revista romana de stomatologie supliment 2008

8/12/2019 Revista Romana de STOMATOLOGIE Supliment 2008

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Revista Romn deSTOMATOLOGIE

Volumul LIV

Nr. 3, SuplimentAn 2008

Cod CNCSIS 756

Prof. Dr. D. BORZEA Cluj-NapocaDr. C. BRUSCAGIN ItaliaProf. Dr. A. BUCUR BucuretiProf. Dr. V. BURLU IaiDr. Ugo CAPURSO Italia

Prof. Dr. V. CRLIGERIU TimiProf. Dr. Elvira COCRL Cluj-NapocaProf. Dr. M. CRIOIU CraiovaConf. Dr. B. DIMITRIU BucuretiProf. Dr. H. DUMITRIU BucuretiProf. Dr. L. ENE BucuretiProf. Dr. Norina FORNA IaiProf. Dr. A. GARFUNKEL IsraelProf. Dr. N. GANUTA BucuretiDr. I.B.T. GEORGESCU BucuretiProf. Dr. Ov. GRIVU Arad

Prof. Dr. A. ILIESCU BucuretiProf. Dr. Ecaterina IONESCU BucuretiConf. Univ. Dr. Ileana IONESCU Bucureti

Prof. Dr. S. IONI BucuretiConf. Dr. D.A. MARI ConstanaG-ral Prof. Dr. T.A. MIHAI BucuretiProf. Dr. S. SANDHAUS ElveiaProf. Dr. Valentina SCNTEI-DOROB Iai

Prof. Dr. A. SCHNEIDER GermaniaDr. Eugenia ROCA ItaliaProf. Dr. Mihaela PUNA BucuretiConf. Dr. Al. PETRE BucuretiProf. Dr. Mariana BrnduaPOPA BucuretiProf. Dr. S. POPA ClujDr. Ion RNDAU BucuretiProf. Dr. Dan Dumitru SLVESCU BucuretiConf. Dr. C. VRLAN BucuretiProf. Dr. Maria VORONEANU IaiProf. Dr. Theodor TRISTARU Bucureti

Conf. Dr. Irina ZETU IaiConf. Dr. Liviu ZETU Iai

ISSN 1843-0805

Redactor ef:Prof. Univ. Dr. Em. HUTU

Redactor ef Adjunct:Conf. Univ. Dr. M.V. CONSTANTINESCU

Secretar General de Redacie:ef Lucr. Dr. Elena-Gabriela DESPA

Dr. E. POPA

Redactor Responsabil de numr:ef Lucr. Dr. Liana STANCIU

Redactori verificare articole:Conf. Univ. Dr. Cornelia BCLEANU

ef Lucr. Dr. Tudor IONESCU, ef Lucr. Dr. Dnu CHIRUDr. Ingrid PINTILIE

Redactori Relaii Internaionale:ef Lucr. Dr. Alina DAN

Dr. Simona MUNTEAN

CONSILIUL TIINIFIC:


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Editura Medical AMALTEA

Editori: Dr. M.C. PopescuDr. Cristian Crstoiu

Director executiv:George StancaRedactori: Oana Cristina Plcint, Alina-Nicoleta Ilie

Prepress: AMALTEA TehnoPlusTehnoredactor:Gabriela Cpitnescu

DTP:Petronella AndreiProducie: Mihaela Conea

Distribuie: Mihaela Stanca________________

CONTACT: [email protected]:[email protected]

Revista este realizat n colaborare cuFacultatea de Medicin Dentar

a Universitii Titu Maiorescu,

Bucureti

TIPAR:

EMPIRE Print RomExpo, Pavilion T, Bucuretitel.: 021 / 316 96 40, 031 / 405 99 99

email: [email protected]

Universitatea de Medicin i Farmacie Carol Davila,

Facultatea de Medicin Dentar, Bucureti

Prof. Dr. Drago STANCIU DecanProf. Dr. Rodica LUCA Prodecan

Conf. Dr. Radu erban OVARU ProdecanConf. Dr. Codru SARAFOLEANU ProdecanProf. Dr. Victor NIMIGEAN Secretar tiinific

Universitatea Titu Maiorescu, Facultatea de Stomatologie, Bucureti

Prof. Dr. D. SLVESCU DecanProf. Dr. V. CHERLEA ProdecanProf. Dr. Mircea IFRIM Prodecan

Conf. Dr. Cornelia BCLEANU Secretar tiinific

Universitatea de Vest Vasile Goldi,

Facultatea de Medicin General i Medicin Dentar, Arad

Prof. Dr. Maria NEGUCIOIUProf. Dr. Voicu SEBEAN

Prof. Dr. Emil URTILConf. Dr. Valeria COVRIGConf. Dr. Mugur POPESCUConf. Dr. Emanuel BRATU


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Cuprins

ODONTOLOGIE1. Cornelia BcleanuAdministrarea de fluor pe cale general i local ____________________________________

2. Cornel Boitor,Anca FrilSensibilitatea dentinar dup restaurri coronare adezive: cauze i mijloace

de prevenie _____________________________________________________________________

3. Cornelia BcleanuPosibiliti terapeutice n distrucii coronare ntinse ___________________________________

PARODONTOLOGIE4. Theresa E. Madden, Brock Herriges, Linda Boyd, Gayle Laughlin, Gary T. Chlodo,David I. RosensteinAlterations in HbA1c Following Minimal or Enhanced Non-surgical,

Non-antibiotic Treatment of Gingivitis or Mild Periodontitis in Type 2

Diabetic Patients: A Pilot Trial_____________________________________________________

MATERIALE DENTARE5. Maurizio Sedda, Andrea Casarotto, Aune Rausita, Andrea Borracchini

Effect of Storage Time on the Accuracy of Casts Made from Different

Irreversible Hydrocolloids ________________________________________________________

CHIRURGIE ORO-MAXILO-FACIAL6. Mirela-Jeni Comancianu

Eludrilul i implicaiile lui n cazul extraciei molarului de minte superior ________________

7. Mehtap Muglali, Ayse Pinar SumerSquamous Cell Carcinoma Arising in a Residual Cyst: A Case Report ___________________

OCLUZOLOGIE8. Andre L.F. Costa, Anelyssa DAbreu, Fernandon Cendes

Temporomandibular Joint Internal Derangement: Association with Headache, Joint Effusion,

Bruxism, and Joint Pain __________________________________________________________

PROTETIC DENTAR9. Anca Fril,Cornel Boitor

Rolul zonei de nchidere velopalatinal n prevenirea eecurilor protezei mobile___________

10. Elena-Gabriela DespaRezultatele studiului clinic i statistic asupra cmpului protetic edentat total ______________

11. Elena-Gabriela Despa, Gabriela Moise

Aspecte ale micrilor mandibulare la edentatul total _________________________________


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REVISTAROMNDESTOMATOLOGIE VOL. LIV, NR. 3, SUPLIMENT, AN2008156

1

METODE DE ADMINISTRARE GENERAL AFLUORULUI

n urma unor studii ample, s-a determinat cfluorul este singurul element mineral unanimcorelat cu rezistena la carie a dinilor.

Prevenirea cariei dentare prin administrarea defluor reprezint modalitatea prin care s-au obinutcele mai importante rezultate.

Ca urmare, administrarea fluorului se poaterealiza pe cale general i pe cale local.

Dintre modalitile de administrare a fluorului, pecale general, cea mai indicat, (n special ca raportcost/eficien) este prin consumul de ap fluorizat.

S-au fcut numeroase studii privind concen-traia optim a fluorului n ap, toate demonstrndca reducerea cea mai spectaculoas a incideneicariei se produce pn la o concentraie de 1 ppm,concentraie la care leziunile distrofice de fluorozsunt rare i de minim gravitate.

O sintez a 95 de studii din 20 de ri, realizaten condiii diferite privind eficacitatea preveniriicariei dentare la copii prin fluorizarea apei, arat

o reducere cu peste 40% a cariilor dinilor per-maneni (Naylor i Murray-1976).De asemenea fluorul prezint o aciune benefic

i asupra persoanelor adulte rezidente permanentntr-o localitate cu ap fluorizat. La acestea s-aconstatat o reducere cu 45% a numrului de su-prafee cariate comparativ cu o populaie ce con-sum ap cu un coninut sczut de fluor.

Astfel se poate concluziona c fluorizarea apeiare un efect protectiv substanial i de durat.

Fluorizarea apei, combinat cu celelalte msuri

preventive a redus prevalena cariei cu circa 75%n general, iar pentru suprafeele aproximale chiarcu 90%.

La adulii cu vrsta ntre 20-44 ani s-a estimatn urma consumului de ap fluorizat o reducere

cu 20-30% a cariilor coronare i o reducerecuprins ntre 20-40% a cariilor radiculare.

De asemenea, s-a demonstrat c fluorul pre-zint efectul cariopreventiv cel mai mare pesuprafeele libere 86%, apoi pe suprafeeleaproximale 75%, iar cel mai mic efect cario-preventiv l prezint la nivelul anurilor i fo-setelor ocluzale 31%.

