performe conditioning
of enamel with phosphoric acid in order to obtain
micro-retention of adhesives within the cavity of the
tooth [1].
Using epoxy resins Newman (1965) emphasis on
direct bonding of brackets, which from that point
becomes widely applied and involves bonding
brackets to previously prepared vestibular surfaces
of the teeth [2].
Impacted canines are according to Pec present
within 2-3% of the general population. Most impac-
ted canines are located palatally while impact rate of
the vestibular canines is from 2 to 3 times less often
[3].
The plan of treatment for retained impacted
canines is projected individually and it's based on
thoroughly conducted orthodontic diagnostic proto-
col. During the orthodontic-surgical therapeutic
protocol it's mandatory to bond attachment to a
surgically shown and previously prepared tooth and
dental arch - as well as it is to have secured position
for retained teeth.
Bonding strength (Shear Bond Strength - SBS)
between attachment and teeth is affect by: enamel
and its variations [4, 5, 6], methods of preparation of
the enamel [7, 8, 9, 10], base orthodontic attachment
[11, 12, 13, 14], types of adhesives [15, 16, 17, 18] and
light sources for polymerization [19, 20, 21].
Objectives of this study were to evaluate the shear
bond strength of connection between attachment
and enamel according to the type of used adhesive
material and exam the shear bond strength of enamel
and attachment under condition of contamination of
the enamel surface.
Materials and Methods
This study was carried out at the Department for
Orthodontics, Faculty of Dentistry in Sarajevo and it
was approved by Ethics Committee. Experimental
materials for this research were extracted human
first premolars with intact vestibular surface. After
extraction, the teeth were stored in saline solution.
The sample contained 120 teeth which were divided
in 6 experimental groups based on used adhesives –
®
3M Unitec Transbond Xt LC+ SEP , Dentaurum Contec
®®
LC i Ormco Enlight LC , and enamel contamination.
As an attachment we used circular shape attachment
with chain, 4 mm diameter and a reticulatar mesh
base. (Figure 1,2). Application of adhesive was done
according to one of the siz following protocols:
Protocol I: 3M Unitec Transbond Xt LC+ A self-etch
®
acidic primer , (3M/ESPE), was placed on the ena-
mel, gently dried with air for 5 seconds. attachments
were bonded and light cured for 10 seconds with LED
Light (5 seconde from each side).
Protocol II: The enamel surface was contaminated
with human blood, after which 3M Unitec Transbond
®
Xt LC+ A self-etch acidic primer , (3M/ESPE) was
applied on the contaminated surface; the brackets
were then bonded and light cured as in protocol I
Protocol III: 37% phosphoric acid was applied for
30 seconds, rinised with watar and air dried, after
®
that Dentaurum Contec LC primer was placed on the
enamel for 20 seconds and light cured for 20 seconds
. attachments were then bonded with Dentaurum
Contect adhesive and light cured for 15 seconds from
each side.
Protocol IV: 37% phosphoric acid was applied for
30 seconds, rinised with watar and air dried. The
enamel surface was contaminated with human blood,
®
after that Dentaurum Contec LC primer was placed
on the enamel for 20 seconds and light cured for 20
seconds. Attachments were then bonded with Denta-
urum Contect adhesive and light cured for 15 seconds
from each side.
Protocol V: 37% phosphoric acid was applied for
30 seconds, rinised with watar and air dried, after
that Ortho solo bond-a® was placed on the enamel
for 20 seconds and light cured for 20 seconds.
Attachments were then bonded with Ormco Enlight
®
LC and light cured for 10 seconds with Led light.
Protocol VI: 37% phosphoric acid was applied for
30 seconds, rinised with watar and air dried. The
enamel surface was contaminated with human blood
®
for 10 seconds, after that Ormco Enlight LC , was
applied on the contaminated surface; the brackets
were then bonded and light cured as in protocol V.
After bonding the teeth were stored in the
physiological saline solution at 37 ° C in an incubator
®
IVOCLAR CULTURE for 24 hours to obtain full
polimerisation of adhesives.
Test of the bonding strength between attachment
and chains for the tooth was carried out at Faculty of
Mechanical Engineering, University of Sarajevo using
digital testing machine from The Zwick Company, Ulm
- Germany.
Results
We examined effects of the preparation of the
enamel surface and the way type of adhesive material
influences on fluctuations in the bonding strength
between enamel and attachment by using the
analysis of variance models (ANOVA).
Average values that were obtained together with
standard deviations and different ranges of values for
each group are shown in Table 1.
As independent variables in the analysis there are
six experimental groups of teeth treated by various
methods of setting attachment. Graphic Figure 1
shows the locations of six points representing the
average value of the force in relation to different
Figure 1.
Attachment, button-chain
Figure 2.
Bonded attachment, button-chain
37
EFFECT OF BLOOD CONTAMINATION ON SHEAR BOND STRENGTH OF ORTHODONTIC BUTTON ATTACHMENT- IN VITRO STUDY Holcner B, Prohić S, Tiro A, Džemidžić V, Redžepagić Vražalica L, Nakaš E
experimental group. It may be noted that group of
teeth without contamination of the blood had higher
average values of force compared with group of teeth
that was contaminated with blood.
Subsequent comparisons with Tamhane test were
applied to show accurately between which groups
there are significant differences in the average va-
lues. Overall results between each experimental
group are shown in Table 2 and 3.
Discussion
This study indicates that there is statistically
significant difference in the shear bonding strength
between the enamel and attachment in different
conditions of contamination for all three adhesive
materials. In the experimental group of teeth without
contamination there was a stronger bonding
strength between enamel and attachment, while the
experimental group of teeth contaminated with
blood recorded weaker bonding strength between
enamel and attachment. All three types of adhesive
material used show similar strength of bonding
strength between enamel and attachment with and
without condition of blood contamination. Regarding
the conditions of blood contamination and effects it
has on bonding strength between enamel surface and
attachment, study results are correlated with those
of the study conducted by Öztoprak and associates
(2007) [22], as well as in the study of Scirbantea and
associates (2013), which points out as well that blood
contamination significantly reduces the strength of
ties [23].
36 Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Graphic figure 1.
The average value of the
force in relation to different
experimental group
0
10
20
30
40
Ormco
Enlight
LC®
Ormco
Enlight
LC®
with blood
contami-
nation
Dentaurum
Contec LC®
Dentaurum
Contec LC®
with blood
contami-
nation
3M
Transbond
XT+SEP®
3M
Transbond
XT+SEP®
with blood
contami-
nation
36,390 36,195
6,320
8,8608,8958,895
35,805
Table 2.
Subsequent comparisons of groups without blood contamination - Tamhane test
Ormco
Enlight LC®
without blood
contamination
Dentaurum
Contec LC®
without blood
contamination
3M Unitek
Transbond
XT LC + SEP®
without blood
contamination
(I) Group (J) Group
(I-J) Lower
limit
Upper
limit
p
Difference 95% Reliability interval
Dentaurum Contec LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
Ormco Enlight LC®
with blood contamination
Dentaurum Contec LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
Ormco Enlight LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
Ormco Enlight LC®
with blood contamination
Dentaurum Contec LC®
with blood contamination
3M Unitek Transbond XT LC + SEP®
with blood contamination
Ormco Enlight LC®
without blood contamination
Dentaurum Contec LC®
without blood contamination
Ormco Enlight LC®
with blood contamination
Dentaurum Contec LC®
with blood contamination
3M Unitek Transbond XT LC + SEP®
with blood contamination
0,585
0,195
27,495
30,070
27,530
-0,585
-0,390
26,910
29,485
26,945
-0,195
0,390
27,300
29,875
27,335
1,000
1,000
0,000
0,000
0,000
1,000
1,000
0,000
0,000
0,000
1,000
1,000
0,002
0,001
0,002
-19,637
-23,394
10,378
13,218
10,637
-20,807
-22,273
12,811
15,729
13,137
-23,784
-21,493
8,110
10,914
8,339
20,807
23,784
44,612
46,922
44,423
19,637
21,493
41,009
43,241
40,753
23,394
22,273
46,490
48,836
46,331
Table 3.
Subsequent comparisons of groups with blood contamination - Tamhane test
Ormco
Enlight LC®
with blood
contamination
Dentaurum
Contec LC®
with blood
contamination
3M Unitek
Transbond
XT LC + SEP®
with blood
contamination
(I) Group (J) Group
(I-J) Lower
limit
Upper
limit
p
Difference 95% Reliability interval
Dentaurum Contec LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
Ormco Enlight LC®
without blood contamination
Dentaurum Contec LC®
with blood contamination
3M Unitek Transbond XT LC + SEP®
with blood contamination
Ormco Enlight LC®
without blood contamination
Ormco Enlight LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
Ormco Enlight LC®
with blood contamination
Ormco Enlight LC®
with blood contamination
Dentaurum Contec LC®
without blood contamination
Dentaurum Contec LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
with blood contamination
3M Unitek Transbond XT LC + SEP®
with blood contamination
-27,495
-26,910
-27,300
2,575
0,035
-30,070
-29,485
-29,875
-2,575
-2,540
-27,530
-26,945
-27,335
-0,035
2,540
0,000
0,000
0,002
0,902
1,000
0,000
0,000
0,001
0,902
0,567
0,000
0,000
0,002
1,000
0,567
-44,612
-41,009
-46,490
-2,875
-5,601
-46,922
-43,241
-48,836
-8,025
-6,537
-44,423
-40,753
-46,331
-5,671
-1,457
-10,378
-12,811
-8,110
8,025
5,671
-13,218
-15,729
-10,914
2,875
1,457
-10,637
-13,137
-8,339
5,601
6,537
37
EFFECT OF BLOOD CONTAMINATION ON SHEAR BOND STRENGTH OF ORTHODONTIC BUTTON ATTACHMENT- IN VITRO STUDY Holcner B, Prohić S, Tiro A, Džemidžić V, Redžepagić Vražalica L, Nakaš E
experimental group. It may be noted that group of
teeth without contamination of the blood had higher
average values of force compared with group of teeth
that was contaminated with blood.
Subsequent comparisons with Tamhane test were
applied to show accurately between which groups
there are significant differences in the average va-
lues. Overall results between each experimental
group are shown in Table 2 and 3.
Discussion
This study indicates that there is statistically
significant difference in the shear bonding strength
between the enamel and attachment in different
conditions of contamination for all three adhesive
materials. In the experimental group of teeth without
contamination there was a stronger bonding
strength between enamel and attachment, while the
experimental group of teeth contaminated with
blood recorded weaker bonding strength between
enamel and attachment. All three types of adhesive
material used show similar strength of bonding
strength between enamel and attachment with and
without condition of blood contamination. Regarding
the conditions of blood contamination and effects it
has on bonding strength between enamel surface and
attachment, study results are correlated with those
of the study conducted by Öztoprak and associates
(2007) [22], as well as in the study of Scirbantea and
associates (2013), which points out as well that blood
contamination significantly reduces the strength of
ties [23].
36 Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Graphic figure 1.
The average value of the
force in relation to different
experimental group
0
10
20
30
40
Ormco
Enlight
LC®
Ormco
Enlight
LC®
with blood
contami-
nation
Dentaurum
Contec LC®
Dentaurum
Contec LC®
with blood
contami-
nation
3M
Transbond
XT+SEP®
3M
Transbond
XT+SEP®
with blood
contami-
nation
36,390 36,195
6,320
8,8608,8958,895
35,805
Table 2.
Subsequent comparisons of groups without blood contamination - Tamhane test
Ormco
Enlight LC®
without blood
contamination
Dentaurum
Contec LC®
without blood
contamination
3M Unitek
Transbond
XT LC + SEP®
without blood
contamination
(I) Group (J) Group
(I-J) Lower
limit
Upper
limit
p
Difference 95% Reliability interval
Dentaurum Contec LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
Ormco Enlight LC®
with blood contamination
Dentaurum Contec LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
Ormco Enlight LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
Ormco Enlight LC®
with blood contamination
Dentaurum Contec LC®
with blood contamination
3M Unitek Transbond XT LC + SEP®
with blood contamination
Ormco Enlight LC®
without blood contamination
Dentaurum Contec LC®
without blood contamination
Ormco Enlight LC®
with blood contamination
Dentaurum Contec LC®
with blood contamination
3M Unitek Transbond XT LC + SEP®
with blood contamination
0,585
0,195
27,495
30,070
27,530
-0,585
-0,390
26,910
29,485
26,945
-0,195
0,390
27,300
29,875
27,335
1,000
1,000
0,000
0,000
0,000
1,000
1,000
0,000
0,000
0,000
1,000
1,000
0,002
0,001
0,002
-19,637
-23,394
10,378
13,218
10,637
-20,807
-22,273
12,811
15,729
13,137
-23,784
-21,493
8,110
10,914
8,339
20,807
23,784
44,612
46,922
44,423
19,637
21,493
41,009
43,241
40,753
23,394
22,273
46,490
48,836
46,331
Table 3.
Subsequent comparisons of groups with blood contamination - Tamhane test
Ormco
Enlight LC®
with blood
contamination
Dentaurum
Contec LC®
with blood
contamination
3M Unitek
Transbond
XT LC + SEP®
with blood
contamination
(I) Group (J) Group
(I-J) Lower
limit
Upper
limit
p
Difference 95% Reliability interval
Dentaurum Contec LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
Ormco Enlight LC®
without blood contamination
Dentaurum Contec LC®
with blood contamination
3M Unitek Transbond XT LC + SEP®
with blood contamination
Ormco Enlight LC®
without blood contamination
Ormco Enlight LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
3M Unitek Transbond XT LC + SEP®
without blood contamination
Ormco Enlight LC®
with blood contamination
Ormco Enlight LC®
with blood contamination
Dentaurum Contec LC®
without blood contamination
Dentaurum Contec LC®
without blood contamination
3M Unitek Transbond XT LC + SEP®
with blood contamination
3M Unitek Transbond XT LC + SEP®
with blood contamination
-27,495
-26,910
-27,300
2,575
0,035
-30,070
-29,485
-29,875
-2,575
-2,540
-27,530
-26,945
-27,335
-0,035
2,540
0,000
0,000
0,002
0,902
1,000
0,000
0,000
0,001
0,902
0,567
0,000
0,000
0,002
1,000
0,567
-44,612
-41,009
-46,490
-2,875
-5,601
-46,922
-43,241
-48,836
-8,025
-6,537
-44,423
-40,753
-46,331
-5,671
-1,457
-10,378
-12,811
-8,110
8,025
5,671
-13,218
-15,729
-10,914
2,875
1,457
-10,637
-13,137
-8,339
5,601
6,537
38 39
EFFECT OF BLOOD CONTAMINATION ON SHEAR BOND STRENGTH OF ORTHODONTIC BUTTON ATTACHMENT- IN VITRO STUDY Holcner B, Prohić S, Tiro A, Džemidžić V, Redžepagić Vražalica L, Nakaš E
6. , Malkoç S, Koyutürk AE, Catalbas B,
Ozer F. Influence of different tooth types on the
bond strength of two orthodontic adhesive
systems. Eur J Orthod. 2008;30(4):407-12.
7. Van Meerbeek B, De Munck J, Yoshida Y, Inoue
S, Vargas M, Vijay P, Van Landuyt K, Lam-
brechts P, Vanherle G. Buonocore memorial
lecture. Adhesion to enamel and dentin: current
status and future challenges. Oper Dent. 2003;
28(3):215-35.
8. Carstensen W. Clinical effects of reduction of
acid concentration on direct bonding of brackets.
Angle Orthod. 1993;63(3):221-4.
9. Urabe H, Rossouw PE, Titley KC, Yamin C.
Combinations of etchants, composite resins, and
bracket systems: an important choice in ortho-
dontic bonding procedures. Angle Orthod. 1999;
69(3):267-75.
10. Yamada R, Hayakawa T, Kasai K. Effect of using
self-etching primer for bonding orthodontic
brackets. Angle Orthod. 2002;72(6):558-64.
11. Fernandez L, Canut JA. In vitro comparison of
the retention capacity of new aesthetic brackets.
Eur J Orthod. 1999;21(1):71-7.
12. Bishara SE, Soliman MM, Oonsombat C,
Laffoon JF, Ajlouni R. The effect of variation in
mesh-base design on the shear bond strength of
orthodontic brackets. Angle Orthod. 2004;
74(3):400-4.
13. Ozer M, Arici S. Sandblasted metal brackets
bonded with resin-modified glass ionomer ce-
ment in vivo. Angle Orthod. 2005;75(3):406-9.
14. Olsen ME, Bishara SE, Jakobsen JR. Evaluation
of the shear bond strength of different ceramic
bracket base designs. Angle Orthod. 1997;
67(3):179-82.
15. Sunna S, Rock WP. An ex vivo investigation into
the bond strength of orthodontic brackets and
adhesive systems. Br J Orthod. 1999;26(1):47-
50.
16. Cacciafesta V, Süssenberger U, Jost-Brink-
mann PG, Miethke RR. Shear bond strengths of
ceramic brackets bonded with different light-
cured glass ionomer cements: an in vitro study.
Eur J Orthod. 1998;20(2):177-87.
Oztürk B
Regarding the type of adhesive used, the study
results are correlated with those in the study conduc-
ted by Owens (2000), which demonstrates signifi-
cantly higher bonding strength of light-curing
®
adhesives 3M Unitek Transbond XT LC + SEP and
®
Ormco Enlight LC - pointing out there are no signifi-
cant mutual differences in relation with the resin-
®
modified glass ionomers like Fuji Ortho LC [24] and
PANDIS (2006), also comparing adhesives Enlight
Ormco and 3M Transbond with the SEP while apply-
ing edgewise GAC Microarch and self-ligating bra-
ckets Ormco Damon2, arguing that there are no
statistically significant differences between these
types of adhesives [25].
Conclusion
Within all limitation of this study we can conclude
that blood contamination of prepared enamel surface
of the tooth prior to application of attachment has a
huge impact in the shear bonding strength between
attachment, adhesive and a tooth. Reduced bonding
strength can lead to undesirable rebonding of
attachment during therapy of retained impacted
canines.
References
1. Buonocore MG. A simple method of increasing the
adhesion of acrylic filling materials to enamel
surfaces. J Dent Res. 1955;34(6):849-53.
2. Newman GV. Epoxy adhesives for orthodontic
attachments: progress report. Am J Orthod.
1965;51(12):901-12.
3. Peck S, Peck L, Kataja M. The palatally displaced
canine as a dental anomaly of genetic origin.
Angle Orthod. 1994;64(4):249-56
4. Zachrisson BU, Arthun J. Enamel surface
appearance after various debonding techniques.
Am J Orthod. 1979;75(2):121-7.
5. Linklater RA, Gordon PH. An ex vivo study to
investigate bond strengths of different tooth
types. J Orthod. 2001;28(1):59-65.
17. , Millett DT, Gilmour WH.
Laboratory evaluation of a self-etching primer for
orthodontic bonding. Eur J Orthod. 2003;
25(4):411-5.
18. Bishara SE, Ajlouni R, Laffoon JF, Warren JJ.
Comparison of shear bond strength of two self-
etch primer/adhesive systems. Angle Orthod.
2006;76(1):123-6.
19. Sfondrini MF, Cacciafesta V, Scribante A,
Klersy C. Plasma arc versus halogen light curing
of orthodontic brackets: a 12-month clinical
study of bond failures. Am J Orthod Dentofacial
Orthop. 2004;125(3):342-7.
