Lupus case report

117

INDIAN JOURNAL OF DENTAL EDUCATION
The Indian Journal of Dental
Education (ISSN 0974-6099, Editor-in-Chief
Registered with Registrar of Balwant Rai
Newspapers for India: Assoc. Prof, Commander, ILWEG Moon Mars Mission, 100 B
DELENG/2008/32281) Kepler Space University, USA
published quarterly, is
dedicated to the
dissemination of new
Executive Editor
knowledge and information Rajnish K. Jain
on all fields of dentistry. The
IJDE publishes original peer-
reviewed articles that examine Deputy Editors
all phases of dental treatment,
Jasdeep Kaur, India
reports on unusual and
interesting case presentations Maria Catalina, Astronaut Teacher Alliance, NASA JPL Solar System
and invited review papers. Ambassador, USA
The aim of this journal is to Editor Emeritus Managing Editor
convey scientific progress in S.C. Anand A. Lal
dentistry for the benefit of the
dental health of the
community. The journal
serves valuable tool for helping
clinicians, general
International Editorial Advisory Board
practitioners, teachers and
Abbas Taher, London, UK Hamid Jafarzadeh, Iran
administrators involved in the Abu-Hussein Muhamad,Athens, Greece Aous Dannan, Germany
prevention and treatment of Adebola Oluyemisi Ehizele, Nigeria Lojain Jibawi, Syria
dental disease. Alexandra Roman, Romania Marit Vandenbruane ,
Clement Chinedu Azodo, Nigeria Netherlands
Dean Boss, USA Helen James, USA
G. Wellam, Belgium L. James, UK
Jaipaul Singh, UK Marcelo Carlos Bortoluzzi, Brazil
Abdel Rahman Mohammad Said, Al-Tawaha,Jordan Natheer H Al-Rawi, UAE
Inayatullah Padhiar, Karachi Patrick T, Belguim
Florent Richy, Belgium Rafael Manfro, Brazil
Ulrich Suchner, Germany Sandrine Brunel-Trotebas,
Figen Cizmeci Senel, Turkey Romania
Bora Bagis, Turkey

National Editorial Advisory Board
Printed at B.K. Behra, Rohtak
Deepti Dwivedi, Lucknow
R.V. Printing Press Manaswin Tripathi, New Delhi
C-97, Okhla Industrial Area Naveen Gupta, New Delhi
Phase-1 R. K. Sharma, Rohtak
New Delhi - 110 020 S. C. Narula, Rohtak
Surendra Nath, Delhi

All right reserved. The views and opinions expressed Corresponding address
are of the authors and not of the Indian Journal of Red Flower Publication Pvt. Ltd.
Dental Education. The Indian Journal of Dental 41/48, DSIDC, Pocket-II, Mayur Vihar Phase-I
Education does not guarantee directly or indirectly P.O. Box 9108, Delhi - 110 091(India)
the quality or efficacy of any product or service Phone: 91-11-65270068/48042168, Fax: 91-11-48042168
featured in the advertisement in the journal, which E-mail: redflowerppl@vsnl.net, Web:www.rfppl.com

Volume 3 Number 3, July-Sept 2010

119

Indian Journal of Dental Education

Volume 3 Number 3
July-Sept 2010

Contents

Role of oral medicine specialist in disclosing systemic lupus erythematosus:
Adiagnostic dilemma, Running title: systemic luapus erythematosus 121
Zahra Delavarian, Maryam Amir Chaghmaghi, Pegah Mosannen Mozafari,
Mohamad Reza Hatef Fard, Rheumatologist

Oral Health Care of elderly in India: Present Scenario and Future Concerns 127
Pankaj Datta, Sonia Sood

A review on repair of fracture porcelain 133
Roseline Meshramkar

The effect of developer age and file thickness on diagnostic accuracy of
Kodak insight (F-speed) and Ektaspeed plus (E-speed) films in position
assessment of file tip to radiographic apex 139
A. Dabaghi, M. Lomee, S. Saati

Instructions to authors 146


121

Role of oral medicine specialist in disclosing systemic lupus
erythematosus: A diagnostic dilemma

Zahra Delavarian*
Maryam Amir Chaghmaghi**
Pegah Mosannen Mozafari***
Mohamad Reza Hatef Fard****

ABSTRACT
Systemic lupus erythematosus(SLE) is a connective tissue disease in which organs such as liver, kidney
and heart in addition to skin and mucosa are involved. Oral findings are one of the diagnostic criteria
which can be presented with ulcer or red and white lesions. In this article we report a case of SLE that is
diagnosed by oral medicine specialist on the basis of oral ulcers. A 16-year-old female was referred to oral
medicine department with 3 months lasting oral ulcers. There was a history of transient artheralgia in
review of systems. In extra oral examination a butterfly diffuse erythema was observed on nasal bridge and
malar prominences. Oral ulcers had different forms and involved different parts of oral mucosa. Due to
chronic oral ulcers , malar rash and history of artheralgia ,a presumably diagnosis of SLE was affirmed. She
was referred and hospitalized to rheumatology department. Oral and skin lesions were improved
significantly in follow up examination. Oral findings may be the first diagnostic presentation of SLE. It is
important for dentists to pay attention to medical history and different systemic symptoms to achieve
accurate clinical diagnosis.
Key words: Systemic lupus erythematosus, Oral ulceration, Case report, Oral Medicine, Iran

INTRODUCTION several factors such as autoantibodies,
immune complex, tissue damage, genetic
factors (e.g. specific HLA types and gene loci),
Systemic lupus Erythematosus (SLE) is one environmental factors (e.g. exposure to sun
of the most important immunity related light and infections) , endocrine agents and
diseases with unknown etiology, although drugs can predispose an individual to this
disease (1,2) .There are four main clinic-
Author’s Affilation: *Associated Professor of Oral pathological forms: systemic, discoid (chronic
Medicine , Dental Research Center of Mashhad Dental Faculty, cutaneous),acute cutaneous and subacute
Mashhad University of Medical Sciences, Mashhad, Iran,
**Assistant Professor of Oral Medicine , Dental Research cutaneous(3).Organ damage occurs as a result
Center of Mashhad Dental Faculty, Mashhad University of of direct attachment of autoantibodies to host
Medical Sciences, Mashhad, Iran, ***Assistant Professor of antigens or precipitation of immune complex
Oral Medicine , Dental Research Center of Mashhad Dental
Faculty, Mashhad University of Medical Sciences, Mashhad, in small vessels and tissues (vasculitis). (1,2,4)
Iran, ****Associated Professor of Rheumatology School of
Medicine, Mashhad University of Medical, Sciences, Imam There is a female predominance (10:1) and
Reza Hospital, Mashhad, Iran. blacks are involved more frequently.
Reprint’s request: Pegah Mosannen Mozafari, Assistant SLE typically arises in adults aged 15 to 45.
Professor of Oral Medicine, Dental Research Center of
Mashhad Dental Faculty, Mashhad University of Medical (1,2,5)Only 15% of individuals with SLE are
Sciences, Mashhad, Iran. Email: Mosannenp@mums.ac.ir, younger than 18 year at the time of
Tell:0098 511 8829501-15, Fax :0098 511 8829500, Mobile
number:0098 915 306 0496.
diagnosis(6).
(Received on 24.08.2010, accepted on 26.010.2010)
© Red Flower Publication Pvt. Ltd

122 Zahra Delavarian, Maryam Amir Chaghmaghi, Pegah Mosannen Mozafari, Mohamad Reza Hatef Fard

Clinical manifestations of this disease vary The affected sites are the buccal mucosa,
upon specific organ involvement. Fever, gingiva, vermilion border of the lips, palate
fatigue and weight loss are of clinical and tongue (1, 8) .Usually diagnosis of SLE is
components. (7) Arthritis is the most common performed by physicians but at least one case
clinical manifestation of this disease (in 90% report exists about diagnosis of SLE by dentist
of patients) (1,7) and usually appears (11).
symmetrically. Interphalanges, knees, wrist This article, presents a case of SLE, in which
and metacarpal joints are affected more the diagnosis was made based on oral
frequently.(1) Malar rash, dry pruritic skin, manifestations. Despite a history of skin lesions
gasterointestinal disorders and muscle spasms and articular pain, the patient had received
are of other clinical signs.(1) Diagnosis of this improper treatments and Oral Medicine
disease can be made via clinical and Specialist could reveal the disease.
paraclinical findings.. If four of 11 criteria
become evident simultaneously or
consecutively in the course of this disease CASE REPORT
diagnosis can be made with a 75% sensitivity
and 95% specificity. (1)
A 16-year-old female was referred to Oral
Oral manifestations can be the first Medicine Department of Mashhad Dental
presentation of disease, and may lead to Faculty in OCT 2008. She complained of oral
diagnosis. Incidence of oral manifestations, ulcers with three months duration. In review
was first reported by Monach (1931)as 50%, of systems, there was a history of transient
(8) and Vasculitis is considered as the main artheralgia in knees, elbows and wrists in 6
etiology of oral lesions (1,7,8,9). months before initiation of oral manifestations.
These manifestations include: nonspecific Ibopruphen, calcium and vitamin D was
chronic ulcers, erosion, inflammation, prescribed for her by an internist, and partial
erythema and keratotic white lesions (papule, relief was obtained after this therapy. There
plaque …) or even granulomatous lesions and was also a history of hair loss. In extra oral
malignant transformation of oral ulcers. examination, generalized erythema was seen
(1,3,7,8)Candidosis, periodontal disease and on nasal bridge and malar region (Butterfly
temporomandibular disorders and rash) with exfoliation of skin in some areas
desquamative or marginal gingivitis are other (Fig 1) accompanied by a thick crust on the
oral findings of SLE. (1, 8, 9, 10,11) In advanced lower vermilion border.
SLE , xerostomia may appear (1).Sometimes
delayed primary and permanent tooth The patient noted exacerbation and
eruption and twisted root formation can be exfoliation of Malar rash after sun exposure.
encountered as a result of corticosteroids She was advised to use sunscreen by a
treatment (10). dermatologist and a few resolution was
acquired.
Fig 1: Butterfly rash and exfoliation of cheeks and nasal bridge skin and lip crust.