Toate aceste date i-au permis lui Horowitz safirme c fluorizarea apei asigur beneficii tuturorpersoanelor dentate de-a lungul ntregii viei.

O alt metod de administrare general afluorului este prin fluorizarea srii de buctrie cese realizeaz cu 200-250 mg fluorur de Na la1kg de sare, asigurndu-se astfel un aport de pnla 2 mg Fluor la un consum mediu de 6g sare/zi.

Fluorizarea srii de buctrie nu necesit dect3% din cantitatea de fluor necesar pentru fluori-zarea apei ns efectul carioprotectiv este ceva maisczut dect cel care se ntlnete n urma fluori-zrii apei potabile.

Fluorizarea laptelui i a buturilor rcoritoareare de asemenea efecte carioprotective ns maisczute dect cele obinute n urma fluorizrii apeipotabile.

Stephen (1981) a artat c un consum zilnic ncoal de 200 ml lapte cu coninut de 1,5 mg defluor pe timp de 4 ani a redus incidena cariei laprimii molari permaneni cu 34% comparativ culotul martor.

De asemenea GEDALIA (1981) a raportat oreducere cu 28% a indicelui DMF S la copiii de

6-9 ani care au consumat la coal 100 g suc deportocale coninnd 1 mg F (10 ppm) pe o perioadde 3 ani.

ADMINISTRAREA DE FLUOR PE CALEGENERAL I LOCAL

General and Local Fluorine Administration

Conf. Dr. Cornelia BcleanuDisciplina Odontoterapie restauratoare, Facultatea de Medicin Dentar,

Universitatea Titu Maiorescu, Bucureti

ODONTOLOGIE


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157REVISTAROMNDESTOMATOLOGIE VOL. LIV, NR. 3, SUPLIMENT, AN2008

n ceea ce privete fluorizarea alimentelor,aceasta prezint dezavantajul unui dozaj relativprin diferenele cantitative de ingestie alimentar

ntre indivizi, iar compoziia deosebit a meniurilorface imposibil stabilirea unui echilibru de dozarea fluorului.

O alt metod de administrare a fluorului pecale general este prin administrarea tabletelor isoluiilor ce conin fluor.

n literatura de specialitate au aprut mai multearticole ce se refer la eficacitatea administrriitabletelor sau soluiilor, articole ce au fost sinteti-zate de ctre DRISCOL 1974 i BINDER 1978.

Aceste cercetri pot fi mprite n trei grupedup modul de administrare:

1. prenatal;2. nainte de vrsta colar;

3. la coal i numai n timpul colii.

1. Administrarea de fluor prenataleste beneficn profilaxia cariei la copii, n special pentru dentiiatemporar dar cele mai bune rezultate se obin daceste continuat prin administrare de fluor la copilct mai curnd dup natere.

2. Potrivit diferitelor studii se arat c efectelecarioprotective mari (circa 50-80%) s-au obinutdac administrarea fluorului s-a nceput nainte devrsta de 2 ani.

Efectele cele mai bune s-au obinut unde dozelede fluor au fost corelate cu concentraia fluoruluidin ap i cu vrsta copilului (HENON 1977).

Studiile privind efectul administrrii fluoruluisub form de tablete sau soluii asupra dinilor per-maneni arat o reducere important a cariilor maiales dac administrarea s-a fcut de la natere celpuin 7 ani (ntre 39 i 80%).

3. Administrarea tabletelor sau soluiilor cufluor n coal ncepnd cu clasa I (6-7 ani), cu o

durat de minimum 5 ani s-a dovedit cario-preventiv n medie de 30% (DRISCOL 1978).Aceste cercetri arat fr nici un dubiu c

folosirea tabletelor sau soluiilor este eficient nprevenirea cariilor dentare att la dinii temporarict i la cei permaneni.

Dup vrsta de 2 ani este de preferat s seadministreze fluorul sub form de tablete, copilulfiind instruit s le sug seara, nainte de culcare,pentru a combina efectul general cu cel localasupra dinilor temporari.

Se folosesc tablete de fluor: Concaden;Zymafluor; Law.

Cu o cantitate de fluor de: 0,25 mg; 0,50 mg;0,75 mg; 1 mg

Cantitatea de fluor administrat trebuie corelatcu:

concentraia fluorului din apa potabil; vrsta copilului; zona climatic.Pentru zona de clim temperat, dac fluorul

din apa potabil nu depete 0,4 ppm, se admi-nistreaz n funcie de greutatea copilului:

de la natere pn la 10 kg 0,25 mg F/zi; de la 10 kg la 15 kg 0,5 mg F/zi; de la 15 kg la 20 kg 0,75 mg F/zi; peste 25 kg 1 mg F/zi.Pentru obinerea efectului cariostatic este ne-

cesar aportul minim de 1,3 mg de fluor zilnic pecale general.

Suplimentarea, indiferent de metod, se rapor-teaz la:

concentraia din apa potabil; cantitatea de ap potabil consumat n

medie pe zi; aportul mediu oferit prin alimente; concentraia din atmosfer, pentru zonele cu

poluare fluorurat.Pentru a fi eficace metodele de administrare ge-

neral trebuie: s foloseasc faza I (amelogenez i mine-

ralizare); s se prelungeasc n faza a II-a (de maturare

preeruptiv); s se prelungeasc chiar i la nceputul fazei

a III-a (posteruptiv) cnd se completeazmaturarea superficial a smalului.

Programul complet ncepe prin administrareazilnic de fluor la femeia gravid ncepnd cu lunaa IV-a de sarcin i pn la natere, se continuadministrarea la copil ncepnd ct mai aproapede momentul naterii, zilnic, pn la vrsta de 12-14ani, fr ntrerupere.

Administrarea numai n prima faz (0-6 ani)sau numai n a II-a faz (6-12 ani) reduce multeficacitatea cu perspectiva de a se pierde efectul

n timp.Dac se respect programul complet (cel puin

de la 0 la 12 ani) n toate metodele se obin rezul-tate egale.

Diferenele sunt doar n privina costului, uu-rina de administrare i posibilitile de abordare aunor colectiviti ct mai mari.

METODE DE FLUORIZARE LOCAL

Fluorizarea local se poate realiza profesionaldar i personal.


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158 REVISTAROMNDESTOMATOLOGIE VOL. LIV, NR. 3, SUPLIMENT, AN2008

Fluorizarea local profesional se poaterealiza cu ajutorul soluiilor simple de NaF sau SnF,soluiilor sau gelurilor cu un pH acid, pastelorprofilactice cu fluor i lacurilor cu fluor.

Dintre soluiile cu fluor utilizate n fluorizareaprofesional local, se folosesc:

a. Fluorura de sodiu 2% ce este cea maiuzual soluie pentru aplicaii topice pe dinii curai(fr plac bacterian) de 2-4 ori pe an.

b. Fluorura de staniu este de 3 ori maieficient n scderea solubilitii smalului la aciziislabi comparativ cu soluia de NaF.

Gelurile de fluor utilizate n fluorizarea localprofesional s-au obinut prin adugarea n soluiia unor ageni de gelificare, cum ar fi metil, hidro-ximetil celuloz.

Din aceast categorie fac parte gelul de fluoro-

rtofosfat ce este uor de utilizat ntr-un confor-mator individual, nu provoac salivaie sau sen-zaie de vom pentru c nu se rspndete n cavi-tatea bucal i are proprieti tixotropice, adic,se transform n soluie sub aciunea presiunii,ptrunznd astfel n anuri i fosete.

n cazul aplicrilor bianuale reducerea cariiloreste de 20-40%.

Alturi de acesta, se mai utilizeaz i gelul defluorur de amin ce reduce solubilitatea smaluluii uureaz prin proprietile lui tensioactive,fixarea de fluor la suprafeele dentare.

Un astfel de gel este gelul ELMEX ce se aplico dat pe sptmn pe suprafeele dinilor, cuajutorul unei canule adaptate la sering, lsndu-se 2-3 minute n contact cu dinii, dup care serealizeaz periajul.

Lacurile cu fluor au fost realizate pentru a re-duce timpul de aplicare, pentru a simplifica tehnicai pentru a crete timpul de contact al fluorului cusuprafeele dinilor.

Produsele cele mai cunoscute sunt: DURAPHAT ce conine 2,26% F subform de NaF, ntr-o soluie alcoolic derini naturale, el adernd uor pe supra-feele umede ale dinilor;

ELMEX PROTECTOR ce conineaminofluoruri ncorporate ntr-un lac depoliuretan autopolimerizabil;

EPOZYLATE ce este un lac protector delung durat i are ncorporat monofluordisodic ntr-un lac de poliuretan auto-

polimerizabil.

n ceea ce privete eficiena acestora, s-aconstatat c, aplicate pe o perioad mai mare detimp i prin aplicri mai frecvente se obine oreducere a incidenei cariei ntre 30 i 38%, fiindla fel de eficiente ca i soluiile i gelurile fluoru-rate.

