Академический Документы
Профессиональный Документы
Культура Документы
(ISSN22783784) VOLUME1ISSUE2 Currentlyindexedin: IndexCopernicus GenamicsJournalSeek UlrichswebGlobalSerialDictionary EditorialBoard KumarAnshul,EditorInChiefManipalCollegeofDentalSciences,India HarshRajvanshi,ExecutiveEditorI.T.SCentreforDentalStudiesandResearch,India AyeshaZaka,ExecutiveEditorHamdardMedicalandDentalCollege,Pakistan Coverartby: EbadullahShafi,DesignandGraphicsInchargeRAKCollegeofDentalSciences,UAE
Covertartillustrationshowsachipaboutthesizeofagrainofricethatstoresaperson'suniqueidentification numberlinkedtohisorherentiremedicalhistory.Thechipisimplantedinatoothwhereitcanneitherbefeltnor rejectedbythebody.
2 FOREWORD Prof.MohamedA.K.ElMassry(MBBCh.,MSc.,BDS.,Ph.D) ProfessorofOral&MaxillofacialSurgery,Alexandria,UN,Egypt. Consultant,MOHKuwait. ItisagreatpleasuretocontributetotheIDJSR,whichinfactcame outasaresultofgreateffortsofyoungDentalStudents.Iwasreally thrilledbytheideaandIhavetoadmitthatIwassurprisedbythe effortsandtheprofessionalattitudeoftheeditorialboard.Using theavailabletoolsoftechnologytobuildupsuchanetworkofambassadorsandcontributors wasanamazingandfantasticwork. Itisthespiritofthoseenthusiasticyoungmenandwomenthatwillleadourprofessioninthe futureandIamsurethatthroughyourhardworkyouwillbeabletoachievealot. Thefirstvolumecameoutwithgreatsuccessanditcontainedgoodarticlesandwasreally impressive. Theaimofourprofessionistodeliverthebestefforttoourpatientsandthiscomesthrough acquiringknowledge,developingresearchandexchangeofopinionsintopicsofmutual interest.Ibelievethroughyourjournal,siteandfacebookpageyouwillbeabletoglobalize youreffortsinaveryshorttime. Iwishyouallthebest.
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
3 EDITORIAL KumarAnshul EditorinChief ManipalCollegeofDentalSciences,Manipal India ThreemonthsagoinMay2012,whenwereleasedthe1 issueof IDJSR,wesawadream. Adreamofrecognizingstudentswork,adreamtocreateaforumforstudentsacrosstheglobe topresenttheirresearch.Inanutshell,togiveachanceandplatformtothestudentsto publish. GettingindexedinIndexCopernicus,GenamicsJournalSeekandUlrichswebGlobalSeries DirectorywasanotherfeatwhichIDJSRachievedafterthereleaseof1stissue. 2ndissuecontainssomeamazingresearch/review/casereportarticlesfromundergraduateas wellaspostgraduatestudentsofIndia,Pakistan,China,CroatiaandCanada.Weareproudthat wearefollowingourpolicyofIDJSRasaSTUDENTONLYjournalsuccessfully. Signingoff,withthewordsofMr.RichardBranson SCREWIT,LETSDOIT
st
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
Welcome in the second issue of the journal. The editorial team is overwhelmed by the tremendous response the first issue has received from all quarters. We aredeeplytouchedbysinceregesturesofexperts,seniors,colleagues,juniors,professionals.Franklywe never anticipated that our immature effort will cultivate such a generous interest amongst all concerned, far and near, above and below, juniors and seniors. Thank you all for the belief you have showninourhumblebeginning. It is very interesting seeing a dream grow. Dream being realized. Taking shape. Evolving into reality. The second issue is coming after London Olympics. USA achieving the medal dominance from China which she lost in Beijing, a remarkable comeback. We watched with bated breath Saina Nehwal achieving the till now unachievable, M.C. Marycom, a proud mother of two, sweating it out to win, Indian Archers battling against unfamiliar hostile London winds, Virtually unknown Vijay Kumar earning glory for the nation. In the same spirit our team tried to identify themselves with the same spirit, holding our heads highwithproudresearchesofstudentsintheglobalDentalCommunity. We believe that this times selection of articles will be palatable to the hungry minds of our readers, we shallbetoohappytoreceivethefreeandfrankopinionsofourvaluedreaders.Weunderstandthatthe data being presented are for the interest of readers and it is our duty that we correct our self to the satisfactionoftheenduser,i.e.thereader. Thisissuehasbeenkeptsmallsothatthereadersareabletofinishthroughthejournalin23ofsittings. We have however restricted ourselves too much because with such a great response from our contributors,itisquiteataskwhattoincludeandwhattoleave. Wewouldrequestourreaderstoapprisewhetherincreaseinvolumeiswelcomeinfutureissues. Once again, we at the editorial desk, express our thanks and gratitude for the warm response received fromallquarters.Weshalltryourbesttobeworthyofyourbeliefinourefforts. Withbestwishes
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
6 REVIEWARTICLE
Graduate Student, Department of Oral Medicine and Radiology, Ahmedabad Dental College and Hospital
www.idjsr.com
Corresponding Author Dr. Suresh Ludhwani Post Graduate Student, Department of Oral Medicine and Radiology, Ahmedabad Dental College and Hospital Email: drgeminia@gmail.com
Use the QR Code scanner to access this article online in our database Article Code: IDJSR 0005
Abstract
Oral mucositis also called stomatitis, is one of the most common and troublesome forms in individual undergoing cancer treatment. Oncology treatment does not distinguish between the malignant cells and normal epithelial cells of mucosa because of their high proliferative capacity. Thus, the mucosa becomes atrophic, and more susceptible to trauma, allowing the development of inflammation and installation of secondary infection, which aggravates the patients clinical conditions and reduce the quality of life. The clinical management of mucositis includes preventive and palliative strategies. The role of the oral physician in prevention and management of chemotherapy and radiotherapy induced mucositis is critical.
