Journal of International Dental and Medical Research

http://www.ektodermaldisplazi.com/journal.htm

Editorial Board of JIDMR 2011 Assoc. Prof. Dr. Izzet YAVUZ Editor-in-Chief and General Director Assist. Prof. Dr. Ozkan ADIGUZEL Associate Editor and Director Assoc. Prof. Dr. Refik ULKU Associate Editor for Medicine Prof. Dr. Zulkuf AKDAG, Prof. Dr. Sinerik N. AYRAPETYAN Associate Editor for Biomedical research Assoc. Prof. Dr. Filiz ACUN KAYA, Assist. Prof. Dr. Sabiha Zelal ULKU Associate Editor for Dentistry Advisory Board Betul KARGUL (TURKEY) Ferranti WONG (UNITED KINGDOM) Gauri LELE (INDIA)

Moschos A. PAPADOPOULOS (GREECE) Gulten UNLU (TURKEY) Jalen Devecioglu KAMA (TURKEY) Editorial Board

Abdel Fattah BADAWI (EGYPT) Abdurrahman ONEN (TURKEY) Ahmet YALINKAYA (TURKEY) Ahmet DAG (TURKEY) Ali Al-ZAAG (IRAQ) Ali BUMIN (TURKEY) Ali GUR (TURKEY) Ali Kemal KADIROGLU (TURKEY) Ali Riza ALPOZ (TURKEY) Allah Bakhsh HAAFIZ (USA) Alpaslan TUZCU (TURKEY) Aziz YASAN (TURKEY) Balasubramanian MADHAN (INDIA) Benik HARUTUNYAN (ARMENIA) Betul KARGUL (TURKEY) Betul URREHMAN (UAE) Bugra OZEN (TURKEY) Carlos Menezes AGUIAR (BRAZIL) Cemil SERT (TURKEY) Chiramana SANDEEP (INDIA) Christine Bettina STAUDT (SWITZERLAND) Cihan AKGUL (TURKEY) Claudia DELLAVIA ( ITALY ) Emin Caner TUMEN (TURKEY) Ertugrul ERCAN (TURKEY) Ertunç Dayı (TURKEY) Fadel M. ALI (EGYPT) Fahinur ERTUGRUL (TURKEY) Feral OZTURK (TURKEY) Ferhan YAMAN (TURKEY) Feridun BASAK (TURKEY) Feriha CAGLAYAN (TURKEY) Ferranti WONG (UNITED KINGDOM) Figen SEYMEN (TURKEY) Filippo BATTELLI (ITALY) Filiz Acun KAYA (TURKEY) Flavio Domingues Das NEVES (BRAZIL) Folakemi OREDUGBA (NIGERIA) Gajanan Kiran KULKARNI (CANADA) Gamze AREN (TURKEY) Gauri LELE (INDIA) Gokhan KIRBAS (TURKEY) Gonul OLMEZ (TURKEY) Guliz Nigar GUNCU (TURKEY) Gulsen YILMAZ (TURKEY) Gulten UNLU (TURKEY) Gungor ATES (TURKEY) Guvenc BASARAN (TURKEY) Guven ERBIL (TURKEY)

Nik Noriah Nik HUSSEIN (MALAYSIA) Sadullah KAYA (TURKEY) Zeki AKKUS (TURKEY PhD. Dr. Ediz KALE Language Editor

Halimah AWANG (MALAYSIA) Halit AKBAS (TURKEY) Heloisa Fonseca MARAO (BRAZIL) Hilal TURKER (TURKEY) Huseyin ASLAN (TURKEY) Igor BELYAEV (SWEDEN) Ilhan INCI (ZURICH) Ilker ETIKAN (TURKEY) Isil TEKMEN (TURKEY) Isin ULUKAPI (TURKEY) Izzet YAVUZ (TURKEY) Jalen DEVECIOGLU KAMA (TURKEY) Kemal CIGDEM (TURKEY) Kemal NAS (TURKEY) Kewal KRISHAN (INDIA) King Nigel MARTYN(HONG KONG SAR, PR CHINA) Kursat ER (TURKEY) Levent ERDINC (TURKEY) Lucianne Cople MAIA (BRAZIL) Luciane Rezende COSTA (BRAZIL) M. Ali FADEL (EGYPT) M. Sabri BATUN (TURKEY) Mahmut METE (TURKEY) Marri Sai ARCHANA (INDIA) Manoj KUMAR (INDIA) Marcelo Rodrigues AZENHA (BRAZIL) Marcia Cancado FIGUEIREDO (BRAZIL) Marco MONTANARI (ITALY) Margaret TZAPHLİDOU (GREECE) Maria Elisa Oliveira dos SANTOS (BRAZIL) Medi GANIBEGOVIC (BOSNIA and HERZEGOVINA) Mehmet DOGRU (TURKEY) Mehmet Emin ERDAL (TURKEY) Mehmet Nuri OZBEK (TURKEY) Mehmet Zulkuf AKDAG (TURKEY) Meliksah ERTEM (TURKEY) Meral ERDİNÇ (TURKEY) Mohamed TREBAK (USA) Mohammed Mustahsen URREHMAN (UAE) Moschos A. PAPADOPOULOS (GREECE) Mostaphazadeh AMROLLAH (IRAN) M.S.Rami REDDY (INDIA) Muhammad FAHIM (INDIA) Mukadder ATMACA (TURKEY) Murat AKKUS (TURKEY) Murat KIZIL (TURKEY) Murat SOKER (TURKEY) Mustafa KELLE (TURKEY) Mustafa ZORTUK (TURKEY)