Aplicaiile topice prin ionoforez reprezint ceamai eficace metod de prevenire prin aplicaiitopice de fluor prin faptul c prin aciunea curen-tului de joas tensiune, ionul de fluor este forats ptrund n cantitate mare i la o adncime maimare, inclusiv pe feele aproximale, n structurasmalului.

n acest fel se aplic soluiile de fluorur desodiu 1% sau de fluorortofosfat 1,4% n ine sau

n gutiere standard sau individuale, conectate la oinstalaie simpl cu baterii electrice, ns metoda

este costisitoare i dificil de aplicat n colectiviti.Fluorizarea local personal se realizeaz de

ctre pacient cu ajutorul pastelor de dini fluoruratei cu aminofluoruri i prin cltiri bucale.

Exist ns rezerve n ceea ce privete folosireapastelor de dini cu coninut ridicat de fluor la copii

n cursul mineralizrii i maturrii smalului dinilorpermaneni, n special n zonele fr deficit defluor n apa potabil, din cauza posibilitii deapariie a fluorozei.

n ceea ce privete cltirile bucale, acestea serealizeaz cu ajutorul unor:

soluii de NaF neutrale n concentraii de la500 ppm la 3 000 ppm;

soluii acidulate de NaF; soluii cu fluoruri de staniu, amoniu, fier,

aluminiu.Cercettorii care au testat mai multe soluii cu

fluor (TAVEL i ERICSON1965) au ajuns laconcluzia c se obin rezultate pozitive cu oricaredin aceste combinaii, eficacitatea depinznd de

concentraia n ion de fluor, i timpul de contactcu suprafeele dentare.n general se obine o reducere de peste 30%

n aplicaii zilnice timp de mai muli ani, ns nuse recomand la copii sub 5 ani care pot nghii ocantitate din soluie cu posibilitatea de supradozarea fluorului ingerat.

n tabelul urmtor sunt reprezentate substanelepe baz de fluor care sunt utilizate pentru aplicaiiprofesionale sau la domiciliu.


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Adres de coresponden:Conf. Dr. Bcleanu Florentina Cornelia, Facultatea de Medicin Dentar, Universitatea Titu Maiorescu, Strada GheorghePetracu, Nr. 67A, Sector 3, Cod Potal 031593, Bucureti



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REVISTAROMNDESTOMATOLOGIE VOL. LIV, NR. 3, SUPLIMENT, AN2008 161

Pentru a putea considera apariia sensibilitiidentinare ca un eec al restaurrilor adezive, tre-buie s eliminm a priori printr-un diagnosticdiferenial toate celelalte cauze posibile, precum:fracturi, fisuri, leziuni carioase, parodontite apicale,eroziuni cuneiforme, abrazii.

Dei mecanismele fiziopatologice de producerea sensibilitii dentinare nu sunt complet elucidate,ipoteza hidrodinamica a lui Brannstrom este mpr-

tit de un numr foarte mare de studii recente(1,2).Din punct de vedere clinic, manifestrile de

sensibilitate post operatorie, dup restaurri adezive,apar ntr-o relaie evident cu pierderea etaneitiimarginale. Principalele cauze ale acestei sensibilitipot fi grupate n umtoarele patru grupe de cauze:

1. Cauze legate de materialul de obturaiecompozit

n cazul compozitelor, principala cauz carepoate duce la apariia sensibilitii postoperatorii

este contracia de polimerizare, care poate variantre 1.5-5% n volum (3,4). Contracia compozi-telor poate avea urmatoarele efecte:

Tensiuni la nivelul esuturilor dentare, carepot antrena flexiuni ale cuspizilor, slbireaprismelor de smal i poate merge pan lafisuri sau fracturi.

Pierderea adaptrii marginale cu apariiaunor hiatusuri ce favorizeaz percolaia mar-ginal. Aceasta se manifest clinic sub formde sensibilitate postopeatorie, carii secun-dare marginale sau inflamaii pulpare.

Contracii interne ale materialului de obtu-raie care poate produce fracturi in masacompozitului.

Diminuarea rezistenei mecanice a compo-zitului.

Posibilitile de prevenire constau n reducereaefectelor nedorite ale contraciei de polimerizarepe baza urmtoarelor proceduri:

Folosirea unui adeziv cu ncrcturmineral mare.

Aplicarea compozitului n straturi succesive

n funcie de configuraia cavitii Adoptarea tehnicii de obturaie sandwich

cu utilizarea unei baze intermediare din

2SENSIBILITATEA DENTINAR DUP

RESTAURRI CORONARE ADEZIVE: CAUZE

I MIJLOACE DE PREVENIEDentinal Sensibility After Adhesive Coronal Restorations:

Causes and Prevention Methods

ef Lucr. Dr. Cornel Boitor,ef Lucr. Dr. Anca FrailFacutatea de Medicin Victor Papilian, Sibiu

REZUMAT

Dei n vitro adeziunea dintre esuturile dentare i materialul de obturaie adeziv ndeplinete caliti remarcabile, n practicacotidian se constat ntr-un proces important de cazuri apariia unei sensibiliti dentinare postoperatorii.Aceast sensibilitate depinde de factorii locali ai pacientului dar i de calitatea sau modul de utilizare al materialelor compozitefolosite.

Cuvinte cheie: adeziune compozit-dinte, contracie de polimerizare, sensibilitate dentinar, prevenie.

ABSTRACT

Althuoght in vitro the adhesion between the dental tissue and adhesive felling materials is very, strong freqently in practice we therea past operatory dentinal sensibility.This sensibility depend an local pacient factors but also on the qualitz of the materials that has been used.

Key words: the dental-composite adhesion, polimerisation contraction, dental sensibility, prevention.

ODONTOLOGIE


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ciment ionomer de sticl modificat

(fotopolimerizabil)

Utilizarea unui strat intern de compozit fluidcare permite diminuarea stresului decontracie cu circa 20-50% (4)

Utilizarea unui compozit pe baz de siloran

(Filtec Siloran -2M ESPE), care are uncoeficient redus de contracie de ordinul0.8% (relativ insuficient confirmat de studiileclinice).

2. Cauze legate de mrimea cavitiiRestaurrile directe din materiale compozite au

ca prim indicaie cavitile coronare de mrimemic i mijlocie. n cazul unor caviti de mrimemare, cu toate msurile de prevenie pe care leputem lua, apare totui o contracie a materialului

de obturaie.Posibilitile de prevenire eficiente se bazeazpe recurgerea la metode indirecte de restaurare detip onlay, cimentat sau colat pe dinte (5).

3. Cauze legate de adezivul folositAdezivii de generaia a 5-a, care conin ntr-un

singur flacon primerul, rina adeziv i solventulsunt foarte uor de aplicat n practic, scurtandtimpul de lucru. Cerina acestui adeziv este s fieaplicat pe o dentin cu un anumit grad de umi-ditate. Dificultatea tehnica a medicului practician,const tocmai n realizarea acestei umiditi cares favorizeze ptrunderea optim n dentin aadezivului. Aplicarea greit poate duce la com-promiterea etaneitii marginale, sensibilitatedureroas, coloraii marginale inestetice sau chiarleziuni curioase secundare.

Posibilitile de prevenire constau n recurgereala sisteme adezive cu autogravare, care reducconsiderabil riscul de aplicare pe o dentin cu umi-ditate nepotrivit (se nlatur etapa de uscare i

splare a dentinei). n plus, acest sistem de auto-gravare nu nlatur detritusul dentinar remanentdin canaliculii dentinari (cepurile canaliculare), ci

l blocheaz i stabilizeaz pe loc, ceea ce previnedeplasarea fluidului prin canaliculii dentinari.Aceasta explic n bun parte rata sczut a sensi-bilitatii dentinare, observat clinic la adezivii deacest tip (6,7).

4. Cauze legate de polimerizareFolosirea unei surse de lumin pentru poli-

merizarea compozitului determin o conrtacie depolimerizare a materialului, n direcia surseiluminoase (6,8). Aceast etap considerat demulte ori consumatoare de timp, a dus la apariiaunor lampi cu timpi de expunere tot mai sczui.

Studiile recente asupra fotopolimerizrii com-pozitelor au artat ca retraciile de polimerizarenu sunt ntr-o legtur liniar direct cu timpul deexpunere i cu intensitea luminoas. n consecin,un timp de expunere mai lung i o intensitate maisczut, determin o rat de polimerizare mai mare

decat un timp scurt cu o intenistate mare a luminii.Polimerizarea progresiv are repercursiuni bene-fice asupra calitii legturii compozit-esut dentar(7).

Modalitile de prevenire a unor erori legatede fotopolimerizare au obiectivul de a realiza ocat mai bun legtur dinte-material de obturaiei pot fi obinute prin:

Straturi de compozit cu grosime de cel mult2 mm (care permite reacia de polimerizare

n condiii optime). Obturaiile de volum mediu i mare trebuie

efectuate n straturi succesive plasate oblicfa de perei, astfel ncat vectorul decontracie s aib o rezultant favorabiladeziuni la esuturi(figura 1. A-D) (8).