20. Cacciafesta V, Sfondrini MF, Scribante A,
Boehme A, Jost-Brinkmann PG. Effect of light-
tip distance on the shear bond strengths of com-
posite resin. Angle Orthod. 2005;75(3):386-91.
21. Türkkahraman H, Küçükeşmen HC. Orthodon-
tic bracket shear bond strengths produced by two
high-power light-emitting diode modes and halo-
gen light. Angle Orthod. 2005;75(5):854-7
Aljubouri YD 22. , Isik F, Sayinsu K, Arun T, Ayde-
mir B. Effect of blood and saliva contamination
on shear bond strength of brackets bonded with 4
adhesives. Am J Orthod Dentofacial Orthop.
2007;131(2):238-42.
23. Scribante A, Sfondrini MF, Gatti S, Gandini P.
Disinclusion of unerupted teeth by mean of self-
ligating brackets: effect of blood contamination
on shear bond strength. Med Oral Patol Oral Cir
Bucal. 2013;18(1):e162-7.
24. Owens SE Jr, Miller BH. A comparison of shear
bond strengths of three visible light-cured ortho-
dontic adhesives. Angle Orthod. 2000;70(5):
352-6.
25. Pandis N, Polychronopoulou A, Eliades T.
Failure rate of self-ligating and edgewise brackets
bonded with conventional acid etching and a self-
etching primer: a prospective in vivo study. Angle
Orthod. 2006;76(1):119-22
Oztoprak MO
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
38 39
EFFECT OF BLOOD CONTAMINATION ON SHEAR BOND STRENGTH OF ORTHODONTIC BUTTON ATTACHMENT- IN VITRO STUDY Holcner B, Prohić S, Tiro A, Džemidžić V, Redžepagić Vražalica L, Nakaš E
6. , Malkoç S, Koyutürk AE, Catalbas B,
Ozer F. Influence of different tooth types on the
bond strength of two orthodontic adhesive
systems. Eur J Orthod. 2008;30(4):407-12.
7. Van Meerbeek B, De Munck J, Yoshida Y, Inoue
S, Vargas M, Vijay P, Van Landuyt K, Lam-
brechts P, Vanherle G. Buonocore memorial
lecture. Adhesion to enamel and dentin: current
status and future challenges. Oper Dent. 2003;
28(3):215-35.
8. Carstensen W. Clinical effects of reduction of
acid concentration on direct bonding of brackets.
Angle Orthod. 1993;63(3):221-4.
9. Urabe H, Rossouw PE, Titley KC, Yamin C.
Combinations of etchants, composite resins, and
bracket systems: an important choice in ortho-
dontic bonding procedures. Angle Orthod. 1999;
69(3):267-75.
10. Yamada R, Hayakawa T, Kasai K. Effect of using
self-etching primer for bonding orthodontic
brackets. Angle Orthod. 2002;72(6):558-64.
11. Fernandez L, Canut JA. In vitro comparison of
the retention capacity of new aesthetic brackets.
Eur J Orthod. 1999;21(1):71-7.
12. Bishara SE, Soliman MM, Oonsombat C,
Laffoon JF, Ajlouni R. The effect of variation in
mesh-base design on the shear bond strength of
orthodontic brackets. Angle Orthod. 2004;
74(3):400-4.
13. Ozer M, Arici S. Sandblasted metal brackets
bonded with resin-modified glass ionomer ce-
ment in vivo. Angle Orthod. 2005;75(3):406-9.
14. Olsen ME, Bishara SE, Jakobsen JR. Evaluation
of the shear bond strength of different ceramic
bracket base designs. Angle Orthod. 1997;
67(3):179-82.
15. Sunna S, Rock WP. An ex vivo investigation into
the bond strength of orthodontic brackets and
adhesive systems. Br J Orthod. 1999;26(1):47-
50.
16. Cacciafesta V, Süssenberger U, Jost-Brink-
mann PG, Miethke RR. Shear bond strengths of
ceramic brackets bonded with different light-
cured glass ionomer cements: an in vitro study.
Eur J Orthod. 1998;20(2):177-87.
Oztürk B
Regarding the type of adhesive used, the study
results are correlated with those in the study conduc-
ted by Owens (2000), which demonstrates signifi-
cantly higher bonding strength of light-curing
®
adhesives 3M Unitek Transbond XT LC + SEP and
®
Ormco Enlight LC - pointing out there are no signifi-
cant mutual differences in relation with the resin-
®
modified glass ionomers like Fuji Ortho LC [24] and
PANDIS (2006), also comparing adhesives Enlight
Ormco and 3M Transbond with the SEP while apply-
ing edgewise GAC Microarch and self-ligating bra-
ckets Ormco Damon2, arguing that there are no
statistically significant differences between these
types of adhesives [25].
Conclusion
Within all limitation of this study we can conclude
that blood contamination of prepared enamel surface
of the tooth prior to application of attachment has a
huge impact in the shear bonding strength between
attachment, adhesive and a tooth. Reduced bonding
strength can lead to undesirable rebonding of
attachment during therapy of retained impacted
canines.
References
1. Buonocore MG. A simple method of increasing the
adhesion of acrylic filling materials to enamel
surfaces. J Dent Res. 1955;34(6):849-53.
2. Newman GV. Epoxy adhesives for orthodontic
attachments: progress report. Am J Orthod.
1965;51(12):901-12.
3. Peck S, Peck L, Kataja M. The palatally displaced
canine as a dental anomaly of genetic origin.
Angle Orthod. 1994;64(4):249-56
4. Zachrisson BU, Arthun J. Enamel surface
appearance after various debonding techniques.
Am J Orthod. 1979;75(2):121-7.
5. Linklater RA, Gordon PH. An ex vivo study to
investigate bond strengths of different tooth
types. J Orthod. 2001;28(1):59-65.
17. , Millett DT, Gilmour WH.
Laboratory evaluation of a self-etching primer for
orthodontic bonding. Eur J Orthod. 2003;
25(4):411-5.
18. Bishara SE, Ajlouni R, Laffoon JF, Warren JJ.
Comparison of shear bond strength of two self-
etch primer/adhesive systems. Angle Orthod.
2006;76(1):123-6.
19. Sfondrini MF, Cacciafesta V, Scribante A,
Klersy C. Plasma arc versus halogen light curing
of orthodontic brackets: a 12-month clinical
study of bond failures. Am J Orthod Dentofacial
Orthop. 2004;125(3):342-7.
20. Cacciafesta V, Sfondrini MF, Scribante A,
Boehme A, Jost-Brinkmann PG. Effect of light-
tip distance on the shear bond strengths of com-
posite resin. Angle Orthod. 2005;75(3):386-91.
21. Türkkahraman H, Küçükeşmen HC. Orthodon-
tic bracket shear bond strengths produced by two
high-power light-emitting diode modes and halo-
gen light. Angle Orthod. 2005;75(5):854-7
Aljubouri YD 22. , Isik F, Sayinsu K, Arun T, Ayde-
mir B. Effect of blood and saliva contamination
on shear bond strength of brackets bonded with 4
adhesives. Am J Orthod Dentofacial Orthop.
2007;131(2):238-42.
23. Scribante A, Sfondrini MF, Gatti S, Gandini P.
Disinclusion of unerupted teeth by mean of self-
ligating brackets: effect of blood contamination
on shear bond strength. Med Oral Patol Oral Cir
Bucal. 2013;18(1):e162-7.
24. Owens SE Jr, Miller BH. A comparison of shear
bond strengths of three visible light-cured ortho-
dontic adhesives. Angle Orthod. 2000;70(5):
352-6.
25. Pandis N, Polychronopoulou A, Eliades T.
Failure rate of self-ligating and edgewise brackets
bonded with conventional acid etching and a self-
etching primer: a prospective in vivo study. Angle
Orthod. 2006;76(1):119-22
Oztoprak MO
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
41Stomatološki vjesnik 2015; 4 (1)
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
ASSESSMENT OF ANGIOGENESIS
BY ENDOGLIN (CD 105) IN
INFLAMED DENTAL PULP
1 2 3
Tahmiščija I* , Radović S , Jukić-Krmek S ,
1 4 5
Konjhodžić-Prcić A , Šečić S , Đapo N
1 Department of Restorative Dentistry and Endodontics, Faculty of Dentistry,
University of Sarajevo, Bosnia and Herzegovina
2 Institute of Pathology, Faculty of Medicine,
University of Sarajevo, Bosnia and Herzegovina
3 Department of Endodontics and Restorative Dentistry,
Faculty of Dental Medicine, University of Zagreb, Croatia
4 Department of Oral Surgery, Faculty of Dentistry,
University of Sarajevo, Bosnia and Herzegovina
5 Department of Psychology, Faculty of Philosophy,
University of Sarajevo, Bosnia and Herzegovina
ABSTRACT
Objective: The study aimed to investigate the angiogenesis in
inflamed dental pulp using endoglin as a marker of activated
endothelium.
Methods: Fifty four (54) samples of dental pulps with clinical
diagnosis of irreversible pulpitis were used as the experimental
group and fifty one (51) healthy pulps extirpated from clinically
intact teeth, which were extracted for orthodontic reasons, were
used as the control group. Pulp samples were fixed into neutral 10%
buffered formalin, embedded in paraffin and sectioned at 3-4 μm
thickness using a microtome. Sections were stained with standard
hematoxylin–eosin for determining the form and intensity of
inflammation. All specimens were immunohistochemically stained
for endoglin antibody (anti-CD105). Positively stained blood vessels
2
were counted by a light microscopy in an area of 1 mm .
Results: The mean number and standard deviation of newly
formed CD105 positive vessels in the group with inflammation (5.98
± 8.62) was significantly higher (p< 0.0001) than the mean number
in the group without inflammation (0.16 ± 0,76).
Conclusion: The study established an increased number of
CD105 positive, newly formed blood vessels in the inflamed human
dental pulp indicating the occurrence of angiogenesis. Endoglin has
proved to be an efficient and reliable marker in the identification of
newly formed blood vessels in the dental pulp.
Key words: angiogenesis, dental pulp.
*Corresponding author
Irmina Tahmiščija, PhD
Department of Restorative
Dentistry and Endodontics
Faculty of Dentistry
University of Sarajevo
Bolnička 4a
71000 Sarajevo
Bosnia and Herzegovina
Phone: +387 33 214 249, ext. 118
e-mail: irmina_slatina@hotmail.com
41Stomatološki vjesnik 2015; 4 (1)
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
ASSESSMENT OF ANGIOGENESIS
BY ENDOGLIN (CD 105) IN
INFLAMED DENTAL PULP
1 2 3
Tahmiščija I* , Radović S , Jukić-Krmek S ,
1 4 5
Konjhodžić-Prcić A , Šečić S , Đapo N
1 Department of Restorative Dentistry and Endodontics, Faculty of Dentistry,
University of Sarajevo, Bosnia and Herzegovina
2 Institute of Pathology, Faculty of Medicine,
University of Sarajevo, Bosnia and Herzegovina
3 Department of Endodontics and Restorative Dentistry,
Faculty of Dental Medicine, University of Zagreb, Croatia
4 Department of Oral Surgery, Faculty of Dentistry,
University of Sarajevo, Bosnia and Herzegovina
5 Department of Psychology, Faculty of Philosophy,
University of Sarajevo, Bosnia and Herzegovina
ABSTRACT
Objective: The study aimed to investigate the angiogenesis in
inflamed dental pulp using endoglin as a marker of activated
endothelium.
Methods: Fifty four (54) samples of dental pulps with clinical
diagnosis of irreversible pulpitis were used as the experimental
group and fifty one (51) healthy pulps extirpated from clinically
intact teeth, which were extracted for orthodontic reasons, were
used as the control group. Pulp samples were fixed into neutral 10%
buffered formalin, embedded in paraffin and sectioned at 3-4 μm
thickness using a microtome. Sections were stained with standard
hematoxylin–eosin for determining the form and intensity of
inflammation. All specimens were immunohistochemically stained
for endoglin antibody (anti-CD105). Positively stained blood vessels
2
were counted by a light microscopy in an area of 1 mm .
Results: The mean number and standard deviation of newly
formed CD105 positive vessels in the group with inflammation (5.98
± 8.62) was significantly higher (p< 0.0001) than the mean number
in the group without inflammation (0.16 ± 0,76).
Conclusion: The study established an increased number of
CD105 positive, newly formed blood vessels in the inflamed human
dental pulp indicating the occurrence of angiogenesis. Endoglin has
proved to be an efficient and reliable marker in the identification of
newly formed blood vessels in the dental pulp.
Key words: angiogenesis, dental pulp.
*Corresponding author
Irmina Tahmiščija, PhD
Department of Restorative
Dentistry and Endodontics
Faculty of Dentistry
University of Sarajevo
Bolnička 4a
71000 Sarajevo
Bosnia and Herzegovina
Phone: +387 33 214 249, ext. 118
e-mail: irmina_slatina@hotmail.com
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
42
ASSESSMENT OF ANGIOGENESIS BY ENDOGLIN (CD 105) IN INFLAMED DENTAL PULP
Introduction
Angiogenesis is the formation of new blood
vessels from preexisting ones [1]. It is a dynamic and
carefully balanced process involving the activation
phase, characterized by increased vascular perme-
ability, degradation of the basement membrane,
endothelial proliferation and migration, as well as the
resolution phase, characterized by inhibition of
endothelial cell proliferation and migration, in pa-
rallel with basement membrane reconstitution [2].
At the stage of maturation, recruiting pericytes and
vascular smooth muscle cells is necessary in order to
maintain the stability of the vessel and protect endo-
thelial cells from apoptosis [3,4].
Angiogenesis occurs in many physiological and
pathological conditions, such as growth and deve-
lopment, inflammation, wound healing and tumor
growth, during which there is an increased need for
oxygen and nutrients in the tissues [5]. In the
inflamed dental pulp, an increased number of blood
vessels was found using the pan-endothelial marker
CD34, indicating angiogenesis [6].
The endothelium is a complex structure that con-
trols the homeostasis of blood vessels, by integrating
signals between the vascular wall and lumen. Endo-
thelial cells have many functions and play a central
role in the control of coagulation, thrombolysis,
vascular tonus and permeability, and in the processes
of inflammation, tissue healing and angiogenesis. In
the human body, endothelial cells are a heterogene-
ous cell population. Functions and molecular charac-
teristics of endothelial cells differ in the vascular tree,
and in the same organ between different vessels. In
physiological conditions, endothelial cells are in the
state that could be labeled as resting or quiescent.
This endothelium is stable and has very low level of
transformation (turnover rate) taking more than
1000 days to be doubled. During angiogenesis, endo-
thelium is subject to rapid transformation and such
endothelium is called activated [7].
Visualization of blood vessels can be realized by
using immune-histochemical markers, which bind to
different components of endothelial cells. Two cate-
gories of human endothelial cell-specific antibodies
are commonly used: the pan-endothelial cell markers
and antibodies that bind selectively to activated or
proliferating endothelium. Pan-endothelial markers
bind to mature endothelial, and for some other cell
types such as fibroblasts, inflammatory and stromal
cells. The most commonly used markers from this
group are: von Willebrand factor, CD31 and CD34.
Other types of markers, such as endoglin, bind only to
activated endothelium i.e. endothelium in prolifera-
tion.
Endoglin is a cellular surface protein that was
identified two decades ago [8] and
[9]. It is overexpressed in vascular
endothelial cells of tissues undergoing angiogenesis
such as regenerating and inflamed tissues or tumors
[10-14].
The aim of our study was to examine angiogenesis
in inflamed dental pulp with the application of
endoglin as a marker of activated endothelium.
Materials and Methods
Sample selection
The protocol for this study was approved by the
institutional review board. The current investigation
did not in any way alter the treatment plan of any
patient.
Fifty four (54) samples of dental pulps with clini-
cal diagnosis of irreversible pulpitis were used as the
experimental group and fifty one (51) healthy pulps
extirpated from clinically intact teeth, which were
extracted for orthodontic reasons, were used as the
control group. The inflamed pulps were obtained
from teeth caused by carious exposure of the pulp
and showing spontaneous pain and/or lingering pain
in response to cold and/or heat stimulus.
Interpretation of inflammation
Pulp samples were fixed in neutral 10% buffered
formalin, embedded in paraffin and sectioned at 3-4
μm thickness using a microtome. All histologic mate-
rial was reviewed by a pathologist to confirm the
histologic diagnosis in each case. Sections were stai-
ned with standard hematoxylin–eosin for determi-
ning the form and intensity of inflammation. The
degree of dental pulp inflammation was graded using
three-tiered system: Grade 1: mild (one third of vi-
sual field filled with inflammatory cells); Grade 2:
moderate (two third of visual field filled with
is classified as an
accessory receptor for transforming growth factor
beta (TGF-β)
inflammatory cells); and Grade 3: intense (entire
visual field filled with inflammatory cells).
Immuno-histochemical staining
Immuno-histochemical staining was performed
according to standard conditions and recommenda-
tion of the manufacturer as it follows. Sections were
mounted on silanized microscope slides, non-pa-
raffinic upon treated with xylene and rehydrated in a
series of decreasing concentrations of ethanol solu-
tions, for five minutes each.
After these procedures the slides were rinsed in
distilled water and washed three times with PBS (pH
7.4). For antigen retrieval, sections were incubated
with citrate buffer (10 mmol/L, pH 6.0) and heated in
a microwave oven at 60°C for 5 minutes. Then,
sections were immersed into 0.3% hydrogen
peroxide in methanol for 30 minutes to block
endogenous peroxidase activity and incubated with
rabbit serum for 10 minutes to block non-specific
reactions.
Tissue sections were incubated with anti-CD105
antibody (clone 4G11; Novocastra Laboratories Ltd,
UK). The slides were next incubated with anti-mouse
secondary antibody conjugated with streptavidin-
biotin-peroxidase complex (LSAB2/HRP kit; DAKO,
Denmark), and a color reaction was developed using
DAB. The sections were counterstained with Mayer's
hematoxylin. The specificity of the immunoreactions
was confirmed by the negative results obtained on
adjacent sections by replacing the primary antibody
with mouse serum.
Interpretation of immune-staining
The final product of immune-histochemical reac-
tion was found in the cytoplasm of vascular endothe-
lial cells. CD105-positive vascular endothelial cells
were clearly identified by their brown staining.
Immuno-histochemical expression is evaluated and
quantified under the light microscope Olympus
BX40. Microscope fields were observed at a magnifi-
cation of ×400 and vessel counts were obtained for 5
2
random fields (field of view= 1 mm ). Every single
brown-stained cell and cell cluster was calculated as
a blood vessel, no matter whether a vessel lumen
structure was seen.
Statistical analysis
Significance of differences in the number of CD
105-positive vascular vessels between experimental
and control group was calculated by nonparametric
Mann-Whitney U test. The point bi-serial correlation
coefficient was used to show associations between
the intensity of inflammation and CD105 positive
blood vessels. All statistical analyses were performed
using SPSS 20.0 software (SPSS Inc., Chicago, IL, USA).
Results
In the experimental group, mild inflammation was
detected in 28 (52%) cases, moderate in 24 (44%),
and intense in two (4%) cases as shown in Figure 1.
CD105 positive vessels in this group were detected in
Tahmiščija I, Radović S, Jukić-Krmek S, Konjhodžić-Prcić A, Šečić S, Đapo N
Figure 1.