Role of oral medicine specialist in disclosing systemic lupus erythematosus: Adiagnostic dilemma 123

In intraoral examination multiple ulcers and palatal aspects of maxillary gingiva
with different patterns were seen in several (premolar and molar region) (Fig 2)
areas of oral mucosa such as palate, buccal Multiple small , clustered ulcers were
region, gingiva and tounge. observed in right lateral side of hard palate
Diffuse map like ulcers were present adjacent to first premolar and molar, involving
bilaterally on buccal aspects of mandibular an area of 1.5×1.5 cm diameter. there was no
attached gingiva (canine, premolar region) keratotic lesion with reticular pattern

Fig 2: A large deep ulcer of 1×3 cm diameter was present on marginal gingiva of first
right permanent molar extending to hard palate.

(lichenoid reaction). SLE was considered as a dl and lymphopenia. CRP, RF and renal
possible clinical diagnosis by an oral medicine function tests were normal.
specialist due to chronic oral ulcers, butterfly Our patient’s condition satisfied Six criteria
rash and history of articular involvement. So, for a diagnosis of SLE: 1)Malar rash 2)Oral
because all of these signs represent a systemic ulcers 3)Photosensitivity 4)Lymphopenia
disease, there was no need for biopsy of oral 5)Positive anti ds DNA 6)Positive ANA, so
lesions (especially when there was no evidence the diagnosis of SLE was confirmed.
of lichenoid pathology). The Patient was
referred to Rheumatology clinic for further The treatment was initiated by
diagnostic tests and appropriate therapy. Prednisolone, Hydroxychloroquine, Calcium
D, Cephteriaxon (due to uretral infection).
She was admitted to Imam Reza hospital After 2 weeks of flare up control, she was
with provisional diagnosis of SLE. Laboratory discharged with instructions to continue her
tests such as CBC, Rheumatoid factor, ANA prior medications. No topical treatment was
(Antinuclear antibody), Anti ds (double needed for oral ulcers, due to rheumatologic
strand) DNA, CRP (C-reactive protein) and clue.
ESR (Erythrocyte sedimentation Rate) and
kidney function tests were ordered for the After 48 days, the patient was examined in
patient. The results included: positive ANA, Oral Medicine Department. Malar rash was
Elevated ESR, Anti ds DNA>300, Hgb=9gr/ relatively faded out and there was no
exfoliation.( Fig 3)The lip ulcers were
Fig 3: Significant improvement in Butterfly rash and lip crust



completely healed and a mild facial edema was after appropriate treatment (9).In one research
evident (possibly due to corticosteroid on Venezuelan patients oral lesions were
therapy). found in first two years after diagnosis (9) Oral
Nine months later (Aug 2009) the patients ulcer was the main oral manifestation in our
was admitted once more for ten days, with a case. Rhodous has reported other oral findings
complaint of extreme fatigue, arthralgia and such as xerostomia (%100 of cases), mucositis
myalgia . Oral ulcers were not evident in this and glossitis (81/3%), glossodynia (87.5%) and
visit. There was no lupus nephritis, avascular angular cheilitis (87.5%), in evaluated
necrosis and cardiopathy. Appropriate patients(7) . the severity of these symptoms is
treatment was administered for her by compatible with disease flare up(7,13)
rheumatologist. although no significant changes in titers of
c3,ANA or Anti ds DNA has been attributed
In October 2009 she was called and no by some authors(13) Lymphadenopathy and
complication was emerged. focal parotid necrosis (14) are another
occasional findings in head and neck area.
DISCUSSION Fernandes et al (10) attempted to address
oral health an TMJ dysfunction in JSLE
patients. They understood that JSLE patients
Although this case represents an unusual had poor oral hygiene , higher incidence of
diagnostic dilemma, but it seems that in gingivitis and TMJ dysfunction especially in
Juvenile SLE(JSLE) ,this kind of error is not so those on long corticosteroid and
rare(6) .In JSLE the presenting signs are immunosuppression treatments.
protean and many of them are common
complaints among adolescents.(e.g. fatigue , In our patient, because histopathologic
artheralgia),so inexperienced physician may examination of oral ulcers had no benefit and
fail to considered SLE in differential diagnosis systemic involvement would lead to diagnosis,
of transient artheralgia and a facial rash in an biopsy was not performed. There are other
adolescent female. differentiated diagnoses for extra oral
manifestations of this patient. Similar malar
Children and adolescents have a more lesions can be seen in achne rosacea, seboreic
severe disease presentation (6) and develop dermatitis and achne vulgaris and some kinds
severe organ damages more quickly. So early of viral infections (15,6) Although other
diagnosis and intervention is a crucial point systemic signs are not compatible with these
to improve overall outcome of treatment. Our diagnoses. Other systemic diseases such as
case had at least nine months diagnostic delay Behçet’s syndrome and dermatomyositis were
despite articular and cutaneous symptoms. also mentioned for this case.
Tucker reported a summary of common Absence of recurring oral and genital ulcers
presenting signs of JSLE with mucocutaneus and presence of malar rash excluded Behçet’s
ulceration as a relatively rare presenting signs syndrome. Absence of muscular and
in this age group.(6) He speculated that every pathognomonic skin involvement ruled out the
adolescent who appear to have unexplained diagnosis of dermatomyositis.
“un wellness” with vague symptoms of SLE
should be further evaluated for diagnosis of DLE was also included in differential
this entity. It is more fundamental in a prone diagnosis. But in DLE, the lesions are limited
ethnic group (e.g. Asian adolescents) to skin and mucosa (with no systemic
involvement) and oral involvement appears
Prevalence of oral manifestations of SLE has as lichenoid reactions in combination with
been reported as %7 to 87.5% (7,12) in different skin discoid rash (a finding not observed in
studies. The difference can be due to lack of our case.) (16)
diagnosis of SLE at the time of oral
presentation or resolution of these findings Immunologic findings also are of diagnostic
criteria for SLE. Elevated Anti Nuclear
Antibody (ANA) titer (1/40 or high) is the most

Role of oral medicine specialist in disclosing systemic lupus erythematosus: Adiagnostic dilemma 125