Muzeyyen YILDIRIM (TURKEY) Neval Berrin ARSERIM (TURKEY) Nezahat AKPOLAT (TURKEY) Nihal HAMAMCI (TURKEY) Nik Noriah Nik HUSSEIN (MALAYSIA) Nurten AKDENIZ (TURKEY) Nurten ERDAL (TURKEY) Orhan TACAR (TURKEY) Ozant ONCAG (TURKEY) Ozgur UZUN (TURKEY) Ozkan ADIGUZEL (TURKEY) Rafat Ali SIDDIQUI (PAKISTAN) Refik ULKU (TURKEY) Remzi NIGIZ (TURKEY) S. Yavuz SANISOGLU (TURKEY) Sabiha Zelal ULKU (TURKEY) Sadullah KAYA (TURKEY) Salih HOSOGLU (TURKEY) Saul Martins PAIVA (BRAZIL) Sedat AKDENIZ (TURKEY) Seher GUNDUZ ARSLAN (TURKEY) Selahattin ATMACA (TURKEY) Selahattin TEKES (TURKEY) Serdar ERDINE (TURKEY) Serdar ONAT (TURKEY) Sergio Adriane Bezerra DE MOURA (BRAZIL) Serhan AKMAN (TURKEY) Serhat ATILGAN (TURKEY) Shailesh LELE (INDIA) Sinerik N. AYRAPETYAN (ARMENIA) Smaragda KAVADIA (GREECE) Sossani SIDIROPOULOU (GREECE) Stephen D. SMITH (USA) Susumu TEREKAWA (JAPAN) Suha TURKASLAN (TURKEY) Suleyman DASDAG (TURKEY) Tekin YILDIZ (TURKEY) Ufuk ALUCLU (TURKEY) Ugur KEKLIKCI (TURKEY) Xiong-Li YANG (CHINA) Vatan KAVAK (TURKEY) Yasar YILDIRIM (TURKEY) Yu LEI (USA) Yuri LIMANSKI (UKRAINE) Zafer C. CEHRELI (TURKEY) Zeki AKKUS (TURKEY) Zeynep AYTEPE (TURKEY) Zuhal KIRZIOGLU (TURKEY) Zurab KOMETIANI (GEORGIA)

Journal of International Dental and Medical Research / ISSN: 1309-100X TABLE OF CONTENTS / 2011 – 4 (2) DENTISTRY EXPERIMENTAL ARTICLE 1. COMPARATIVE EVALUATION OF DIAMETRAL TENSILE STRENGTH OF PHOSPHATE BONDED INVESTMENT MATERIALS AFTER DRYING BY VARIOUS METHODS”–AN INVITRO STUDY Gopinadh Anne, Polavarapu Jaya Krishna Babu, Oliganti Swetha Hima Bindu, Chiramana Sandeep Pages 54-58 CLINICAL ARTICLE 2. ETIOLOGY AND TYPE OF DENTO-ALVEOLAR INJURIES IN PRESCHOOL CHILDREN Ceyhan Altun, Bugra. Ozen, Gunseli Guven Pages 59-63 CLINICAL ARTICLE 3. EVALUATION OF DENTAL WASTE MANAGEMENT IN THE EMIRATE OF AJMAN, UNITED ARAB EMIRATES Raghad Hashim, Roaa Mahrouq, Neam Hadi Pages 64-69 CASE REPORT 4. MANAGEMENT OF RECURRENT HERPES LABIALIS IN IMMUNOSUPPRESSED PATIENT – A CASE REPORT Joslei Carlos Bohn, Lucimari Teixeira, Cassiano Lima Chaiben, Adriano Kuczynski, Francisca Berenice Dias Gil, Antonio Adilson Soares de Lima Pages 70-73 CASE REPORT 5. BIFID UVULA AND SUBMUCOUS CLEFT PALATE IN CORNELIA DE LANGE SYNDROME Michele Callea, Marco Montanari, Franco Radovich, Gabriella Clarich, Izzet Yavuz Pages 74-76 CASE REPORT 6. A NOVEL TREATMENT APPROACH FOR EXTRUDED MAXILLARY MOLARS Julia Elodie Vlachojannis, Margherita Santoro Pages 77-86 REVIEW 7. OCCUPATIONAL HAZARDS AMONG DENTISTS: A REVIEW OF LITERATURE Prashant Babaji, Firoza Samadi, JN Jaiswal, Anju Bansal Pages 87-93 MEDICAL & BIOMEDICAL RESEAERCH EXPERIMENTAL ARTICLE 8. EFFECTS OF EXPOSURES TO A MIX OF FAST NEUTRONS AND 50Hz, 0.05mT MAGNETIC FIELD ON RAT TESTES” (IN VIVO STUDY) Fadel Mohammed Ali, Wafaa Nemat Allal Ahmed, Samira Abdel Hamid, Eman Sayed Abd EL–Fattah, Mona Ahmed Pages 94-99 CASE REPORT 9. A MIDDLE AGED WOMAN WITH MOSAIC TURNER SYNDROME: A CASE REPORT Selda Simsek, Ahmet Yalinkaya, Diclehan Oral, Aysegul Turkyilmaz, Selahattin Tekes, Turgay Budak Pages 100-103 CASE REPORT 10. A CARDIAC ARREST ASSOCIATED WITH DOUBLE LUMEN ENDOBRONCHIAL TUBE: CASE REPORT Adnan Tufek, Feyzi Celik, Orhan Tokgoz, Haktan Karaman, Refik Ulku, Zeynep Baysal Yildirim, Gonul Olmez Kavak Pages 104-105