A

B


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ConcluziiSensibilitatea dentinar aprut, dup efectuarea

restaurrilor adezive din compozit este consideratun eec al tratamentului.

El este pus n legtur direct cu pierdereanchider ii marginale datori t contrac ii lor din

timpul polimerizrii sau unor greeli tehnice deutilizare a materialelor adezive.

Prin aplicarea unor msuri stricte privindprotocolul de polimerizare, sensibilitatea dentinarpost operatorie poate fi prevenit.

C

DFigura 1. A-D

Modaliti de plasare i polimerizare a materialului deobturaie n cavitile medii i mari cu scopul de a

obine un vector de polimerizare favorabil adeziunii laesuturi (8).

BIBLIOGRAFIE

1. Branstrom M et all Sutdy of the mechanism of pain elicited fromthe dentin. Arch Oral Biol 1967; 12: 209-216

2 . Pashley DH Dynamics of the pulpodentin complex. Crit Rev OralBiol Med, 1996; 23:104-109

3. Peutzfeld A et al l Rezin compozite propertis and energy densityof light cure. J Dent Res 2005;84:659-662.

4. Roth F Les composites, Ed Masson 2002.5. Kemp-Scholte CM et all Marginal integrity related to bond

strenght and strain capacity of composite resin restorative systems. JProsthet Dent 1990;64:658-664.

6. Peutzfeldt A et all Adhesive systems :effect on bond strength ofincorrect use. J Adhes Dent2002:233-242.

7. Opdam NJ et al l Class 1 oclusal composite resin restoration invivo postoperative sensitivity, wall adaptation and microleakage. AmJ Dent 1998; 1:229-234.

8 . Lehmann N Les sensibilites postoperatoires. Causes et solutionspreventives. Clinic, Les echecs. Hors Serie, Iunie 2008, 19-24.

Adres de coresponden:ef Lucr. Dr. Fril Anca, Facultatea de Medicin Victor Papilian, Str. Pompeiu Onofreiu, Nr. 2-4, Sibiu, Cod Potal 550166email: [email protected]


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3 ODONTOLOGIE

POSIBILITI TERAPEUTICE NDISTRUCII CORONARE NTINSETherapeutic Possibilities in Flat Coronal Lesions

Conf. Dr. Bcleanu CorneliaFacultatea de Medicin Dentar, UTM, Bucureti

REZUMAT

Tratamentul cariei dentare este strict conservator i vizeaz att eliminarea leziunii propriu-zise, ct i a efectelor secundare ale

acesteia asupra esuturilor din vecintate.Scopul final al acestui tratament este refacerea corect a morfologiei coronare dentare astfel nct s nu se produc suferineocluzo-articulare sau n timp, suferine ale organului pulpar, precum i recidiva de carie.Scop: Aceasta lucrare ii propune s prezinte tratamentul leziunilor coronare ntinse, att restaurrile directe cu materialeadezive dar i tratamentele utilizate atunci cnd nu se mai pot aplica tehnici conservative i este nevoie de restaurri coronare prinancorri cu dispozitive radiculare, dup tratamentul endodonticMaterial i metod: Studiul s-a realizat pe un lot de 20 pacieni (12 femei, 8 brbai) cu vrste cuprinse ntre 25 si 55 ani, care s-auprezentat pentru rezolvarea unor distrucii coronare mari situate n zona frontal (13) i zona lateral (7).Rezultate i discuii: Sunt prezentate cteva cazuri clinice care reflect modaliti de restaurare a cariilor extinse.Concluzii: Aplicarea unor tehnici pot remedia neajunsurile ce pot aprea n restaurarea leziunilor carioase ntinse.

Cuvinte cheie: leziuni carioase ntinse, factor C, contracie de polimerizare

ABSTRACTThe treatment of dental caries is strictly conservative, aiming the elimination both of the wound itself and its side effects on theneighbouring tissues.The goal of this treatment is the proper restoration of the tooth morphology without damaging the integrity of the dental pulp.Purpose: This paper aims to present the treatment of the flat coronary lesions through both of direct restorations and by usingradicular pin after endodontic treatment.Material and method:The study was conducted on a lot of 20 patients (12 women, 8 men) aged between 25 and 55 years, whichpresented large coronary caries located in the frontal (13) and lateral area (7)of the arcades.Results and Discussion: Are presented several clinical cases which reflect different ways for the restoration of extensivecavities.Conclusions: The application of described techniques can remedy the shortcomings that may arise in the restoring of the flatcaries.

Key words: flat carious lesions, Factor C, contraction polymerization

INTRODUCERE

Tratamentul cariei dentare este strict conservatori vizeaz att eliminarea leziunii propriu-zise, cti a efectelor secundare ale acesteia asupra esutu-rilor din vecintate.

Scopul final al acestui tratament este refacerea

corect a morfologiei coronare dentare astfel ncts nu se produc suferine ocluzo-articulare saun timp, suferine ale organului pulpar, precum irecidiva de carie.

SCOP

Aceasta lucrare ii propune s prezintetratamentul leziunilor coronare ntinse, attrestaurrile directe cu materiale adezive dar i trata-mentele utilizate atunci cnd nu se mai pot aplicatehnici conservative i este nevoie de restaurri

coronare prin ancorri cu dispozitive radiculare,dup tratamentul endodontic


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MATERIAL I METOD

Studiul s-a realizat pe un lot de 20 pacieni (12femei, 8 brbai) cu vrste cuprinse ntre 25 i 55ani, care s-au prezentat pentru rezolvarea unordistrucii coronare mari situate n zona frontal (13)

i zona lateral (7) fig. 1

dontic i restaurare prin ancorare n canalul ra-dicular pentru creterea retentivitii (fig. 3).

Figura 1Repartiia lotului pe zone

Etiologia leziunilor coronare/grupe de vrsteste prezentat n fig. 2

Figura 2Etiologia leziunilor/grupe vrst

Restaurrile s-au realizat cu materiale com-pozite, 8 cazuri, 4 au fost restaurate cu amalgam,iar 8 dintre cazuri au necesitat tratament endo-

Figura 3Repartiie lot dup material de restaurare

CAZURI CLINICE

Caz 1

Pacient n vrst de 25 ani prezint fractur co-ronar la nivelul lui 12, cu interesarea pulpei den-tare.

Tratamentul a constat din restaurare direct,dup depulpare, cu pin intraradicular i restaurarecoronar cu material compozit.

Protocol terapeutic1. Tratament endodontic i obturaie canal2. Dezobturarea canalului cu freza Gates

(Antaeos, VDW GmbH, Munchen, Germany)pe 2/3 din lungime

3. Demineralizarea canalui cu acid fosforic37%, splare, uscare cu conuri de hrtie.

4. Aplicara a 2 straturi de agent bonding (SingleBond 2, 3M ESPE), fotopolimerizare 20 sec.

5. Aplicarea pinului cu 2R 1,2mm in canal siproba sa (Stick Tech Ltd, Turku, Finland)

6. Cimentare cu rasina de cimentare aplicatacu Lentullo (Rely X Unicem, 3M ESPE,Seefeld, Germany), fotopolimerizare

7. Reconstructie coronara prin aplicare instraturi a compozitului (Gradia Direct, GCCorporation, Tokyo, Japan)

8. Reechilibrare ocluzala pentru indepartareacontactelor premature


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Caz 2

Pacienta prezint o leziune carioas extins cer-vical. Restaurarea s-a realizat cu materiale com-pozite dup o tehnic special. Pentru o mai bunvizualizare tehnica este exemplificat pe un dinteextras.

Tehnica: se aplic primul strat de compozit apoi se se

fac dou incizii diagonale de 1,5 mm prin toatgrosimea materialului mprindu-l astfel npatru pri cu forme triunghiulare, plane.

se fotopolimerizeaz 40 sec dinspre vesti-bular.

urmtorul strat se aplic ntr-o 1/2 inciziediagonal i se fotopolimerizeaz.

urmtorul strat se aplic n cea de-a douaincizie i se fotopolimerizeaz, etc.

se aplic alt strat orizontal, se fac tieturidiagonale i aa pn la umplerea completa cavitii

Aceast tehnic reduce factorul C i contraciade polimerizare Factorul C este definit ca fiind relaia dintre

suprafeele care au fcut priz i cele carenu au fcut priz n urma bonding-ului.

Dac raportul este mare n favoarea supra-feelor care nu au fcut priz denot opresiune mare datorit polimerizrii.

Supraf. cu bondingFactorul C=

Supraf. fr bonding

Factorul C calculat ca fiind 5 nainte de incizii,obinut atunci cnd stratul e n contact cu podeauacavitii si cu cei patru perei nconjurtori, a fost

Figura 4Aspect iniial

Figura 5Cimentare pin

Figura 6Aplicare compozit

Figura 7Aspect final

9. Finisare (kit Soflex, 3M ESPE, St Paul, MN,USA)


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redus la 0,5 cnd fiecare parte triunghiular era ncontact (ader) cu un singur perete i o ptrimedin podeaua cavitii.