sensitive diagnostic criterion for SLE in kept in mind by general dentists to reveal an
serologic tests, and was positive in this case. undetermined systemic condition.
Elevated ANA titers can be found in %99 of
SLE patients; however, in early stage of
REFERENCES
disease, it can be negative. ANA is not an
specific test for SLE since one study revealed
elevated ANA titers in %32 of normal adults 1. Albilia JB, Lam DK, Clokie CML, Saìndor GKB.
(5,16) Systemic lupus erythematosus: A review for
dentists. J of the Can Den Assoc, 2007; 73(9):
ANA is positive in other diseases such as
823-28.
Sjögren’s syndrome (%68), sclerodermy (40-
%75) and rheumatoid arthritis (25-50%) but 2. Sharon GC. The pathogenesis of systemic lupus
erythematosus. Orthopedic Nursing, 2006; 25(2):
lower titers and different immuno fluorescent
140-5.
pattern are observed in these cases.
3. Compilato D, Cirillo N, Termine N, Kerr AR,
Anti ds DNA survey has high specificity Paderni C, Ciavarella D,Campisi G.Long-
and low sensitivity for SLE and in JSLE is a standing oral ulcers: Proposal for a new ‘S-C-D
prominent laboratory profile. In this patient it classification system’. J Oral Pathol Med, 2009;
was increased. Although complement levels 38(3): 241-253.
(C3, C4, C5) are normal in variable kinds of 4. Ramos-casals,M.Nardi,n.Lagrutta,m.Brito-
vasculitis, they are decreased in SLE, as a result zeron,P.Bove,A.Delgado,G.(et al) vasculitis in
of consumption. In inflammatory process in systemic lupus Erythematosus: prevalence And
second administration (flare up) of this patient, clinical characteristics in 670 patients. Medicine,
C3 and C4 levels were low. SLE owns episodes 2006; 85(2): 95-104
of flare up and remission (2, 7) and decreased 5. Oral lupus Erythematosus[on line].Available
levels of complement is the sign of disease flare from URL:http://www.eaom.net/app/prvt/
up. (17) VediNotizia.d/Notizia-96 .accessed sept 20,
2006.
The aim of treatment for SLE in acute phase
is management of acute attacks. And because 6. Tucker LB. Making the diagnosis of systemic
of multiple organ involvement, treatment plan lupus erythematosus in children and
adolescents. Lupus, 2007; 16: 546-9.
is based on clinical presentation. (1)
7. Rhodus, L.Johnson D K. the prevalence of Oral
Management regimen in these patients
manifestations of systemic lupus erythematosus.
include NSAIDS, corticosteroids, Anti malaria Quintessence International, 1990; 21(6): 461-5.
drugs and Immunosuppressants.(1) Prognosis
8. Fernandes, R,L. Review of systemic lupus
depends on severity and extent of organ
Erythematosus. Oral Surg Oral Med Oral Pathol
involvement and complications of treatment. Oral Radiol Endod, 2001; 91(5): 512-6.
poor prognostic factors are young age at onset,
male gender, poor socioeconomic status and 9. López-Labady J, Villarroel-Dorrego M, González
N,Pérez R, Mata De Henning M .Oral
positive titers of antiphospholipid antibodies.
manifestations of systemic and cutaneous lupus
(1) Since oral lesions respond well to systemic erythematosus in a Venezuelan population . J
therapy, no additional treatment is necessary. Oral Pathol Med, 2007; 36(9): 524-527.
10. Fernandes, RL,Savioli C,Siqueira JTT,Silva CAA.
CONCLUSION Oral health and masticatory system in juvenile
systemic lupus Erythematosus. Lupus, 2007; 16:
713-9.
SLE is a systemic disease with multiple organ 11. Jayakumar ND, Jaiganesh R, Padmalatha O,
involvement and variable diagnostic features. Sheeja V. Systemic lupus erythematosus.Ind J
So one may be referred to a dentist with Dent Res, 2006; 17: 91-3.
chronic oral ulcers, with an undiagnosed SLE. 12. Meyer V, kleinheinz J, Handschel J, kruse-losler
Importance of achieving a complete “review B, weingart D, joos V. Oral findings in three
of systems” and accompanying signs must be different groups of immuno compromised
patients. J Oral pathol med, 2000; 29(4): 153-8.



13. Urman JD, Lowenstein MB, Abeles M, Weinstein 15. Zuber MA.Butterfly rash: No lupus. Zeitschrift
A. Oral mucosal ulceration in systemic lupus fur Rheumatologie, 2009; 68(5): 409-10.
erythematosus. Artheritis Rheumatism, 2005; 21: 16. Gill JM, Quisel AM, Rocca PV, Walter DT.
58-61. Diagnosis of systemic lupus erythematosus. Am
14. Carron J, Karakla DW, Watkins DV. Focal Fam Physician, 2003; 68(11): 2179-86.
parotid necrosis in systemic lupus 17. Roane DW, Griger DR. An approach to
erythematosus: Case report and review of the diagnosis and initial management of systemic
literature. Oral Surgery Oral Medicine Oral vasculitis Am Fam Physician, 1999; 60(5): 1421-
Pathology Oral Radiology Endodontology, 1999; 30.
88: 455-460 .


127
Volume 3 Number 3, July - Septemebr 2010

Oral Health Care of Elderly in India: Present Scenario and Future
Concerns
Pankaj Datta*
Sonia Sood**

ABSTRACT
India has a rapidly growing elderly (60 +) population of 77 million which is likely to rise up to 300
million by 2050. For the most of this rapidly growing geriatric population there are no specialized oral
health services. The elderly suffer from multiple oral health problems. The Indian population in the 21st
century requires an in-depth understanding of the co-relation between oral health and general well being.1
Viewing these issues through the lens of oral health care provider allows an analysis of current oral
health care status of the elderly in India; understand the cause of their poor oral health, their attitudes and
treatment needs. The unique combination of growing age, physical disability, personal habits, socio-
economic status and our oral healthcare system presents challenges for appropriate oral health care.2 The
present article highlights on the need to understand the shortfalls in its current oral heath status in elderly
and formulate strategies to improve its oral healthcare structure as well as education policy in geriatric
dentistry to help resolve problems of oral health care for the elderly in India.
Key words: elderly, oral healthcare, dental treatment needs, geriatric dentistry

INTRODUCTION million and 177 million elderly in the year 2001
and 2025 respectively, which will rise to 300
million in 2050 3. Special features of the elderly
Demographic ageing is a global in India are: 52% of elderly in the country are
phenomenon. India’s booming population of women. 71% of the elderly reside in rural
above one billion people and improved life areas. Nearly 75% of the elderly are
expectancy (63 for males and 65 for females) economically dependent. 30% of the elderly
1,3
has led to rapidly increasing number of are below the poverty line. 73% of the elderly
elderly people (>60 years age group). This are illiterate. It is estimated that 90% of the
includes both healthy adults and adults who old people belong to unorganized sector (i.e.
are cognitively and physically challenged without gratuity, pension etc.) 4. With such
and/or medically compromised. large population estimates of the elderly, out
The 20.2 million population of elderly was of which most of them are underserved,
5.60% (4) (5.6%) in 1951 which climbed to considerable efforts are required to support the
7.63% in 2001 and is likely to climb to 14% in geriatric oral health.
2025 2. In absolute numbers there are 77

EXTENT OF POOR ORAL HEALTH
Author’s Affilation: *Vice-Principal & Head, Deptt. Of
Prosthodontics, Inderprastha Dental College & Hospital,
Sahibabad, Ghaziabad UP, **Post-graduate Student,
Department of Public Health Dentistry, ITS-CDSR, As per the National Oral Health Survey
Muradnagar, Ghaziabad , UP (2004), poor oral health among elderly has
Reqrint’s request: Dr. Pankaj Datta, C-86, Anand Vihar, resulted in a high level of tooth loss (29.3%),
Delhi – 110 092, Mob; 9811774350/9811274799, E-mail: dental caries status (84.7%), periodontal
pankajdatta97@rediffmail.com.

© Red Flower Publication Pvt. Ltd

128 Pankaj Datta, Sonia Sood

disease (79.4%), mucosal lesions (10%) and drugs prescribed for these chronic diseases can
oral cancer (0.5%) 5. cause adverse effects to the oral mucosa,
lichenoid reactions, hypersensitivity and
xerostomia 18, 19.
A LINK TO SYSTEMIC HEALTH
Elderly are especially at risk for caries and
periodontal diseases if they suffer from
The ill effects of poor oral conditions are xerostomia. It may be caused by illness,
particularly significant among older people in radiation therapy and chemotherapy apart
the form of caries, periodontitis and from medication.
edentulousness. Direct ill effects cause a state Dental professionals must understand that
of partial or complete edentulousness. the elderly must be considered under the
Extensive tooth loss/ Ill-fitting prostheses category of “special needs and care” for
reduces chewing performance and affects treatment due to their social, psychological,
food choice; edentulous people tend to avoid physical and medical conditions 20. Thus, at
dietary fiber and prefer refined foods leading times it may necessitate alterations in the
to poor nutrition 6, weight loss 7 and problems treatment objectives, deviating from the
in communication besides low esteem 8. standard norms with the prime objective to
Poor oral health is a common risk factor for “compress morbidity and chewing disability”
many systemic diseases; severe periodontal and keeping oro-dental apparatus in a state
disease is associated with diabetes mellitus 9, of reasonable function.
ischemic heart disease 10, 11, chronic respiratory
disease 12 and osteoporosis 13. The challenge
of maintaining oral health for the nursing CURRENT SHORTFALLS IN ORAL
elderly holds additional danger of aspiration HEALTH CARE OF THE ELDERLY
pneumonia 14, 15.
As more epidemiological evidence links To have and maintain oral health, there are
dental infections and systemic complications, three basics tenets that must be in place. For
it should be clear that dental and health older adults, one or more of these tenets may
benefits should not be compartmentalized be absent. As a result, the prevalence and
rather it should be replaced with a new severity of oral diseases and conditions in older
paradigm—that of including dental care in adults are a significant public health concern.
comprehensive medical care improve our 1. Knowledge of the importance of oral
geriatric patients’ quality of life and outlook.16 health and its value to overall health.
There are compounding factors such as
CHALLENGES OF ORAL HEALTH CARE deficiencies in knowledge, attitudes, practices
IN ELDERLY and socioeconomic status which predispose
the elderly to oral health problems. Fear of
surgical nature of work may make them
As they age, older people are more likely to apprehensive of dental care, and may deter
live alone, may be socially isolated and some them from seeking it. Many may not realize
are unable to manage walking without the benefits of good oral health as the effects
assistance, have failing eyesight and other at times may not be evident instantly.
physical infirmities.
The high prevalence of oral cancer in India
The maintenance of oral health becomes is related to behavioral risk factors such as
more difficult if the elderly person is also poor oral hygiene, improper diet, alcohol and
suffering from other systemic illness e.g. tobacco abuse.
arthritis, diabetes, cardiovascular disease,
osteoporosis, neurological diseases associated 2. Physical ability to maintain oral health
with age such as stroke, Alzheimer’s disease through oral hygiene practices.
and Parkinson’s disease. 17. Many systemic