Introduction
Oral mucositis may be defined as inflammation of oral mucosa with extensive ulceration and painful irritation (1).It is considered an acute inflammation caused by the necrosis of the basal layer of the oral mucosa. The more important clinical features are erythema and/or ulceration (6), which may extend from the mouth to the rectum (2). It
can induce several life-threatening complications, such as intestinal obstruction and perforation (3), reducing the patients quality of life and leading to severe infections, which may require the interruption of the antineoplasic treatment (6). Oral and throat pain caused by the mucosa ulceration, abdominal pain, vomits and diarrhea are characteristics that compromise the patients nutritional status because of a decrease of
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
7
food intake, leading to weight loss (5). The progression of oral lesions and its impact on general conditions of the patient may require parenteral nutrition or temporary interruption of the antineoplasic treatment (7). It is a complex biological process divided into four phases, which are interdependent and can occur due to action of cytokines on epithelium. These phases are 1. Inflammatory or vascular phase: day 0 2. Epithelial phase: days 4-5 3. Ulcerative or bacteriologic phase: days 6-12 4. Healing phase: days 12-162 proliferation and cellular differentiation occur, restoring the integrity of the mucosa (12). The anti cancer drug most commonly associated with oral mucositis include bleomycin, doxorubicin, fluorouracil and methotrexate. The cancer therapy agents vincristine and daunorubicin have a toxic effect on the mucosa [Kstler et al., 2001]. Either the use of these drugs or the cancer itself leads to neutropenia, which predisposes the mucosa to mucostitic lesions and also enables bacterial invasion of the submucosa and vascular walls, leading to bacteraemia and septicaemia [Sonis, 2004; Brown and Wingard, 2004]. The patient in the case described here initially exhibited bacteraemia, the remission of which occurred following haematological recovery associated to the use of meropenem and vancomycin. In radiotherapy, an inflammatory response is influenced by the depth and volume of radiation, total gray delivered and the number and frequency of treatments. The onset, duration and intensity vary with the individual but most often the onset starts with second week of therapy or after a dose of about 2000cGy.radiation therapy causes loss of taste by damaging the microvilli and outer surface of taste cells, the onset is rapid and progressive with ageusia or mouth blindness occurring after 3000 cGy.
Epidemiology
Mucositis has received significant attention from the physician community in the last two decades of life. It is estimated that oral mucositis affects 40% of the patients undergoing chemotherapy, 75% of the patient undergoing chemotherapy and bone marrow transplantation and more than 90% patient undergoing radiotherapy for head and neck cancer. According to chiappelli, 40% of the patient undergoing radiotherapy develop mucositis. (12)
Pathophysiology
Firstly, the chemotherapy drugs induce the death of the basal epithelial cells, which may occur by the generation of free radicals. These free radicals activate second messengers that transmit signals from receptors on the cellular surface to the inner cell environment, leading to up-regulation of pro-inflammatory cytokines, tissue injury, and cell death. The pro-inflammatory cytokines produced by macrophages, such as TNF-, amplify the mucosal injury; the production of these proinflammatory cytokines can also be stimulated by a superimposed infection of the ulcerated areas of the mucosa. Later, epithelial
Clinical Manifestation
The first symptoms reported by patients with oral mucositis are burning mouth and color changes in the mucosa, which becomes white because of insufficient keratin desquamation. Then, this epithelium is replaced by atrophic, edematous, erythematous, and friable mucosa, allowing the development of ulcerated areas with the formation of a pseudomembrane, characterized by the presence of a fibrinopurulent, yellow, and outstanding layer (6,9). The ulcerated lesions are painful and compromise the patient nutrition and oral
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
8
hygiene, and also are considered sites for the development of local and systemic infections. In the oral mucosa, this condition involves the ventral portion of tongue, floor of the mouth and soft palate (scully et al;2004). According to the World Health Organization, oral mucositis is classified into the following grades: Grade 0 absence of mucositis; Grade I presence of painful ulcerations and erythema; Grade II presence of painful, erythema, edema or ulcerations that do not affect the patient food intake; Grade III confluent ulcerations that affect the food intake; Grade IV the patient requires parenteral nutrition (13).
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
CATEGORY LIPS
RATING 1234
1234
Pale and slightly dry; one or two isolated lesions, blisters or reddened areas.
3 Dry and somewhat swollen, may have one or two isolated blisters; inflammatory line or demarcation Dry and somewhat swollen, generalized redness; more than two isolated lesions, blisters or reddened areas.
4 Very dry and edematous ;entire lip inflamed; generalized blisters or ulcerations Very dry and edematous; thick and engorged; entire tongue very inflamed; tip very red and demarcated with coating; multiple blisters or ulcers. Very dry and edematous; thick and engorged; entire tongue very inflamed; tip very red and demarcated with coating; multiple blisters or ulcers. Teeth covered with debris Saliva thick and ropy, viscid or mucid Severe dysfunction 16-20
Tongue
1234
Slightly dry; one or two isolated reddened areas; papillae prominent , particularly at base.
Dry and somewhat swollen,; generalized redness but tip and papillae are redder; one or two isolated lesions or blisters.
Teeth
1234
Clean; No debris
Saliva
1234
No dysfunction 5
Moderate debris clinging to one-half of visible enamel Saliva scanty and maybe somewhat thicker than normal Moderate dysfunction 11-15
Treatment modalities
Antioxidants Antioxidants may he particularly important since cancer treatment is an oxidative process. Radiotherapy and chemotherapy generate free radical species, which require anfioxidants to be neutralized Beta-carotene This has been proven to be useful in chemotherapy-induced mucositis. In one trial, chemotherapy patients were given 400,000 IU per day for 3 weeks and then 125,000 IU for an additional 4 weeks.
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
10
release of the arachidonic acid cycle, which is an initiator of the inflammatory process. Corticosteroid mouthwashes These may be beneficial and are contraindicated if the patient bas a bacterial or viral infection. Triamcinolone acetonide 0.2% aqueous suspension can be used as a rinse for 1 minute twice a day and expectorated. Chamomile mouthwashes These have been used to improve mucosal healing. With controversial results. However, rinsing with 15 drops in 10 mL of warm water, three times a day, has reduced the incidence and severity of mucositis in cancer patients. Local anesthetic mouthwashes These may help to relieve pain on a temporary basis.