2011 - Volume 4 – Number 2

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Diametral Tensile Strength of Investment Materials Gopinadh Anne et al

COMPARATIVE EVALUATION OF DIAMETRAL TENSILE STRENGTH OF PHOSPHATE BONDED INVESTMENT MATERIALS AFTER DRYING BY VARIOUS METHODS”–AN INVITRO STUDY Gopinadh Anne1, Polavarapu Jaya Krishna Babu2, Oliganti Swetha Hima Bindu3, Chiramana Sandeep4 1. Professor and Head, Department of Prosthodontics, SIBAR Institute of Dental Sciences, Guntur-522509 ,Andhra Pradesh, India.

2. Senior Lecturer , Department of Prosthodontics, SIBAR Institute of Dental Sciences, Guntur-522509 , Andhra Pradesh, India.

3. PG Student, Department of Prosthodontics, SIBAR Institute of Dental Sciences, Guntur-522509 , Andhra Pradesh, India.

4. Professor, Department of Prosthodontics, SIBAR Institute of Dental Sciences, Guntur-522509, Andhra Pradesh, India.

Abstract The study is to evaluate and compare the Diametral Tensile strength of Phosphate bonded Investment materials (Wirovest, Cromocasting Fast and Accuvest) after drying by Air dried method, Conventional Hot air oven method and Microwave oven method.

A total of 90 cylindrical specimens were prepared from three different commercially available phosphate bonded investment materials. Thus 30 samples for each material were prepared and 10 of each were Air dried for 60 minutes, 10 were dried in a Conventional Hot air oven for 60 minutes t 265 c to 300 ˚c nd 10 were dried in Microw ve oven with 600 w tts t frequency of 2450 MHz for 10 minutes. All the samples were subjected to diametral compression test using a computer coordinated Universal testing machine at 2 hour interval at a crosshead speed of 0.5 cm/min.

The results illustrate that the method of Microwave drying of the samples of all the materials could withstand high compressive loads when compared to the other two methods i.e., Air dried and Hot air oven dried methods respectively .And the material Wirovest is considered to be the one with high diametral tensile strengths of all the compared phosphate bonded investment materials.

Within the limitations of this study, the Mean Diametral tensile strengths of the Microwave oven dried samples were highest, followed by the Hot air oven dried samples and Air dried samples. The Mean Diametral tensile strengths of the Wirovest material show highest values than Cromocasting fast investment material and Accuvest material.

Experimental article (J Int Dent Med Res 2011; 4: (2), pp. 54-58) Keywords: Diametral tensile strength, Investment materials, Hot air oven, Microwave oven, Time saving procedure.

Received date: 25 January 2011 Accept date: 26 July 2011 Introduction The strength of the refractory cast made of Phosphate bonded investment materials for the fabrication of a partial denture framework must be adequate to prevent fracture or chipping during burnout and casting procedures1, in order to with stand the impact of molten alloy. *Corresponding author: Dr. P. Jaya Krishna Babu , M.D.S, Senior Lecturer, Department of Prosthodontics, SIBAR Institute of Dental Sciences, Guntur, 522509 Andhra Pradesh, India.