Oral Health Care of Elderly in India: Present Scenario and Future Concerns 129

Most elderly due to poor manual dexterity education and promotion of oral healthcare
have difficulty in performing routine oral of elderly in underserved communities needs
hygiene procedures, which increases the to be implemented by outreach activities of
prevalence of dental decay, periodontal public health professionals.
disease and edentulism in this population 21. There is need of setting up of mobile oral
3. Ability to access professional oral health health care services involving multidisciplinary
services. teams to provide domiciliary services to the
In India, primary health centres do not have elderly in the rural areas. Regular preventive
the provision for dental care. This has left oral dental care with portable dental equipment
health far behind other health services. It can be used to serve the functionally
appears that oral health is not a priority in dependent elderly at home/nursing homes to
our health care system. Except those in reduce the development of harmful oral health
organized sectors like in government jobs, conditions.
railways, defense services and public sector, Use mass media (particularly TV) to raise
majority of the elderly have no oral health the public awareness and understand the
security. importance and benefits of good oral hygiene.
Most services for geriatric patients are on a Educate the public about the harmful effects
“fee-for-service” basis in the private clinics of tobacco and alcohol abuse on the oral health
which is expensive and not within the reach as it predisposes them to a high risk of
of most of the elderly with reduced retirement periodontal disease and precancerous oral
income. With the paucity of government lesions. Oral cancer is more common after age
dental colleges/ dental departments of sixty and early detection is among a major
government hospitals in the country; most of approach to prevention of the disease.
the elderly patients do not get comprehensive
treatment either due to lack of facilities or long
waiting period 22 . There are no health TRAINING IN GERIATRIC DENTISTRY
insurance plans which cover dental treatment
except in an emergency (trauma). With an increasing awareness in the society
Improper distribution of dental manpower about oral health and treatment needs, there
in India has created a void in the desired has been a greater demand for geriatric
healthcare status in the elderly. Older adults specialists in dentistry. To serve them better,
are often at risk of limited access to oral health it is important to understand the physical,
care because of transportation, economics, mental and socioeconomic background of the
medical illness, social and personal reasons. elderly, their illnesses, medication and age-
related disabilities. Thus, special training in
geriatric dentistry is required 22. However,
RESPONDING TO GERIATRIC ORAL there is no institute to provide it in India. Till
HEALTH NEEDS the time we have geriatric dentists there will
INCREASING THE AWARENESS AND remain an urgent need of specialists in
KNOWLEDGE AT COMMUNITY LEVEL endodontics, periodontics, prosthodontics
and public health to club together as a part of
rehabilitative team to minimize the oral
About 70% of the rural population does not disability and restore the oral health of elderly.
have access to dental facilities 23. Currently,
only 2% 24 of the specialists are being trained In the current scenario, the dental education
in public health dentistry, whereas in a needs to be reframed with the rising need of
country like India, there is a greater need for preparing students to care for the increasing
these specialists to emphasize on the numbers of medically complex, dentate
importance of oral health among elderly. elderly. It is time for a new model of dental
Primary prevention, imparting dental health education to be implemented at
undergraduate level so that it is more


130 Pankaj Datta, Sonia Sood

27
integrative with a variety of elderly patients, , there is acute shortage of dental manpower
health care providers and individuals who are in the rural areas due to significant geographic
involved in health care management of older imbalance in the distribution of dental
population. colleges. This has resulted in two unfavorable
Apart from people involved in dentistry outcomes.
other health professionals must be provided (1) Though it improved the overall dentist
oral health training and information on the to population ratio, there has been a great
specific needs of older adults. variation in the dentist to population ratio in
rural and urban areas. The dentist: population
Lastly, there is an urgent need to educate
ratio is 1:13,000 in the urban areas 23 and
caregivers in families, assisted living,
1:250,000 in rural areas 28.
supportive housing and nursing homes on
how they can effectively assist older adults for (2) It left a big void in the geriatric oral health
oral hygiene practices. care services in rural areas. Since, most of the
dental colleges provide free dental treatment
to people in nearby periurban and rural areas.
NEED TO IMPROVE ORAL HEALTH To cover up the shortage of dentists to serve
SERVICES the underserved populations in rural area
there is an urgent need of expanding the use
To fill up the desired level of oral health of dental auxiliaries in the provision of dental
amongst elderly in India, National Oral Health services. Dental auxiliaries can provide
Policy needs to be implemented. The negative services to rural patients without much
impact of poor oral health on the quality of financial impact on the health agencies. When
life of elderly is an important public health hygienists are utilized to the full scope of
issue which must be addressed by policy- preventive practice, they can free time for
makers. The need of dentists and dental restorative procedures by dentists. Denturists
auxiliaries in National Health Program was can be utilized for directly providing removable
suggested for providing oral health care at prostheses to the elderly.
primary health care (PHC) and community Lastly, we need support other than dentists’
health care (CHC) as per the Bajaj Committee to help us to lobby government for geriatric
Report 25 . This was further recommended by dental care. It is time for us to look after the
National Oral Health Care Program, but generation which brought us to this level and
unfortunately still the implementation part is let them feel proud of themselves for raising
missing at PHC and CHC level 26. Till the time us.
any positive step is taken by the government
it is incumbent on us, as oral health
professionals, to deal with this need and CONCLUSION
provide access to care for elderly patients.
The major cause of poor oral health due to There is a growing demand for oral health
the absence of primary health care approach care among elderly in India. India needs a
in dentistry is the prime area of focus where comprehensive gerontological oral health care
oral health professionals (dentists and dental program with the following objectives. First,
auxiliaries) should be increased. In 1990 there there is deficient data about the current oral
were 3,000 registered hygienists and 5,000 health status and disease trends. Second, we
laboratory technicians in India. There are no need to learn more about the efficacy of the
registered dental nurses, chair side assistants current treatment modalities. Third, the future
and denturists 24. dental needs and demands of the elderly needs
To improve the shortage of dental to be explored. Fourth, the organization of the
professionals, permission to open new dental dental health care delivery system to catch and
colleges was granted. Despite increased address the changing and probably new oral
number of dental colleges (291) in the country health problems of the elderly needs to be
expanded. Fifth, to meet these challenges,