Intensity of inflammation
in dental pulp
mild inflammation
moderate inflammation
intense inflammation
Series 1; intense inflammation;
2; 4%
Series 1;
moderate inflammation;
24; 44%
Series 1;
mild inflammation;
28; 52%
43
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
42
ASSESSMENT OF ANGIOGENESIS BY ENDOGLIN (CD 105) IN INFLAMED DENTAL PULP
Introduction
Angiogenesis is the formation of new blood
vessels from preexisting ones [1]. It is a dynamic and
carefully balanced process involving the activation
phase, characterized by increased vascular perme-
ability, degradation of the basement membrane,
endothelial proliferation and migration, as well as the
resolution phase, characterized by inhibition of
endothelial cell proliferation and migration, in pa-
rallel with basement membrane reconstitution [2].
At the stage of maturation, recruiting pericytes and
vascular smooth muscle cells is necessary in order to
maintain the stability of the vessel and protect endo-
thelial cells from apoptosis [3,4].
Angiogenesis occurs in many physiological and
pathological conditions, such as growth and deve-
lopment, inflammation, wound healing and tumor
growth, during which there is an increased need for
oxygen and nutrients in the tissues [5]. In the
inflamed dental pulp, an increased number of blood
vessels was found using the pan-endothelial marker
CD34, indicating angiogenesis [6].
The endothelium is a complex structure that con-
trols the homeostasis of blood vessels, by integrating
signals between the vascular wall and lumen. Endo-
thelial cells have many functions and play a central
role in the control of coagulation, thrombolysis,
vascular tonus and permeability, and in the processes
of inflammation, tissue healing and angiogenesis. In
the human body, endothelial cells are a heterogene-
ous cell population. Functions and molecular charac-
teristics of endothelial cells differ in the vascular tree,
and in the same organ between different vessels. In
physiological conditions, endothelial cells are in the
state that could be labeled as resting or quiescent.
This endothelium is stable and has very low level of
transformation (turnover rate) taking more than
1000 days to be doubled. During angiogenesis, endo-
thelium is subject to rapid transformation and such
endothelium is called activated [7].
Visualization of blood vessels can be realized by
using immune-histochemical markers, which bind to
different components of endothelial cells. Two cate-
gories of human endothelial cell-specific antibodies
are commonly used: the pan-endothelial cell markers
and antibodies that bind selectively to activated or
proliferating endothelium. Pan-endothelial markers
bind to mature endothelial, and for some other cell
types such as fibroblasts, inflammatory and stromal
cells. The most commonly used markers from this
group are: von Willebrand factor, CD31 and CD34.
Other types of markers, such as endoglin, bind only to
activated endothelium i.e. endothelium in prolifera-
tion.
Endoglin is a cellular surface protein that was
identified two decades ago [8] and
[9]. It is overexpressed in vascular
endothelial cells of tissues undergoing angiogenesis
such as regenerating and inflamed tissues or tumors
[10-14].
The aim of our study was to examine angiogenesis
in inflamed dental pulp with the application of
endoglin as a marker of activated endothelium.
Materials and Methods
Sample selection
The protocol for this study was approved by the
institutional review board. The current investigation
did not in any way alter the treatment plan of any
patient.
Fifty four (54) samples of dental pulps with clini-
cal diagnosis of irreversible pulpitis were used as the
experimental group and fifty one (51) healthy pulps
extirpated from clinically intact teeth, which were
extracted for orthodontic reasons, were used as the
control group. The inflamed pulps were obtained
from teeth caused by carious exposure of the pulp
and showing spontaneous pain and/or lingering pain
in response to cold and/or heat stimulus.
Interpretation of inflammation
Pulp samples were fixed in neutral 10% buffered
formalin, embedded in paraffin and sectioned at 3-4
μm thickness using a microtome. All histologic mate-
rial was reviewed by a pathologist to confirm the
histologic diagnosis in each case. Sections were stai-
ned with standard hematoxylin–eosin for determi-
ning the form and intensity of inflammation. The
degree of dental pulp inflammation was graded using
three-tiered system: Grade 1: mild (one third of vi-
sual field filled with inflammatory cells); Grade 2:
moderate (two third of visual field filled with
is classified as an
accessory receptor for transforming growth factor
beta (TGF-β)
inflammatory cells); and Grade 3: intense (entire
visual field filled with inflammatory cells).
Immuno-histochemical staining
Immuno-histochemical staining was performed
according to standard conditions and recommenda-
tion of the manufacturer as it follows. Sections were
mounted on silanized microscope slides, non-pa-
raffinic upon treated with xylene and rehydrated in a
series of decreasing concentrations of ethanol solu-
tions, for five minutes each.
After these procedures the slides were rinsed in
distilled water and washed three times with PBS (pH
7.4). For antigen retrieval, sections were incubated
with citrate buffer (10 mmol/L, pH 6.0) and heated in
a microwave oven at 60°C for 5 minutes. Then,
sections were immersed into 0.3% hydrogen
peroxide in methanol for 30 minutes to block
endogenous peroxidase activity and incubated with
rabbit serum for 10 minutes to block non-specific
reactions.
Tissue sections were incubated with anti-CD105
antibody (clone 4G11; Novocastra Laboratories Ltd,
UK). The slides were next incubated with anti-mouse
secondary antibody conjugated with streptavidin-
biotin-peroxidase complex (LSAB2/HRP kit; DAKO,
Denmark), and a color reaction was developed using
DAB. The sections were counterstained with Mayer's
hematoxylin. The specificity of the immunoreactions
was confirmed by the negative results obtained on
adjacent sections by replacing the primary antibody
with mouse serum.
Interpretation of immune-staining
The final product of immune-histochemical reac-
tion was found in the cytoplasm of vascular endothe-
lial cells. CD105-positive vascular endothelial cells
were clearly identified by their brown staining.
Immuno-histochemical expression is evaluated and
quantified under the light microscope Olympus
BX40. Microscope fields were observed at a magnifi-
cation of ×400 and vessel counts were obtained for 5
2
random fields (field of view= 1 mm ). Every single
brown-stained cell and cell cluster was calculated as
a blood vessel, no matter whether a vessel lumen
structure was seen.
Statistical analysis
Significance of differences in the number of CD
105-positive vascular vessels between experimental
and control group was calculated by nonparametric
Mann-Whitney U test. The point bi-serial correlation
coefficient was used to show associations between
the intensity of inflammation and CD105 positive
blood vessels. All statistical analyses were performed
using SPSS 20.0 software (SPSS Inc., Chicago, IL, USA).
Results
In the experimental group, mild inflammation was
detected in 28 (52%) cases, moderate in 24 (44%),
and intense in two (4%) cases as shown in Figure 1.
CD105 positive vessels in this group were detected in
Tahmiščija I, Radović S, Jukić-Krmek S, Konjhodžić-Prcić A, Šečić S, Đapo N
Figure 1.
Intensity of inflammation
in dental pulp
mild inflammation
moderate inflammation
intense inflammation
Series 1; intense inflammation;
2; 4%
Series 1;
moderate inflammation;
24; 44%
Series 1;
mild inflammation;
28; 52%
43
45
ASSESSMENT OF ANGIOGENESIS BY ENDOGLIN (CD 105) IN INFLAMED DENTAL PULP Tahmiščija I, Radović S, Jukić-Krmek S, Konjhodžić-Prcić A, Šečić S, Đapo N
Discussion
Inflammation and hypoxia are major factors that
stimulate angiogenesis. Inflammation increases vas-
cular permeability and promotes chemokine-media-
ted recruitment of monocytes, macrophages, plate-
lets, mast cells and other leukocytes that can synthe-
size angiogenic cytokines and growth factors [15,
16]. Hypoxia promotes angiogenesis as a consequen-
ce of signaling mediated by hypoxia-inducible trans-
cription factors [17].
Chronic inflammatory diseases are often accom-
panied by intense angiogenesis. Irreversible pulpitis
is also accompanied by angiogenesis, being confir-
med using a pan endothelial marker CD34 [6].
33 (61%) tissue samples. CD105 positive vessels in
normal pulp were rare and detected in only 3 (5.9%)
tissue samples. The mean number and standard de-
viation of newly formed CD105 positive vessels in the
group with inflammation (5.98 ± 8.62) was signifi-
cantly higher (p< 0.0001) than the mean number in
the group without inflammation (0.16 ± 0, 76). Figu-
re 2. and Figure 3. show sections of inflamed dental
pulp immune-stained with CD105. The newly formed
vessels are visualized in brown (arrows). Figure 4.
shows sections of normal dental pulp which is CD105
negative. There was no statistically significant corre-
lation (p = 0.280) between the intensity of inflamma-
tion and the number of CD105 positive blood vessels.
CD105 is a proliferation-associated and hypoxia-
inducible glycoprotein abundantly expressed in
angiogenic endothelial cells [18]. Unlike CD31 and
CD34, which stain both mature and immature
vessels, CD105 appears to be much more specific for
new, immature vessels.
Our research has demonstrated overexpression of
CD105 in endothelial cells of inflamed dental pulp
where it is implicated in promoting angiogenesis. The
number of CD105 positive blood vessels in normal
dental pulp used as control was significantly lower in
accordance with the slow turnover of normal
endothelial cells in comparison with inflamed pulp.
CD105 is a powerful marker of angiogenesis in dental
pulp inflammation.
There was no correlation between the extent of
angiogenesis and the intensity of inflammation in
dental pulp. It remains an open question whether
angiogenesis in dental pulp limits the initial effects of
inflammation or tends to prolong and intensify the
inflammatory response.
Conclusion
Our research has demonstrated an increased
number of CD105 positive blood vessels, which
indicates the occurrence of angiogenesis in the
inflamed pulp. The efficiency and reliability of CD105
in the identification of newly formed blood vessels in
inflamed dental pulp were also improved.
References
1. Risau W. Mechanisms of angiogenesis. Nature.
1997; 386(6626): 671–674.
2. Goumans MJ, Valdimarsdottir G, Itoh S, Rosendahl
A, Sideras P, et al. Balancing the activation state of
the endothelium via two distinct TGF-β type I
receptors. EMBO J. 2002;21(7): 1743–1753.
3. Gaengel K, Genove G, Armulik A, Betsholtz C.
Endothelial-mural cell signaling in vascular deve-
lopment and angiogenesis. Arterioscler Thromb
Vasc Biol. 2009;(5);29: 630–638.
4. Bouck N, Stellmach V, Hsu SC. How tumors beco-
me angiogenic. Adv Cancer Res. 1996;69:
135–174.
6. Tahmiščija I. Immuno-histochemical evaluation
of small blood and lymphatic vessels density in
the inflamed human dental pulp [master thesis].
Sarajevo, University in Sarajevo, School of Dental
medicine, 2009.
7. Bakić M. The role of endothelium in inflamma-
tion. Acta Medica Medianae. 2006;45(4):32-36.
5. Carmeliet P. Angiogenesis in health and disease.
Nat Med 2003;9(6):653–660.
8. Quackenbush EJ, Letarte M. Identification of
several cell surface proteins of non-T, non-B acute
lymphoblastic leukemia by using monoclonal
antibodies. J Immunol. 1985;134:1276-1285.
44 Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Figure 2.
CD105 positive, newly
formed blood vessels
(arrows) in inflamed pulp
(IH, X400)
Figure 4.
Normal dental pulp showing
no CD105 staining (IH, x400)
Figure 3.
CD105 positive endothelial
cells with (black arrows)
and without (white arrows)
formed vascular lumen in
inflamed dental pulp
(IH, x400).
45
ASSESSMENT OF ANGIOGENESIS BY ENDOGLIN (CD 105) IN INFLAMED DENTAL PULP Tahmiščija I, Radović S, Jukić-Krmek S, Konjhodžić-Prcić A, Šečić S, Đapo N
Discussion
Inflammation and hypoxia are major factors that
stimulate angiogenesis. Inflammation increases vas-
cular permeability and promotes chemokine-media-
ted recruitment of monocytes, macrophages, plate-
lets, mast cells and other leukocytes that can synthe-
size angiogenic cytokines and growth factors [15,
16]. Hypoxia promotes angiogenesis as a consequen-
ce of signaling mediated by hypoxia-inducible trans-
cription factors [17].
Chronic inflammatory diseases are often accom-
panied by intense angiogenesis. Irreversible pulpitis
is also accompanied by angiogenesis, being confir-
med using a pan endothelial marker CD34 [6].
33 (61%) tissue samples. CD105 positive vessels in
normal pulp were rare and detected in only 3 (5.9%)
tissue samples. The mean number and standard de-
viation of newly formed CD105 positive vessels in the
group with inflammation (5.98 ± 8.62) was signifi-
cantly higher (p< 0.0001) than the mean number in
the group without inflammation (0.16 ± 0, 76). Figu-
re 2. and Figure 3. show sections of inflamed dental
pulp immune-stained with CD105. The newly formed
vessels are visualized in brown (arrows). Figure 4.
shows sections of normal dental pulp which is CD105
negative. There was no statistically significant corre-
lation (p = 0.280) between the intensity of inflamma-
tion and the number of CD105 positive blood vessels.
CD105 is a proliferation-associated and hypoxia-
inducible glycoprotein abundantly expressed in
angiogenic endothelial cells [18]. Unlike CD31 and
CD34, which stain both mature and immature
vessels, CD105 appears to be much more specific for
new, immature vessels.
Our research has demonstrated overexpression of
CD105 in endothelial cells of inflamed dental pulp
where it is implicated in promoting angiogenesis. The
number of CD105 positive blood vessels in normal
dental pulp used as control was significantly lower in
accordance with the slow turnover of normal
endothelial cells in comparison with inflamed pulp.
CD105 is a powerful marker of angiogenesis in dental
pulp inflammation.
There was no correlation between the extent of
angiogenesis and the intensity of inflammation in
dental pulp. It remains an open question whether
angiogenesis in dental pulp limits the initial effects of
inflammation or tends to prolong and intensify the
inflammatory response.
Conclusion
Our research has demonstrated an increased
number of CD105 positive blood vessels, which
indicates the occurrence of angiogenesis in the
inflamed pulp. The efficiency and reliability of CD105
in the identification of newly formed blood vessels in
inflamed dental pulp were also improved.
References
1. Risau W. Mechanisms of angiogenesis. Nature.
1997; 386(6626): 671–674.
2. Goumans MJ, Valdimarsdottir G, Itoh S, Rosendahl
A, Sideras P, et al. Balancing the activation state of
the endothelium via two distinct TGF-β type I
receptors. EMBO J. 2002;21(7): 1743–1753.
3. Gaengel K, Genove G, Armulik A, Betsholtz C.
Endothelial-mural cell signaling in vascular deve-
lopment and angiogenesis. Arterioscler Thromb
Vasc Biol. 2009;(5);29: 630–638.
4. Bouck N, Stellmach V, Hsu SC. How tumors beco-
me angiogenic. Adv Cancer Res. 1996;69:
135–174.
6. Tahmiščija I. Immuno-histochemical evaluation
of small blood and lymphatic vessels density in
the inflamed human dental pulp [master thesis].
Sarajevo, University in Sarajevo, School of Dental
medicine, 2009.
7. Bakić M. The role of endothelium in inflamma-
tion. Acta Medica Medianae. 2006;45(4):32-36.
5. Carmeliet P. Angiogenesis in health and disease.
Nat Med 2003;9(6):653–660.
8. Quackenbush EJ, Letarte M. Identification of
several cell surface proteins of non-T, non-B acute
lymphoblastic leukemia by using monoclonal
antibodies. J Immunol. 1985;134:1276-1285.
44 Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Figure 2.
CD105 positive, newly
formed blood vessels
(arrows) in inflamed pulp
(IH, X400)
Figure 4.
Normal dental pulp showing
no CD105 staining (IH, x400)
Figure 3.
CD105 positive endothelial
cells with (black arrows)
and without (white arrows)
formed vascular lumen in
inflamed dental pulp
(IH, x400).
46
ASSESSMENT OF ANGIOGENESIS BY ENDOGLIN (CD 105) IN INFLAMED DENTAL PULP
14. Chung YC, Hou YC, Pan AC: Endoglin (CD105)
expression in the development of haemorrhoids.
Eur J Clin Invest. 2004;34(2):107-112.
15. Folkman J. Angiogenesis in cancer, vascular,
rheumatoid and other disease. Nature Medicine.
1995; 1(1): 27–31.
16. Simpson KJ, Henderson NC, Bone-Larson CL,
Lukacs NW, Hogaboam CM, Kunkel SL. Che-
mokines in the pathogenesis of liver disease: so
many players with poorly defined roles. Clinical
Science. 2003;104(1):47–63.
17. Pugh CW, Ratcliffe PJ. Regulation of angiogenesis
by hypoxia: role of the HIF system. Nature
Medicine. 2003; 9(6):677–684
18. Duff SE, Li C, Garland JM, Kumar S. CD105 is im-
portant for angiogenesis: evidence and potential
applications Faseb J. 2003;17:984-992.
9. Wong SH, Hamel L, Chevalier S, Philip A. Endoglin
expression on human microvascular endothelial
cells association with betaglycan and formation
of higher order complexes withTGF-beta signa-
ling receptors. Eur J Biochem. 2000;267:5550-
5560.
10. Wang JM, Kumar S, Pye D, van Agthoven AJ, Kru-
pinski J, Hunter RD. A monoclonal antibody de-
tects heterogeneity in vascular endothelium of
tumors and normal tissues. Int J Cancer. 1993;
54(3):363-370.
11. Krupinski J, Kaluza J, Kumar P, Kumar S, Wang JM:
Role of angiogenesis in patients with cerebral
ischemic stroke. Stroke. 1994;25(9):1794-1798.
12. Schimming R, Marme D. Endoglin (CD105)
expression in squamous cell carcinoma of the oral
cavity. Head Neck. 2002;24(2):151-156.
13. Torsney E, Charlton R, Parums D, Collis M, Arthur
HM. Inducible expression of human endoglin
during inflammation and wound healing in vivo.
Inflamm Res. 2002;51(9):464-470.
Stomatološki vjesnik 2015; 4 (1) 47
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
MICROLEAKAGE OF TEMPORARY
FILLING MATERIALS
1
Prskalo K* , 1
Vinković D
1 Department for Endodontics and Restorative Dentistry,
Faculty of Dental Medicine, University of Zagreb, Zagreb, Croatia
ABSTRACT
Cavit and Systemp.inlay are frequently used temporary filling
materials among the various materials available on the market.
Although both materials are clinically acceptable in the everyday
work, the objective of this study was to examine the marginal
leakage degrees of Cavit G and Systemp.inlay. The study was made
on 60 mandibular and maxillary molars, extracted for periodontal
reasons.
The samples were randomly divided into two groups of 30
teeth each. The preparation of the Class I cavity was made on each
tooth. The cavities were then filled with temporary materials
following the manufacturer's instructions. After that, the surface
of each tooth was coated with two layers of a nail polish and the
teeth were immersed in a contrast solution for ten days. The teeth
were then rinsed with water and cut down with a diamond disk in
the buccal-lingual direction. The depth of ink penetration was
measured by a stereomicroscope.
The average value of the ink leakage degree was calculated for
each material and Wilcoxon Rank Sum Test was used to prove the
existence of a statistically significant difference. Cavit
demonstrated better marginal sealing properties than
Systemp.inlay, in whose case the marginal leakage was
considerably greater.