Vitamin E in combination with vitamin C Both act on a cellular level by protecting the cell membrane and preventing peroxidation. Glutamine A precursor of glutathione, this is very important for stress periods. It is the most abundant amino acid in the human body, and it is now considered a conditionally essential amino acid during periods of catabolism. Early studies show that glutamine has a positive effect through three mechanisms: (1) as a cellular fuel; (2) as a precursor for nucleotides needed for cell regeneration; and (3) as a source of glutathione, which is a potent antioxidant's The use of 4 grams of powdered glutamine in oral rinse in a swish and swallow suspension, twice per day, decreases the intensity and duration of the mucositis Lysofylline A protectant that reduces lipid peroxidation also decreases oxidative injury. It is presently being tested in chemoradiation trials of head and neck cancer
Analgesics
Capsaicin This is found in chili peppers and acts upon nerve endings to provide temporary pain relief. The exact mechanism of action is unknown Morphine A central nervous system analgesic, it depresses pain impulse transmission. It is effective for managing mucositis pain in cancer patients, but dry mouth is one of its adverse reactions. (13)It does not improve the health of the mucosa. Fentanyl (transdermal patch) A very potent short acting opioid, it is used primarily as an anesthetic. It is available in a sustained-release transdermal delivery system (duragesic) with a half-life of 22 hours.
Mucosal barriers
Clobetasol (0.05% ointment 1:1 with Orbase). As a topical corticosteroid, it plays a role in inflammation and immunosuppression. It is contraindicated in infection.
Mouthwashes
Benzydamine hydrochloride As an oral rinse, this has been shown to be effective, safe, and well tolerated in ameliorating the symptoms of cancer treatment induced mucositis. Rinsing then expectorating 15 mL of 0.15% solution every 2 hours will help with the painful inflammation of the mouth and throat. Benzydamine base local analgesic, antimicrobial, and antiinflammatory properties. It prevents the
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
11
Immunomodulators
Thalidomide An immunomodulatory and antiangiogenic agent, it inhibits tumor necrosis factor-alpha (TNF-o;), which is associated with oropharyngeal ulcers. In multiple studies, the efficacy of this medication against oral and esophageal ulcers bas been demonstrated. In one trial, 92% of patients had complete healing after 4 weeks by taking 200 mg by mouth at bedtime.
Grade 2 & 3 Increase frequency of oral hygiene to every 2-3 hours Use foam oral wash if brushing is too painful Use agent to protect mucosa Apply topical agent for pain control Supplement oral intake with enteral or parental support. Provide proper analgesics and/or antibiotics if indicated Cultural suspect areas Grade 4 Continue frequent oral hygiene I.V antibiotics Laser therapy Cryotherapy
Nonpharmacologic approach
Cryotherapy This produces vasoconstriction, which reduces blood flow and diminishes the distribution of the chemotherapeutic agent to the oral mucosa. Ice swishing for 30 minutes following cancer therapy has been shown to be beneficial for these patients Low-intensity laser therapy This may improve wound healing and accelerate replication of the cells. Low-energy helium-neon (He-Ne) laser seems to be a safe, simple, atraumatic, and efficient method for the prevention and treatment of chemotherapy/radiotherapyinduced mucositis.
Conclusion
Mucositis is a common side effect of radio and/or chemotherapy anticancer treatments, but it has a complex pathophysiology and requires management strategies that have not been standardized yet. To identify patients at high risk to develop this condition is essential to reduce the costs of the anticancer treatment and to avoid its interruption after the installation of mucositis. There are many agents used for the treatment of mucositis with different mechanisms of action. However, there are no conclusive evidences on their effectiveness to establish protocols for patients undergoing radio and/or chemotherapy
Management protocol
Grade 1 Brush with soft bristled nylon brush and floss daily Rinse with salt and soda or 15% hydrogen peroxide Apply a moisturizer. Promote oral hydration and nutritional intake Remove and clean denture
References
1. Implications for evidence-based research in alternative and complementary palliative treatments. Evid Based Complement Alternat Med 2005;2:489-94. 2. Epstein JB, Schubert MM. Oral mucositis in myelosuppressive cancer therapy. Oral
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
12
Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:273-6. 3. Gibson RJ, Bowen JM, Keef DM. Technological advances in mucositis research: new insights and new issues. Cancer Treat Rev 2008;34:476-82. 4. Rubenstein EB, Peterson DE, Schubert M, Keefe D, McGuire D, Epstein J et al. Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis. Cancer 2004;100:2026-46. 5. Volpato LE, Silva TC, Oliveira, TM, Sakai VT, Machado MA. Radiation therapy and chemotherapy-induced oral mucositis. Rev Bras Otorrinolaringol 2007;73:562-568. 6. Keefe DM, Schubert MM, Elting LS, Sonis ST, Epstein JB, Raber- Durlacher JE et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer 2007;109: 820-31. 7. Arora H, Pai KM, Maiya A, Vidyasagr MS, Rajeev A. Efficacy of He- Ne Laser in the prevention and treatment of radiotherapyinduced oral mucositis in oral cancer patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:180 8. Lionel D, Christophe L, Marc A, Jean-Luc C. Oral mucositis induced by anticancer treatments: physiopathology and treatments. The Clin Risk Manag 2006;2:159-68. ___________End of Article__________
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
13 REVIEWARTICLE
IMPORTANCEOFINFORMEDCONSENTINDENTISTRY
1Dr.
Annie Mehnaz Mirza Access this Article Online SVS Institute of Dental Sciences, India
www.idjsr.com
1BDS,
Use the QR Code scanner to access this article online in our database Article Code: IDJSR 0007
Abstract
The aim of this article is to provide fundamental information regarding consent when providing dental care. The change in attitude of patients with emphasis on being involved and informed of every aspect of care is not only apparent in adults but also when providing care for children and young adults. It is important for the dentist to be well informed of the fundamental process of consent, which exists under the law affecting both adults and minors in order to provide care within the legal framework. 2 consent are sometimes unclear in clinical work - the reasons for this are assessed and illustrated. Standards of good practice in obtaining informed consent are suggested.