Phone: +919885098177 E-mail: drjkprostho@gmail.com

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Phosphate bonded investment materials are familiar and versatile dental materials, first patented for use in dentistry by Moore and Watts in 1949. Their use in the construction of removable partial denture frameworks was described by Earnshaw2 in 1960.

There are various methods to increase the strength of the investment materials. Craig M Powers3 suggested Air dried method which is time consuming.

Kenneth L.Stewart 4 suggested Hot air oven drying t 265°c to 300 ˚c for 60 to 90 minutes and Leubke R.J5 suggested Microwave drying at power of 600 watts for 10 minutes.

However Investment Materials are brittle materials6 which are weaker in tension than in compression which may contribute to failure of material in service.

Page 54

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Diametral Tensile Strength of Investment Materials Gopinadh Anne et al

The purpose of this study is to compare the influence of other methods of drying the investment material to the conventional Air drying method and their effects on the diametral tensile strength (DTS) of three commercial available, Phosphate bonded investment materials.

Materials and methods According the ADA specification number 25, eight metal dies were made out of 304 stainless steel rod, with dimensions of 40 mm of length and 20 mm of diameter. A ring of size 45 mm of height and 100 mm diameter from 304 stainless steel pipe was cut .Care was taken so that all the dies had parallel ends. (Figure 1)

Figure 2. Samples Retrival.

For the Air dried method, the samples were wrapped in aluminium foil and stored for 2 hrs in open air and were tested for diametral tensile strength3. For the Hot air oven drying method, the samples were placed in an oven for 60 minutes t 230˚c for drying5 after which they were wrapped in aluminium foil and kept for bench drying for 2 hours. For the Microwave oven drying, the samples were placed in an oven for 10 minutes using an output of 600 watts,5 a 200ml cup of water was placed in the oven to protect the Magnetron. After that they were wrapped in aluminium foil and kept for bench drying for 2 hours before testing the Diametral tensile strength.

Figure 1. Duplicating mould and dies.

These dies were fixed onto a glass slab with cyanoacrylate drop with even distribution within the ring5. An Addition Silicone - Unisil was mixed in vacuum mixer with the ratio of 1:1 and poured on a vibrator into the ring. The mold with dies is left to under go complete polymerization for 48 hours at room temperature. There after the dies were removed using a jet air spray. (Figure 2) Each phosphate bonded investment material selected for the study was weighed c refully to follow the m nuf cturer’s directions for liquid powder ratio of 60ml/400gm. (Table I) The materials were vacuum mixed for 20 seconds and gently poured into the mold obtained placed on a vibrator. After the mold was completely filled a flat surfaced glass slab is placed on to ensure even ends of the samples.

After the initial setting time the samples were removed carefully without causing any damage.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Figure 3. Universal Testing machine.

All the samples so prepared were subjected to diametral compression test using a computer co-ordinated Universal testing machine Page 55

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Diametral Tensile Strength of Investment Materials Gopinadh Anne et al

by DAK Systems,Mumbai. (Figure 3) This mode of testing is an indirect tensile strength measuring test and the results so obtained were used to calculate the diametral tensile strength.

After the DTS values were calculated and the mean and standard error was calculated for all the samples. The method of Statistical Analysis used in this study were One way analysis of variance and Two way analysis of variance to test the difference between groups.

Calculation of Diametral tensile strength2 (DTS): The formula used σх =2P / ∏dt The tensile stress ‘σх’ ,Lo d pplied ‘P’ in compression ‘d’ is the di meter of the specimen nd ‘t’ is the thickness of the specimen.

Table 2. Anova: two factor without replication Summary.

Results Among all the drying methods, the Microwave oven dried samples had the maximum compressive load bearing capacity, which is followed by Conventional Hot air oven dried and Air dried samples.

The material Wirovest showed high Diametral tensile strength values than Accuvest and Cromocasting fast.

Table 3. Anova two way factor without replication.

3

2.5

2

Table 1- shows the materials and the manufacturers recommendations to use them.

WIROVEST 1.5

CROMO-CAST ACCUVEST

1

Table 2- shows the Anova Two factor without replication - Summary.

0.5

0 1

Table 3- shows the Anova Two way factor without replication.

2

3

Bar Diagram 1. Column Chart for three Methods.

(1- Air dried, 2- Hot air oven, 3- Microwave oven) 3

2.5

2 AIR DRIED 1.5

HOT AIR OVEN MICRO WAVE OVEN

1

0.5

0 WIROVEST

Table 1. Materials and the manufacturers recommendations.

CROMO-CASTING

ACCUVEST

Bar Diagram 2. Column Chart for Each Material.