Key words: cavity, temporary filling, marginal leakage
*Corresponding author
Katica Prskalo, PhD, Professor
Faculty of Dental Medicine,
University of Zagreb
Gundulićeva 5
10000 Zagreb
Croatia
Phone: + 38514802126
e-mail: prskalo@sfzg.hr
Stomatološki vjesnik 2015; 4 (1)
46
ASSESSMENT OF ANGIOGENESIS BY ENDOGLIN (CD 105) IN INFLAMED DENTAL PULP
14. Chung YC, Hou YC, Pan AC: Endoglin (CD105)
expression in the development of haemorrhoids.
Eur J Clin Invest. 2004;34(2):107-112.
15. Folkman J. Angiogenesis in cancer, vascular,
rheumatoid and other disease. Nature Medicine.
1995; 1(1): 27–31.
16. Simpson KJ, Henderson NC, Bone-Larson CL,
Lukacs NW, Hogaboam CM, Kunkel SL. Che-
mokines in the pathogenesis of liver disease: so
many players with poorly defined roles. Clinical
Science. 2003;104(1):47–63.
17. Pugh CW, Ratcliffe PJ. Regulation of angiogenesis
by hypoxia: role of the HIF system. Nature
Medicine. 2003; 9(6):677–684
18. Duff SE, Li C, Garland JM, Kumar S. CD105 is im-
portant for angiogenesis: evidence and potential
applications Faseb J. 2003;17:984-992.
9. Wong SH, Hamel L, Chevalier S, Philip A. Endoglin
expression on human microvascular endothelial
cells association with betaglycan and formation
of higher order complexes withTGF-beta signa-
ling receptors. Eur J Biochem. 2000;267:5550-
5560.
10. Wang JM, Kumar S, Pye D, van Agthoven AJ, Kru-
pinski J, Hunter RD. A monoclonal antibody de-
tects heterogeneity in vascular endothelium of
tumors and normal tissues. Int J Cancer. 1993;
54(3):363-370.
11. Krupinski J, Kaluza J, Kumar P, Kumar S, Wang JM:
Role of angiogenesis in patients with cerebral
ischemic stroke. Stroke. 1994;25(9):1794-1798.
12. Schimming R, Marme D. Endoglin (CD105)
expression in squamous cell carcinoma of the oral
cavity. Head Neck. 2002;24(2):151-156.
13. Torsney E, Charlton R, Parums D, Collis M, Arthur
HM. Inducible expression of human endoglin
during inflammation and wound healing in vivo.
Inflamm Res. 2002;51(9):464-470.
Stomatološki vjesnik 2015; 4 (1) 47
ORIGINAL SCIENTIFIC ARTICLE / ORIGINALNI NAUČNI RAD
MICROLEAKAGE OF TEMPORARY
FILLING MATERIALS
1
Prskalo K* , 1
Vinković D
1 Department for Endodontics and Restorative Dentistry,
Faculty of Dental Medicine, University of Zagreb, Zagreb, Croatia
ABSTRACT
Cavit and Systemp.inlay are frequently used temporary filling
materials among the various materials available on the market.
Although both materials are clinically acceptable in the everyday
work, the objective of this study was to examine the marginal
leakage degrees of Cavit G and Systemp.inlay. The study was made
on 60 mandibular and maxillary molars, extracted for periodontal
reasons.
The samples were randomly divided into two groups of 30
teeth each. The preparation of the Class I cavity was made on each
tooth. The cavities were then filled with temporary materials
following the manufacturer's instructions. After that, the surface
of each tooth was coated with two layers of a nail polish and the
teeth were immersed in a contrast solution for ten days. The teeth
were then rinsed with water and cut down with a diamond disk in
the buccal-lingual direction. The depth of ink penetration was
measured by a stereomicroscope.
The average value of the ink leakage degree was calculated for
each material and Wilcoxon Rank Sum Test was used to prove the
existence of a statistically significant difference. Cavit
demonstrated better marginal sealing properties than
Systemp.inlay, in whose case the marginal leakage was
considerably greater.
Key words: cavity, temporary filling, marginal leakage
*Corresponding author
Katica Prskalo, PhD, Professor
Faculty of Dental Medicine,
University of Zagreb
Gundulićeva 5
10000 Zagreb
Croatia
Phone: + 38514802126
e-mail: prskalo@sfzg.hr
Stomatološki vjesnik 2015; 4 (1)
48 49
MICROLEAKAGE OF TEMPORARY FILLING MATERIALS Prskalo K, Vinković D
tissue using a curette. Class I cavity preparation was
completed on each tooth's occlusal surface using a
cylindrical diamond burr (Edenta, G830L.016,
F40724) attached to a turbine and under water
cooling.
The cavities were prepared according to Black's
principles of preparation so the walls were parallel to
each other and vertical to the bottom of the cavity.
The depth of the cavities was measured with a
graduated probe in order to provide 4 mm in the
shallowest place. The cavities were then rinsed with
water jets, dried with compressed air and randomly
divided into two groups of 30 teeth each. The cavities
of the first teeth group were filled with Cavit G (3M
ESPE) by placing and adapting the material with the
Heideman instrument.
The cavities of the second group were filled with
the Systemp.inlay (Ivoclar Vivadent, Lot J05940)
photosensitive resin, which was placed in one layer,
adapted with the Heideman instrument and
polymerized for 20 seconds as in-structed by the
manufacturer. After the fillings were made, the whole
surface of the teeth except for the area 1 to 2 mm from
the margin of the filling was coated with two layers of
a red nail polish (7 days long, Deborah, Great Britain).
All teeth were then immersed in glass jars with a
black contrast solution (Rotring Ink, R591017,
Germany) for ten days at the temperature of 37 °C
(Figure 1).
Ten days after the teeth were rinsed with water to
completely remove the black colour of the ink. The
samples were then cut down with the diamond disk
Introduction
Some dental procedures that are complicated and
time-consuming (e.g. making of an inlay, endodontic
interventions, whitening of non-vital teeth) require
the work to be done in several phases. It is necessary
to adequately protect the treated tooth between
appointments and enable the normal functioning of
patient's stomatognathic system by placing a tem-
porary filling. The materials for temporary fillings
have to fulfil numerous requirements such as: being
easy to work with, sufficient resistance to chewing
pressure, biocompatibility with pulp and surroun-
ding tissue, proper marginal sealing, and shape re-
tention and volume stability [1]. The most
used temporary filling materials available on the
market are Cavit and Systemp.inlay. Cavit is zinc
oxide, zinc sulphate cement with artificial resin used
as a single-component material. It is easy to use
because it stays plastic up to ten minutes [1]. It is also
hydroscopic, what leads to its expansion in contact
with moisture and thus ensuring better sealing and
good adaptation to the teeth tissue [2,3,4]. According
to information from the literature, 3 to 4 millimetres
of Cavit in a Class I cavity ensures good sealing for up
to two weeks, which justifies Cavit's frequent use [5].
Systemp.inlay is a reinforced photosensitive resin. It
contains a photosensitive substance and after being
placed into a cavity is polymerized for 20 seconds. It
is especially suitable as a temporary filling for inlay
preparations because it is removed from a cavity by
inserting a sharp probe into the material [6]. Al-
though both Cavit and Systemp.inlay have exhibited a
satisfactory performance in everyday clinical work,
the objective of this study was to examine their mar-
ginal leakage since an inadequate sealing of a cavity
leads to a bacterial contamination, which can affect
the outcome of the dental therapy.
Material and methods
The study was performed on sixty extracted
maxillary and mandibular molars with intact or
slightly damaged crowns, which were extracted for
periodontal reasons. While being collected the teeth
were stored in saline solution at the temperature of
37°C. Before the start of the research, all teeth were
manually cleaned from the remains of plague and soft
frequently
(Edenta, Order No. 355.504.190HP) attached to the
dental unit, set transversely in the buccal-lingual
direction (Figure 2).
The cross-sections of the teeth were examined
through the stereomicroscope (Olympus Stereo
SZX12, Japan) with the 50 x magni-fication to
measure the depth of ink penetration (Figure 3 and
Figure 4).
Marginal leakage was defined according to the
following degrees:
·Degree 0 = no ink penetration
·Degree 1 = ink penetration extending up to one
third the total length of the lateral walls of the
filling
·Degree 2 = ink penetration extending up to two
thirds the total length of the lateral walls of the
filling
·Degree 3 = ink penetration extending the full
length of the lateral walls of the filling
·Degree 4 = ink penetration reached the bottom of
the cavity (Figure 5).
For each sample the leakage depth was measured
in two places, i.e. on the mesial and distal sections of
the cut tooth. The average value of the penetration
degree was calculated for each material based on the
measurements of the depth ink penetration. Wilcox-
on Rank Sum Test was used to assess the difference in
the average values. All tests were made at the
significance level of 0.05. Windows-based Statistica
software package was used in the statistical analysis.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Figure 1.
Tooth sample after the contrast solution is rinsed off
Figure 4.
The cross-section of a sample from the Systemp.inlay group
(ink penetration reached the bottom of the filling (50x)
Figure 3.
The cross-section of the sample from the Cavit G group
(no ink penetration along the walls of the cavity (50x)
Figure 2.
Tooth sample prepared for the microscope examination
Figure 5.
The scheme of ink penetration degrees
0
1
2
3
4
48 49
MICROLEAKAGE OF TEMPORARY FILLING MATERIALS Prskalo K, Vinković D
tissue using a curette. Class I cavity preparation was
completed on each tooth's occlusal surface using a
cylindrical diamond burr (Edenta, G830L.016,
F40724) attached to a turbine and under water
cooling.
The cavities were prepared according to Black's
principles of preparation so the walls were parallel to
each other and vertical to the bottom of the cavity.
The depth of the cavities was measured with a
graduated probe in order to provide 4 mm in the
shallowest place. The cavities were then rinsed with
water jets, dried with compressed air and randomly
divided into two groups of 30 teeth each. The cavities
of the first teeth group were filled with Cavit G (3M
ESPE) by placing and adapting the material with the
Heideman instrument.
The cavities of the second group were filled with
the Systemp.inlay (Ivoclar Vivadent, Lot J05940)
photosensitive resin, which was placed in one layer,
adapted with the Heideman instrument and
polymerized for 20 seconds as in-structed by the
manufacturer. After the fillings were made, the whole
surface of the teeth except for the area 1 to 2 mm from
the margin of the filling was coated with two layers of
a red nail polish (7 days long, Deborah, Great Britain).
All teeth were then immersed in glass jars with a
black contrast solution (Rotring Ink, R591017,
Germany) for ten days at the temperature of 37 °C
(Figure 1).
Ten days after the teeth were rinsed with water to
completely remove the black colour of the ink. The
samples were then cut down with the diamond disk
Introduction
Some dental procedures that are complicated and
time-consuming (e.g. making of an inlay, endodontic
interventions, whitening of non-vital teeth) require
the work to be done in several phases. It is necessary
to adequately protect the treated tooth between
appointments and enable the normal functioning of
patient's stomatognathic system by placing a tem-
porary filling. The materials for temporary fillings
have to fulfil numerous requirements such as: being
easy to work with, sufficient resistance to chewing
pressure, biocompatibility with pulp and surroun-
ding tissue, proper marginal sealing, and shape re-
tention and volume stability [1]. The most
used temporary filling materials available on the
market are Cavit and Systemp.inlay. Cavit is zinc
oxide, zinc sulphate cement with artificial resin used
as a single-component material. It is easy to use
because it stays plastic up to ten minutes [1]. It is also
hydroscopic, what leads to its expansion in contact
with moisture and thus ensuring better sealing and
good adaptation to the teeth tissue [2,3,4]. According
to information from the literature, 3 to 4 millimetres
of Cavit in a Class I cavity ensures good sealing for up
to two weeks, which justifies Cavit's frequent use [5].
Systemp.inlay is a reinforced photosensitive resin. It
contains a photosensitive substance and after being
placed into a cavity is polymerized for 20 seconds. It
is especially suitable as a temporary filling for inlay
preparations because it is removed from a cavity by
inserting a sharp probe into the material [6]. Al-
though both Cavit and Systemp.inlay have exhibited a
satisfactory performance in everyday clinical work,
the objective of this study was to examine their mar-
ginal leakage since an inadequate sealing of a cavity
leads to a bacterial contamination, which can affect
the outcome of the dental therapy.
Material and methods
The study was performed on sixty extracted
maxillary and mandibular molars with intact or
slightly damaged crowns, which were extracted for
periodontal reasons. While being collected the teeth
were stored in saline solution at the temperature of
37°C. Before the start of the research, all teeth were
manually cleaned from the remains of plague and soft
frequently
(Edenta, Order No. 355.504.190HP) attached to the
dental unit, set transversely in the buccal-lingual
direction (Figure 2).
The cross-sections of the teeth were examined
through the stereomicroscope (Olympus Stereo
SZX12, Japan) with the 50 x magni-fication to
measure the depth of ink penetration (Figure 3 and
Figure 4).
Marginal leakage was defined according to the
following degrees:
·Degree 0 = no ink penetration
·Degree 1 = ink penetration extending up to one
third the total length of the lateral walls of the
filling
·Degree 2 = ink penetration extending up to two
thirds the total length of the lateral walls of the
filling
·Degree 3 = ink penetration extending the full
length of the lateral walls of the filling
·Degree 4 = ink penetration reached the bottom of
the cavity (Figure 5).
For each sample the leakage depth was measured
in two places, i.e. on the mesial and distal sections of
the cut tooth. The average value of the penetration
degree was calculated for each material based on the
measurements of the depth ink penetration. Wilcox-
on Rank Sum Test was used to assess the difference in
the average values. All tests were made at the
significance level of 0.05. Windows-based Statistica
software package was used in the statistical analysis.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Figure 1.
Tooth sample after the contrast solution is rinsed off
Figure 4.
The cross-section of a sample from the Systemp.inlay group
(ink penetration reached the bottom of the filling (50x)
Figure 3.
The cross-section of the sample from the Cavit G group
(no ink penetration along the walls of the cavity (50x)
Figure 2.
Tooth sample prepared for the microscope examination
Figure 5.
The scheme of ink penetration degrees
0
1
2
3
4
50 51
MICROLEAKAGE OF TEMPORARY FILLING MATERIALS Prskalo K, Vinković D
it is necessary that the materials are easily placed and
removed from a cavity. The quality of sealing, or the
marginal leakage degree, is most often determined by
the depth of contrast solution's penetration, which is
quoted by many authors as a relevant method for
testing this particular property [5,7]. The average
value of leakage degrees for Cavit G in our study is
1.13 while for Systemp.inlay is 2.33 (Table 1, Figure
1). Wilcoxon Rank Sum Test showed a statistically
significant difference in the porosity of these mate-
rials (Table 1).
Cavit exhibited satisfying sealing properties for
ten days, which is a usual period between two
appointments, thus justifying its indication for every-
day use. On the other hand, Systemp.inlay showed a
greater marginal leakage, which indicates the neces-
sity to use a coating in order to protect dentin from a
bacterial contamination. How important is to know
the properties and performance of the materials for
temporary fillings is proved by a considerable num-
ber of studies in the available literature. The proper-
ties of materials were examined in various con-
Results
The marginal leakage of the materials was asses-
sed through the stereomicroscopic measurements of
the ink penetration depth along the walls of the
cavity. Figure 6 shows the degree of ink penetration
with a statistically significant difference between the
tested materials. Table 1 shows the average value of
the penetration degree for Cavit and Systemp.inlay as
well as the results of Wilcoxon Rank Sum Test.
Discussion
All dental materials including the materials for
temporary fillings differ among themselves by their
properties, which determine the indications for their
use. One of the important requirements that the
materials have to fulfil is to achieve as good sealing as
possible in order to prevent a marginal leakage and a
bacterial contamination of dentin. On the other hand,
ditions, which tried to simulate as much as possible
the situation inside the mouth [8,9].
According to the study made by Weston et al. [10]
a 4-mm layer of Cavit in a Class I cavity prevents the
penetration of Streptococcus mutans for at least 14
days while in the Class II cavity with a 2 to 3 millime-
tres of Cavit the contamination was observed already
on the first day.
Other studies also confirm the extraordinary sea-
ling properties of 4-mm layers of Cavit [3, 11] which
is in line with the results of our study. According to
the study made by Srikumar et al. [12] Cavit G shows
minimal leakage value in the dye penetration test
followed by Coltosol F, zinc polycar-boxylate cement,
zinc oxide eugenol and maximum leakage value of
dye penetration was exhibited by zinc phosphate
cement.
Results from the literature differ among them-
selves depending on the conditions in which the
material properties were tested. Thus, in the study
performed on the samples of acrylic tooth models,
Weston et al. [10] pointed out that there was no
significant statistical difference in the porosity of
Cavit placed with or without sterile cotton wool.
Contrary to that, Newcomb et al. [13] reported that
even a very small amount of cotton that passed from
the inner surface of the restoration to the outer
surface dramatically reduced the sealing quality of
the temporary restoration.
It is necessary to point out that the researchers
used glass tubes that simulated teeth cavities, which
were filled with temporary material and cotton
fibres. Slutzky et al. [14] researched the antibacterial
properties of Systemp.inlay and proved that it
retained its antibacterial properties up to seven days
in Streptococcus mutans culture while in contact with
Enterococcus faecalis failed to demonstrate any
antibacterial properties. By that they tried to show
that the composition and properties of a material
determine its antibacterial performance towards
certain bacteria.
Deveaux [15] compared the porosity of Cavit, IRM,
TERM and Fermit, which is, like Systemp.inlay, an
reinforced photosensitive resin, in contact with
Streptococcus sanguis. The samples were stored in
the culture with the bacteria and the measurements
were done on certain days. On the second day Cavit
presented the highest leakage among the all mate-
rials, while on the seventh day the highest leakage
was observed in the case of Fermit and then IRM and
TERM, while Cavit demonstrated the best protection.
These results were also confirmed by our study and
the only difference is that in order to measure leakage
we used a contrast solution.
The findings of Shahi in vitro study [16] suggest
that Zonalin and Zanherir temporary restorative
materials have low microleakage and canal contami-
nation in comparison to Coltosol and IRM [16].
Contrary to that, quite reverse results were reported
by the study made by Cruz [17]. Fermit demonstrated
good sealing properties, whereas Caviton and Cavit
being second and third best. Cavit's good marginal
sealing properties, proved not only by our study, but
also by the majority of research data from the
literature, are probably the results of the material's
hygroscopic properties. In a moist environment the
material slightly expands, which contributes to
better sealing of a cavity.
A poorer sealing degree in the case of Systemp.
inlay is probably the result of material's polyme-
rization shrinkage. However, because it can be
extremely easily removed from a cavity without need
for drilling, and thus, destroying the appearance of
the cavity, it is highly suitable for the protection of the
cavities in the case of indirect restorations. In clinical
work, it is necessary to consider both the protection
of dentin and the time between the particular work
phases.
Conclusion
Through measuring the depths of contrast
solution's penetration the materials for temporary
fillings that were tested demonstrated a statistically
significant difference in marginal leakage. Cavit G de-
monstrated good sealing properties in 4 millimetres
cavities that justifying material's frequent use in the
everyday clinical work. The material enables the
success of a dental intervention by preventing the
penetration of oral fluids and bacteria into a cavity
between appointments. Systemp.inlay is characte-
rized by a greater marginal leakage because of the
material's poorer adhesion to the tooth's hard tissue
or material shrinkage. However, because it can be
easily removed without damaging a prepared cavity
it is acceptable as a material for a temporary filling in
the case of indirect restorations. In the case of vital
teeth the protection of the dentin is recommended.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Table 1.
Comparison of marginal
leakage between two
tested materials
Figure 6.