Introduction
Patients informed consent is a legal regulation and a moral principle. It represents patients rights to take part in the clinical decisions concerning their treatment. In order to practice in a professionally responsible manner, dentists must assist patients to make well-informed decisions about treatment procedures. The importance of obtaining informed consent in dentistry is increasingly recognized for moral and legal arguments which are explored. Morally, patients have the right to self-determination and respect for it underpins the relationship of trust deemed so important for clinical success.3 Legally, this right is reinforced through the risk of dentists being sued for negligence if they do not adequately respect it. The practical implications of the doctrine of informed
How it is done
Dentists have a duty to explain clearly about the pros and cons of a treatment. That does not mean that he must engage in an explanation equal to the depth of three hours of dental continuing education! It does mean, however, that a dentist must inform, in laymans terms, the condition or disease present and the treatments available to the patient, whether or not the practitioner performs all of the treatments discussed. For example, a general dentist must discuss the option of implants as well as bridges and partial dentures, even if that dentist does not place or restore implants, if he plans to
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
14
remove a tooth or two on the lower right quadrant. The patient must understand not only the importance of replacing the extracted teeth but all of the available options to do so as well. There are three essential components to valid consent: Competence: It means that the patient has sufficient ability to understand the nature of the treatment and the consequences of receiving or declining that treatment. Voluntariness: It means that the patient has fully agreed to have the treatment and there has been no coercion or undue influence to accept or decline the treatment. Information and knowledge: It means that sufficient comprehensible information is disclosed to the patient regarding the nature and consequences of the proposed and alternative treatments. All these three elements are interdependent but must be present for consent to be ethically and legally valid. procedures and prophylaxis, provided that full records are documented. 3. Written Consent: A written consent is necessary in case of extensive intervention involving risks where anesthesia or sedation is used, restorative procedures, any invasive or surgical procedures, administering of medications with known high risks etc. When the Patient disagrees As is often the case in the dental office, patients arrive in pain and simply want the pain to stop no matter what the consequences. In such cases, it is best to alleviate the pain with local anesthetic to allow a less clouded judgment and normal thought process to emerge. In the eyes of the law, a person cannot consent to anything if his or her judgment is impaired in any way. This was often meant to include drugs and alcohol, which remove the ability to make sound decisions, yet pain should also be included in this category since it too often impairs the ability to think in a rational manner. Patients have the ultimate say when it comes to treatment, but it is the practitioners duty to make sure all options for treatment are explored. In this case, a signed refusal protects the doctor by documenting the conditions found and the treatment options presented. This is called an Informed Refusal.4 A competent patient has a right to refuse medical treatment for any reason. It has been established that it does not matter if the decision is not what others would consider to be reasonable, nor does it matter if it leads to fatality as a result of the decision. What exactly is needed in the Informed Consent? It is not sufficient that a dentist simply document in the chart that he or she went over all risks of treatment and the patient understands. Specific risks must be written down, and patients must be given the opportunity to discuss with the doctor and question those issues which they do not understand. It should consist of a well formed questionnaire including but not limiting to:
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
15
care and consent for the child or young person should lay with his/her parents. Patients under the age of majority or adults with diminished mental capacity should have treatment consent obtained from a parent or legal guardian. The adult accompanying the pediatric patient may not be a legal guardian allowed by law to consent to medical procedures. Examples of this include a grandparent, stepparent, noncustodial parent or friend of the family. 6 Where a child requires treatment without a parent or legal guardian present: Telephone consent may be obtained. Where the child or minor is assessed as competent they may provide consent. Where a responsible adult (i.e. teacher, Grandparent) is with the child, evidence of parental consent to treatment must be sighted or parental consent obtained.
The proposed treatment plan (indicating to what extent it depends upon established versus relatively new or controversial procedures) and its cost. Likely prognosis, outcomes and benefits. Possible complications, side-effects and material risks inherent in the treatment. Possible alternative treatments and cost options. Likely consequences of no treatment. Any other aspects requested by the patient.5
This should be immediately followed by the patients signature/date, doctors signature/date and witnesss signature/date. Make sure that the patients name is legibly printed somewhere on the form since some signatures are illegible. In most cases, a consent form need be little more than one page for most dental procedures if it is organized well. When is Consent not required? In case of an emergency the treatment is a necessity and there is no written advance directive by the patient to the contrary. Treatments authorised by statute are medical treatments/interventions identified in law, including compulsory drug screening and certain procedures relating to mental health patients. Any medical treatment/intervention to be carried out or ceased as a result of a direction/order of the court. Valid informed consent by the patient is not required.
When problem arise with the child and parents with different opinions then, according to law a person with parental responsibility can always override decisions made by children. In case of an emergency, the health practitioner has a right to treat the patient without the consent.
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
16
chances of the practitioner being sued for releasing the information.
References
1. Lewis Laska, Nashville, TN -Medical Malpractice Verdicts, Settlements and Experts. 2. Seema Lal, Consent in Dentistry, Pacific Health Dialog, Volume 10, 2003. 3. Dr. Jay Baxley, A Peer Reviewed article,Informed Consent 4. ACT - Consent to treatment, Patient safety and Quality Unit. 5. Australian Dental Association, Guidelines for good Dentistry, Consent for Care in Dentistry by Federal Council, 1999. 6. American Academy of Pediatric Dentistry- Guidelines of Informed Consent, 2005.
___________End of article____________
Conclusion
However, in dentistry, just as in medicine, unforeseen mishaps occur despite our best efforts. Therefore, it is just as important for dentists to obtain informed consent prior to every invasive and/or irreversible procedure. At first glance, most patients appear friendly and most dental procedures appear routine, but once a procedure goes wrong, an unhappy patient with a skilful attorney can become a dentists worst nightmare. A signed, written informed consent may be the only evidence that the mishap that occurred was a foreseeable risk acknowledged by the dentist and accepted by the patient. Although obtaining informed consent may at first seem awkward, cumbersome, and time-consuming, it may very well save a practitioner countless hours in the courtroom and thousands of rupees in legal fees should some mishap occur.
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
17 REVIEWARTICLE
MICROENDODONTICS:AGGRANDIZEMENTOFROOTCANAL TREATMENT
Sameer D Jain1 M.G.Vs K.B.H Dental College and Hospital [Mahatashtra University of Health Sciences (M.U.H.S)], Mumbai Agra Highway, Panchavati, Nashik, Maharashtra, India
1BDS,
Corresponding Author Sameer D Jain A-1 Kaustubh Park, SVP Road, Borivali-W, Mumbai-400103, Maharashtra, India Contact no. 022 28944364 +91 9892490644 +91 9029297516 Fax 022 28954657 E-Mail: sam777_25@yahoo.co.in
www.idjsr.com Use the QR Code scanner to access this article online in our database Article Code: IDJSR 0009
Abstract
This article presents a review of the history of the dental-operating microscope and how it experienced slow acceptance. Following its introduction in 1982, it wasnt until 1997 that microscopy training became mandatory for Advanced Specialty Education Programs in Endodontics. Undoubtedly, microscopic enhanced endodontics ultimately reshaped clinical practice and created a potential for a higher standard of care.