Oral Health Care of Elderly in India: Present Scenario and Future Concerns 131

geriatric dentistry needs to be developed to 13. Clare Van Sant. Preparing your office and team
create a trained and dedicated workforce for the care of geriatric patients. Available at
which can effectively plan and administer http://www.dentistrytoday.com/ME2/
geriatric oral healthcare delivery, education dirmod.asp (accessed on 5th March 2010).
and research in India. Finally, the relationship 14. Abea S, Ishihaara K, Adachib M, Okuda K. Oral
between oral health and general health must hygiene evaluation for effective oral care in
preventing pneumonia in dentate elderly.
be understood, if oral health care is to have a
Archives of Gerontology and Geriatrics, 2006;
reasonable chance of success.
l43(1): 53-64
15. Awano S, Ansai T, Takata Y, Soh I et al Oral
REFERENCES Health and Mortality Risk from Pneumonia in
the Elderly. J Dent Res, 2008; 87(4): 334-339.
16. Rubinstein Helena Gail. Access to oral health
1. Available at http://www.prb.org/pdf08/
care for elders: mere words or action? Journal of
08WPDS_Eng.pdf (accessed on July 27th 2010)
Dental Education, 2005; 69(9): 1051-1057.
2. Swami H M, Bhatia V. Primary geriatric health
17. Scully C, Ettinger RL. The influence of systemic
care in India needs initiative in the new
diseases on oral health care in older adults. J
millennium. Indian J Prev. Soc. Med, 2003; 34(3):
Am Dent Assoc, 2007; 138:7S-14S.
4.
18. Abdollahi M, Radfar M. A review of drug-
3. Peterson P E, Yamamoto T. Improving the oral
induced oral reactions. J Contemp Dent Pract,
health of older people: the approach of the WHO
2003; 4(1): 10-31.
global oral health programme. Community Dent
Oral Epidemiol, 2005; 33: 81-92. 19. DeRossi SS, Hersh EV. A review of adverse oral
reactions to systemic medications. Gen Dent,
4. Shah N, Tank P. Rehabilitation and Residential
2006; 54(2): 131-8.
Care Needs of the Elderly. Indian journal of
psychiatry-CPG-2007. 20. Sandra Nagel Beebe. The special needs of elderly
patients. Available at http://
5. National Oral Health Survey and Flouride
www.irishdentist.ie/articles/articles_
Mapping, 2002-2003. New Delhi: Dental
(accessed on July 24th 2010).
Council of India, Ministry of Health and Family
Welfare, Govt. of India, 2004. 21. Talwar M, Chawla HS. Geriatric dentistry: Is
rethinking still required to begin undergraduate
6. Walls AWG, Steele JG, Sheiham A, Marcenes W,
education? Indian J Dent Res, 2008; 19: 175-7.
Moynihan PJ. Oral health and nutrition in older
people. J Public Health Dent, 2000; 60: 304–7. 22. Shah N. Geriatric dentistry: The need for a new
speciality in India. The National Medical Journal
7. Ritchie CS, Joshipura K, Silliman RA, Miller B,
of India, 2005; 18(1).
Douglas CW. Oral health problems and
significant weight loss among community- 23. DCI Perspective. Dentistry India. Sep 2007 —
dwelling older adults. J Gerontol A Biol Sci Med Vol. 1, Iss. 1 available at http://
Sci 2000;55: M366–71. www.dentistryindia.net/article.php?id=1010,
8. Smith JM, Sheiham A. How dental conditions 24. Tandon S. Challenges to the Oral Health
handicap the elderly. Community Dent Oral Workforce in India. J Dent Educ, 2004; 68 (7).
Epidemiol, 1979; 7: 305–10. 25. Bajaj Committee report available at http://
9. Shlossman M, Knowler WC, Pettitt DJ, Genco nihfw.org/NDC/DocumentationServices/
RJ. Type 2 diabetes and periodontal disease. J Reports/Bajaj%20Committee%20report.pdf
Am Dent Assoc, 1990; 121: 532–6. (accessed on 2nd August 2010).
10. Trichopoulos D, Ascherio A, Willett WC. Poor 26. National Oral Health Care Programme
oral health and coronary heart disease. J Dent (NOHCP) Implementation Strategies. Indian
Res, 1996; 75: 1631–6. Journal of Community Medicine, 2004; XXIX(1).
11. Joshipura KJ, Hung H-C, Rimm EB, Willett WC, 27. Available at http://mohfw.nic.in/
Ascherio A. Periodontal disease, tooth loss and Adental.html. (accessed on 21st July 2010).
incidence of ischemic stroke. Stroke, 2003; 34: 28. Industry Insight Indian dental industry;
47–52. available at http://www.cygnusindia.com/
12. Scannapieco F. Role of oral bacteria in pdfs (accessed on 3rd Jan 2010).
respiratory infection. J Periodontol, 1999; 70:
793–802.


132


Library Recommendation Form
If you would like to recommend this journal to your library, simply complete the
form below and return it to us. Please type or print the information clearly. We will
forward a sample copy to your library, along with this recommendation card.
Please send a sample copy to:
Name of Librarian
Library
Address of Library

Recommended by:
Your Name/ Title

Department

Address

Dear Librarian,
I would like to recommend that the library subscribe to the Indian Journal of Dental
Education. I believe the major future uses of the journal for our library would be:
1. As useful information for members of my specialty.
2. As an excellent research aid.
3. As an invaluable student resource.
4. I have a personal subscription and understand and appreciate the value an
institutional subscription would mean to our staff.
5. Other
Should the journal you’re reading right now be a part of your University or institution’s
library? To have a free sample sent to your librarian, simply fill out and mail this today!

Stock Manager
Red Flower Publication Pvt. Ltd.
41/48, DSIDC, Pocket-II, Mayur Vihar, Phase-I
P.O. Box No. 9108, Delhi - 110 091 (India)
Tel: 91-11-65270068, 22754205, Fax: 91-11-22754205
E-mail: redflowerppl@gmail.com, redflowerppl@vsnl.net
Website: www.rfppl.com


133

A review on repair of fractureon repair
A review porcelain of fracture porcelain
Roseline Meshramkar

ABSTRACT
Because of their high esthetic qualities and mechanical stability in the oral environment, ceramic
restorations are commonly used in daily dental practice. Due to the inherently brittle nature of porcelain
restorative materials, failure of metal ceramic restorations under intraoral conditions is not uncommon.
The majority (65%) of failures are observed in the anterior region (60% in labial, 27% in buccal, 50% in
incisal and 80% in occlusal regions). Clinical studies show failure rates upto 90% for ceramic veneers.
Because it is arduous to remove the ceramic restorations from the mouth, they are repaired intraorally,
using a bonding system and composite resins. It is necessary to know the possible causes of fracture of
porcelain, the various bonding systems and the composites resins used for repairing. The current review
takes into account the majority of papers published in the last few decades concerning the issue of bonding
composite resins to porcelains.
Key Words: Porcelain fracture, bonding agent, ceramic repair, composite.

INTRODUCTION porcelain fused to metal restorations are
commonly used in daily dental practice.[7] It is
to be expected that with increased application
Since 1728, when Fauchard [1] first of this technique the number of failures also
suggested the use of porcelain, the art and will increase.[8] Clinically failures often begin
science of ceramics in restorative dentistry has as porcelain fractures that may be caused by
evolved into a revolutionary method for inappropriate coping design, poor abutment
aesthetically treating dental needs of a wide preparation, technical errors, contamination,
variety. Porcelain inlays and crowns as well physical trauma or premature occlusion. [9]
as the use of porcelain facial veneers are These fractures are mainly in the maxilla [75%]
reported several decades ago. [2-4]Although and predominantly at the labial surface.[10] It
aesthetically satisfactory, the brittle nature of is necessary to assess the possible cause of
the early porcelain restorations limited their fracture so that the most suitable treatment
wider application.[5] can be recommended. Depending on the
In the 1960’s gold was used as a reinforcing extent of the area to be restored, cost and time
under structure. [6], followed by MacLean’s available treatment may range from making
application of high aluminous ceramic a new prosthesis, faceting or overcastting to
substructure for fixed partial dentures. resin composite repairs.[11] Replacement of a
Because of their high aesthetic qualities and failed restoration is not necessarily the most
mechanical stability in the oral environment practical solution for obvious economic
reasons and because of the complex nature of
the restoration. [12] Because it is arduous to
Author’s Affilation: Professor, Dept of Prosthodontics,
SDM Collge of Dental Sciences, Dharwad E-mail: remove these restorations from the mouth
roselinemeshramkar@yahoo.co.in, Received on 01.12.2010, ceramic restorations are repaired intra-
accepted on 06.01.2010 orally.[10]
Reprint’s request: Dr. Roseline Meshramkar, Professor,
With development of the composite
Dept of Prosthodontics, SDM Collge of Dental Sciences,
Dharwad E-mail: roselinemeshramkar@yahoo.co.in. restorative materials and the introduction of
(Received on 01.12.2010, accepted on 06.01.2010) organosilanes by Bowen [13] in 1962; solutions
VolumeFlower Publication Pvt. Ltd
© Red 3 Number 3, July-Sept 2010