Distribution of the leakage
degrees for tested materials
Cavit
Systemp. inlay
Number of cavity
Degree of penetration
16
14
12
10
8
6
4
2
0
0 1 2 3 4
Degree of penetration
MATERIAL
Cavit
Systemp. inlay
N
30
30
0
15
6
1
0
4
2
11
2
3
4
10
4
0
8
1,13
2,33
0,001406
Average
value
Wilcoxon
Rank Sum
Test
50 51
MICROLEAKAGE OF TEMPORARY FILLING MATERIALS Prskalo K, Vinković D
it is necessary that the materials are easily placed and
removed from a cavity. The quality of sealing, or the
marginal leakage degree, is most often determined by
the depth of contrast solution's penetration, which is
quoted by many authors as a relevant method for
testing this particular property [5,7]. The average
value of leakage degrees for Cavit G in our study is
1.13 while for Systemp.inlay is 2.33 (Table 1, Figure
1). Wilcoxon Rank Sum Test showed a statistically
significant difference in the porosity of these mate-
rials (Table 1).
Cavit exhibited satisfying sealing properties for
ten days, which is a usual period between two
appointments, thus justifying its indication for every-
day use. On the other hand, Systemp.inlay showed a
greater marginal leakage, which indicates the neces-
sity to use a coating in order to protect dentin from a
bacterial contamination. How important is to know
the properties and performance of the materials for
temporary fillings is proved by a considerable num-
ber of studies in the available literature. The proper-
ties of materials were examined in various con-
Results
The marginal leakage of the materials was asses-
sed through the stereomicroscopic measurements of
the ink penetration depth along the walls of the
cavity. Figure 6 shows the degree of ink penetration
with a statistically significant difference between the
tested materials. Table 1 shows the average value of
the penetration degree for Cavit and Systemp.inlay as
well as the results of Wilcoxon Rank Sum Test.
Discussion
All dental materials including the materials for
temporary fillings differ among themselves by their
properties, which determine the indications for their
use. One of the important requirements that the
materials have to fulfil is to achieve as good sealing as
possible in order to prevent a marginal leakage and a
bacterial contamination of dentin. On the other hand,
ditions, which tried to simulate as much as possible
the situation inside the mouth [8,9].
According to the study made by Weston et al. [10]
a 4-mm layer of Cavit in a Class I cavity prevents the
penetration of Streptococcus mutans for at least 14
days while in the Class II cavity with a 2 to 3 millime-
tres of Cavit the contamination was observed already
on the first day.
Other studies also confirm the extraordinary sea-
ling properties of 4-mm layers of Cavit [3, 11] which
is in line with the results of our study. According to
the study made by Srikumar et al. [12] Cavit G shows
minimal leakage value in the dye penetration test
followed by Coltosol F, zinc polycar-boxylate cement,
zinc oxide eugenol and maximum leakage value of
dye penetration was exhibited by zinc phosphate
cement.
Results from the literature differ among them-
selves depending on the conditions in which the
material properties were tested. Thus, in the study
performed on the samples of acrylic tooth models,
Weston et al. [10] pointed out that there was no
significant statistical difference in the porosity of
Cavit placed with or without sterile cotton wool.
Contrary to that, Newcomb et al. [13] reported that
even a very small amount of cotton that passed from
the inner surface of the restoration to the outer
surface dramatically reduced the sealing quality of
the temporary restoration.
It is necessary to point out that the researchers
used glass tubes that simulated teeth cavities, which
were filled with temporary material and cotton
fibres. Slutzky et al. [14] researched the antibacterial
properties of Systemp.inlay and proved that it
retained its antibacterial properties up to seven days
in Streptococcus mutans culture while in contact with
Enterococcus faecalis failed to demonstrate any
antibacterial properties. By that they tried to show
that the composition and properties of a material
determine its antibacterial performance towards
certain bacteria.
Deveaux [15] compared the porosity of Cavit, IRM,
TERM and Fermit, which is, like Systemp.inlay, an
reinforced photosensitive resin, in contact with
Streptococcus sanguis. The samples were stored in
the culture with the bacteria and the measurements
were done on certain days. On the second day Cavit
presented the highest leakage among the all mate-
rials, while on the seventh day the highest leakage
was observed in the case of Fermit and then IRM and
TERM, while Cavit demonstrated the best protection.
These results were also confirmed by our study and
the only difference is that in order to measure leakage
we used a contrast solution.
The findings of Shahi in vitro study [16] suggest
that Zonalin and Zanherir temporary restorative
materials have low microleakage and canal contami-
nation in comparison to Coltosol and IRM [16].
Contrary to that, quite reverse results were reported
by the study made by Cruz [17]. Fermit demonstrated
good sealing properties, whereas Caviton and Cavit
being second and third best. Cavit's good marginal
sealing properties, proved not only by our study, but
also by the majority of research data from the
literature, are probably the results of the material's
hygroscopic properties. In a moist environment the
material slightly expands, which contributes to
better sealing of a cavity.
A poorer sealing degree in the case of Systemp.
inlay is probably the result of material's polyme-
rization shrinkage. However, because it can be
extremely easily removed from a cavity without need
for drilling, and thus, destroying the appearance of
the cavity, it is highly suitable for the protection of the
cavities in the case of indirect restorations. In clinical
work, it is necessary to consider both the protection
of dentin and the time between the particular work
phases.
Conclusion
Through measuring the depths of contrast
solution's penetration the materials for temporary
fillings that were tested demonstrated a statistically
significant difference in marginal leakage. Cavit G de-
monstrated good sealing properties in 4 millimetres
cavities that justifying material's frequent use in the
everyday clinical work. The material enables the
success of a dental intervention by preventing the
penetration of oral fluids and bacteria into a cavity
between appointments. Systemp.inlay is characte-
rized by a greater marginal leakage because of the
material's poorer adhesion to the tooth's hard tissue
or material shrinkage. However, because it can be
easily removed without damaging a prepared cavity
it is acceptable as a material for a temporary filling in
the case of indirect restorations. In the case of vital
teeth the protection of the dentin is recommended.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Table 1.
Comparison of marginal
leakage between two
tested materials
Figure 6.
Distribution of the leakage
degrees for tested materials
Cavit
Systemp. inlay
Number of cavity
Degree of penetration
16
14
12
10
8
6
4
2
0
0 1 2 3 4
Degree of penetration
MATERIAL
Cavit
Systemp. inlay
N
30
30
0
15
6
1
0
4
2
11
2
3
4
10
4
0
8
1,13
2,33
0,001406
Average
value
Wilcoxon
Rank Sum
Test
52
MICROLEAKAGE OF TEMPORARY FILLING MATERIALS
and material thickness on microbial leakage
through Cavit using a tooth model system. Oral
Med Oral Pathol Oral Radiol & Endod. 2008;
105(4):530-5.
11. Turner JE, Anderson RW, Pashley DH, Pantera EA.
Microleakage of temporary endodontic restora-
tions in teeth restored with amalgam. J Endod.
1990; 16:1-4.
12. Strikumar GPV, Ravi Varma K, Harish Shetty K,
Pramod Kumar. Coronal microleakage with five
different temporary restorative materials follo-
wing walking bleach technique: An ex-vivo study.
Contemp Clin Dent. 2012 Oct-Dec; 3(4):421-6.
13. Newcomb BE, Clark SJ, Eleazer PD. Degradation of
the sealing properties of a zincoxide-calcium
sulfate-based temporary filling material by
entrapped cotton fibers. J Endod. 2001;
27(12):789-90.
14. Slutzky H, Slutzky-Goldberg I, Weiss EI, Matalon
S. Antibacterial properties of temporary filling
materials. J Endod. 2006; 32(3):214-7.
15. Deveaux E, Hilderbert P, Neut C, Romond C.
Bacterial microleakage of Cavit, IRM, TERM and
Fermit: a 21- day in vitro study. J Endod. 1999;
25(10):653-9.
16. Shahi S, Samiei M, Rahini S, Nezami H. In vitro
comparison of dye penetration through four
temporary restorative materials. Iran Endod J.
2010; 5(2):59-63-
17. Cruz EV, Shigetani Y, Ishikawa K, Kota K, Iwaku M,
Goodis HE. A laboratory study of coronal
microleakage using four temporary restorative
materials. J Endod. 2002; 35(4):315-20.
References
1. Šutalo J, i sur. Patologija i terapija tvrdih zubnih
tkiva. Zagreb: Naklada Zadro, 1994.
2. Widerman FH, Eames WB, Serene TP. The
physical and biologic properties of Cavit. J Am
Dent Assoc. 1971; 82:378-82.
3. Webber RT, del Rio CE, Brady JM, Segal RO. Sealing
quality of a temporary filling materials. Oral Surg
Oral Med Oral Pathol. 1978; 46:123-30.
4. Pashley EL, Tao L, Pashley DH. The sealing
properties of temporary filling materials. J Prosth
Dent. 1988; 60:292-6.
5. Zmener O, Banegas G, Panejer CH. Coronal micro-
leakage of three temporary restorative materials:
An in vitro study. J Endod. 2004; 30(8):582-4.
6. Christensen GJ. The fastest and best provisional
restorations. J Am Dent Assoc. 2003; 134(5):637-
9.
7. Barthel CR, Zavitzki FF, Raab WH, Zimmer S.
Bacterial leakage in roots filled with different
medicaments and sealed with Cavit. J Endod.
2006; 32(2):127-9.
8. Koaqel SO, Mines P, Apicella M, Sweet M. In vitro
study to compare the coronal microleakage of
Tempit UltraF, Tempit, IRM and Cavit by using the
fluid transport model. J Endod. 2008; 34(4):442-
4.
9. Balto H. An assesment of microbial coronal lea-
kage of temporary filling material in endodonti-
cally treated teeth. J Endod. 2002; 28(11):762-4.
10. Weston C, Barfield R, Rubby J, Litaker M, McNeal
SF, Eleazer PD. Comparison of preparation design
Stomatološki vjesnik 2015; 4 (1) 53
CASE REPORT / PRIKAZ SLUČAJA
THE USE OF COLD FLOWABLE
GUTTA-PERCHA IN ENDODONTIC
THERAPY
1
Korać S* , Jakupović S , Konjhodžić-Prcić A ,
1 1 1
Tahmiščija I , Džanković A , Hasić Branković L
1 1
1 Department of Restorative Dentistry and Endodontics, Faculty of Dentistry,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Many obturation techniques of the root canals in modern
endodontics are described, with the different indications,
advantages and disadvantages. Cold lateral condensation of
gutta-percha is still the most commonly used technique. However,
in certain cases, the cold flowable gutta-percha, which is injected
directly into the canal, is shown as the most preferred technique.
This paper describes several cases of endodontic therapy by using
two-component system GuttaFlow2 that combines radiopaque
polydimethylsiloxane filler particles and gutta-percha in one
material for root canal filling.
Key words: GuttaFlow, Root Canal Obturation, Filling
Materials
*Corresponding author
Samra Korać, MSc
Department of Restorative
Dentistry and Endodontics,
Faculty of Dentistry,
University of Sarajevo
Bolnička 4a
71000 Sarajevo,
Bosnia and Herzegovina
Phone: +387 (33) 214 249
e-mail: skorac@sf.unsa.ba,
samragk@gmail.com
Stomatološki vjesnik 2015; 4 (1)
52
MICROLEAKAGE OF TEMPORARY FILLING MATERIALS
and material thickness on microbial leakage
through Cavit using a tooth model system. Oral
Med Oral Pathol Oral Radiol & Endod. 2008;
105(4):530-5.
11. Turner JE, Anderson RW, Pashley DH, Pantera EA.
Microleakage of temporary endodontic restora-
tions in teeth restored with amalgam. J Endod.
1990; 16:1-4.
12. Strikumar GPV, Ravi Varma K, Harish Shetty K,
Pramod Kumar. Coronal microleakage with five
different temporary restorative materials follo-
wing walking bleach technique: An ex-vivo study.
Contemp Clin Dent. 2012 Oct-Dec; 3(4):421-6.
13. Newcomb BE, Clark SJ, Eleazer PD. Degradation of
the sealing properties of a zincoxide-calcium
sulfate-based temporary filling material by
entrapped cotton fibers. J Endod. 2001;
27(12):789-90.
14. Slutzky H, Slutzky-Goldberg I, Weiss EI, Matalon
S. Antibacterial properties of temporary filling
materials. J Endod. 2006; 32(3):214-7.
15. Deveaux E, Hilderbert P, Neut C, Romond C.
Bacterial microleakage of Cavit, IRM, TERM and
Fermit: a 21- day in vitro study. J Endod. 1999;
25(10):653-9.
16. Shahi S, Samiei M, Rahini S, Nezami H. In vitro
comparison of dye penetration through four
temporary restorative materials. Iran Endod J.
2010; 5(2):59-63-
17. Cruz EV, Shigetani Y, Ishikawa K, Kota K, Iwaku M,
Goodis HE. A laboratory study of coronal
microleakage using four temporary restorative
materials. J Endod. 2002; 35(4):315-20.
References
1. Šutalo J, i sur. Patologija i terapija tvrdih zubnih
tkiva. Zagreb: Naklada Zadro, 1994.
2. Widerman FH, Eames WB, Serene TP. The
physical and biologic properties of Cavit. J Am
Dent Assoc. 1971; 82:378-82.
3. Webber RT, del Rio CE, Brady JM, Segal RO. Sealing
quality of a temporary filling materials. Oral Surg
Oral Med Oral Pathol. 1978; 46:123-30.
4. Pashley EL, Tao L, Pashley DH. The sealing
properties of temporary filling materials. J Prosth
Dent. 1988; 60:292-6.
5. Zmener O, Banegas G, Panejer CH. Coronal micro-
leakage of three temporary restorative materials:
An in vitro study. J Endod. 2004; 30(8):582-4.
6. Christensen GJ. The fastest and best provisional
restorations. J Am Dent Assoc. 2003; 134(5):637-
9.
7. Barthel CR, Zavitzki FF, Raab WH, Zimmer S.
Bacterial leakage in roots filled with different
medicaments and sealed with Cavit. J Endod.
2006; 32(2):127-9.
8. Koaqel SO, Mines P, Apicella M, Sweet M. In vitro
study to compare the coronal microleakage of
Tempit UltraF, Tempit, IRM and Cavit by using the
fluid transport model. J Endod. 2008; 34(4):442-
4.
9. Balto H. An assesment of microbial coronal lea-
kage of temporary filling material in endodonti-
cally treated teeth. J Endod. 2002; 28(11):762-4.
10. Weston C, Barfield R, Rubby J, Litaker M, McNeal
SF, Eleazer PD. Comparison of preparation design
Stomatološki vjesnik 2015; 4 (1) 53
CASE REPORT / PRIKAZ SLUČAJA
THE USE OF COLD FLOWABLE
GUTTA-PERCHA IN ENDODONTIC
THERAPY
1
Korać S* , Jakupović S , Konjhodžić-Prcić A ,
1 1 1
Tahmiščija I , Džanković A , Hasić Branković L
1 1
1 Department of Restorative Dentistry and Endodontics, Faculty of Dentistry,
University of Sarajevo, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Many obturation techniques of the root canals in modern
endodontics are described, with the different indications,
advantages and disadvantages. Cold lateral condensation of
gutta-percha is still the most commonly used technique. However,
in certain cases, the cold flowable gutta-percha, which is injected
directly into the canal, is shown as the most preferred technique.
This paper describes several cases of endodontic therapy by using
two-component system GuttaFlow2 that combines radiopaque
polydimethylsiloxane filler particles and gutta-percha in one
material for root canal filling.
Key words: GuttaFlow, Root Canal Obturation, Filling
Materials
*Corresponding author
Samra Korać, MSc
Department of Restorative
Dentistry and Endodontics,
Faculty of Dentistry,
University of Sarajevo
Bolnička 4a
71000 Sarajevo,
Bosnia and Herzegovina
Phone: +387 (33) 214 249
e-mail: skorac@sf.unsa.ba,
samragk@gmail.com
Stomatološki vjesnik 2015; 4 (1)
54 55
THE USE OF COLD FLOWABLE GUTTA-PERCHA IN ENDODONTIC THERAPY Korać S, Jakupović S, Konjhodžić-Prcić A, Tahmiščija I, Džanković A, Hasić Branković L
For many years, gutta-percha (GP) has been wide-
ly used as a basic solid material for obturation of root
canals, associated with different types of sealers [2].
The major advantages of GP are its plasticity, low
toxicity, radio-opacity, easily manipulating and re-
moval [1].
Obturation techniques in general can be divided
into techniques using cold or warm GP. The cold
lateral condensation of GP is one of the most com-
monly used techniques in endodontics. However, its
ability for homogeneous filling of irregularly shaped
root canals has been questioned. Incomplete adhe-
sion between GP cones, spreader tracts, voids and
lack of surface adaptation have been reported [3].
Thermoplastic obturation techniques have been
developed in order to improve the homogeneity and
surface adaptation of GP.
Considering that heat-softened gutta-percha can
fill the lateral and accessory canals, as well as inter-
canal communications, thermoplastic obturation
techniques are indicated in the cases of complex
morphology of the root canal. Adverse effects of high
temperature on the surrounding tissues, shrinkage of
GP that occurs during cooling process which could
lead to the leakage, often difficult manipulation
requiring highly-trained therapist and less length
control [1] are main disadvantages of these techni-
ques.
In order to overcome the flaws of apical extrusion
and shrinkage in the thermo-plasticized condensa-
tion, cold, free-flow obturation technique has been
recently introduced. Material for this technique
named GuttaFlow (Coltène / Whaledent, Altstätten,
Switzerland) and its newer version GuttaFlow 2 were
created by modifying the silicone-based sealer RSA
RoekoSeal Automix (Roeko Dental Products, Lange-
nau, Germany).
This new filling system combines a large amount
of gutta-percha in powder form with particle size of
30 microns, silicone matrix (polydimethylsiloxane
sealer) and Nano-silver particles in individual
capsules. Trituration of silicone matrix with gutta-
percha powder in a standard triturator forms
injectable flowable, non-heated "two in one“ filling
system, following its hardening in the canal (Figures
1 and 2).
Polydimethylsiloxane is a silicone that is nontoxic
[4,5], inert and nonflammable; at high temperatures
it acts like a viscous liquid, similar to honey; at low
Introduction
Three-dimensional root canal filling is the final
phase of endodontic treatment. This filling prevents
the spread of bacteria and their byproducts from the
canal system periapically as well as the growth and
development of microorganisms that remain after
chemo-mechanical treatment.
In the second half of the last century, Grossman
specified features that the ideal material for endo-
dontic filling should have, having been preserved as
the "gold standard" to the present days [1]. Never-
theless, the material that would satisfy all of the
features of "gold standard" has not been developed
yet. Therefore, new materials for the root canal obtu-
ration are continuously being developed in order to
get closer to the criteria listed in the Table 1.
Along with improved materials, new obturation
techniques have been developed over the years. Ma-
ny of studies have focused on finding new techniques
or modification of existing techniques which would
provide adequate three-dimensional obturation.
temperatures, it acts like an elastic solid, similar to
rubber [5]. The properties of the material are
improved due to the addition of Nano-silver particles
and the gutta-percha in the form of a powder [7].
Silicones do not show antibacterial activity, but
Nano-silver prevent further spread of bacteria [4].
Silver particles within the sealer enhance radio-
opacity [1] and serve as a preservative [4,8]. Nano-
silver do not cause corrosion or color changes in the
GuttaFlow [4,6].