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
18 Introduction
It may seem surprising that the microscope is not a high-tech instrument. It has been used in the medical field for over 50 years. According to the Zeiss Company, the microscope was first introduced to otolaryngology around 1950, and then to neurosurgery in the 1960s, and to endodontics in the early1990s (1). Dentistry, therefore, is about 40 years behind medicine in this respect. As in medicine, the incorporation of the microscope in clinical endodontics has had profound effects on the way endodontics is done and has changed the field fundamentally. For this reason, the 1998 American Dental Association accreditation requirement change states that all accredited United States postgraduate programs must teach the use of the microscope in nonsurgical and surgical endodontics (2). This was a giant step forward in the advancement of endodontics. This article outlines the key prerequisites for the use of the microscope in nonsurgical endodontic procedures. There are many microscopes on the market; the three most popular ones are presented in Fig. 1. Rubber dam placement The placement of a rubber dam prior to any endodontic procedure is an absolute requirement for sterility purposes. This technique is taught at all dental schools. In endodontics, however, the purpose is greater. Here, the rubber dam placement is necessary because direct viewing through the canal with the microscope is difficult, if not impossible. A mirror is needed to reflect the canal view that is illuminated by the focused light and magnified by the lens of the microscope. If the mirror were used for this purpose without a rubber dam, then the mirror would fog immediately from the exhalation of the patient. Thus, the powerful microscope magnification and illumination would be rendered totally useless for the necessary visualization of the chamber floor and the canal anatomy. To absorb reflected bright light and to accentuate the tooth structure, it is recommended to use blue or green rubber dams (Fig. 2).
Fig. 2: The use of a rubber dam is essential for effective microscope use Fig. 1: The three most popular microscopes in endodontics
Methods
Prerequisites for the use of the microscope in nonsurgical endodontics:
Indirect view and patient head position. As mentioned previously, it is nearly impossible to view the pulp chamber directly under the microscope. Instead, the view seen through the microscope lens is a view reflected by way of a mirror. To maximize the access and quality of the view by this indirect means, the
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
19
position of the patient (especially the head position) is important (Fig. 3). The optimum angle between the microscope and the mirror is 450, and the clinician should be able to obtain this angle without requiring the patient to assume an uncomfortable position. The maxillary arch is rather easy for indirect viewing. Basically, the patients head is adjusted to create a 900 between the maxillary arch and the binocular (Fig. 4). In this position, the mirror placement will be close to 450 for best viewing (3). endodontic instruments. Readjusting the mirror will necessitate refocusing of the microscope, making the entire operation timeconsuming and, at times, frustrating. This is especially true during a lengthy perforation repair. With practice, however, the correct placement of the mirror will become automatic. Some key instruments The ability to locate hidden canals is the most important and significant benefit gained from using the microscope. To do this effectively and efficiently, clinicians must use specially designed microinstruments. An explorer can pick the entrance of a canal under the microscope, but negotiating the canal with a file can be challenging because there is only a tiny space between the mirror and the tooth for a finger with a file to move around. Files specially designed by Maileffer, called microopeners, have with different sized tips and can be extremely useful (Fig. 5). These hand-held files allow the clinician to initially negotiate the canal, verifying that the catch is truly a canal. After the canal is located in this manner, clinicians can instrument the canal normally without the microscope. The use of GatesGlidden burs to enlarge the canal entrance prior to full instrumentation, however, can be easily achieved under the microscope, facilitating the subsequent steps of canal instrumentation.
Fig. 3: Patients should wear protective dark glasses and have support for the neck, such as a moldable pillow
Fig. 4: Positioning the microscope. Notice the ergonomics of the clinician and comfortable patient position
Mouth mirror placement It is always a good idea to use the best mirror for this purpose. If a rubber dam has been placed, then the mirror must be placed away from the tooth within the confines of the rubber dam. If the mirror is placed close to the tooth, then it will be difficult to use other
Fig. 5: Micro-openers by Maillefer are ideal instruments for exploration of hidden canals at high magnification
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
20
It has been found that nearly an astounding 50% of all molars (maxillary and mandibular) have a fourth canal, more than 30% of all premolars have a third canal, and close to 25% of all anterior teeth have two canals. What was considered a rare exception in the past has become a routine finding when using the microscope. Considering this as the benefit of using the microscope for endodontic procedures is obvious. There are teeth where the canal bifurcates at 3 to 5 mm into the canal and in the maxillary second molar, where the MB and DB are in very close proximity of each other; the microscope is an invaluable tool in clearly detecting the bifurcation and the two separate canals (4). Management of calcified canals With normal vision or low-power loupes, calcified canal in the pulp chamber is not detectable. When the calcified canal is looked at through the microscope at high magnification, however, the difference in the color and texture between the calcified canal and the remaining dentin can be easily seen. Careful probing and use of ultrasonics with CPR or Buc tips (Obtura/Spartan, Fenton, Missouri) will allow clinicians to detect and negotiate the calcified canal easily (Fig. 7). Sometimes in these cases, the ultrasonic preparation of the canal or canals has to go as far as a couple of millimeters short of the apex. Again, the microscope allows the clinician to detect and prepare conservatively, and not to gouge the healthy dentin structures (Fig. 8). Perforation repair Perforation does occasionally occur no matter how carefully the tooth is accessed for endodontic therapy. When a perforation occurs, the microscope is the key instrument to identify and evaluate the damaged site.
For what procedures is the microscope really essential? Some enthusiasts claim that the microscope must be used for all steps of nonsurgical endodontic procedures. This may a noble idea, but in reality, it is not needed or desired. A clinician must consider the benefit/risk ratio when using the microscope. The following procedures are those that benefit from the use of the microscope. Diagnosis The microscope is an excellent instrument to detect microfractures that cannot be seen by the naked eye or by loupes. Under 16_ to 24_ magnification and focused light, any micro fracture can be easily detected (Fig. 6). Methylene blue staining of the microfracture area assists this effort greatly. A persistently painful tooth after endodontic therapy may be due to an untreated missing canal (eg, MB2 in a maxillary molar). Re-examination of the chamber at high magnification under the microscope may locate the missing canal (see the article by Kim elsewhere in this issue [Fig. 5]). Locating hidden canals The most important utility of the microscope in nonsurgical endodontics is locating hidden canals. The canal anatomy is extremely complex. All endodontic textbooks have information on molar teeth with three canals, premolars with two canals, and anterior teeth with one canal. Often, dental anatomy is not that predictable.
Fig. 6: Microfracture detected under the microscope (A) and the same tooth after extraction (B) Arrows identify the fracture line.