Figura 8Factorul C n cele dou tehnici

Figura 9

Aplicare matrice

Figura 10Formarea peretelui proximal

Figura 11Aplicare strat orizontal

Aceeai tehnic de aplicare n straturi pe care

se fac tieturi n diagonal combinat cu ostratificare a culorilor, pentru a reduce factorul Ci contracia de polimerizare se poate aplica ipentru restaurarea unei caviti de cls a 2 a .(demonstraie pe dinte extras)

Tehnica de lucru dup terminarea preparaiei, se aplic o matrice cu ajutorul unei spatule de plastic se aplic primul

strat de compozit (nuanta A1, smal) pe suprafaa

intern a benzii conformatoare i exteriorulpereilor vestibular, oral i gingival, urmate defotopolimerizare dinspre ocluzal 40 sec.

ndeprtarea matricei, lsarea icului i com-pletarea fotopolimerizarii dinspre V i oral

restul peretelui proximal a fost restaurat prinaplicarea a 2 sau 3 straturi de compozit lanivelul peretelui parapulpar (nu mai gros de1,5 mm) urmate de fotopolimerizare dinspreocluzal 40 sec.

n cavitatea proximal, fiecare strat orizontalde compozit, a fost mprtit de o diagonal,n 2 portiuni naintea fotopolimerizrii. nacest fel, fiecare poriune de strat mprit aluat contact cu 1/2 din peretele gingival.

se adaug urmtorul strat i se fotopoli-merizeaz dinspre ocluzal 40 sec. pn seajunge la nivelul peretelui pulpar al poriuniiorizontale

urmtorul strat se aplic pe peretele pulpar

al poriunii orizontale i se practic o tiaturn diagonal delimitandu-se 4 poriuni triun-ghiulare care vin n contact doar cu 2 pereiai cavitii, reducndu-se astfel factorul C,se fotopolimerizeaz dinspre ocluzal

urmtorul strat acoper taieturile diagonale,etc (Fig. 8-14).


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CONCLUZII

Evoluia cariei dentare are ca rezultat pierderimari de substan dur dentar care produccontacte dentare nefuncionale, cu conse-cine grave pentru ntreg aparatul dento-maxilar. Aceste dezechilibre ocluzale gene-reaz suprasolicitarea dinilor antrenai nproces i influeneaz negativ funciona-litatea arcadelor dentare, a sistemului mus-cular i a ATM.

Restaurarea se poate face prin tehnicidirecte, utliliznd materiale adezive sau prinutilizarea unor mijloace suplimentare de

Figura 12Realizare tieturi diagonale

Figura 13Aplicare strat orizontal 2

Figura 14Realizare tieturi diagonale 2

Figura 15Aspect final

retenie prin ancorarea n canalul radiculardup tratamentul endodontic.

n scopul realizrii unei interfee flexibiledinte/restaurare, compozitul de restauraretrebuie plasat de aa manier nct contraciade polimerizare s fie redus la minim. nfelul acesta se evit formarea hiatusului mar-ginal i apariia microinfiltraiilor marginale.

Aplicarea compozitului n straturi i reali-zarea unor tieturi n diagonal reducefactorul C i deci, contracia de polimerizare.


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BIBLIOGRAFIE

1. Ferracane JL, Mi tchem JC Relationship between compositecontraction stress and leakage in Class V cavities. Am J Dent 2003;16:239-243.

2. Giachetti L, Scaminaci Russo D, Bambi C, Grandini R Areview of polymerization shrinkage stress: Current techniques forposterior direct resin restorations. J Contemp Dent Pract 2006;

4:079-088.

3. Khamis Hassan, Salwa Khier Composite resin restorations oflarge Class II cavities using split-increment horizontal placementtechnique, Operative Dentistry, may-june 2006

4. Khamis Hassan, Salwa Khier Split-increment Technique:AnAlternative Approach for Large Cervical Composite ResinRestorations, J Contemporary Dental Practice, 2007, 8(2)

Adres de coresponden:Conf. Dr. Bcleanu Florentina Cornelia, Facultatea de Medicin Dentar, Universitatea Titu Maiorescu, Strada GheorghePetracu, Nr. 67A, Sector 3, Cod Potal 031593, Bucureti



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INTRODUCTION

Oral Health and Glycemic Control

For the diabetic patient, tremendous impro-vements in health and quality of life are therewards of maintaining life-long normoglycemia.

(1-2) The American Diabetes Association Stan-dards of Medical Care (2006) recommend diabeticpatients strive to maintain the HbA1c 7 but < 9%) and severelyelevated (>9%) were randomized to one of two non-surgical periodontal therapy protocols. Patients in the minimal therapy (MT)group received scaling, root planning, and oral hygiene instructions on two occasions six months apart. Participants randomizedto the frequent therapy (FT) protocol received scaling, root planing, and oral hygiene instructions at two-month intervals andwere provided a 0.12% chlorhexidine rinse for home use twice daily. Neither systemic nor local antibiotics were provided to eithergroup. Subjects were asked to report any changes in diabetic medications, nutrition, and physical activity. Data analyses (ANOVA,t-test, Mann-Whitney) grouped subjects according to baseline HbA1c (>7 and < 9%, or > 9%), treatment protocol (minimal orfrequent), and +/- medication change.Results: In both MT and FT groups the clinical attachment level (CAL) remained unchanged but the other measures [gingivalindex (GI) and pocket dept (PD)] of periodontal health improved. Mean reductions in plaque showed improvement but calculuswas worse in the FT group, likely due to the use of chlorhexidine. At six months, the largest reduction of HbA1c was 3.7;experienced by a subject receiving FT but no changes in diabetic medication. Among the MT and no medication change subjects,the maximum reduction was 1.6.Overall mean reduction in HbA1c of 27 subjects with baseline HbA1c >9.0 and no medication change was 0.6 with no statisticaldifference between the MT and FT groups. Among the medication-change subjects with baseline HbA1c >9.0, mean reduction of1.38 was seen with FT compared to 1.10 with MT.Conclusion: Overall, modest improvements in HbA1c were detected with a trend towards FT being better than MT. Although thispilot trial was under-powered to detect small between-group differences, the magnitude of our findings (0.6 mean improvement inHbA1c) matches closely findings from the only meta-analysis conducted on this topic to date. Larger scale studies must beundertaken on diabetic patients with periodontal problems.Clinical Significance: Preventive periodontal regimens for diabetic patients should be sufficiently intense and sustained toeliminate periodontal inflammation and should be closely coordinated with the patients overall clinical diabetic management.

Key words: Diabetes, periodontal disease, HbA1c

patients have difficulty maintaining this level ofglycemic control, those achieving intermediateand/or intermittent control experience far fewercomplications such as retinopathy, nephropathy,neuropathy, fatigue, weakness, memory loss,cardiovascular disease, need for amputations, tooth

loss, and periodontal infection. (1-5,9-28) Usinga proportional hazards model and stringentcontrols of potential confounders, it has beenshown the risk of diabetic nephropathy and cardiac

PARODONTOLOGIE


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mortality in Pima Indians is elevated 3.2 fold (95%CI 1.1-9.3) in those with severe periodontaldisease. (23)

Excellent glycemic control is achieved withstrict regimens of diet, exercise, weight loss,avoidance of infections, fastidious self-care,

avoidance of tobacco, medication adjustments,frequent medical attention, and self-monitoring ofblood glucose levels using home glucometers.Emerging evidence suggests the reduction ofperiodontal inflammation may be one additionalstrategy in reducing HbA1c. (29-31) When a seriesof studies of various sizes were subjected to asystematic review and meta-analysis, periodontalintervention reduced HbA1c by 0.66 in type 2diabetic patients. (31)

For this pilot study, a small number of diabetic

patients with elevated HbA1c were recruited.Because subjects with moderate and severe perio-dontitis were excluded, the use of antibiotics duringthis short-term intervention was avoided. Chlor-hexidine gluconate was the sole chemotherapeuticagents tested because it has been shown to beeffective in managing gingivitis. (32-35)

METHODS AND MATERIALS

With approval from the Oregon Health andScience University Institutional Review Board,eligible subjects were recruited using flyers andadvertisements in newspapers in the greaterPortland area. A screening oral examination, me-dical history review, and blood sample to deter-mine HbA1c were carried out to confirm eligibility(see Table 1 for inclusion and exclusion criteria)and to answer participant questions about thestudy. Fifty eligible, consenting subjects wererandomized (by flip of a coin) to either the minimal

therapy (MT) or frequent therapy (FT) groups. Thetreatment groups were balanced for gender only.Following the pre-treatment assessment, all

subjects were provided with oral home careinstructions, oral prophylaxes including scaling,and root planing was limited to the inflamedperiodontal pockets with clinical attachment loss.These services were provided in one appointmentwhich varied in time between 60 and 90 minutes.Control subjects were recalled for oral hygieneinstructions and oral prophylaxes with scaling and

localized root planing at one six-month interval.FT subjects were recalled for oral prophylaxes withlocalized scaling. Localized root planing and oralhygiene instruction every two months (four

sessions total) were provided at no cost and 0.12%chlorhexidine gluconate rinse (Peridex, ZilaPharmaceuticals) was given for twice daily, 30second, oral rinsing. All treatment provided in thisprotocol was delivered by the research dentalhygienist, and all periodontal evaluations were

performed by a graduate periodontology residentwho was blinded to the subjects group assignment.