The material is believed to flow into lateral canals
and completely fill the space between the root canal
and the master cone. In addition, as no heat is used
with placement of the material, no shrinkage is
considered to occur.
Case Reports
All reported cases are treated at the Department
of Restorative Dentistry and Endodontics at Faculty
of Dentistry University of Sarajevo, by the Specialists
of Restorative Dentistry and Endodontics. In all cases,
the used obturation material was GuttaFlow2
(Coltène Whaledent, Langenau, Germany).
Case 1: The patient (22) was referred to our de-
partment due to discoloration of tooth 21. According
to anamnesis, patient injured the tooth two months
ago. The clinical examination revealed the discolored
left upper central incisor, not responsive to sensiti-
vity test, whereas right upper central incisor was
vital. The radiograph of the maxillary right incisor
revealed an irregularly shaped canal (Figure 3). The
diagnosis of internal resorption of tooth 11 and pulp
necrosis of tooth 21was established and teeth were
subjected to endodontic therapy. Treatment was
conducted with extirpation of pulp in teeth 11,
chemo-mechanical and ultrasonic instrumentation
of the teeth with irrigation using 1.5% sodium
hypochlorite, and calcium hydroxide as intra-canal
dressing. Obturation of root canals in teeth 11 and 21
was completed using GuttaFlow2 material. The oval-
shaped enlargement of the root canal space of the
tooth 11, as a result of internal resorption, was
adequately filled; furthermore entering of flowable
gutta-percha in the lateral canal of tooth 21 is
observed (Figure 4).
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Table 1.
Properties of an ideal sealer [1]
tacky to provide good adhesion
provide hermetic seal
radiopaque
easily mixed
no shrinkage upon setting
no staining,
bacteriostatic
slowly set
insoluble in tissue fluids
non-irritating
soluble in a common solvent for retreatments Figure 3.
Initial radiograph of teeth 11 and 21 showed an large area of
internal resorption in the apical-third of the tooth 11.
The diagnosis of root resorption was made by means of an x-ray.
Figure 2.
Application of GuttaFlow2 through a cannula
Figure 1.
GuttaFlow2 capsule and application gun
54 55
THE USE OF COLD FLOWABLE GUTTA-PERCHA IN ENDODONTIC THERAPY Korać S, Jakupović S, Konjhodžić-Prcić A, Tahmiščija I, Džanković A, Hasić Branković L
For many years, gutta-percha (GP) has been wide-
ly used as a basic solid material for obturation of root
canals, associated with different types of sealers [2].
The major advantages of GP are its plasticity, low
toxicity, radio-opacity, easily manipulating and re-
moval [1].
Obturation techniques in general can be divided
into techniques using cold or warm GP. The cold
lateral condensation of GP is one of the most com-
monly used techniques in endodontics. However, its
ability for homogeneous filling of irregularly shaped
root canals has been questioned. Incomplete adhe-
sion between GP cones, spreader tracts, voids and
lack of surface adaptation have been reported [3].
Thermoplastic obturation techniques have been
developed in order to improve the homogeneity and
surface adaptation of GP.
Considering that heat-softened gutta-percha can
fill the lateral and accessory canals, as well as inter-
canal communications, thermoplastic obturation
techniques are indicated in the cases of complex
morphology of the root canal. Adverse effects of high
temperature on the surrounding tissues, shrinkage of
GP that occurs during cooling process which could
lead to the leakage, often difficult manipulation
requiring highly-trained therapist and less length
control [1] are main disadvantages of these techni-
ques.
In order to overcome the flaws of apical extrusion
and shrinkage in the thermo-plasticized condensa-
tion, cold, free-flow obturation technique has been
recently introduced. Material for this technique
named GuttaFlow (Coltène / Whaledent, Altstätten,
Switzerland) and its newer version GuttaFlow 2 were
created by modifying the silicone-based sealer RSA
RoekoSeal Automix (Roeko Dental Products, Lange-
nau, Germany).
This new filling system combines a large amount
of gutta-percha in powder form with particle size of
30 microns, silicone matrix (polydimethylsiloxane
sealer) and Nano-silver particles in individual
capsules. Trituration of silicone matrix with gutta-
percha powder in a standard triturator forms
injectable flowable, non-heated "two in one“ filling
system, following its hardening in the canal (Figures
1 and 2).
Polydimethylsiloxane is a silicone that is nontoxic
[4,5], inert and nonflammable; at high temperatures
it acts like a viscous liquid, similar to honey; at low
Introduction
Three-dimensional root canal filling is the final
phase of endodontic treatment. This filling prevents
the spread of bacteria and their byproducts from the
canal system periapically as well as the growth and
development of microorganisms that remain after
chemo-mechanical treatment.
In the second half of the last century, Grossman
specified features that the ideal material for endo-
dontic filling should have, having been preserved as
the "gold standard" to the present days [1]. Never-
theless, the material that would satisfy all of the
features of "gold standard" has not been developed
yet. Therefore, new materials for the root canal obtu-
ration are continuously being developed in order to
get closer to the criteria listed in the Table 1.
Along with improved materials, new obturation
techniques have been developed over the years. Ma-
ny of studies have focused on finding new techniques
or modification of existing techniques which would
provide adequate three-dimensional obturation.
temperatures, it acts like an elastic solid, similar to
rubber [5]. The properties of the material are
improved due to the addition of Nano-silver particles
and the gutta-percha in the form of a powder [7].
Silicones do not show antibacterial activity, but
Nano-silver prevent further spread of bacteria [4].
Silver particles within the sealer enhance radio-
opacity [1] and serve as a preservative [4,8]. Nano-
silver do not cause corrosion or color changes in the
GuttaFlow [4,6].
The material is believed to flow into lateral canals
and completely fill the space between the root canal
and the master cone. In addition, as no heat is used
with placement of the material, no shrinkage is
considered to occur.
Case Reports
All reported cases are treated at the Department
of Restorative Dentistry and Endodontics at Faculty
of Dentistry University of Sarajevo, by the Specialists
of Restorative Dentistry and Endodontics. In all cases,
the used obturation material was GuttaFlow2
(Coltène Whaledent, Langenau, Germany).
Case 1: The patient (22) was referred to our de-
partment due to discoloration of tooth 21. According
to anamnesis, patient injured the tooth two months
ago. The clinical examination revealed the discolored
left upper central incisor, not responsive to sensiti-
vity test, whereas right upper central incisor was
vital. The radiograph of the maxillary right incisor
revealed an irregularly shaped canal (Figure 3). The
diagnosis of internal resorption of tooth 11 and pulp
necrosis of tooth 21was established and teeth were
subjected to endodontic therapy. Treatment was
conducted with extirpation of pulp in teeth 11,
chemo-mechanical and ultrasonic instrumentation
of the teeth with irrigation using 1.5% sodium
hypochlorite, and calcium hydroxide as intra-canal
dressing. Obturation of root canals in teeth 11 and 21
was completed using GuttaFlow2 material. The oval-
shaped enlargement of the root canal space of the
tooth 11, as a result of internal resorption, was
adequately filled; furthermore entering of flowable
gutta-percha in the lateral canal of tooth 21 is
observed (Figure 4).
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Table 1.
Properties of an ideal sealer [1]
tacky to provide good adhesion
provide hermetic seal
radiopaque
easily mixed
no shrinkage upon setting
no staining,
bacteriostatic
slowly set
insoluble in tissue fluids
non-irritating
soluble in a common solvent for retreatments Figure 3.
Initial radiograph of teeth 11 and 21 showed an large area of
internal resorption in the apical-third of the tooth 11.
The diagnosis of root resorption was made by means of an x-ray.
Figure 2.
Application of GuttaFlow2 through a cannula
Figure 1.
GuttaFlow2 capsule and application gun
56 57
THE USE OF COLD FLOWABLE GUTTA-PERCHA IN ENDODONTIC THERAPY Korać S, Jakupović S, Konjhodžić-Prcić A, Tahmiščija I, Džanković A, Hasić Branković L
Case 3: A 40-year-old female patient was referred
to our department because of the pain in region of
tooth 24. The diagnosis of symptomatic irreversible
pulpits of the maxillary first left premolar was made
after clinical examination and radiograph analysis. A
canal was detected, treated and filled with cold
flowable gutta-percha GuttaFlow2 at the same visit.
During injection of flowable gutta-percha the patient
felt pain, which could be a result of penetration of the
silicon based sealer in the lateral canal with vital pulp
tissue (Figure 6). After a follow up period of three
years, a control radiograph was done, where a com-
pact filling in the main canal and lateral ramifications
still has been found (Figure 7).
Case 2: A 38- year-old male patient was referred
to our department because of severe pain in the
region of tooth 37. The diagnosis of symptomatic
irreversible pulpitis of tooth 37 was established.
During endodontic treatment four root canals
(mesio-buccal, mesio-lingual, disto-buccal, disto-
lingual) were detected and chemo-mechanically
treated. Obturation of the tooth 37 was completed
with a polyvinyl-siloxane-based root canal filling
material – GuttaFlow2 in significantly shorter time,
compared to the standard treatment (lateral
condensation) (Figure 5). Post-treatment radio-
graph showed adequate density and length of the
filling.
Case 4: A 35-year-old male patient was admitted
to our clinic for root canal treatment. He had a pain
reaction on cold stimulation in maxillary left second
premolar (25) for a few days. By intraoral exami-
nation and radiograph analysis, profound caries,
overhanging restoration and irreversible symptoma-
tic pulpitis of tooth 25 were found (Figure 8). After
adequate endodontic treatment, the tooth was obtu-
rated with the polydimethylsiloxane-based system –
GuttaFlow2, where the cold flowable gutta-percha
filled root canal ramifications. Control radiograph
showed no loss of sealing after two years period
(Figure 9).
Discussion
GuttaFlow2 is relatively new obturation system
introduced in 2004, containing silicone-based sealer
as a semi-liquid paste and master gutta-percha point.
A gutta-percha powder is incorporated in silicone
based sealer thus making a unique feature of this root
canal filling material.
Since the introduction of this material in clinical
usage, few studies have been available. In vitro stu-
dies confirmed biocompatibility of silicone based
sealers [8] and antibacterial effect on E. coli due to
presence of silver particles [4]. No data have been
published about systemic toxicity and allergy to this
material [3].
The recent comparative study evaluated the
bacterial leakage of three root canal filling systems:
GuttaFlow, Resilon/Epiphany system and AH plus
with guttapercha [9]. In this study, Guttaflow pro-
vided better sealing ability than conventional cold
lateral compaction with AH plus and better resistan-
ce to bacterial penetration than traditional tested
sealers. An improved adhesion to root dentin walls
[3, 4] of GuttaFlow may be attributed to slight
expansion of material (0, 2%) inside the root canals
during setting period. GuttaFlow system has a good
adaptability and penetration into the dentinal tubu-
les [10]. It has been proposed that penetration of the
sealer into the dentinal tubules may have a root
strengthening effect due to filling of the voids [11].
Silicon-based sealers have a potential of forming
mono-block, thus reinforcing root canal of endodo-
nticaly treated teeth [3]. Compared to other tested
techniques, GuttaFlow exhibited least voids and gaps
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Figure 4.
Periapical radiograph showing canals of teeth
11 and 21 obturated using GuttaFlow2
Figure 6.
Postoperative radiograph showing obturation in maxillary first
premolar, using Gutta-Flow2 system. Filled lateral canal is observed
Figure 5.
X-ray following the obturation with GuttaFlow2. Four root canals found in tooth 37
Figure 9.
X-ray check-up taken two years after root canal
obturation using flowable cold technique.
Figure 8.
Preoperative radiograph of maxillary second premolar.
Caries profunda and overhanging restoration
in tooth 25 were found, with clinical diagnosis of
symptomatic irreversible pulpitis.
Figure 7.
Radiograph of tooth 24 taken three years
after root canal obturation.
56 57
THE USE OF COLD FLOWABLE GUTTA-PERCHA IN ENDODONTIC THERAPY Korać S, Jakupović S, Konjhodžić-Prcić A, Tahmiščija I, Džanković A, Hasić Branković L
Case 3: A 40-year-old female patient was referred
to our department because of the pain in region of
tooth 24. The diagnosis of symptomatic irreversible
pulpits of the maxillary first left premolar was made
after clinical examination and radiograph analysis. A
canal was detected, treated and filled with cold
flowable gutta-percha GuttaFlow2 at the same visit.
During injection of flowable gutta-percha the patient
felt pain, which could be a result of penetration of the
silicon based sealer in the lateral canal with vital pulp
tissue (Figure 6). After a follow up period of three
years, a control radiograph was done, where a com-
pact filling in the main canal and lateral ramifications
still has been found (Figure 7).
Case 2: A 38- year-old male patient was referred
to our department because of severe pain in the
region of tooth 37. The diagnosis of symptomatic
irreversible pulpitis of tooth 37 was established.
During endodontic treatment four root canals
(mesio-buccal, mesio-lingual, disto-buccal, disto-
lingual) were detected and chemo-mechanically
treated. Obturation of the tooth 37 was completed
with a polyvinyl-siloxane-based root canal filling
material – GuttaFlow2 in significantly shorter time,
compared to the standard treatment (lateral
condensation) (Figure 5). Post-treatment radio-
graph showed adequate density and length of the
filling.
Case 4: A 35-year-old male patient was admitted
to our clinic for root canal treatment. He had a pain
reaction on cold stimulation in maxillary left second
premolar (25) for a few days. By intraoral exami-
nation and radiograph analysis, profound caries,
overhanging restoration and irreversible symptoma-
tic pulpitis of tooth 25 were found (Figure 8). After
adequate endodontic treatment, the tooth was obtu-
rated with the polydimethylsiloxane-based system –
GuttaFlow2, where the cold flowable gutta-percha
filled root canal ramifications. Control radiograph
showed no loss of sealing after two years period
(Figure 9).
Discussion
GuttaFlow2 is relatively new obturation system
introduced in 2004, containing silicone-based sealer
as a semi-liquid paste and master gutta-percha point.
A gutta-percha powder is incorporated in silicone
based sealer thus making a unique feature of this root
canal filling material.
Since the introduction of this material in clinical
usage, few studies have been available. In vitro stu-
dies confirmed biocompatibility of silicone based
sealers [8] and antibacterial effect on E. coli due to
presence of silver particles [4]. No data have been
published about systemic toxicity and allergy to this
material [3].
The recent comparative study evaluated the
bacterial leakage of three root canal filling systems:
GuttaFlow, Resilon/Epiphany system and AH plus
with guttapercha [9]. In this study, Guttaflow pro-
vided better sealing ability than conventional cold
lateral compaction with AH plus and better resistan-
ce to bacterial penetration than traditional tested
sealers. An improved adhesion to root dentin walls
[3, 4] of GuttaFlow may be attributed to slight
expansion of material (0, 2%) inside the root canals
during setting period. GuttaFlow system has a good
adaptability and penetration into the dentinal tubu-
les [10]. It has been proposed that penetration of the
sealer into the dentinal tubules may have a root
strengthening effect due to filling of the voids [11].
Silicon-based sealers have a potential of forming
mono-block, thus reinforcing root canal of endodo-
nticaly treated teeth [3]. Compared to other tested
techniques, GuttaFlow exhibited least voids and gaps
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
Figure 4.
Periapical radiograph showing canals of teeth
11 and 21 obturated using GuttaFlow2
Figure 6.
Postoperative radiograph showing obturation in maxillary first
premolar, using Gutta-Flow2 system. Filled lateral canal is observed
Figure 5.
X-ray following the obturation with GuttaFlow2. Four root canals found in tooth 37
Figure 9.
X-ray check-up taken two years after root canal
obturation using flowable cold technique.
Figure 8.
Preoperative radiograph of maxillary second premolar.
Caries profunda and overhanging restoration
in tooth 25 were found, with clinical diagnosis of
symptomatic irreversible pulpitis.
Figure 7.
Radiograph of tooth 24 taken three years
after root canal obturation.
58 59
THE USE OF COLD FLOWABLE GUTTA-PERCHA IN ENDODONTIC THERAPY Korać S, Jakupović S, Konjhodžić-Prcić A, Tahmiščija I, Džanković A, Hasić Branković L
therefore necessary to minimize the risk of overfil-
ling with adequate working length control, using
apical constriction as the end point of root canal
instrumentation.
Long-term in vivo studies are required for
confirming dimensional stability and durability, as
well as non-toxicity and non-irritating properties
after prolonged contact of silicone-based materials
with periodontal tissues.
Conclusion
Three-dimensional obturation of complicated
root canal morphology could be impossible to
achieve using standard lateral condensation and may
require technique and material modifications.
GuttaFlow may be recommended as a very suitable
obturation material for teeth with internal resorp-
tion, C-shaped canal, taurodontism and extremely
thinned root canal walls. Guttaflow obturation mate-
rial is inert, dimensionally stable and biocompatible
material with post-setting expansion, suitable for
fast and efficient work in endodontic practice.
Declaration of Interest:
Authors declare no conflict of interest.
References
1. Hargreaves KM, Cohen S, Berman LH. Cohen's
pathways of the pulp. 10th ed. St. Louis: Mosby
Elsevier; 2011.
2. Hammad M, Qualtrough A, Silikas N. Evaluation of
Root Canal Obturation: A Three-dimensional In
Vitro Study. J Endod. 2009; 35(4):541-544.
3. Tyagi S, Mishra P, Tyagi P. Evolution of root canal
sealers: An insight story. Eur J Gen Dent. 2013;
2:199-218.
4. Jain P, Pruthi V, Sikri VK. An ex vivo evaluation of
the sealing ability of polydimethylsiloxane-based
root canal sealers. Indian J Dent Res. 2014;
25(3):336-339.
5. De-Deus G, Brandão MC, Fidel RA, Fidel SR. The
sealing ability of GuttaFlow in oval-shaped
canals: an ex vivo study using a polymicrobial
leakage model. Int Endod J. 2007; 40(10):794-
799.
[2]. Besides the fact that GuttaFlow2 is well tolerated
by periapical tissue, this material has good dimensio-
nal stability [7] and low water sorption [3].
Cold flowable root canal filling system combines
all the advantages of cold techniques with basic
benefits of warm gutta-percha techniques. This
technique is suitable for obturation of root canals
with irregular shape as well as warm thermoplastic
techniques, without adverse effects of high tempe-
ratures on the surrounding tissues. GuttaFlow2 is
flowable at room temperature and this feature makes
it very suitable for root canal obturation with internal
resorption (Figures 3 and 4). Obturation of this root
canal irregularity would be impossible to achieve
using standard lateral condensation.
Introduction of new root canal instrumentation
systems, techniques and sealers with improved
characteristics resulted in more frequent usage of
single cone obturation technique. The single-cone
technique comprises the use of sealers with single
gutta-percha point corresponding to the geometry of
the NiTi rotary instruments, providing better
adaptation of the point to the root canal walls [12,
13]. In cases where extensive root canal instrumenta-
tion is indicated, there is a risk of root fracture during
obturation. Using GuttaFlow2 system, there is no
need for lateral compaction of gutta-percha, signi-
ficant pressure on the root canal walls is missing and
vertical fracture risk is reduced.
Flowable cold technique does not require a high
degree of practice and manipulative skills of the
operator. It is fairly simple and time consuming tech-
nique. Root canal filling procedure of multi rooted
tooth could be performed in significantly less time.
This material has a setting time of 25-30 minutes and
post-endodontic restoration could be done on the
same day. Silicone based sealer can be removed from
the canals more easily then resin based sealer [3].