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
21
Retrieval of broken files With the more frequent use of nickel-titanium rotary files in general dentistry, the incidence of file separation within the canals has increased. When the file is broken at the apex, the microscope cannot be of help. If the file breaks within the coronal half of the canal, however, then the microscope is essential to guide the clinician to retrieve the broken files. In this manner, the broken file can be removed while minimizing the damage to the surrounding dentin. Final examination of the canal preparation It takes a simple step to see whether a canal is completely cleaned. Under the microscope, a small amount of sodium hypochlorite, a popular irrigation solution, is deposited into the canal and observed carefully at high magnification. If there are bubbles coming from the prepared canal, then there is still remnant pulp tissue in the canal. In short, the canal needs more cleaning.
Fig. 7: Buc tips (Obtura/Spartan) are ideal ultrasonic instruments for cleaning the pulp chamber and floor for clear viewing of the canals.
Fig. 8: Access preparation and management of calcified canals at a high magnification under the microscope (A F)
The results of a careful inspection will be the basis for which the preparation of the perforation repair will be made. Briefly, the microscopic procedure is to place a matrix precisely, just outside of the perforation site (i.e. just exterior of the root substance). The matrix can be calcium sulfate or resorbable collagen. After the matrix is placed, mineral trioxide aggregate is packed against the matrix. This procedure requires delicate and careful handling of the materials so as not to extrude, overfill, or underfill. The microscope is essential for this procedure.
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
22
curve, endodontic procedures can be done in less time because of the greater visibility of the root canal anatomy. Procedural errors can be greatly reduced (5), if not eliminated, and complicated cases become less so under the microscope. Another benefit of the microscope is the flexibility with documentation. Compared with intraoral video cameras, microdental images can be captured on computer or digital camera. The information can then be shared with referring dentists or patients and the images are, of course, also required information for the patient record. 3. Branson BG, Bray KK, GadburyAmyot C, et al. Effect of magnification lenses on student operator posture. J Dent Educ. 2004;68:384-389. Valachi B. Vision quest: finding your best working distance when using loupes. Dental Practice Report. 2006;4:49-50. 4. Spear FM. One clinicians journey through the use of magnification in dentistry. Advanced Esthetics and Interdisciplinary Dentistry. 2006; 2:30-32. 5. Cuomo GM. Posture-directed vs. image-directed dentistry: ergonomic and economic advantages through dental microscope use. http://www. heryschein.com/usen/dental/services/ce hp/HomeStudy.aspx. Published April 27, 2006. Accessed November 14, 2008.
References
1. Syngcuk Kim. Modern Endodontic Practice: Instrumentsand Techniques, Dent Clin N Am 2004; 48: 19. 2. Syngcuk Kim, Seungho Baek. The microscope and endodontics. Dent Clin N Am 2004; 48: 1118.
__________End
of
article_______
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
23 CASEREPORT
Corresponding Author Dr. Saurabh S. Chandra MDS, Assistant Professor, Dept. Of Conservative Dentistry & Endodontics, School Of Dental Sciences, Sharda University, Greater Noida, India Email: saurabhchandra@yahoo.com Access this Article Online
MDS, Senior Lecturer, Dept. Of Periodontology, Sree Bankey Bihari Dental College, Ghaziabad, India
2
www.idjsr.com
Use the QR Code scanner to access this article online in our database Article Code: IDJSR 0013
4 Intern,
Abstract
A rare case of a three-rooted mandibular permanent second molar in a 21-year-old male patient is reported. After clinical and radiographic examination, four separate root canal orifices were detected. A mesial shift radiograph confirmed the presence of an additional disto-lingual root. The tooth was treated by orthograde endodontic treatment in two visits. The case report underlines the importance of complete knowledge about root canal morphology and possible variations that exist in mandibular molars; coupled with full clinical and radiographic examination, in order to increase the ability of clinicians to treat root canal aberrancies. Aim: Clinicians should be aware of these unusual root morphologies in the mandibular second molars. The initial diagnosis of a third root before root canal treatment is important to facilitate the endodontic procedure, and to avoid missed canals. Keywords: Dental Anomalies, Mandibular molars, Radix Entomolaris, Three rooted mandibularmolar
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
24
Introduction
Orthograde endodontic treatment comprises of meticulous cleaning & shaping, disinfection of the entire root canal space followed by a three dimensional obturation. Root canals may be left untreated during endodontic therapy if the clinician fails to identify their presence, particularly in teeth with anatomical variations or extra root canals.1,2 Comprehensive knowledge of the presence of unusual root canal anatomy and morphology is important for successful dental practice and for identifying features of anthropological significance. It is commonly acknowledged that both deciduous and permanent mandibular molars display several anatomical variations. The majority of mandibular second molars are two-rooted with two mesial and one distal canal.3 However, the number of roots and root canals may vary. An additional third root, first mentioned in the literature by Carabelli, is called the Radix Entomolaris (RE).4 This supernumerary root is located distolingually in mandibular molars, mainly first molars. An additional root at the mesiobuccal side is called the radix paramolaris (RP).1,4-6 The identification and external morphology of these root complexes, containing a lingual or buccal supernumerary root, are described by Carlsen and Alexandersen.6 This supernumerary root (RE) has a frequency of less than 4% in Caucasians, 2.8% in African populations, whereas in populations with Mongoloid traits (Chinese, Indians and Eskimos) this macrostructure occurs with a frequency between 5% and 30%.1,2,6 In these populations, RE is considered to be a normal morphological variant and can be seen as an Asiatic trait.1 The aim of this paper is to report a mandibular second molar featuring
Case Report