134 Roseline Meshramkar

to the repair problem were possible. Two types from his experiments that cold-cured resins
of bond, metal-resin and porcelain-resin are produced a stronger bond than mechanically
involved in the repair process of ceramo-metal retained porcelain teeth, but that thermal
restorations. Surface configuration, reactivity cycling was detrimental to the bond. A study
of the bonding surface and the use of adhesive of porcelain teeth in cold-cured dentures by
resins are important for metal-resin and Duhaney HN [27] in 1970 indicated that
porcelain-resin bond. [14] To achieve a retention by bonding with silane solution was
satisfactory bond between porcelain and as satisfactory as mechanical retention.
composite resin several mechanical and Jochen and Caputo [28] reported that the
chemical retention systems were developed. abrasion of the surface of porcelain with a
Mechanical roughening of porcelain surfaces diamond rotary instrument increased the
with a coarse diamond, Air-abrasion retention of the repair material. In 1978,
(sandblasting) and acid etching with Eames et al [29] evaluated the composite resins
hydrofluoric acid [15], acidulated phosphate utilizing silane coupling agents for repair of
fluoride [16] , Ammonium biflouride [17] or porcelain. Porcelain denture teeth were used
phosphoric acid[18] are some of the commonly in this study and acceptable bond strength for
used methods to achieve retentive porcelain temporary repairs was reported. In 1978,
surface texture. The organosilane repair Newburg and Pameijer [8] also studied the
materials enhance the adhesions of the repair bond strength of composite resin to porcelain
resin to the porcelain surface.[19,20] Within the denture teeth utilizing a silane coupling agent,
last few years, several types of porcelain repair and reported that the samples produced a
systems have been developed for use by the reliable bond. Highton et al [30] 1979 also
dental profession. The purpose of this article studied the effects of silane coupling agents
is to review the treatment pertaining to the on the composite resin/porcelain bond. The
various porcelain repair systems. study indicated that the repair system using a
bonding agent with acrylic resin was
THE EVOLUTION OF PORCELAIN significantly stronger than the repair system
REPAIR SYSTEMS using a composite resin.
Nowlin et al [31] reported that fusion plus
concise (3M Co. Dent products Div., st. Paul
Historically, intraoral repair of fractured Minn) was superior to Dent-mat and 18% of
porcelain restorations has required the original porcelain strength was regained.
roughening of the porcelain surface with a
rotary abrasive, application of silane fallowed In 1983, Ferrando et al [32] concluded that
by composite to replace the contour of the Enamalite (Lee pharmaceuticals, South El
restoration. [21,22] Early in the 1960s Monte, Calif.) was superior to Fusion plus
manufacturers’ reinforced plastics with Adaptic (Johnson and Johnson Dental
particles of glass treated with silane bonding products co., East Windsor, N.J.), Adaptic,
agents, Bowen (1962)[13] used these materials Dent-mat porcelain repair kit and cyano-
in the development of composite resins that veneer (Ellman International Manufacturing
were reported to the dental profession in Inc., Hewlet., N.Y) in tensile strength and had
1963. [23] the least leakage at the resin-porcelain
interface.
Paffenbarger et al 1967[24] bonded porcelain
teeth to acrylic resin using silane solution as The adhesion of resin to dental porcelain
the coupling agent. In 1968, Semmelman and was enhanced by etching the porcelain surface
Kulp [25] reported results of bonding porcelain with hydrofluoric acid (Horn 1983[33]; Calamia
denture teeth to acrylic resin with a silane 1983 [34] ) and using silane coupling agents
coupling agent. The study indicated that (Calamia and Simonsen, 1984). [35]
failure occurred not at the tooth resin interface, Combination of hydrofluoric acid etching and
but within the body of the porcelain indicating the application of silane coupling agent was
a true bonding. In 1969 Myerson [26] concluded shown to be an effective method for improving



the adhesion of resin. (Stangel et al 1987; retention of resin composite.[42] The mechanical
Shetch et al 1988[5]; Aida et al 1990) bonding always poses an inherent
As an alternative to hydrofluoric acid, disadvantage of microleakage.[43]
acidulated phosphate fluoride (Lacy et al[25] Chemical bonding to ceramic surface is
1988) or phosphoric acid (Newburg and achieved by silanization with a bifunctional
Pameijer [8] 1987; Okamoto et al [36] 1989; coupling agent.[44] Silane coupling agents can
Matsumara et al[37] 1989) were investigated. improve the bonding of composite resin to
However, neither etching with hydrofluoric porcelain by approximately 25%. [5] Silane
acid nor adding silane resulted in an adequate coupling agents possess the general chemical
resin bond to some new high-strength structure X-(CH2)3 Si-(OR)3 and have ability
ceramics. [38] High-alumina [39] or Zirconia- to bond chemically to both organic and
reinforced ceramics[40] cannot be roughened inorganic surfaces.[45] The coupling agent at
by hydrofluoric acid etching since such one end chemically bonds to the hydrolyzed
ceramics do not contain a silicon dioxide (silica) silicon dioxide of the ceramic surface and a
phase. methacrylate group at the other end
For this reason, special conditioning systems polymerizes with the adhesive resin.[44] The
are indicated for these newer types of ceramics. type of resin composite also effects of bond
Modern surface conditioning methods utilize strength to porcelain. It is assumed that larger
air-particle abrasion for achieving sufficient particle size resin composites or hybrid.[16]
bond strength between the resins and high
strength ceramics that are reinforced either THE MATERIALS AND THE TESTING
with alumina or Zirconia.[40] In this technique METHODS USED FOR THE BOND TEST
the surfaces are air abraded with aluminium
oxide particles modified with silicic acid with
different particle sizes ranging from 30 to Material selection and clinical
250µm.[40] The blasting pressure results in the recommendation of resin bonding to ceramics
embedding of silica particles on the ceramic are based on mechanical laboratory tests that
surface, rendering the silica-modified surface show great variability in materials and
chemically more reactive to the resin through methods.[7,46] Many methods of measuring the
silane coupling agents.[41] in-vitro bond strength affected by porcelain
repair systems have been described. These
include torsion, flexural,[19] tensile and shear
THE BOND BETWEEN PORCELAIN bond strength tests.[47] The most commonly
AND THE RESIN COMPOSITE employed is the shear bond strength test. The
crosshead speed used for testing the samples
Bonding of resin to a ceramic surface is range from 0.5 mm/min to 5 mm/min. But as
based on the combined effect of yet there is no universally accepted bond
micromechanical interlocking and chemical strength tests for resin composite bonded to
bonding. The bond strength of composite to ceramic.
porcelain is affected by the surface preparation The ceramic-composite bond is susceptible
and the type of bonding agent.[42] to chemical, [48] thermal,[49] and mechanical[50]
Mechanical roughening of porcelain influences under intraoral conditions. A
surfaces with coarse diamond has notable feature of some studies [51] is the
demonstrated improved repair strength. [28,32] observation that, the failure mode is often
Sandblasting with aluminium oxide (Al2O5) cohesive within the ceramic bases rather than
is another method of surface roughening[15] at the adhesive interface. On the basis of which
and porcelain can also be etched with it has been suggested that the bond strength
hydrofluoric acid, ammonium biflouride, exceeds the cohesive strength of the ceramic.
phosphoric acid or acidulated phosphate But this ignores the nature of the stresses
fluoride gel to facilitate micromechanical generated and their distribution within the



adhesive zone which can have a profound durable resin bond to zirconium oxide
influence on the mode of failure. Finite element ceramic [56] The equipments for airborne
stress analysis (FEA) has been used to study particle abrasion are recently simplified and
the sensitivity of bond strengths to specimen brought to the chairside.[41]
design and changes in testing conditions. [52]
These studies show that there is need for a
more critical approach on the design of DISCUSSION
appropriate tests for evaluating the bond
strength of resin composite to ceramic if the Intraoral repair of fractured porcelain
design for a standardized test procedure is to restorations with resin composite presents a
be achieved. substantial challenge for clinicians. Newer
generation multipurpose adhesive systems
RECENT DEVELOPMENTS involve several treatment steps and agents for
porcelain repair with resin composite. [57]
Several studies focus on mechanical retention,
Bonding to traditional silica based ceramics chemical agents and the combination of these
is a predictable procedure yielding durable two methods.[10,51,42] Because of the insufficient
results when certain guidelines are bonding characteristics of the chemical agents,
followed. [45] The physical properties and physical alteration of the porcelain surface
composition of high strength ceramic materials must be used together with these agents to
like aluminium oxide-based [40,53] and promote adhesion. Wolf et al[45] concluded that
Zirconium oxide-based ceramics [41] differ sandblasting with Al 2O 3 or roughening by
substantially from silica based ceramics and burs achieve satisfactory bond strength but
require alternative bonding techniques to when more durable and higher bond strength
achieve a strong, long term and durable resin is desired, hydrofluoric acid etching is the most
bond.[40] significant step in the surface treatment
Modern surface conditioning methods because of deep acid penetration.
require airborne particle abrasion of the The silane coupling agents achieve a
surface before bonding in order to achieve chemical link between the resin composite and
high bond strengths. One such system is silica porcelain; moreover they promote wetting of
coating. In this technique the surfaces are air the porcelain surface so that it enhances the
abraded with aluminium oxide particles flow of the low-viscosity resin composites.
modified with silisic acid. [54] The blasting They improve the bond of resin composite to
pressure results in the embedding of silica porcelain by approximately 25%. [22]
particles on the ceramic surface, tending the Aluminium oxide and Zirconium oxide-based
silica modified surface chemically more ceramics require the use of special resin cement
reactive to the resin through silane coupling along with airborne article abrasion.
agents. Silane molecules after being Compared with silica-based ceramics, the
hydrolyzed to silanol can form polysiloxane number of in vitro studies on the resin bond
network or hydroxyl groups cover the silica to high-strength ceramics is small. Further
surface. Monomeric ends of the silane controlled clinical trials are required to test
molecules react with the methacrylate groups specific treatment modalities and their long-
of the adhesive resins by free radical term durability.
polymerization process, when a ceramic
exhibits chemical states of silicone and oxygen.
The siloxane bond will be achieved as these REFERENCES
represent the bonding sites for the coupling
agent to the ceramic surface.[55] 1. Jones DW. Development of dental ceramics: a
The phosphate modified resin cement after historical perspective. Dent Clin North Am,
airborne particle abrasion provide a long-term 1985; 29: 621-44.
2. Ernsmere JB. Porcelain dental work. Br J Dent


Sci, 1900; 43: 547. on the bond of resin to dental porcelain. Dental
3. Wells JO. The evolution of the artificial crown. Mater, 1992; 8: 238-40.
Dent Sci J, 1901; 44: 540. 19. Bailey JH. Porcelain to composite bond strengths
4. Pincus CL. Building mouth personality. J Cal using four organosilane materials. J Prosthet
Dent Assoc, 1938; 14: 125. dent, 1989; 61: 174-7.