From the perspective of clinical practice, the material
is inexpensive, very manipulative and does not requ-
ire additional instruments and devices for its proper
application.
Disadvantage of clinical use GuttaFlow2 material,
as well as other injection systems, is overextension of
material in surrounding periapical tissues due to its
viscosity [3]. Failure of working length determina-
tion, such as apical perforation or enlargement of the
apical constriction, may lead to material overfilling
with increased incidence of postoperative pain, pro-
longed healing period and lower success rate. It is
6. Kontakiotis EG, Tzanetakis GN, Loizides AL. A 12-
month longitudinal in vitro leakage study on a
new silicon-based root canal filling material
(Gutta-Flow). Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2007; 103(6):854-859.
7. Konjhodžić-Prcić A. Evaluation of bio-compati-
bility of different endodonic sealers on the
culture of humane fibroblasts and fibroblasts of
mouse in Sarajevo: University in Sarajevo, Faculty
of Dentistr ; 2012
8. Martins VJ, Lins RX, Berlinck TC, Fidel RA.
Cytotoxicity of root canal sealers on endothelial
cell cultures. Braz Dent J. 2013; 24(1):15-20.
9. Nawal RR, Parande M, Sehgal R, Rao NR, Naik A. A
comparative evaluation of 3 root canal filling
systems. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2011; 111(3):387-393.
10. Leski M, Pawlicka H. A comparison of the pene-
tration of three sealers into dentinal tubules: a
SEM study. Int Endod J. 2005:38;932–934.
11. Saraf-Dadpe A, Kamra A.I. A scanning electron
microscopic evaluation of the penetration of root
canal dentinal tubules by four different endodon-
tic sealers: A zinc oxide eugenol-based sealer, two
rasin-based sealers and polydimethylsiloxane-
based sealer – An in vitro study, Endodontology,
2012 Dec; 24 (2): 50-58
12. Economides N, Kokorikos I, Kolokouris I, Pana-
giotis B, Gogos C. Comparative study of apical
sealing ability of a new resin-based root canal
sealer. J Endod. 2004;30(6):403-405.
13. Monticelli F, Sadek FT, Schuster GS, Volkmann KR,
Looney SW, Ferrari M. Efficacy of two contempo-
rary single-cone filling techniques in preventing
bacterial leakage. J Endod. 2007;33(3):310-313.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
58 59
THE USE OF COLD FLOWABLE GUTTA-PERCHA IN ENDODONTIC THERAPY Korać S, Jakupović S, Konjhodžić-Prcić A, Tahmiščija I, Džanković A, Hasić Branković L
therefore necessary to minimize the risk of overfil-
ling with adequate working length control, using
apical constriction as the end point of root canal
instrumentation.
Long-term in vivo studies are required for
confirming dimensional stability and durability, as
well as non-toxicity and non-irritating properties
after prolonged contact of silicone-based materials
with periodontal tissues.
Conclusion
Three-dimensional obturation of complicated
root canal morphology could be impossible to
achieve using standard lateral condensation and may
require technique and material modifications.
GuttaFlow may be recommended as a very suitable
obturation material for teeth with internal resorp-
tion, C-shaped canal, taurodontism and extremely
thinned root canal walls. Guttaflow obturation mate-
rial is inert, dimensionally stable and biocompatible
material with post-setting expansion, suitable for
fast and efficient work in endodontic practice.
Declaration of Interest:
Authors declare no conflict of interest.
References
1. Hargreaves KM, Cohen S, Berman LH. Cohen's
pathways of the pulp. 10th ed. St. Louis: Mosby
Elsevier; 2011.
2. Hammad M, Qualtrough A, Silikas N. Evaluation of
Root Canal Obturation: A Three-dimensional In
Vitro Study. J Endod. 2009; 35(4):541-544.
3. Tyagi S, Mishra P, Tyagi P. Evolution of root canal
sealers: An insight story. Eur J Gen Dent. 2013;
2:199-218.
4. Jain P, Pruthi V, Sikri VK. An ex vivo evaluation of
the sealing ability of polydimethylsiloxane-based
root canal sealers. Indian J Dent Res. 2014;
25(3):336-339.
5. De-Deus G, Brandão MC, Fidel RA, Fidel SR. The
sealing ability of GuttaFlow in oval-shaped
canals: an ex vivo study using a polymicrobial
leakage model. Int Endod J. 2007; 40(10):794-
799.
[2]. Besides the fact that GuttaFlow2 is well tolerated
by periapical tissue, this material has good dimensio-
nal stability [7] and low water sorption [3].
Cold flowable root canal filling system combines
all the advantages of cold techniques with basic
benefits of warm gutta-percha techniques. This
technique is suitable for obturation of root canals
with irregular shape as well as warm thermoplastic
techniques, without adverse effects of high tempe-
ratures on the surrounding tissues. GuttaFlow2 is
flowable at room temperature and this feature makes
it very suitable for root canal obturation with internal
resorption (Figures 3 and 4). Obturation of this root
canal irregularity would be impossible to achieve
using standard lateral condensation.
Introduction of new root canal instrumentation
systems, techniques and sealers with improved
characteristics resulted in more frequent usage of
single cone obturation technique. The single-cone
technique comprises the use of sealers with single
gutta-percha point corresponding to the geometry of
the NiTi rotary instruments, providing better
adaptation of the point to the root canal walls [12,
13]. In cases where extensive root canal instrumenta-
tion is indicated, there is a risk of root fracture during
obturation. Using GuttaFlow2 system, there is no
need for lateral compaction of gutta-percha, signi-
ficant pressure on the root canal walls is missing and
vertical fracture risk is reduced.
Flowable cold technique does not require a high
degree of practice and manipulative skills of the
operator. It is fairly simple and time consuming tech-
nique. Root canal filling procedure of multi rooted
tooth could be performed in significantly less time.
This material has a setting time of 25-30 minutes and
post-endodontic restoration could be done on the
same day. Silicone based sealer can be removed from
the canals more easily then resin based sealer [3].
From the perspective of clinical practice, the material
is inexpensive, very manipulative and does not requ-
ire additional instruments and devices for its proper
application.
Disadvantage of clinical use GuttaFlow2 material,
as well as other injection systems, is overextension of
material in surrounding periapical tissues due to its
viscosity [3]. Failure of working length determina-
tion, such as apical perforation or enlargement of the
apical constriction, may lead to material overfilling
with increased incidence of postoperative pain, pro-
longed healing period and lower success rate. It is
6. Kontakiotis EG, Tzanetakis GN, Loizides AL. A 12-
month longitudinal in vitro leakage study on a
new silicon-based root canal filling material
(Gutta-Flow). Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2007; 103(6):854-859.
7. Konjhodžić-Prcić A. Evaluation of bio-compati-
bility of different endodonic sealers on the
culture of humane fibroblasts and fibroblasts of
mouse in Sarajevo: University in Sarajevo, Faculty
of Dentistr ; 2012
8. Martins VJ, Lins RX, Berlinck TC, Fidel RA.
Cytotoxicity of root canal sealers on endothelial
cell cultures. Braz Dent J. 2013; 24(1):15-20.
9. Nawal RR, Parande M, Sehgal R, Rao NR, Naik A. A
comparative evaluation of 3 root canal filling
systems. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2011; 111(3):387-393.
10. Leski M, Pawlicka H. A comparison of the pene-
tration of three sealers into dentinal tubules: a
SEM study. Int Endod J. 2005:38;932–934.
11. Saraf-Dadpe A, Kamra A.I. A scanning electron
microscopic evaluation of the penetration of root
canal dentinal tubules by four different endodon-
tic sealers: A zinc oxide eugenol-based sealer, two
rasin-based sealers and polydimethylsiloxane-
based sealer – An in vitro study, Endodontology,
2012 Dec; 24 (2): 50-58
12. Economides N, Kokorikos I, Kolokouris I, Pana-
giotis B, Gogos C. Comparative study of apical
sealing ability of a new resin-based root canal
sealer. J Endod. 2004;30(6):403-405.
13. Monticelli F, Sadek FT, Schuster GS, Volkmann KR,
Looney SW, Ferrari M. Efficacy of two contempo-
rary single-cone filling techniques in preventing
bacterial leakage. J Endod. 2007;33(3):310-313.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
61
Orthodontics is a fast developing science such as
the very field of dentistry in general. The attempt of
this book is to propose the basics of orthodontic
diagnostics beside the ones presented in established
and outstanding publications available elsewhere.
Presented chapters transmit basic information as
well as other clinical experiences concerning
orthodontic diagnostics. In the hands of the reader
this book may be an useful tool for exploring the
application of information and knowledge to some
orthodontic issues and questions.
With a concise, focused review of orthodontic
concepts of diagnostics and current clinical
information this book is the resource you need to
achieve the best results for success regarding the
competencies in examinations as well as for excellent
clinical outcomes. Regarding essential concepts of
treatment planning and clinical treatment, this book
includes a variety of information from distinguished
educators and practicing professionals that may help
you to prepare your clinical and met rical
examinations. The chapter “Radiological diagnostics”
addresses the key clinical issues answered with the
use of digital models and cone beam CT (CBCT)
becoming the standard for the investigation of
maxillofacial structures in all three dimensions -
especially in orthodontics and maxillofacial surgery.
BOOK REVIEW / PRIKAZ KNJIGE
The chapter “Determination of biological age”
addresses craniofacial growth and dentition
development, helping to select the proper timing of
orthodontic treatment for different problems.
This comprehensive resource offers a concise
review of orthodontic concepts, diagnosis and
treatment planning.
A practical
review makes this book an excellent study tool for the
students' exams, helps dentists in general practice
and in consultations with orthodontists, and assists
experienced orthodontists who wish to review their
diagnostics and keep up to date with advances in the
field.
The book is d ivided in seven chapters,
systematically organized to bring reader to successful
orthodontic diagnostics. The chapters are:
1. The Anatomical characteristics of craniofacial
system
2. Characteristics of primary dentition
3. Characteristics of mixed dentition
4. Characteristics of permanent dentition
5. Metrical analysis of study models
6. Radiologic diagnostics
7. The determination of biological age
The book is enriched with
numerous illustrations and as such, is extremely
useful not only for dental students but also to general
dentists and residents of orthodontics.
TITLE:
AUTHORS:
PUBLISHER:
LANGUAGE:
FORMAT:
NUMBER OF PAGES:
DATE OF ISSUE:
ISBN:
Basics of orthodontic
diagnostics
Enita Nakaš,
Alisa Tiro,
Vildana Džemidžić,
Lejla Redžepagić-Vražalica,
Muhamed Ajanović
Faculty of Dentistry with Clinics,
University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
Bosnian
Softcover
95
2014
978-9958-9051-5-5
Stomatološki vjesnik 2015; 4 (1)
61
Orthodontics is a fast developing science such as
the very field of dentistry in general. The attempt of
this book is to propose the basics of orthodontic
diagnostics beside the ones presented in established
and outstanding publications available elsewhere.
Presented chapters transmit basic information as
well as other clinical experiences concerning
orthodontic diagnostics. In the hands of the reader
this book may be an useful tool for exploring the
application of information and knowledge to some
orthodontic issues and questions.
With a concise, focused review of orthodontic
concepts of diagnostics and current clinical
information this book is the resource you need to
achieve the best results for success regarding the
competencies in examinations as well as for excellent
clinical outcomes. Regarding essential concepts of
treatment planning and clinical treatment, this book
includes a variety of information from distinguished
educators and practicing professionals that may help
you to prepare your clinical and met rical
examinations. The chapter “Radiological diagnostics”
addresses the key clinical issues answered with the
use of digital models and cone beam CT (CBCT)
becoming the standard for the investigation of
maxillofacial structures in all three dimensions -
especially in orthodontics and maxillofacial surgery.
BOOK REVIEW / PRIKAZ KNJIGE
The chapter “Determination of biological age”
addresses craniofacial growth and dentition
development, helping to select the proper timing of
orthodontic treatment for different problems.
This comprehensive resource offers a concise
review of orthodontic concepts, diagnosis and
treatment planning.
A practical
review makes this book an excellent study tool for the
students' exams, helps dentists in general practice
and in consultations with orthodontists, and assists
experienced orthodontists who wish to review their
diagnostics and keep up to date with advances in the
field.
The book is divided in seven cha pters,
systematically organized to bring reader to successful
orthodontic diagnostics. The chapters are:
1. The Anatomical characteristics of craniofacial
system
2. Characteristics of primary dentition
3. Characteristics of mixed dentition
4. Characteristics of permanent dentition
5. Metrical analysis of study models
6. Radiologic diagnostics
7. The determination of biological age
The book is enriched with
numerous illustrations and as such, is extremely
useful not only for dental students but also to general
dentists and residents of orthodontics.
TITLE:
AUTHORS:
PUBLISHER:
LANGUAGE:
FORMAT:
NUMBER OF PAGES:
DATE OF ISSUE:
ISBN:
Basics of orthodontic
diagnostics
Enita Nakaš,
Alisa Tiro,
Vildana Džemidžić,
Lejla Redžepagić-Vražalica,
Muhamed Ajanović
Faculty of Dentistry with Clinics,
University of Sarajevo,
Sarajevo, Bosnia and Herzegovina
Bosnian
Softcover
95
2014
978-9958-9051-5-5
Stomatološki vjesnik 2015; 4 (1)
63
INSTRUCTIONS FOR THE AUTHORS
Submissions of manuscripts are made through
the submission form available at web page of
the Journal (www.stomatoloskivjesnik.ba) or
by sending the email to Editorial office at
radovi@stomatoloski vjesnik.ba
E-mail must be composed of:
A) Covering letter, in which authors explain the
importance of their study (Explanation why we
should publish your manuscript ie. what is new
and what is important about your manuscript,
etc).
B) Title of the manuscript
C) Authors' names and email addresses (mark
corresponding author with *)
D) Abstract
E) Attached file of the Copyright assignment form
and
F) Manuscript.
Authors should NOT in addition post a hard copy
of the manuscript and submission letter, unless they
are supplying artwork, letters or files that cannot be
submitted electronically, or have been instructed to
do so by the editorial office.
Please read Instructions carefully to improve
yours paper's chances for acceptance for publi-
shing.
Thank you for your interest in submitting an
article to Stomatološki vjesnik.
Type of papers suitable for publishing in Sto-
matološki vijesnik (Journal in following text):
Original Articles, Case Reports, Letters to the Edi-
tors, Current Perspectives, Editorials, and Fast-Track
Articles are suitable for publishing in Stomatološki
vjesnik. Papers must be fully written in English with
at least title, abstract and key words bilingual in Bos-
nian/Croatian/Serbian language (B/C/S) and Eng-
lish language.
Editorial process:
All submitted manuscripts are initially evaluated
by at least two scientific and academic members of
editorial board. An initial decision is usually reached
within 3–7 days.
Submitted manuscripts may be rejected without
detailed comments after initial review by editorial
board if the manuscripts are considered inappro-
priate or of insufficient scientific priority for publi-
cation in Stomatološki vjesnik.
If sent for review, each manuscript is reviewed by
scientists in the relevant field. Decisions on reviewed
manuscripts are usually reached within one month.
When submission of a revised manuscript is invited
following review, the revision must be received in
short time of the decision date.
Criteria for acceptance:
Submitted manuscripts may be rejected without
detailed comments after initial review by editorial
board if the manuscripts are considered inappropria-
te or of insufficient scientific priority for publication
in the Journal. All other manuscripts undergo a com-
plete review by reviewers or other selected experts.
Criteria for acceptance include originality, validity of
data, clarity of writing, strength of the conclusions,
and potential importance of the work to the field of
dentistry and similar bio-medical sciences. Submit-
ted manuscripts will not be reviewed if they do not
meet the Instructions for authors, which are based on
"Uniform Requirements for Manuscripts Submitted
to Biomedical Journals" (http://www.icmje.org/).
INSTRUCTIONS FOR THE AUTHORS
made in accordance with the recommendations of the International
Committee of Medical Journal based on "Uniform Requirements for
Manuscripts Submitted to Biomedical Journals" (http://www.icmje.org/).
Stomatološki vjesnik 2015; 4 (1)
63
INSTRUCTIONS FOR THE AUTHORS
Submissions of manuscripts are made through
the submission form available at web page of
the Journal (www.stomatoloskivjesnik.ba) or
by sending the email to Editorial office at
radovi@stomatoloski vjesnik.ba
E-mail must be composed of:
A) Covering letter, in which authors explain the
importance of their study (Explanation why we
should publish your manuscript ie. what is new
and what is important about your manuscript,
etc).
B) Title of the manuscript
C) Authors' names and email addresses (mark
corresponding author with *)
D) Abstract
E) Attached file of the Copyright assignment form
and
F) Manuscript.
Authors should NOT in addition post a hard copy
of the manuscript and submission letter, unless they
are supplying artwork, letters or files that cannot be
submitted electronically, or have been instructed to
do so by the editorial office.
Please read Instructions carefully to improve
yours paper's chances for acceptance for publi-
shing.
Thank you for your interest in submitting an
article to Stomatološki vjesnik.
Type of papers suitable for publishing in Sto-
matološki vijesnik (Journal in following text):
Original Articles, Case Reports, Letters to the Edi-
tors, Current Perspectives, Editorials, and Fast-Track
Articles are suitable for publishing in Stomatološki
vjesnik. Papers must be fully written in English with
at least title, abstract and key words bilingual in Bos-
nian/Croatian/Serbian language (B/C/S) and Eng-
lish language.
Editorial process:
All submitted manuscripts are initially evaluated
by at least two scientific and academic members of
editorial board. An initial decision is usually reached
within 3–7 days.
Submitted manuscripts may be rejected without
detailed comments after initial review by editorial
board if the manuscripts are considered inappro-
priate or of insufficient scientific priority for publi-
cation in Stomatološki vjesnik.
If sent for review, each manuscript is reviewed by
scientists in the relevant field. Decisions on reviewed
manuscripts are usually reached within one month.
When submission of a revised manuscript is invited
following review, the revision must be received in
short time of the decision date.
Criteria for acceptance:
Submitted manuscripts may be rejected without
detailed comments after initial review by editorial
board if the manuscripts are considered inappropria-
te or of insufficient scientific priority for publication
in the Journal. All other manuscripts undergo a com-
plete review by reviewers or other selected experts.
Criteria for acceptance include originality, validity of
data, clarity of writing, strength of the conclusions,
and potential importance of the work to the field of
dentistry and similar bio-medical sciences. Submit-
ted manuscripts will not be reviewed if they do not
meet the Instructions for authors, which are based on
"Uniform Requirements for Manuscripts Submitted
to Biomedical Journals" (http://www.icmje.org/).
INSTRUCTIONS FOR THE AUTHORS
made in accordance with the recommendations of the International
Committee of Medical Journal based on "Uniform Requirements for
Manuscripts Submitted to Biomedical Journals" (http://www.icmje.org/).
Stomatološki vjesnik 2015; 4 (1)
65
64
INSTRUCTIONS FOR THE AUTHORS
national bodies should be avoided. Use only standard
abbreviations. Avoid abbreviations in the title and
abstract. The full term for which an abbreviation
stands should precede its first use in the text unless it
is a standard unit of measure-ment.
The Title Page should carry the full title of the pa-
per and a short title to be used as a 'running head'
(and which should be so identified). The first name,
middle initial and last name of each author should
appear marked with superscript numbers or/and
symbols corresponding to their affiliation or/and
note. Affiliations of the authors should be written be-
low authors name list. Full name, address, phone and
fax number and e-mail of the author responsible for
correspondence should appear on the Title Page.