Bar Diagram 1. shows the column chart for the three methods in which the X axis

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Page 56

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

represents the methods and the Y –axis represents the Diametral tensile strengths in Mpa. Bar Diagram 2. shows the column chart for the three materials in which the X axis represents the materials and the Y –axis represents the Diametral tensile strengths in Mpa. Discussion The Accuracy of a partial denture framework is affected by many variables such as the total compensating expansion of the casting investment7,8,9 the duplicating material, the compressive strength of the investment at the casting temperature10 and the technique of handling the materials11..

Many years of dental application have made phosphate bonded investments a familiar and versatile class of materials used in the laboratory. The present study was to compare and evaluate the Diametral Tensile strengths of three different commercially available Phosphate bonded Investment materials, after drying by three Methods i.e., Air dried, Hot Air Oven Dried And Microwave Oven Dried Methods.

Luebke and Schneider5 tested the compressive strength of various dental stones using air conventional oven and micro wave oven drying which was also conducted at a high power.

They found that the microwave and oven drying methods produced similar compressive strength results.

Tuncer12 et al observed the optimal length of drying time and degree of power for the microwave drying method. Type III and Type IV dental stones and a type III investment material were studied .The results showed that after 24 hrs Compressive strength values of the two gypsum products did not show much difference , but the investment subjected to 2 hour lowpower microwave oven drying had a higher compressive strength than the air dried specimens.

Senay canay13 et al compared the diametral tensile strength of phosphate bonded investment materials by conventional dried and microwave oven dried methods and found higher DTS values for microwave dried specimens. The study was performed at two intervals i.e., 2 hours and 4 hours but no significance of time is observed.

The present study conducted to find out compressive strength of three different Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Diametral Tensile Strength of Investment Materials Gopinadh Anne et al

investment materials (Wirovest , Cromocasting fast and Accuvest ) when dried by the Microwave oven method ,when compared to the Air dried and Hot air oven dried methods at a 2 hour.

Conclusions Within the limitations of this study the following conclusions can be drawn. The Mean DTS of the Microwave oven dried samples showed highest values followed by the Hot air oven dried samples and Air dried samples. The Mean DTS of the Wirovest material used were of highest values followed by Cromocasting fast investment material and Accuvest material .

Microwave oven use is considered to be acceptable time saving procedure for drying any investment material, when compared to the use of other mehtods. It not only saves the time but also increase the strength of the Investment material.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Ahmed Ali Evaluation of compressive strength for refractory casts made from different investment materials, Al Rafidian Dent J 2007; 7:166-172.

2. Andrej S Juszczyk and David R Radford Sensitivity of disc rupture test to test to air bubble pores in phosphate bonded investment materials at elevated temperatures J Dent Mater 2002;18:255262.

3. John M Powers, Ronald L Sakagachi , Mechanical Properties of Dent l M teri ls nd Gypsum Products nd Investments; Cr ig’s Restorative Dental Materials, 12th edition, St Louis, Mosby ,2007; 65-87,324-332.

4. Stewart,Rudd and Kuebker, Laboratory procedures for Frame work construction, Kenneth L .Stewart ,Clinical removable partial prosthodontics, 2nd edition, Medico dental media international 2003: 27-361.

5. R.J Leubke and R.L Schneider Microwave drying of artificial stone, J Prosthetic Dentistry 1985;53:261-265.

6. Tay W.M. and M Braden load deformation behavior during a diametral test Biomaterials 1990 ;11:361-366.

7. Takao Fusayama Factors and technique of Precision Casting Part I J Prosthetic Dentistry 1959;9:468-485.

8. Takao Fusayama Factors and technique of Precision Casting Part II J Prosthetic Dentistry 1959;9:468-485.

9. Earnshaw .R The effect of Casting ring liners on the potential expansion of a gypsum bonded Investment J Dent Res 1988;67 1366-1370.

10. Pedro Cesar and gelson luis Influence of the final temperature of the investment heating on the tensile strength and Vickers hardness of CP TI and Ti-6AL-4V alloy J Oral Sci 2007;15:4448.

11. Edmea Lodovici, Josete barbosa Expansion of high flow mixtures of gypsum bonded investments in contact with absorbent liners Dent Mat 2005;21:573-579.

Page 57

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Diametral Tensile Strength of Investment Materials Gopinadh Anne et al

12. N Tuncer and DrMedDent Investigation on the compressive strength of several gypsum Products dried by microwave oven with different programmes, J Prosthet 1993;69:333-339.

13. Senay Canay and Nur Hersek comparison of diametral tensile strength of microwave and oven dried investment materials, J Prosthetic Dentistry1999;82:286-290.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Page 58

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Dental Trauma in Preschool Children Ceyhan Altun et al

ETIOLOGY AND TYPE OF DENTO-ALVEOLAR INJURIES IN PRESCHOOL CHILDREN Ceyhan Altun1*, Bugra. Ozen2, Gunseli Guven1 1. Associate Professor, Department of Pediatric Dentistry, Center of Dental Sciences, Gulhane Medical Academy, Ankara, Turkey.