The weight and medical history of each par-ticipant was updated at each appointment toidentify factors that might impact glycemic controlwithin the six weeks preceding the serological andperiodontal data collection. These specific factorsincluded: weight gain or loss, infections, illnesses,the use of antibiotics, steroids, or any other newmedications that are known to interfere with bloodglucose control. All subjects were also interviewed

to gather information on exercise levels andfrequency of glucose monitoring and medications.HbA1c was measured at baseline, six months, andeight months following randomization and repre-sented the primary endpoint in this investigation.

The study also evaluated the severity of perio-dontal disease in subjects using several indices oforal health at baseline, six months, and eightmonths. Inflammation (GI), clinical attachmentloss (CAL), probing depth (PD), plaque index (PI),and calculus index (CI) all were quantified. PI andCI scores were quantified using indices in whichthe four smooth surfaces of all existing teeth arescored and a percentage of surfaces with plaqueor calculus are recorded. The Le and Silness GI36(Table 2) was used to assess inflammation of thegingiva on the mesial, distal, buccal, and lingualsurfaces of the Ramfjord index teeth (#3, 9, 12,19, 25, and 28).37

The GI procedure consisted of inserting acalibrated periodontal probe no more than 2 mm

into the gingival sulcus, starting just distal to themidpoint of the buccal surface, then moving theprobe tip gently into the mesial interproximal area.CAL and PD were measured at six sites for theindex teeth using the Michigan Probe calibratedin 2 mm increments. Because PD recordings canvary significantly according to positions of theprobe tip, all probing and recession measurementswere completed and then repeated for a secondset of measurements. Where there was a differencebetween these two readings, the two numbers were

averaged.In the FT group mouth rinse compliance was

evaluated by questioning the participants and bymeasuring remaining rinse in the bottles returnedat the follow-up appointments.


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ANALYTICAL AND STATISTICAL METHODS

Data from baseline, six month, and eight monthfollow-up evaluations were summarized for eachoral health variable by calculating means andstandard deviations. Significant differences in oralhealth indices between the FT, enhanced oraltreatment regimen, and the control regimen overtime were calculated by using the Students t-testanalysis for continuous data (PD, CAL) and the

Mann-Whitney test for non-parametric data (PI,CI, GI, and HbA1c). The main point of interest,the influence of dental treatment on the metabolicindicator, was analyzed using a mixed betweenwithin subjects analysis of variance (ANOVA) to

test whether there were effects due to treatmentgroup, time of examination, or interaction of thesetwo independent variables.

Using the upper limit of the average HbA1clevel in type 2 diabetes in the United States (9.0)as a defining value, subjects in each group weredivided into those who had baseline levels above9.0 from those below 9.0. This data was analyzedfor improvement in HbA1c at six and eight months.Those subjects undergoing physicianadviseddiabetic medication changes during the studyperiod were grouped separately. Obviouslyimprovements in HbA1c cannot be attributedsolely to the periodontal intervention in thesesubjects.

RESULTSThe study enrolled 50 subjects who met the

inclusion/exclusion criteria at baseline andrandomized 25 to the control treatment group and25 to the FT group. Two subjects passed-awayfor reasons unrelated to the study. Six subjects werewithdrawn from the study due to violations in theinclusion/exclusion criteria, such as smoking. Ofthe 42 remaining subjects who completed thestudy, 15 had their diabetes medications changed

at the advice of their physicians. There were 27subjects who did not have diabetic medicationchanges. No subjects needed to be omitted fromthe analysis because of significant changes in diet,weight, or exercise habits.

Table 2.Gingival Index.36

Table 1.Inclusion and exclusion criteria.


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Figure 1 and Table 3 demonstrate the changesthat were observed in the oral health variables.With the exception of CAL, all oral healthmeasurements demonstrated significant (p 9, it must beassumed the medication change influenced theseresults. In the HbA1c > 9 subjects with no medi-cation change about half as much improvementin HbA1c was seen at six months. Mean reduc-tions of 0.58 (FT) and 0.64 (MT) were encouraging

but do not indicate more periodontal therapy isbetter as had been expected.

DISCUSSION

As expected, the periodontal health of allsubjects improved; the FT subjects demonstratedgreater improvements in PD, PI, and GI comparedto MT subjects, and no changes in CAL occurredbecause very few (n=3) baseline pocket depthswere greater than 3 mm. Increased levels of

calculus in the FT groups is certainly explainedby their use of chlorhexidine. (35)

Figure 1.Observed changes in oral health variables.


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Diabetic subjects entering the study withHbA1c levels above 9.0 experienced a trendtoward greater HbA1c reductions than those withlevels below 9.0 at baseline, regardless of the studycondition to which they were exposed. These sub-

jects experienced 0.6 reduction in HbA1c, whichis similar to other periodontal interventions of thisnature. (38-40) However, because of the smallsamples sizes, the differences between groups didNOT reach statistical significance. At the eighthmonth follow-up, mean HbA1c in all groups gravi-tated toward return to baseline levels as has beenseen in other periodontal and diabetes studies.(30,4,42)

Sample size presented the major flaw in thisstudy and was exacerbated by the need to accom-

modate statistically for 15 subjects (nine in the FTand six in the MT groups) undergoing changes intheir diabetes medications. In addition, as this studywas being completed, results of a systematic reviewof like studies indicate much larger samples sizes

are needed to determine what intensity and durationof periodontal therapy is needed to answer thequestion, particularly when the severity ofperiodontitis is mild. (31)

Other modest limitations of this study includefailure to have a non-treatment control group,failure to provide placebo rinse to the MT group,measuring GI and CAL only on the six Ramfjordteeth (39) instead of the entire dentition, andinherent difficulties blinding an examiner whenchlorhexidine stain is present. As in alluniversitybased studies, the results may not be asgeneralizable to real world patients as would bethe results from practice-based and community-based studies.

With the limitations noted, a reduction of 0.6

(or 6%) HbA1c should be considered clinicallydesirable in a given patient with mild periodontalinflammation. As little as a 1% decrease in HbA1chas been shown to reduce myocardial infarctionsby 14%, (46) and a 1% elevation in HbA1c results

Table 3.Oral health variables.


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Table 4.Effect of periodontal treatment on HbA1c. (Subjects with no medication change.)

Figure 2.No significant difference was found between experimentaland control HbA1C levels (p>.05) at baseline, six months,

and eight months.

Table 5.Effect of periodontal treatment in subjects requiring medication change.


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in a 25% increase in complications. (45) Largescale (medical, non-dental) studies in the US andUK of intensive medical treatment regimensresulted in an average HbA1c reduction of 1.86

(or approximately 19%). (1-2,10,21) Thesereductions are comparable to periodontalintervention studies of severe periodontitis patientswhich yield HbA1c reduction (up to 17.1%) whenusing antibiotics with special populations moreseverely affected by periodontitis and diabetes,such as Pima Indians and US Veterans. (23,30)

Clearly, the modest, short-term improvementin metabolic control achieved with a group ofdiabetic patients with fairly good oral health points

to the need to perform a larger-scale, longertermstudy with diabetic patients who have more seriousinflammatory and infectious oral diseases. Whileit is likely practicing dentists and physicians areintuitively aware that alleviation of oral diseaseand the associated infection has a beneficial effecton metabolic control of diabetes, the magnitude

of this effect and its long-term sequelae needadditional documentation.

CONCLUSION

Overall, modest improvements in HbA1c weredetected with a trend towards FT being better thanMT. Although this pilot trial was under-poweredto detect small between-group differences, themagnitude of our findings (0.6 mean improvementin HbA1c) matches closely findings from the onlymeta-analysis conducted on this topic to date.Larger scale studies must be undertaken ondiabetic patients with periodontal problems.

CLINICAL SIGNIFICANCE

Preventive periodontal regimens for diabeticpatients should be sufficiently intense and sustainedto eliminate periodontal inflammation and shouldbe closely coordinated with the patients overallclinical diabetic management.

Figure 3.Comparison of changes in HbA1C over time for test subjects and those excluded because of medication changeduring trial period, grouped according to initial levels. There were no significant differences within each group overtime but significant (p9% can be seen to be about wice that notedfor the test groups >9% (downward arrows).

Articol publicat cu acordul The Journal of Contemporary Dental Practice, Volume 9, No. 5, July 1, 2008


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23. Nelson RG, Shlossman M, Budding LM, Pettitt DJ, Saad MF,

Genco RJ, Knowler WC Periodontal disease and NIDDM inPima Indians. Diabetes Care. 1990; 13(8):836-40.