5. Sheth J, Jensen M, Tolliver D. Effect of surface 20. O’Brien WJ. Dental porcelains. In Craig RG ed.
treatment on etched porcelain bond strength to Dental Materials Review. Ann Arbor University
enamel. Dent Mater, 1988; 4: 328-37. of Michigan Press, 1977; 123-35.

6. Dunswarth FD. Porcelain fused to gold. J 21. Friedman MJ. A 15-year review of porcelain
Prosthet Dent, 1958; 8: 635-9. veneer failure- a clinician’s observations.
Compend Contin Educ Dent, 1998; 19: 625-36.
7. McLean JW. A higher strength porcelain for
crown and bridge work. Br Dent J, 1965; 119: 22. Hsu CS, Strangel I, Nathanson D. Shear bond
268-72. strength of resin to etched porcelain. J Dent

8. Newburg R, Pameijer CH. Composite resins Res, 1985; 64: 296.
bonded to porcelain with silane solution. J Am 23. Bowen RL. Properties of a silica-reinforced
Dent Assoc, 1978; 96: 288-91. polymer for dental restorations. J Am Dent
9. Kelly JR, Nishumura I, Campbell SD. Ceramics Assoc, 1963; 66: 57-64.
in dentistry: Historical roots and current 24. Paffenbarger GC, Sweeney WT, Bowen RL.
perspectives. J Prosthet Dent, 1996; 75: 18. Bonding porcelain teeth to acrylic resin denture
10. Appeldoorn RE, Wilwerding TM, Barkmeier bases. J Am Dent Assoc, 1967; 74: 1018-23.
WW. Bond strength of composite resin to
porcelain with newer generation porcelain 25. Semmelman JO, Kulp PR. Silane bonding
repair systems. J Prosthet Dent, 1993; 70: 6-11. porcelain teeth to acrylic. J Am Dent Assoc, 1968;
11. Kussaono CM, Bonfante G, Batista JG, Pinto 96: 69.
JHN. Evaluation of shear bond strength of 26. Myerson RL. Effects of silane bonding of acrylic
composite to porcelain according to surface resins to porcelain on porcelain structure. J Am
treatment. Braz Dent J, 2003; 14: 132-5. Dent Assoc, 1969; 78: 113-9.
12. Thurmond JW, Barkmeier WW, Wilwerding TM. 27. Duhaney HN. A clinical and laboratory study
Effect of porcelain surface treatments on bond of silane bonding of porcelain teeth to the auto-
strengths of composite resin bonded to
curing methyl methacrylate base, thesis. Boston
porcelain. J Prosthet Dent, 1994; 72: 355-9.
University School of Graduate Dentistry, 1970.
13. Bowen RL. Dental filling material comprising
28. Jochen DG, Caputo AA. Composite resin repair
vinyl silane-treated fused silica and a binder
of porcelain denture teeth. J Prosthet Dent, 1977;
consisting of a reaction product of bisphenol
38: 673-9.
and glycidyl acrylate. US Patent no. 3,066, 12
Nov. 1962. 29. Eames WB, Rogers LB, Feller PR, Price WR.
Bonding agents for repairing porcelain and
14. Kato H, Matsumura H, Tanaka T, Atsuta M.
Bond strength and durability of porcelain gold: an evaluation. Oper Dent, 1977; 2: 118-24.
bonding systems. J Prosthet Dent, 1996; 75: 163- 30. Highton RM, Caputo AA, Maryas J.
8. Effectiveness of porcelain repair systems. J
15. Bertolotti RL, Lacy AM, Watanable LG. Adhesive Prosthet Dent, 1979; 42: 292-4.
monomers for porcelain repair. Int J 31. Nowlin TP, Barghi N, Norling BK. Evaluaiton
Prosthodont, 1989; 2: 483-9. of the bonding of three porcelain repair systems.
16. Llobell A, Nicholls JI, Kois JC, Daly CH. Fatigue J Prosthet Dent, 1981; 46: 516-8.
life of porcelain repair systems. Int J Prosthodont 32. Ferrando J MP, Gracer GN, Tallents RH and
1992; 5: 205-13. Jarvis RH. Tensile strength and microleakage
17 . Lacy AM, Laluz J, Watanabe LG, Dellinges M. of porcelain reapir materials. J Prosthet Dent,
Effect of porcelain surface treatment on the bond 1983; 50: 44-50.
to composite. J Prosthet Dent, 1988; 60: 288-91. 33. Horn HR. Porcelain laminate veneers bonded
18. Hayakawa T, Horie H, Aida M et al. the influence to etched enamel. Dent Clin North Am, 1983; 27:
of surface conditioners and silane agents 671-84.



34. Calamia JR. Etched porcelain facial veneers: a 46. Fradeani M. Six year follow-up with Empress
new treatment modality based on scientific and veneers. Int J Periodontics Restorative Dent,
clinical evidence. NYJ Dent, 1983; 53: 255-9. 1998; 18: 216-25.
35. Calamia JR, Simonsen RJ. Effect of coupling 47. Chadwick RG, Mason AG, Sharp W. Attempted
agents on bond strength of etched porcelain. J evaluation of three porcelain repair systems.
Dent Res, 1984; 63: 197. What are we really testing? J Oral Rehabil, 1998;
25: 610-5.
36. Okamoto A, Kobayashi Y, Nakai T et al. The
study of silane coupling agent for reaparing 48. McKinney JE, Wu W. Chemical softening and
fractured porcelain. Jpn J Conserv Dent, 1989; wear of dental composites. J Dent Res, 1985; 64:
32: 978-85. 1326-31.

37. Matsumura H, Kawahara M, Tanaka T, Atsuta 49. Palmer DS, Barco MT, Billy EJ. Temperature
M. A new porcelain repair system with a silane extremes produced orally by hot and cold
coupler, ferric chloride and adhesive opaque liquids. J Prosthet Dent, 1992; 67: 325-7.
system. J Dent Res, 1989; 68: 813-8. 50. Harrison A, Moores GE. Influence of abrasive
38. Rosenstein SF, Gupta PK, Van der Sluys RA, particle size and compressive stress on the wear
Zimmermann MH. Strength of a dental glass- rate of dental restorative materials. Dent Mater,
ceramic after surface coating. Dent Mater, 1993; 1985; 1: 14-8.
9: 274-9. 51. Diaz-Arnold AM, Schneider RL, Aquilino SA.
39. Kern M and Thomson VP. Bonding to glass Bond strengths of intraoral repair materials. J
infiltrated alumina ceramic: adhesive methods Prosthet Dent, 1989; 61: 305-9.
and their durability. J Prosthet Dent, 1995; 73: 52. Von Noort R, Noroozi S, Howard IC, Cardew G.
240-9. A critique of bond strength measurements, J
40. Kern M, Wegner SM. Bonding to Zirconia Dent, 1989; 17: 61-7.
ceramic: adhesion methods and their durability. 53. Zeng K, Oden A, Rowcliffe D. Evaluation of
Dent Mater, 1998; 14: 64-71. mechanical properties of dental ceramic core
41 Amaral R, Õzcan M, Bottino MA, Valandro LF. materials in combination with porcelains. Int J
Microtensile bond strength of a resin cement to Prosthodont, 1998; 11: 183-9.
glass infiltrated zirconia-reinforced ceramic: The 54. Wegner SM, Kern M. Long-term resin bond
effect of surface conditioning. Dent mater, 2006; strength to zirconia ceramic. J Adhes Dent, 2000;
22: 283-90. 2: 139-47.
42. Suliman AA, Swift EJ, Perdigao J. Effects of 55. Piconi C, Maccauro G. Zirconia as a ceramic
surface treatment and bonding agents on bond biomaterial. Biomaterials, 1999; 20: 1-25.
strength of composite to porcelain. J Prosthet 56. Strub JR, Stiffler S, Scharer P. Causes of failure
dent, 1993; 70: 118-20. following oral rehabilitation: biological versus
43. Lu R, Harcourt JK, Tyas MJ, Alexander B. An technical factors. Quintessence Int 1988; 19: 215-
investigation of the composite resin/porcelain 22.
interface. Aust Dent J, 1992; 37: 12-9. 57. Guler AU, Yilmaz F, Ural C, Guler E. evaluation
44. chwatz RS, Summit JB, Robbins JW. of 24-Hr shear bond strength of resin composite
Fundamental of operative dentistry. to porcelain according to surface treatment.
Quintessence Publication Co. Inc, 1996. Int J Prosthodont, 2005; 18: 156-60.
45. Wolf DM, Powers JM, O’Keefe KL. Bond strength
of composite to porcelain treated with new
porcelain repair agents. Dent Mater 1992; 8:
158-61.