2. Pediatric Dentist, PhD, Department of Pediatric Dentistry, Center of Dental Sciences, Gulhane Medical Academy, Ankara, Turkey.

Abstract The aim of this study was to identify the etiology and type of dento-alveolar injuries in children.

The study involved 2492 children (1344 boys, 1148 girls) aged 1-5 years examined. Injuries were classified according to drawings and texts based on the WHO classification system, as modified by Andreasen and Andreasen.

Boys accounted for a higher percentage of injuries than girls. The difference in cause of injury between younger children (1-2 years) and older children (2-5 years) was statistically significant (p<0.001). The difference in affected teeth by cause of injury was statistically significant (p=0.021).

The most common type of injury in children aged 1-2 years, 2-3 years and 3-4 years was subluxation, whereas the most common type of injury in children aged 4-5 was intrusive luxation.

The difference in type of injury by age group was also statistically significant (p<0.001).

However, there was no significant difference in type or rate of injury by sex (p=0.771).

Children between 2-3 years of age had the highest rate of traumatic dental injuries.

Clinical article (J Int Dent Med Res 2011; 4: (2), pp. 59-63) Keywords: Dental trauma; primary tooth; tooth injury.

Received date: 16 October 2010 Introduction Orofacial trauma represents a complex problem for child orodental and general health due to the possible medical, esthetic and psychological consequences it can have on children, as well as their parents.1-5 Epidemiological studies indicate that approximately 30 percent of all children under age seven have sustained injuries to one or more of their primary incisors6,7 and that most injuries to primary dentition, as well as most serious injuries, occur among children aged 1-3 years.1 Epidemiological research has reported a high incidence of injuries to primary dentition related to accidents within and around the home,

*Corresponding author: Ceyhan ALTUN, DDS, PhD. Department of Pediatric Dentistry Center of Dental Science Gulhane Medical Academy ETLIK/ANKARA TURKEY Phone: +90 (312) 3046045 E-mail : ceyhanaltun@yahoo.com

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Accept date: 30 November 2010 which is the site of most dental trauma occurring as a result of falls among children ages 1-3.8-11 The type and extent of traumatic tooth injury depend on the direction and intensity of the acting force. An intrusive injury is caused by the impact of a force in an axial direction that results in displacement of the tooth into the socket, whereas an avulsion is the result of a blunt impact and is associated with the high resilience of tooth-supporting structures.8,12 Although exact mechanisms are as yet unknown, it is agreed that lateral luxations are the result of a direct impact on the incisal edge in an axial/lateral direction, the energy from which can lead to crown fracture.12 Intrusion and avulsion are the most severe types of injuries to affect primary dentition in children up to 2 years of age.13-15 Injury to primary dentition is serious because of the potential for periapical sequelae, which can adversely affect the developing occlusion as well as the development of permanent teeth.16,17 Treatment of oral and maxillofacial injuries requires fastidious diagnosis and coordination between all treating professionals from the moment of injury. Prompt and appropriate management can significantly Page 59

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

improve the prognosis for many dento-alveolar injuries.14 Complications can be reduced with the correct diagnosis.13,14 The aim of this study was to identify the etiology and type of dento-alveolar injuries among children aged 1-5 years treated at the Gulhane Medical Academy Department of Pediatric Dentistry’s Centre of Dental Sciences in Ankara, Turkey in order to develop a basis for determining optimal treatment approaches and teaching needs. Attention was focused on primary dentition due to the frequency with which primary teeth are affected by traumatic injury.

Dental Trauma in Preschool Children Ceyhan Altun et al

in the other age groups included in the study.

(Examination of children under age 1 revealed no injuries to primary incisors; therefore, findings pertaining to this age group were excluded from the study results.)

Of the 210 children with injuries, 107 children had injured 1 primary tooth, 78 children had injured 2 primary teeth, 8 children had injured 3 primary teeth and 17 children had injured 4 primary teeth. The most frequently injured teeth were the maxillary central incisors (74.6%), with the maxillary right central incisor accounting for 43.9 percent of all injured teeth (Table 1).

Materials and methods This cross-sectional survey was carried out at the Gulhane Medical Academy Department of Pediatric Dentistry’s Centre of Dental Sciences in Ankara, Turkey in 2007. The study involved 2492 children (1344 boys, 1148 girls) aged 1-5 years (mean age: 3.42±1.03) examined at the clinic over a one-year period.