24. Campbell D, Pollick HF, Lituri KM, Horowitz AM, Brown J,Janssen JA, Yoder K, Garcia RI, Deinard A, Hemphill S, de la

Torre MA, Shrestha B, Vargas CM Improving the oral health ofAlaska natives. Am J Public Health. 2005; 95(5):769-73.

25. Jones JA, Miller DR, Wehler CJ, Rich S, Krall E, ChristiansenCL, Rothendler JA, Garcia RI Study design, recruitment, andbaseline characteristics: the Department of Veterans Affairs DentalDiabetes Study. J Clin Periodontol. 2006 Oct 13;.[Epub ahead of

print].26. Ainamo J, Lahtinen A, Uitto VJ Rapid periodontal destructionin adult humans with poorly controlled diabetes: a report of twocases. J Clin Periodontol. 1990; 17:22-8.

27. Shlossman M, Knowler WC, Pettitt D, Arevalo A, Genco RJ Type II diabetes and periodontal disease (Abs). J Dent Res. 1987;66:256.

28. Saremi A, Nelson RG, Tulloch-Reid M, Hanson RL, SieversML, Taylor GW, Shlossman M, Bennett PH, Genco R, KnowlerWC Periodontal disease and mortality in type 2 diabetes. DiabetesCare. 2005; 28(1):27-32.

29. Faria-Almeida R, Navarro A, Bascones A Clinical andmetabolic changes after conventional treatment of type 2 diabeticpatients with chronic periodontitis. J Periodontol. 2006; 77(4):591-8.

30. Grossi SG, Skrepcinski FB, DeCaro T, Robertson DC, Ho AW,

Dunford RG, Genco RJ Treatment of periodontal disease indiabetics reduces glycated hemoglobin. J Periodontol. 1997; 68:713-9.

31. Janket SJ, Wightman A, Baird AE, Van Dyke TE, Jones JA Does periodontal treatment improve glycemic control in diabeticpatients? A meta-analysis of intervention studies. J Dent Res. 2005;84(12):1154-19.

32. Lindhe J, Nyman S Long-term maintenance of patients treated foradvanced periodontal disease. J Clin Periodontol. 1984; 11:504-14.

33. Wennstrom J, Lindhe J The effect of mouthrinses onparameters characterizing human periodontal disease. J ClinPeriodontol. 1986; 13:86-93.

34. Schaeken MJ, Keltjens HM, Van der Hoeven JS Effects offluoride and chlorhexidine on the microflora of dental root surfacesand progression of root-surface caries. J Dent Res. 1991; 70:150-3.

35. Lang NP, Grec MC Chlorhexidine digluconate - an agent forchemical plaque control and prevention of gingival inflammation. JPeriodontal Res. 1986; suppl:74-89.

36. Loe H, Silness J Periodontal disease in pregnancy. I - Prevalenceand severity. Acta Odont Scand. 1963; 21:533-51.

37. Ramfjord, SP Indices for prevalence and incidence of periodontaldisease. J Peridontol. 1959; 30:51-9.

38. Iwamoto Y, Nishimura F, Nakagawa M, Sugimoto H, Shikata K,Makino H, Fukuda T, Tsuji T, Iwamoto M, Murayama Y Theeffect of antimicrobial periodontal treatment on circulating tumornecrosis factor-alpha and glycated hemoglobin level in patients withtype 2 diabetes. J Periodontol. 2001 Jun; 72(6):774-8.

39. Stewart JE, Wager KA, Friedlander AH, Zadeh HH The effectof periodontal treatment on glycemic control in patients with type 2diabetes mellitus. J Clin Periodontol. 2001 Apr; 28(4):306-10.

40. Seppala B, Seppala M, Ainamo J A longitudinal study oninsulin-dependent diabetes mellitus and periodontal disease. J ClinPeriodontol 1993; 20:161-5.

41. Miller LS, Manwell MA, Newbold D, Reding ME Therelationship between reduction in periodontal inflammation anddiabetes control: A report of 9 cases. J Periodontal. 1992; 63:843-8.

42. Sastrowijoto SH, van der Velden U, van Steenbergen TJM,Hillemans, P, Hart AAM, de Graaff J, Abraham-Inpijn L Improved metabolic control, clinical periodontal status andsubgingival microbiology in insulin-dependent diabetes mellitus: aprospective study. J Clin Periodontol. 1990; 17:233-242.

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44. Fisher M Prevention of macrovascular complications. European

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INTRODUCTION

Alginate-based impression materials have beenused in dentistry since 1947. (1) Originally usedas precision impression materials in fixedprosthodontics1 they are more commonly used forthe initial impression to obtain a preliminary modelused for diagnostic purposes, treatment planning,

and for the fabrication of a provisional prosthesisor custom tray. The dimensional stability ofalginate-based impression materials has beenstudied since the 1970s.2 In particular, thephenomena of syneresis has received a greatamount of attention. (3-47) Syneresis is intendedas the expression of fluid onto the surface of gelstructures. (48) The clinical consequence is theshrinkage of the material due to the loss of waterby evaporation. (48) The actual ISO 156349 statesthe requirements for the alginate-based impression

materials, however, no information is provided onthe methodological test valid for the evaluation oftheir dimensional stability. In recent years differenttests have been developed for analyzing this

property. (4-6,36,42,50-54) The most commonone consists of taking the impression from amaster cast (usually made of acrylic or stainlesssteel) and measuring the discrepancy between thelatter and the obtained cast. Although themeasurement of a single die can be performed withgreater accuracy, (6) the distance between various

dies is an important variable that should beconsidered in order to perform the test in clinicallyrelevant conditions. Shrinkage occurring in thepalatal zone of the impression might reduce thedistance between the teeth of different semi-arches.

The aim of this study was to verify thedimensional stability of five different alginate-based impression materials stored in a 100%relative humidity environment after differentperiods of time. The null hypotheses tested were:

(1) there is no difference in dimensional stabilityamong different alginate-based materials and (2)the dimensional stability is not affected by storagetime.

5EFFECT OF STORAGE TIME ON THE

ACCURACY OF CASTS MADE FROM

DIFFERENT IRREVERSIBLE HYDROCOLLOIDSMaurizio Sedda, CDT, DDS, MSc; Andrea Casarotto;

Aune Rausita, DDS, PhD; Andrea Borracchini, MD, DDS

ABSTRACT

Aim: Several new irreversible hydrocolloid formulations have recently become available with claims of an improved dimensionalstability by the manufacturers. The aim of this study was to evaluate the accuracy of casts made from alginate impression

materials poured immediately and after specific storage periods.Methods and Materials: Five alginates were tested: CA 37 (Cavex); Jeltrate (Dentsply Caulk); Jeltrate Plus (Dentsply LatinAmerica); Hydrogum 5 (Zhermack); and Alginoplast (Heraeus Kulzer). A master model was mounted on a special device and usedto obtain the impressions. These impressions were stored at 23C and 100% relative humidity, then poured with gypsumimmediately, and again after 24, 72 and 120 hours. The casts were measured and the data were analyzed by one way analysis ofvariance (ANOVA) and Tukey test at p0.05).Conclusion: The dimensional stability of the alginate impressions is influenced by the selected material and the storage time.Clinical Significance: Alginate impressions should generally be poured immediately. However, some new types of alginate mayhave the pouring delayed.

Key words: Alginate, hydrocolloid, impression, dimensional stability

MATERIALE DENTARE


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METHODS AND MATERIALS

With the aim to reproduce the clinical conditions anew stainless steel testing device (TST) was developed(Figures 1 and 2). The TST consists of three parts: thebase, the master model, and the carrier.

The base is a quadrangular block on which threepins are entirely engaged into three holes on thestainless steel standard tray. The device may beassembled and dissembled with precision bymeans of an accuracy engagement feature. On thebase, four studs allow the master model to slide.The master model consists in a quadrangular plateto which four cylinders are welded. The head ofeach cylinder was well-rounded and a truncatedcone with a global tapered shape of 6 wasobtained to simulate a clinical die. The lower

corner of the truncated cone was considered to bethe finish line of the die. An acrylic resin modelwas prepared and fixed on the plate allowing theexposure of the head of the cylinder to simulatean upper arch with four dies in FDI World DentalFederation (FDI) tooth number positions 13, 23,17, and 27 (Figure 2). To leave a thickness ofapproximately 3 mm of alginate between the topof the dies and the tray, four stainless steel spacerswere machined and positioned on the studs of thebase. The carrier is a quadrangular plate on which

four trapezoidal grooves are realized. The groovesare aimed at maintaining the cast obtained fromthe impression in a fixed and stable position.

A total of 200 stainless steel standard non-perforated rimlock trays were prepared for theexperiment. In each tray three holes were drilledwith a numerical control machine (accuracy 0.01mm). Each tray was measured, and a performancetest was rendered to ensure a full engagement.