Please include the word count of the abstract and
word count of text on the title page.
The second page should carry a structured
abstract of no more than 250 words. The abstract
should state the Objective(s) of the study or investi-
gation, basic Methods (selection of study subjects or
laboratory animals; obser-vational and analytical
methods), main Results (giving specific data and
their statistical significance, if possible), and the
principal Conclusions. It should emphasize new and
important aspects of the study or observations.
The abstract should be followed by a list of 3–10
keywords or short phrases which will assist the
cross-indexing of the article and which may be publi-
shed. When possible, the terms used should be from
the Medical Subject Headings list of the National
Library of Medicine (http://www.nlm.nih.gov/
mesh/meshhome.html).
Body of the manuscript text of an experimental
or observational nature may be divided into sections
headed Introduction, Materials and Methods (inclu-
ding ethical and statistical information), Results,
Discussion and Conclusion, although reviews may
require a different format.
Original Articles: original experimental and clini-
cal studies should not exceed 4400 words (up to 15
pages) including tables and references.
With Case Reports: presentation of a clinical case
which may suggest novel working hypotheses, with a
short discussion on the pertinent literature. The text
should not exceed 2400 words (up to 8 pages).
Letters to the Editors should not exceed 500
words, should not be signed by more than three
authors and should not have more than 5 references.
Preferably, letters should be in reference to a Journal
article published within the last 3 months or to novel
hypotheses so as to stimulate comments on issues of
common interest. Authors of the letters accepted for
publication will receive the galley proofs. The Editors
will generally solicit replies. The Editors reserve the
right to modify the text.
Current Perspectives: invited articles by recogni-
zed authorities, to include position papers, reviews,
and special topics of general interest. Independent
submission will also be considered.
Editorials: invited articles or brief editorial com-
ments that represent opinions of recognized leaders
in biomedical research.
Fast-Track Articles: short articles on laboratory or
clinical findings, representing important new in-
sights or major advances, produced with established
methods or new applications of an established or
new method. The text should not exceed 2400 words.
Acknowledgements: One or more statements
should specify (a) contributions that need acknow-
ledging but do not justify authorship, such as general
support by a department chairman; (b) acknow-
ledgements of technical help; (c) acknowledgements
of financial and material support, specifying the
nature of the support. Persons who have contributed
intellectually to the paper but whose contributions
do not justify authorship may be named and their
function or contribution described – for example,
'scientific adviser', 'critical review of study proposal',
'data collection', 'participation in clinical trial'. Such
persons must have given their permission to be na-
med. Authors are responsible for obtaining written
permission from persons acknowledged by name
because readers may infer their endorsement of the
data and conclusions.
Declaration of Interest
A statement must be provided listing all financial
support received for the work and, for all authors, any
INSTRUCTIONS FOR THE AUTHORS
Authorship:
All authors have to sign the copyright assignment
form. We ask all authors to confirm that: they have
met the criteria for authorship as established by the
International Committee of Medical Journal Editors;
they believe that the paper represents honest work,
and are able to verify the validity of the results re-
ported.
Redundant or duplicate publication:
We ask the authors to confirm in the copyright
assignment form that the paper has not been publi-
shed in its current form or a substantially similar
form (in print or electronically, including on a web
site), that it has not been accepted for publication
elsewhere, and that it is not under consideration by
another publication. The International Committee of
Medical Journal Editors has provided details of what
is and what is not duplicate or redundant publi-
cation (http://www.icmje.org). In the submission
letter to the editors, authors are asked to draw
attention to any published work that concerns the
same patients or subjects as the present paper.
Author Contributions:
Authors are required to include a statement
to verify the contributions of each co-author in the
copyr i ght assi g nm e nt f or m (avail a bl e at
www.stomatoloskivjes nik.ba ).
Patient consent forms:
The protection of a patient's right to privacy is
essential. The authors may be asked by the editorial
board to send copy of patient consent forms on which
patients or other subjects of the experiments clearly
grant permission for the publication of photographs
or other material that might identify them. If the
consent form for the research did not specifically
include this, authors should obtain it or remove the
identifying material.
Ethics committee approval:
The authors must state clearly in the submission
letter and in the Methods section that the conducted
studies on human participants are with the approval
of an appro-priate named ethics committee. Please
also look at the latest version of the Declaration of
Helsinki (http:// www.wma.net/e/policy/b3.htm).
Similarly, the authors must confirm that experiments
involving animals adhered to ethical standards and
must state the care of animal and licensing guidelines
under which the study was perfor-med. The editorial
board may ask author(s) for copy of ethical
committee approval.
Declaration of Interest:
We ask the authors to state all potential financial
support received for the work. This applies to all
papers including editorials and letters to the editor
(see below). If you are sure that there is no conflict of
interest, please state that.
Copyright:
Copyright assignment form contains authors' sta-
tement that all the copyrights are transferred to the
publisher if and when the manuscript is accepted for
publishing.
Subscribers may reproduce tables of contents or
prepare lists of articles including abstracts for inter-
nal circulation within their institutions. Permission
of the Publisher is required for resale or distribution
outside the institution and for all other derivative
works, including compilations and translations. If
excerpts from other copyrighted works are included,
the author(s) must obtain written permission from
the publisher and credit the source(s) in the article.
Formatting requirements:
Manuscript should be written in Times New Ro-
man 12, Normal, double spacing.
Include the following sections, each starting on a
separate page: Title Page, Abstract and Keywords,
Text, Acknowledgements, Declaration of interest, Re-
ferences, Individual tables and figures with captions.
Margins should be not less than 3 cm. Pages
should be numbered consecutively, beginning with
the Title Page, and the page number should be placed
in the bottom right hand corner of each page.
Abbreviations should be defined on their first
appearance in the text; those not accepted by inter-
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
65
64
INSTRUCTIONS FOR THE AUTHORS
national bodies should be avoided. Use only standard
abbreviations. Avoid abbreviations in the title and
abstract. The full term for which an abbreviation
stands should precede its first use in the text unless it
is a standard unit of measure-ment.
The Title Page should carry the full title of the pa-
per and a short title to be used as a 'running head'
(and which should be so identified). The first name,
middle initial and last name of each author should
appear marked with superscript numbers or/and
symbols corresponding to their affiliation or/and
note. Affiliations of the authors should be written be-
low authors name list. Full name, address, phone and
fax number and e-mail of the author responsible for
correspondence should appear on the Title Page.
Please include the word count of the abstract and
word count of text on the title page.
The second page should carry a structured
abstract of no more than 250 words. The abstract
should state the Objective(s) of the study or investi-
gation, basic Methods (selection of study subjects or
laboratory animals; obser-vational and analytical
methods), main Results (giving specific data and
their statistical significance, if possible), and the
principal Conclusions. It should emphasize new and
important aspects of the study or observations.
The abstract should be followed by a list of 3–10
keywords or short phrases which will assist the
cross-indexing of the article and which may be publi-
shed. When possible, the terms used should be from
the Medical Subject Headings list of the National
Library of Medicine (http://www.nlm.nih.gov/
mesh/meshhome.html).
Body of the manuscript text of an experimental
or observational nature may be divided into sections
headed Introduction, Materials and Methods (inclu-
ding ethical and statistical information), Results,
Discussion and Conclusion, although reviews may
require a different format.
Original Articles: original experimental and clini-
cal studies should not exceed 4400 words (up to 15
pages) including tables and references.
With Case Reports: presentation of a clinical case
which may suggest novel working hypotheses, with a
short discussion on the pertinent literature. The text
should not exceed 2400 words (up to 8 pages).
Letters to the Editors should not exceed 500
words, should not be signed by more than three
authors and should not have more than 5 references.
Preferably, letters should be in reference to a Journal
article published within the last 3 months or to novel
hypotheses so as to stimulate comments on issues of
common interest. Authors of the letters accepted for
publication will receive the galley proofs. The Editors
will generally solicit replies. The Editors reserve the
right to modify the text.
Current Perspectives: invited articles by recogni-
zed authorities, to include position papers, reviews,
and special topics of general interest. Independent
submission will also be considered.
Editorials: invited articles or brief editorial com-
ments that represent opinions of recognized leaders
in biomedical research.
Fast-Track Articles: short articles on laboratory or
clinical findings, representing important new in-
sights or major advances, produced with established
methods or new applications of an established or
new method. The text should not exceed 2400 words.
Acknowledgements: One or more statements
should specify (a) contributions that need acknow-
ledging but do not justify authorship, such as general
support by a department chairman; (b) acknow-
ledgements of technical help; (c) acknowledgements
of financial and material support, specifying the
nature of the support. Persons who have contributed
intellectually to the paper but whose contributions
do not justify authorship may be named and their
function or contribution described – for example,
'scientific adviser', 'critical review of study proposal',
'data collection', 'participation in clinical trial'. Such
persons must have given their permission to be na-
med. Authors are responsible for obtaining written
permission from persons acknowledged by name
because readers may infer their endorsement of the
data and conclusions.
Declaration of Interest
A statement must be provided listing all financial
support received for the work and, for all authors, any
INSTRUCTIONS FOR THE AUTHORS
Authorship:
All authors have to sign the copyright assignment
form. We ask all authors to confirm that: they have
met the criteria for authorship as established by the
International Committee of Medical Journal Editors;
they believe that the paper represents honest work,
and are able to verify the validity of the results re-
ported.
Redundant or duplicate publication:
We ask the authors to confirm in the copyright
assignment form that the paper has not been publi-
shed in its current form or a substantially similar
form (in print or electronically, including on a web
site), that it has not been accepted for publication
elsewhere, and that it is not under consideration by
another publication. The International Committee of
Medical Journal Editors has provided details of what
is and what is not duplicate or redundant publi-
cation (http://www.icmje.org). In the submission
letter to the editors, authors are asked to draw
attention to any published work that concerns the
same patients or subjects as the present paper.
Author Contributions:
Authors are required to include a statement
to verify the contributions of each co-author in the
copyr i ght assi g nm e nt f or m (avail a bl e at
www.stomatoloskivjes nik.ba ).
Patient consent forms:
The protection of a patient's right to privacy is
essential. The authors may be asked by the editorial
board to send copy of patient consent forms on which
patients or other subjects of the experiments clearly
grant permission for the publication of photographs
or other material that might identify them. If the
consent form for the research did not specifically
include this, authors should obtain it or remove the
identifying material.
Ethics committee approval:
The authors must state clearly in the submission
letter and in the Methods section that the conducted
studies on human participants are with the approval
of an appro-priate named ethics committee. Please
also look at the latest version of the Declaration of
Helsinki (http:// www.wma.net/e/policy/b3.htm).
Similarly, the authors must confirm that experiments
involving animals adhered to ethical standards and
must state the care of animal and licensing guidelines
under which the study was perfor-med. The editorial
board may ask author(s) for copy of ethical
committee approval.
Declaration of Interest:
We ask the authors to state all potential financial
support received for the work. This applies to all
papers including editorials and letters to the editor
(see below). If you are sure that there is no conflict of
interest, please state that.
Copyright:
Copyright assignment form contains authors' sta-
tement that all the copyrights are transferred to the
publisher if and when the manuscript is accepted for
publishing.
Subscribers may reproduce tables of contents or
prepare lists of articles including abstracts for inter-
nal circulation within their institutions. Permission
of the Publisher is required for resale or distribution
outside the institution and for all other derivative
works, including compilations and translations. If
excerpts from other copyrighted works are included,
the author(s) must obtain written permission from
the publisher and credit the source(s) in the article.
Formatting requirements:
Manuscript should be written in Times New Ro-
man 12, Normal, double spacing.
Include the following sections, each starting on a
separate page: Title Page, Abstract and Keywords,
Text, Acknowledgements, Declaration of interest, Re-
ferences, Individual tables and figures with captions.
Margins should be not less than 3 cm. Pages
should be numbered consecutively, beginning with
the Title Page, and the page number should be placed
in the bottom right hand corner of each page.
Abbreviations should be defined on their first
appearance in the text; those not accepted by inter-
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
67
66
INSTRUCTIONS FOR THE AUTHORS
financial involvement (including employment, fees,
share ownership) or affiliation with any organization
whose financial interests may be affected by material
in the manuscript, or which might potentially bias it.
This applies to all papers including editorials and
letters to the editor. If you are sure that there is no
conflict of interest, please state this.
References
References should be numbered consecutively in
the order in which they first appear in the text. They
should be assigned Arabic numerals, which should be
given in brackets, e.g. [17]. References should include
the names of all authors when six or fewer; when
seven or more, list only the first six names and add et
al. References should also include full title and source
information (Vancouver style).
Journal names should be abbreviated as in
MEDLINE (http://www.medscape.com/Home/
Search/ IndexMedicus/IndexMedicus.html).
Examples of citation:
Standard journal article:
Tashiro H, Shimokawa H, Sadamatu K, Yamamoto
K. Prognostic significance of plasma concentra-
tions of transforming growth factor-ß. Coron
Artery Dis 2002; 13(3):139-143.
More than six authors:
Yetkin E, Senen K, Ileri M, Atak R, Tandogan I,
Yetkin Ö, et al. Comparison of low-dose dobuta-
mine stress echocardiography and echocardio-
graphy during glucose-insulin-potassium infu-
sion for detection of myocardial viability after
anterior myocardial infarction. Coron Artery Dis
2002; 13(3):145-149.
Books:
Heger JW, Niemann JT, Criley JM. Cardiology, 5th
ed. Philadelphia: Lippincott, Williams & Wilkins;
2003.
Chapter in a book:
Braunwald E, Perloff JK. Physical examination of
the heart and circulation. In; Braunwald E, Zipes
DP, Libby P (eds). Heart disease; a textbook of
cardiovascular medicine, 6th edn. Philadelphia:
WB Saunders; 2001, pp. 45-81.
Personal communications and unpublished work
should not feature in the reference list but should
appear in parentheses in the text. Unpublished work
accepted for publication but not yet released should
be included in the reference list with the words 'in
press' in parentheses beside the name of the journal
concerned. References must be verified by the
author(s) against the original documents.
Tables
• Provide each table on a separate page of the
manuscript after the references.
• Each table should be typed on a separate sheet in
double spacing.
• Number the table according to their sequence in
the text. The text should include references to all
tables. Each table should be assigned an Arabic
numeral, e.g. (Table 3).
• Include a brief and self-explanatory title with
explanations essential to the understanding of the
table at the bottom of the table.
• Identify statistical measures of variations, such as
standard deviation and standard error of the
mean or other where appropriate.
Figures
• Provide each figure on a separate page of the
manuscript after the references. Number the
figures according to their sequence in the text. The
text should include references to all figures.
• Graphs and figures should be in black/white or
greyscale format. Colour illustrations are accep-
table but not guaranteed. Minimal quality 300dpi,
figures should be filed in suitable format (*.JPG,
*.PNG, .*TIFF)
• If figures are not original provide source and
permition.
• All figures should be 100% of a suitable final size
and have the printing resolution of 300dpi and be
cropped to include the figure only (no blank
space).
INSTRUCTIONS FOR THE AUTHORS
Units of measurement
Measurements of length, height, weight, and volu-
me should be reported in metric units (meter, kilo-
gram, or liter) or their decimal multiples. All
hematologic and clinical chemistry measurements
should be reported in the metric system in terms of
the International System of Units (SI).
Post acceptance
All correspondence concerning the copy, editing
and production of accepted manuscripts should be
addressed to Stomatološki vjesnik.
Charges
Authors will not be charged fees in a first year of
publishing Stomatološki vjesnik. Optional charges
for colour reproduction of figures may apply. Authors
will be informed about this when the poof is supplied
to them. The charges must be completed before the
article is released.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
67
66
INSTRUCTIONS FOR THE AUTHORS
financial involvement (including employment, fees,
share ownership) or affiliation with any organization
whose financial interests may be affected by material
in the manuscript, or which might potentially bias it.
This applies to all papers including editorials and
letters to the editor. If you are sure that there is no
conflict of interest, please state this.
References
References should be numbered consecutively in
the order in which they first appear in the text. They
should be assigned Arabic numerals, which should be
given in brackets, e.g. [17]. References should include
the names of all authors when six or fewer; when
seven or more, list only the first six names and add et
al. References should also include full title and source
information (Vancouver style).
Journal names should be abbreviated as in
MEDLINE (http://www.medscape.com/Home/
Search/ IndexMedicus/IndexMedicus.html).
Examples of citation:
Standard journal article:
Tashiro H, Shimokawa H, Sadamatu K, Yamamoto
K. Prognostic significance of plasma concentra-
tions of transforming growth factor-ß. Coron
Artery Dis 2002; 13(3):139-143.
More than six authors:
Yetkin E, Senen K, Ileri M, Atak R, Tandogan I,
Yetkin Ö, et al. Comparison of low-dose dobuta-
mine stress echocardiography and echocardio-
graphy during glucose-insulin-potassium infu-
sion for detection of myocardial viability after
anterior myocardial infarction. Coron Artery Dis
2002; 13(3):145-149.
Books:
Heger JW, Niemann JT, Criley JM. Cardiology, 5th
ed. Philadelphia: Lippincott, Williams & Wilkins;
2003.
Chapter in a book:
Braunwald E, Perloff JK. Physical examination of
the heart and circulation. In; Braunwald E, Zipes
DP, Libby P (eds). Heart disease; a textbook of
cardiovascular medicine, 6th edn. Philadelphia:
WB Saunders; 2001, pp. 45-81.
Personal communications and unpublished work
should not feature in the reference list but should
appear in parentheses in the text. Unpublished work
accepted for publication but not yet released should
be included in the reference list with the words 'in
press' in parentheses beside the name of the journal
concerned. References must be verified by the
author(s) against the original documents.
Tables
• Provide each table on a separate page of the
manuscript after the references.
• Each table should be typed on a separate sheet in
double spacing.
• Number the table according to their sequence in
the text. The text should include references to all
tables. Each table should be assigned an Arabic
numeral, e.g. (Table 3).
• Include a brief and self-explanatory title with
explanations essential to the understanding of the
table at the bottom of the table.
• Identify statistical measures of variations, such as
standard deviation and standard error of the
mean or other where appropriate.
Figures
• Provide each figure on a separate page of the
manuscript after the references. Number the
figures according to their sequence in the text. The
text should include references to all figures.
• Graphs and figures should be in black/white or
greyscale format. Colour illustrations are accep-
table but not guaranteed. Minimal quality 300dpi,
figures should be filed in suitable format (*.JPG,
*.PNG, .*TIFF)
• If figures are not original provide source and
permition.
• All figures should be 100% of a suitable final size
and have the printing resolution of 300dpi and be
cropped to include the figure only (no blank
space).
INSTRUCTIONS FOR THE AUTHORS
Units of measurement
Measurements of length, height, weight, and volu-
me should be reported in metric units (meter, kilo-
gram, or liter) or their decimal multiples. All
hematologic and clinical chemistry measurements
should be reported in the metric system in terms of
the International System of Units (SI).
Post acceptance
All correspondence concerning the copy, editing
and production of accepted manuscripts should be
addressed to Stomatološki vjesnik.
Charges
Authors will not be charged fees in a first year of
publishing Stomatološki vjesnik. Optional charges
for colour reproduction of figures may apply. Authors
will be informed about this when the poof is supplied
to them. The charges must be completed before the
article is released.
Stomatološki vjesnik 2015; 4 (1) Stomatološki vjesnik 2015; 4 (1)