Examination for traumatic dental injuries included maxillary and mandibular primary incisors only. Injuries were classified according to drawings and texts based on the WHO classification system, as modified by Andreasen and Andreasen.2 Patient records were examined with regard to age (at the time of injury to the primary tooth), gender, number and type of teeth involved, cause of injury (falling while walking or running; bicycle/tricycle accident; impact against a hard object; other causes, including traffic accidents, self-inflicted, earthquake, unknown) and type of injury (crown discoloration, enamel fracture, enamel/dentin fracture, enamel/dentin/pulp fracture, subluxation, lateral luxation, intrusive luxation, extrusive luxation, avulsion ).

Statistical analysis was carried out using the SPSS computer program. Chi-square tests were used to determine significant differences in data (P<0.05).

Results Of the 2492 children included in this study, a total of 355 traumatic primary teeth injuries were observed among 210 children. Boys accounted for a higher percent of these children (54.8%) than girls (45.2%), and children aged 2-3 had more traumatic dental injuries than children Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Table 1. Distribution of injured primary teeth (n=355).

Table 2 shows the cause of injury. Falling while walking or running accounted for the greatest number of traumatic dental injuries (97 children, 46.2%; 151 teeth, 42.5%) followed by impact against a hard object (54 children, 25.7%; 95 teeth, 26.8%), bicycle/tricycle accident (33 children,15.7%; 56 teeth, 15.8%) and other causes (traffic accident, earthquake, self-inflicted, unknown) (26 children, 12.4%; 53 teeth; 14.9%).

In children aged 1-2, impact against a hard object was the most common cause of dental trauma (44.7%), whereas falling while walking or running was the most common cause among children aged 2-3, 3-4 and 4-5 years (63.1%, 32.2% and 46.2%, respectively). This difference was statistically significant (p<0.001).

Table 2. Cause of injury in primary dentition Table 3 shows the distribution of injured teeth by tooth type. Tooth No. 51 (FDI notation) was the tooth most affected by falls, impact with a hard object and other types of injuries, whereas Tooth No. 61 was the most affected in the case of bicycle injuries. The difference in cause of Page 60

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

injury by tooth type was statistically significant (p=0.021).

Dental Trauma in Preschool Children Ceyhan Altun et al

injury by age was statistically significant (p<0.001). No significant difference was found in type of injury by sex (p=0.771).

Table 3. Distribution of injured teeth by cause of injury Table 4 shows the distribution of injured teeth by age and sex. Children aged 2-3 were found to have the highest rate of traumatic injury (30.9%). Among the overall sample, boys were found to have a higher rate of traumatic injuries than girls; however, when analyzed by age group, no significant difference was observed in injury rates between boys and girls (p>0.05).

Table 4. Distribution of injured teeth by age and sex.

Table 5 shows the distribution of injured teeth by type of injury. Overall, the most common injuries in children were subluxations (31.0%), followed by intrusive luxations (17.5%), extrusive luxations (12.7%), crown discoloration (12.1%), lateral luxations (9.6%), enamel/dentin fractures (7.6%), enamel fractures (5.3%), avulsion (2.8%) and enamel/dentin/pulp fractures (1.4%).

Looked at by age group, subluxation was the most common type of injury in children aged 1-2 years, 2-3 years and 3-4 years, whereas intrusive luxation was the most common type of injury in children aged 4-5 years. The difference in type of Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Table 5. Distribution of injured teeth by type of injury and sex.

Discussion Dental trauma is a frequent occurrence among young children. Rodriguez (2007) has stated that traumatic injuries occur mainly during early infancy.16 Although some earlier studies have reported an equal distribution of traumatic dental injury in young children between boys and girls,1,18 the present study is in line with other studies19-22 among children aged 1-5 that showed boys sustained injuries more often than girls. The higher incidence of injuries found among boys than girls may be explained by more vigorous play.23 Because of their exposed position in the dental arch, the maxillary central incisors are affected by traumatic injury at significantly higher rates than other teeth. The next-most frequently affected are the maxillary and mandibular lateral incisors and the upper canines.24,25 In this study, 74.6 percent of injured teeth were maxillary central incisors and 18.3 percent were maxillary lateral incisors. These rates are consistent with the rates reported in the literature.15,18,20,21 In this study, of those children with traumatic dental injuries, the majority (51.0%) had one damaged tooth, 37.1 percent had two damaged teeth, 3.8 percent had three damaged teeth and 8.1 percent had four damaged teeth.

These rates are also similar to those reported in the literature.18,26 The main causes of traumatic injury found in this study were falling while walking or running (46.2%); impact by a hard object (25.7%); a bicycle or tricycle accident (15.7%); and other causes, including traffic accidents, self-inflicted and earthquakes, or unknown reasons (12.4%).

Page 61

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

These findings, as well as findings from the literature related to age and cause of traumatic injury, suggest that primary tooth trauma frequently occurs as children begin to learn to walk and run,2,27,28 making it difficult to prevent.

Most of the traumatic injuries in this study occurred at home or at pre-school, either indoors or outdoors.