Five alginates were selected: CA 37 (Cavex, Haarlem, Nederland) Jeltrate (Dentsply Caulk, Milford, DE, USA) Jeltrate Plus (Dentsply Latin America, Rio

de Janeiro, Brazil) Hydrogum 5 (Zhermack Spa, Badia

Polesine, Italy) Alginoplast (Heraeus Kulzer, Hanau, Germany)The alginate powder was stored for three days at

231C and 5010% relative humidity in atemperature controlled-room. All the procedures

were carried out in the same conditions. Four differentstorage times (0, 24, 72 and 120 hours) were testedby taking ten impressions for each period of time. Atotal of 20 groups were obtained (Table 1). The mastermodel was used as a control group.

IMPRESSION PROCEDURE

The tray was locked on the base, and an aerosoluniversal adhesive (Fix Adhesive, Dentsply DeTrey

GmbH, Konstanz, Germany) was sprayed on thetray and left to dry for 5 minutes according to Leunget al. (9) A quantity of 30 g of powder was weighed(HP 5000 CE, Micron, Cavaria, Varese, Italy). Thecorresponding amount of distilled water wascalculated as indicated by the manufacturer andintroduced inside the cup (55) of an electronicvacuum mixing machine (Twister Evolution,Renfert, Hilzingen, Germany). The powder wasadded and immediately mixed by hand for 5seconds. The mechanical mixing was then

performed under vacuum at 250 rpm for 30 secondswith a rotation sense inverted every 5 seconds.The resulting alginate was immediately placed

in the locked tray, and the impression of the mastermodel was taken within the setting time indicatedby the manufacturer at 23C. Once set, the alginatewas trimmed at the border of the tray before theremoval to allow boxing of the impression duringpouring. The master model was gently separatedfrom the impression and the latter from the base.To simulate clinical conditions the impression was

then immediately stored in a hermetic nylon bagin which a paper sheet (weight 5 g) wetted with30 g of distilled water had been inserted 10minutes before, according to Schleier et al. (6) Thepaper was positioned to avoid direct contact with

Figure 1The master model mounted on the base.

Figure 2The acrylic master model containing four stainless steel dies.


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the tray and the alginate. (55) The bag wasimmediately introduced in a 3500 mL plasticstorage box in which another paper sheet(weight10 g approximately) wetted with 60 g ofdistilled water had been inserted 10 minutespreviously, (6) then stored at 231C for the time

indicated in Table 1 prior to pouring with gypsum.For the storage time indicated as 0 hours, thecasts were poured immediately after the removalfrom the master model.

CAST FORMATION

When the predetermined storage time hadelapsed, the impression was removed from theplastic bag and locked again on the TST base.Then 150 g of Type III gypsum powder (Elite

Model Type III) was mixed with 75 g of distilledwater using an electronic vacuum mixing machine(Twister Evolution) at 250 rpm for 30 seconds andpoured into the impression. The TST carrier was

Table 1.Groups of tested materials and storage time in hours (h).


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then placed and maintained in position for thesetting time indicated by the gypsum manu-facturer. After final setting of the gypsum, thecarrier was gently removed and the cast was care-fully separated from the impression. The materialwas stored for 48 hours at 23C and 50% relative

humidity prior to measuring.

MEASUREMENT AND STATISTICAL ANALYSIS

The carrier was compiled in a HB 350 measuringmachine (Starrett Sigma, North Yorkshire, England),and the posterior corner was set parallel to the axismovement of the machine. The cast was placedon it and maintained in position by means of thefour reference grooves.

Six measurements (mm) were recorded for each

model (Figure 3): D1.3: diameter of die 1.3 D2.3: diameter of die 2.3 d3: internal distance between dies 1.3 and

2.3 D1.7: diameter of die 1.7 D2.7: diameter of die 2.7 d7: internal distance between dies 1.7 and

2.7

RESULTS

The results of the statistical analysis are shownin Tables 2 and 3. In order to simplify the inter-pretation of the achieved results, a summary isprovided in Table 4.

Groups 1, 5, 9, 13, 14, 15, 16, 17, and 18showed no statistically significant difference fromthe control group (p > 0.05). When the impressionswere poured immediately, all the tested alginateswere able to reproduce the master model withoutany statistically significant difference (p > 0.05)in all the tested measurements. After 24 hours ofstorage, only Alginoplast and Hydrogum 5 fit allthe measurements (p > 0.05).

The only casts able to comply with the controlgroup in all the measurements after 72 and 120

hours were obtained from Hydrogum 5 (p > 0.05).

DISCUSSION

The five alginates tested in this study yieldeddifferent results, showing the dimensional stabilityof the impression is directly related to the type ofmaterial used. Thus, the first null hypothesis, thereis no difference in dimensional stability amongdifferent alginate-based materials is rejected.Immediate pouring of the impression has been

traditionally suggested as a means to counteractthe well-known dimensional instability ofconventional alginate-based materials. However,if the impression could be stored for a reasonabletime prior to pouring, this could improve themanagement of chair side procedures, offering apotential advantage for the clinician.

In this study the impressions were stored at100% relative humidity and pouring was delayedup to five days (i.e., 120 hours). Different results

recorded for the tested alginate-based materialscould be related to differences in chemicalcomposition of the alginate materials. However,little information is provided in manufacturerinstruction sheets and there is no recent literatureon the influence of individual chemicalcomponents on the dimensional stability of theseimpression materials.

Water evaporation may induce the shrinkageof hydrocolloids materials, (48) and the powder/water mixing ratio may have some influence on

the dimensional stability of the impression. In thepresent study the same amount of alginate powderwas used for each impression (30 g). Hydrogum5, the most stable among the five tested materials,was mixed with a weight ratio of 2.143 (64.3 g of

Figure 3Measurements analyzed in the master model and in the

obtained casts

All measurements were carried out three times,1 mm below the finish line of each die.

The results were statistically analyzed with SPSS12.0 (SPSS, Inc., Chicago, IL, USA). The Levene

Test was used to verify the homogeneity of varian-ces, followed by one way analysis of variance(ANOVA), and a Tukey Test for post-hoc com-parison between the groups. The level of signi-ficance was set at p


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distilled water), while the mixing ratio of JeltratePlus, Alginoplast, and Jeltrate were 2.375, 2.381,and 2.714 (71.3, 71.4, and 81.4 g of distilledwater), respectively. However, the mixing ratio

and the dimensional stability did not seem toinfluence the results since CA 37 had the samemixing ratio as Hydrogum 5 but showed lessdimensional change. Furthermore, no recent

Table 2

Measurements of D1.3, D2.3, and d3.


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Table 3Measurements of D1.7, D2.7, and d7.


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literature was found regarding the influence of thepowder/water ratio on the dimensional stability.This is probably more related to the ability of thematerial to keep water inside the mass than to theglobal amount of water present in each impression.

By analyzing the measurements for eachalginate material it was shown the dimensional

stability of the tested alginate impression materialschanges with storage time. This warrants therejection of the second null hypothesis, thedimensional stability is not affected by storagetime. Dies became wider and distances between

them become smaller with time. These findingsare in agreement with Schleier et al. (6) and maybe related to the shrinkage of the mass due tosyneresis. The widening of the dies could beexplained as follows: the master model reproducedan upper jaw with the dies positioned on the arch.During the impression procedure the arch leaves

a semicircular void in the impression and thematerial is mainly pushed in the palatal andvestibular zone of the impression tray. As the resultof the shrinkage, the impression material aroundthe die was subjected to centrifugal tensile forces,

Table 4Summary of obtained results.


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so its diameter was increased (dies became wider).Furthermore, as usually occurs in clinicalsituations, the greatest amount of alginate wasvisibly located in the palatal zone and theshrinkage of this area may explain why thedistance between dies decreased.

Some limitations of this study can be identified.First, the acrylic master model used to take theimpressions was prepared with the least numberof undercuts, to prevent the distortion of thematerial during the removal of the impression. Inclinical situations the impression is usually lesseasy to remove from the patients mouth and thematerial could be more subjected to distortion.

Second, the impressions were not subjected todisinfection procedures. However, if a properdecontamination protocol is followed, the influ-

ence of disinfection procedures on dimensionalstability is not clinically relevant. (4,56) Taylor etal.4 found in some cases disinfected impressionscan even have an overall improvement indimensional accuracy. One hypothesis advancedby the investigators to account for thisimprovement is the initial syneresis may becounteracted by imbibition during disinfection.

CONCLUSION

Within the limits of this study, the followingconclusions can be drawn:

The dimensional stability of the alginateimpression was influenced by either the type

of alginate or the storage time prior to pouring. Impressions recorded with CA 37 (Cavex),Jeltrate (Dentsply Caulk), and Jeltrate Plus(Dentsply Latin America) should be pouredimmediately.

The impressions recorded with Alginoplast(Heraeus Kulzer) can be poured after 24hours if correctly stored.

The impressions recorded with Hydrogum5 (Zhermack) can be poured after five daysif correctly stored.

CLINICAL SIGNIFICANCE

When alginate materials are used, an immediatepouring of the cast is still recommended. However,the results suggest pouring may be delayed, pro-vided a stable alginate is used and the impressionis correctly stored.

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