A 21-year-old southeast-Asian male patient reported to the Department of Conservative Dentistry and Endodontics, Ragas Dental college & Hospital, Chennai with the chief complaint of spontaneous dull pain in the lower right region for the preceding few months. His medical history was noncontributory. An intraoral clinical examination revealed a deep carious lesion in the right mandibular second molar (tooth #31) with tenderness on percussion. Radiographic and sensitivity tests were performed that led to a diagnosis of irreversible pulpitis with apical periodontitis, necessitating endodontic treatment (Fig. 1). The tooth was anesthetized using 2% lignocaine with 1:100,000 adrenalin (Lignox; Indoco Remedies, Mumbai, India) and isolated under rubber dam (Hygenic Dental Dam, Coltne Whaledent, Germany). Caries was excavated, and an adequate endodontic access cavity was made using an Endo Access bur (Dentsply Maillefer, Ballaigues, Switzerland). The chamber was flushed with 3% sodium hypochlorite (Dentpro, Chandigarh, India) to remove the debris. Observation via a conventional access cavity revealed the presence of 3 canal orifices, 2 mesial and 1 distal. The dentinal map on the floor of the chamber was traced and explored using a DG 16 endodontic explorer (Hu-Friedy, Chicago, IL) following which the pulp tissue was extirpated using barbed broaches (Dentsply Maillefer, Tulsa, OK). On inspection with 2.5 magnification prismatic loupes (Seiler, St. Louis, MO), a dark line was observed between the distal canal orifice and the distolingual corner of the pulp chamber floor. At this corner overlying dentin was removed with a diamond bur with
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
25
a noncutting tip (Diamendo, Dentsply Maillefer) and a second distal canal orifice was detected (Fig.2). Canal patency was established using a #10 K file (Mani, Tochigi, Japan). The canal length was determined electronically using an electronic apex locator (Root ZX II; J. Morita, Tokyo, Japan) and subsequently verified with an intraoral periapical radiograph. Root canal instrumentation was performed with ProTaper Ni-Ti rotary files (Dentsply Maillefer, Tulsa, OK) using a crown-down technique. During preparation, EDTA (Glyde File Prep, Dentsply Maillefer, Tulsa, OK) was used as a lubricant and the root canals were disinfected with 3% sodium hypochlorite solution (Dentpro, Chandigarh, India). The canals were finally rinsed with saline (Marck Biosciences, Gujrat, India), dried with sterile absorbent paper points (Dentsply Maillefer), and an intra canal medicament of calcium hydroxide was place. Initially, the distolingual root canal was thought to be a second canal in one distal root. Radiographically the outlines of the distal root(s) were unclear; however, the unusual location of the orifice far to the distolingual indicated a supernumerary root, and the presence of an RE was confirmed on the postoperative radiograph. The patient was recalled after a week and the canals were obturated with cold laterally condensed guttapercha (Dentsply Maillefer) using AH Plus resin sealer (Dentsply Maillefer). A postoperative radiograph (Fig. 3) was taken; the opening cavity was sealed with posterior composite (Solare, GC Fuji, Japan) and the patient was scheduled for a permanent coronal restoration. supernumerary root can be found on the first, second and third mandibular molar, occurring least frequently on the second molar.1 There are various case reports of mandibular first molars featuring an RE. On the contrary, RE in the mandibular second molars has been seldom reported. Poorni et al. reported a case of mandibular second molar featuring an RE confirmed using spiral CT.7 The RE is located distolingually, with its coronal third completely or partially fixed to the distal root. The dimensions of the RE can vary from a short conical extension to a mature root with normal length and root canal.1 In most cases the pulpal extension is radiographically visible. In general, the RE is smaller than the distobuccal and mesial roots and can be separate from, or partially fused with, the other roots. A classification by Carlsen and Alexandersen describes four different types of RE according to the location of the cervical part of the RE: types A, B, C and AC.6 Types A and B refer to a distally located cervical part of the RE with two normal and one normal distal root components, respectively. Type C refers to a mesially located cervical part, while type AC refers to a central location, between the distal and mesial root components. This classification allows for the identification of separate and nonseparate RE. The etiology behind the formation of the RE is still unclear.1 In dysmorphic, supernumerary roots, its formation could be related to external factors during odontogenesis, or to penetrance of an atavistic gene or polygenetic system (atavism is the reappearance of a trait after several generations of absence). In eumorphic roots, racial genetic factors influence the more profound expression of a particular gene that results in the more pronounced phenotypic manifestation.5,6 Curzon suggested that the three-rooted molar trait has a high degree of genetic penetrance as its dominance was reflected in the fact that
Discussion
Anatomical variations of mandibular molars are documented in the literature. Nonetheless, variations of the anatomy of the root canal system in molars are not appreciated by a great number of general practitioners. A
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
26
the prevalence of the trait was similar in both pure Eskimo and Eskimo/ Caucasian mixes. position and the other taken either 30 mesially or distally. This buccal object rule has also been called Clarks rule, the same lingual, opposite buccal (SLOB rule) and Waltons projection. It is imperative that a comprehensive pre-operative radiographic evaluation is done prior to initiation of endodontic therapy.
The location of the orifice of the root canal of an RE has implications for the opening cavity. The orifice of the RE is located disto- to mesiolingually from the main canal or canals in the distal root.1 An extension of the triangular opening cavity to the (disto) lingual results in a more rectangular or trapezoidal outline form. If the RE canal entrance is not clearly visible after removal of the pulp chamber roof, a more thorough inspection of the pulp chamber floor and wall, especially in the distolingual region, is necessary. Visual aids such as a surgical loupes, or dental microscope can be useful. A dark line on the pulp chamber floor can indicate the precise location of the RE canal orifice. The distal and lingual pulp chamber wall can be explored with an angled probe to reveal overlying dentin or pulp roof remnants masking the root canal entrance. The calcification, which is often situated above the orifice of the RE, has to be removed for a better view and access to the RE. An initial relocation of the orifice to the lingual is indicated to achieve straightline access. 8 These anatomic variations in distal root anatomy may be identified through careful reading of angled radiographs. Slowley has demonstrated how difficult it is to detect extra roots, let alone extra canals.9 On the contrary, completing a thorough radiographic study of the involved tooth with exposure from three different horizontal projections, the standard buccal-to-lingual projection, 20 from the mesial, and 20 from the distal reveals the basic information regarding the anatomy of the tooth in order to perform endodontic treatment.8,9 However, using the buccal object rule with two radiographs with different horizontal angulations may suffice to determine the position of a lingual root. One of these radiographs is taken in the orthoradial
Conclusion
Knowledge of both normal and abnormal anatomy of the mandibular molars dictates the parameters for execution of root canal therapy and can directly affect the probability of success. Therefore, practitioners must be familiar with all molar abnormalities, as well as their prevalence.