139

The effect of developer age and file thickness on diagnostic accuracy of
Kodak insight (F-speed) and Ektaspeed plus (E-speed) films in
position assessment of file tip to radiographic apex

A. Dabaghi*
M. Lomee**
S. Saati***
ABSTRACT
Objectives : To determine the effect of developer age and file thickness on diagnostic
accuracy of E and F- speed films in position assessment of file tip to radiographic apex., Study
design: Endodontic files size 10 and 15 were placed in mandibular first molar and second
premolar up to the root apex or 1.5 mm shorter. Ten series of radiographs were made with
two types of film: Kodak insight (F-speed film) and Ektaspeed plus (E-speed film) in different
positions of file in apex or 1.5 mm short. The films of each series were processed manually on
each day, using Champion chemicals. The films were assessed by four endodontists. They
rated the position of file tip to radiographic apex using a 3-point confidence scale in the
questionnaires (tip to tip, 1.5 mm under, can not diagnose). The diagnostic performance of
observers was compared with true diagnosis., Results : Mean Az value of E and F-speed
films, that shows the diagnostic accuracy is 0.986 and 0.983 for E and F-speed films respectively,
that was not significantly different (P = 0.777). Also diagnostic accuracy of films processed
during 10 days was not statistically different (P = 0.726). Assessment of files tip size 10 and 15
in lower molar and premolar canals was not significantly different (P = 0.712)., Conclusion :
The performance of the F-speed film was not statistically different from E-speed for assessment
of file tip to radiographic apex. Because of less required exposure, we suggest to use Kodak
insight (F-speed film) in clinical examination.
Key words: Diagnostic accuracy, Intra oral radiographic film, Working length

INTRODUCTION is the best technique for assessment and
measuring the working length [2]. Ektaspeed
plus films usually are used to determine the
Radiography is an essential tool in routine working length because of their excess
dental practice for caries diagnosis and root availability [3,4].
canal treatment [1]. Assessment of the working
length is an initial important stage in root A major objective of diagnostic radiology is
canal therapy. Parallel periapical radiography to provide images of optimal quality at a
radiation dose as low as reasonably achievable
[1]. One of the most effective ways to reduce
Author’s Affiliation: *Assistant Professor of Oral and patient radiation exposure is using more
Maxillofacial Radiology, Faculty of Dentistry, Ahvaz Jundi
Shapur University of Medical Science, **Post Graduated
sensitive films (Kodak insight F-speed film).
Student of Endodontics, Faculty of Dentistry, Mashhad These films have larger silver halid grains and
University of Medical Science, ***Post Graduated Student of thicker emulsion, thus need lower x-ray
Oral and Maxillofacial Radiology, Faculty of Dentistry, Ahvaz
Jundi Shapur University of Medical Science. radiation (20% less x-ray exposure compared
Reprints’s request: A. Dabaghi, M. Lomee Assistant
with E-speed films) to produce equal
Professor of Oral and Maxillofacial Radiology, Faculty of diagnostic accuracy [5,6]. According to former
Dentistry, Ahvaz Jundi Shapur University of Medical Science. studies, the conditions of processing influence

VolumeFlower Publication Pvt. Ltd
© Red 3 Number 3, July-Sept 2010

140 A. Dabaghi, M. Lomee, S. Saati

the sensiometric characteristics of F-speed films consisted of eight different modes and
[7,8]. therefore 32 radiographs were obtained. To
Today in dental office, developers are used assessment the effect of developer age on
in little volume (about 250 cc) and about one diagnostic accuracy of radiographs, this
week. If the diagnostic accuracy of E and F- procedures was done 10 days and finally 320
speed films in low volume developer was radiographs were made.
similar, it would reduce patients and The films were processed manually with
personnel dose and increase x-ray tube life. In Champion chemicals (X-ray Iran Co, Tehran,
addition, the effect of developer age and file Iran) in the same condition (1min developing,
thickness on diagnostic accuracy of E and F- 15s washing, 2min fixing and 5min final
speed films to determine the position of file washing) at 25 C ± 1. For similarity to dental
tip to radiographic apex, have been studied. office, little volume developer (250cc) was
used. Every day, 32 radiographs randomly
MATERIALS AND METHODS were divided into eight groups of four. Each
group was processed in individual set (eight
similar set for developer, fixer and water). To
In order to simulate clinical examination, a similarity the number of processed
dried human mandibular segment containing radiographs with dental office and helping
premolar and molar teeth was used. The root developer aging, eight radiographs of a step-
canal of the left second premolar and the wedge were processed until day 9 th . Four
mesiobuccal and distobuccal canals of the first endodontists were asked to rate the position
molar were accessed. The radiographic length of file tip in relation to the apex of the tooth
of the root canals was determined under the on a three-piont scales: U:1.5mm under, T: tip
supervision of endodontist with a #20 K-file to tip and CD: can not diagnose.
(Dentsply-Maillefer, Ballaigues, Switzerland) Data analysis was performed with ROC, T-
and Kodak Ektaspeed dental film(Eastman test and ANOVA tests.
Kodak Co. NY, USA). Endodontic #10 and Az
15 K-files (Dentsply-Maillefer, Ballaigues,
Switzerland) were placed at the apex or 1.5 RESULTS
mm shorter. A light-cured composite resin stop
was used, so that, the files could be reused in
the same position. A series of radiographs with Mean value (showing diagnostic
different combinations of correct and short file
accuracy) of Kodak insight (F-speed) and
length was made with Planmeca Prostyle x-
Ektaspeed plus (E-speed) films were
ray unit (Planmeca Oy, Helsinki, Finland)
determined with ROC analysis and were
operating at 63 kvp, 8 mA and 36 cm SID.
compared with each other (Table 1- Figure1).
The parallel technique with a endodontic film
value of E-speed film was 0.986 and for F-
holder (Endoray , Rinn Densply) was used to
speed film was 0.983. According to the
minimize the magnification and distortion.
analysis, there was no significant difference
The exposure time was 0.20s for E-speed between two types of films in determining the
dental film and 0.16s for F-speed dental film position of file tip in relation to the apex (P =
according to the manufacturer’s 0.777).
recommendation (about 20% less exposure for
Diagnostic accuracy of determining the
F-speed film compared with E-speed film).
position of size #10 and 15 K-files, was not
1.7cm selfcure acrylic resin was used as
statistically different in mandibular second
scattering agent to stimulate soft tissue.
premolar and first molar canals (P=0.712).
Four identical series of radiographs were Also, the comparison of mean Az value from
obtained with each type of films and file sizes. day 1 st to day 10th showed that, diagnostic
because of different file length (tip to tip or accuracy of processed films in 10 days of
1.5mm shorter) in three canals, each series


The effect of developer age and file thickness on diagnostic accuracy of Kodak insight (F-speed) and 141
Ektaspeed plus (E-speed) films in position assessment of file tip to radiographic apex

Figure 1: Az mean values of four observers with E and F-speed films

Table1: Az values of four observers with E and F-speed films, and comparison them with
T-test analysis

Az of E Az of F film
film
No.1 observer 0.994 0.992
A Mean 0.986 0.983
z
value

developer aging, was not significantly different DISCUSSION
(P = 0.726) (Table 2).

Az Az Az
Az Az Az Az Az Az Az
Thir Sixt Tent
First Secon Fourt Fifth Sevent Eight Nint
d h h
day d day h day day h day h day h day
day day day
No.1
0.97 0.99 1.00
observe 0.990 0.979 0.990 1.000 1.000 1.000 1.000
9 0 0
r
No.2
0.96 0.99 0.96
observe 0.948 0.990 0.938 0.938 0.990 0.958 0.938
9 0 9
r
No.3
0.97 1.00 1.00
observe 0.990 0.969 0.990 1.000 1.000 1.000 1.000
9 0 0
r
No.4
0.97 1.00 1.00
observe 0.958 1.000 1.000 1.000 1.000 0.990 0.990
9 0 0
r
Az 0.99 0.99
0976 0.971 0.984 0.979 0.984 0.997 0.987 0.982
Mean 5 2
value


Lupus case report

Recommended

Recommended

More Related Content

Similar to Lupus case report

Similar to Lupus case report (20)

More from Abu-Hussein Muhamad

More from Abu-Hussein Muhamad (20)

Recently uploaded

Recently uploaded (20)

Lupus case report