References
1. Calberson FL, De Moor RJ, Deroose CA. The radix entomolaris and paramolaris: clinical approach in endodontics. J Endod 2007;33:5863. 2. De Moor RJ, Deroose CA, Calberson FL. The radix entomolaris in mandibular first molars: an endodontic challenge. Int Endod J 2004;37:789 99. 3. Skidmore AE, Bjorndal AM. Root canal morphology of the human mandibular first molar. Oral Surg Oral Med Oral Pathol 1971;32:778-784 4. Carabelli G. Systematisches Handbuch der Zahnheilkunde. 2nd ed. Vienna: Braumller and Seidel 1844; 114. 5. Bolk L. Bemerkungen ber Wuzelvariationen am menschlichen unteren Molaren. Zeitschrift fr Morphologie Anthropologie 1915;17:60510. 6. Carlsen O, Alexandersen V. Radix entomolaris: identification and
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
27
7. morphology. Scan J Dent Res. 1990;98:16373. 8. Poorni S, Senthilkumar A, Indira R. Radix entomolaris in mandibular molars confirmed using spiral CT: a case report. Endond Prac Today 2010;4 9. Ingle JI, Heithersay GS, Hartwell GR et al. Endodontic diagnostic procedures. In: Ingle JI, Bakland LF, eds. Endodontics, 5th edn. Hamilton, London, UK: BC Decker Inc., 2002;20358. 10. Slowley RR. Radiographic aids in the detection of extra root canals. Oral Surgery, Oral Medicine and Oral Pathology 1974;37, 76272.
Legends Fig. 1 Pre-operative radiograph Fig. 2 View of Pulp chamber Fig. 3 Post operative radiograph
Fig. 1
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
28
Fig. 2
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
29 ORIGINALARTICLE
College
General
2. Manish Pilania G-43, Shastri Nagar, Jodhpur Contact no. (+91)9461055068 Email: manishpilania3@gmail.com
2Intern,
Department of Conservative Dentistry and Endodontics, Jodhpur Dental College General Hospital, Jodhpur, Rajasthan, India
www.idjsr.com
Corresponding Authors 1. Narendra Parehar Khanda Falsa, Jalori Gate, Jodhpur. Contact no. (+91)9799108142 Email: narenparihar.np@gmail.com
Use the QR Code scanner to access this article online in our database Article Code: IDJSR 0014
Abstract
Background: The purpose of this study was to investigate the relationship between etching of enamel and dentin with different acids: 37% phosphoric acid, 10% maleic acid and 24% EDTA, at different etch durations of 15 and 60 seconds; so as to analyze the surface characteristics of etched enamel, diameter of the dentinal tubules and the depth of demineralization in the tubules under scanning electron microscope (SEM). Method: Thirty freshly extracted maxillary and mandibular premolars, indicated for orthodontic extraction were selected from patients in the age group of 14 to 21 years. The teeth were randomly divided into 3 groups of 10 teeth each and were etched with 37% phosphoric acid, 24% EDTA gel and 10% maleic acid gel respectively for 15 and 60 seconds. The samples were then split along their long axes, dehydrated and sputtered with palladium gold. The sputtered specimens were examined under scanning electron microscope. Results: Acid etching causes various types of etching patterns in enamel indicating preferential dissolution of the enamel prisms. With 37% phosphoric acid, type 2 etching pattern is seen; with 10% maleic acid, type 1 etching pattern is predominant and etching with 24% EDTA leads to type 4 etching pattern. In dentin, etchants widen the dentinal tubule orifices due to demineralization of peritubular dentin and this demineralization extends deep into the dentinal tubules for varying depths depending upon the type of acid used and time of its application. No statistically significant difference exists in the widening of the dentinal tubule orifices between the group I (37% phosphoric acid) and group III (10% maleic acid) specimens. Conclusion: It can be suggested that 15 seconds etching with a milder acid like 10% maleic acid instead of 37% phosphoric acid is sufficient to obtain adequate bond strength because there is no significant difference within the observational parameters, except for the depth of demineralization in tubules. Additional depth is unnecessary because the adhesive systems cannot penetrate completely into the dentinal tubules, leading to nanoleakage.
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
30 Introduction
An ideal restorative material would be the one which chemically bonds to the tooth and has strength comparable to that of the tooth structure. In 1955, Buonocore instituted the use of 85% phosphoric acid solution to cause selective decalcification of tooth structure. This produced microporosities in the enamel, increased the surface area, as well as enhanced wettability of the surface providing an intimate contact between tooth and restoration thereby changing the retention form from mechanical to micromechanical. In 1979, Fusayama introduced and popularized the concept of etching of dentin.3 Stronger acids like phosphoric acid not only decalcify the enamel and dentin surfaces but also demineralize in depth to a greater extent. The increased depth of demineralization is not essentially required because the adhesive systems are not able to penetrate till the complete depth, leading to nanoleakage and incessant degradation.6 Dentin being a vital tissue and containing more organic content than enamel, requires use of milder acids (10% maleic acid and 24% EDTA) so as to prevent damage to micromorphological structure and preserve the integrity of the collagenous mass as they do not denature it.2
37% phosphoric acid gel. 24% Ethylenediamine (EDTA) gel. 10% maleic acid gel. tetracetic acid
The etchant gels were applied on the flat buccal surfaces with the help of a brush, the gel was rinsed off from the teeth with 10ml distilled water for 20 seconds. The specimens were then sectioned into two halves with a sharp chisel and mallet by placing the chisel into the groove which had been prepared along the long axis of the samples. The sectioned specimens were utilized for analyzing the depth of demineralization in dentin by the etchants.
The prepared samples were randomly divided into three groups:Group I, Group II and Group III.
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
31
The samples were transferred to small bottles containing graded concentrations of ethyl alcohol (60% to100%). The samples remained in each alcohol concentration for two hours. The dehydrated samples were removed from 100% ethyl alcohol and were mounted on aluminium stubs and placed in vacuum chamber to desiccate them completely.
Samples were viewed under scanning electron microscope (LEO) at various magnifications. The magnifications selected were:For enamel For dentin -
x 3,000 x 2,000
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
32
2 pattern together with regions in which the pattern of etching could not be related to prism morphology.
Type 1
of the in a
* *
Diameter of the widened dentinal tubules Depth of demineralization in the dentinal tubules.
The diameter of the tubules and the depth of demineralization were measured in m ()
Type 3
INTERNATIONALDENTALJOURNALOFSTUDENTSRESEARCH|JuneSep2012|Volume1|Issue2
33 Statistical Analysis
Using the standard deviation, the student t-test was applied The probability value (p value) was kept constant at 5% significance STATISTICAL ANALYSIS FOR THE WIDTH OF LOSS OF ENAMEL PRISM CORE / PERIPHERY Intragroup comparison Mean Standard Deviation Standard Error T-value Status p<0.05