Active participation in sporting activities such as cycling, especially among small children, often increases the risk of traumatic injuries to dental and oral tissue.28,29 In this study, the left primary central incisor was the most commonly affected tooth in traumatic bicycle injuries, whereas the right primary central incisor was the most commonly affected tooth in all other injuries.

We believe the main reason for this difference is that children are less able to control their movement in the case of a fall from a bicycle in comparison to other situations resulting in traumatic injury. The difference may also be attributed to developing motor coordination.16 According to the literature, crown fracture is the most common type of injury among permanent dentition, whereas luxation is the most common among primary dentition. 24,30,31 In the present study, the most frequently observed type of injury was subluxation (31.0%), followed by intrusive luxation (17.5%), extrusive luxation (12.7%) and crown discoloration (12.1%).

Significantly higher rates of crown fracture were observed in other retrospective studies conducted with pre-school children by GarciaGodoy et al (83%),32 Otuyemi et al (66.8%)33 and Hargreaves et al (71.8%).34 Careful attention should be paid when analyzing type of injury, which has been shown to vary according to study setting, i.e. hospital, private practice, or educational institution.32,35 The main objectives in the diagnosis and treatment of traumatic injuries involving primary dentition are pain management and the prevention of possible damage to the developing tooth germ.15 In such cases, treatment strategy is dictated by a concern for the safety of the permanent dentition.30 According to Dale,36 a dentist should be consulted immediately after dental trauma. In some cases, an interval of less than 1 h between traumatic incident and examination can increase the chances of successful treatment and minimize the likelihood of pain, sequelae and additional costs. As a general rule, if the apex is displaced toward or Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Dental Trauma in Preschool Children Ceyhan Altun et al

through the labial bone plate, the tooth can be left for spontaneous re-eruption.37,38 However, if the apex is displaced toward the permanent tooth germ, the tooth should be extracted.37,38 A high risk of potential dental and oral injury exists during childhood and adolescence.

In order to understand the complexities of dental trauma etiology and to allow for the implementation of preventive strategies to reduce the increasing frequency of trauma, more epidemiological studies of representative populations that employ standardized trauma classifications are required.

Conclusions 1. Among children aged 1-5 years, children between 2-3 years of age had the highest rate of traumatic dental injuries.

2. Boys suffered traumatic dental injuries slightly more often than girls.

3. The most frequently injured primary tooth was the right central maxillary incisor (43.9%).

4. The most common cause of traumatic dental injuries was falling while walking or running either indoors or outdoors.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Cardoso M, de Carvalho Rocha MJ. Traumatized primary teeth in children assisted at the Federal Universty of Santa Catarina, Brazil.

Dent Traumatol 2002;18:129-33.

2. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic Injuries to the Teeth. 4th edition. Copenhagen: Munksgaard; 2007.

3. Lalloo R. Risk factors for major injuries to the face and teeth.

Dent Traumatol 2003;19:12-4.

4. Al-Jundi SH. Dental emergencies presenting to a dental teaching hospital due to complications from traumatic dental injuries. Dent Traumatol 2002;18:181-5.

5. Glendor U. On dental trauma in children and adolescentes. İncidence, risk, treatment, time and costs. Swed Dent J Suppl 2000;140:1-52.

6. Borum MK, Andreasen JO. Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition. Endod Dent Traumatol 1998;14:31-44.

7. Odersjö ML, Koch G. Developmental disturbances in permanent successors after injuries to maxillary primary incisors. Eur J Pediatr Dent 2001;2:165-72.

8. Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: a review of the literature. Aust Dent J 2000;45:2-9.

9. Schatz JP, Joho JP. A retrospective study of dento-alveolar injuries. Endod Dent Traumatol 1994;10:11-4.

Page 62

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

10. Onetto JE, Flores MT, Garbarino ML. Dental trauma in children and adolescents in Valparaiso, Chile. Endod Dent Traumatol 1994; 10: 223-27.

11. Gassner R, Bosch R, Tuli T, Emshoff R. Prevelance of dental trauma in 6000 patients with facial injuries: implications for prevention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87: 27-33.

12. Harlamb SC, Messer HH. Endodontic management of a rare combination (intrusion and avulsion) of dental trauma. Endod Dent Traumatol 1997;13:42-6.

13. Diab M, elBadrawy HE. Intrusion injuries of primary incisors.

Part III: effects on the permanent successors. Quintessence Int 2000;31:377-84.

14. Holan G, Ram D, Fuks AB. The diagnostic value of lateral extraoral radiography for intruded maxillary primary incisors. Pediatr Dent 2002;24:38-42.

15. E.C. Tumen, O. Adiguzel, S. Kaya, E. Uysal, I. Yavuz, F. Atakul, “The Prevalence and etiology of dental trauma among 5-72 months preschool children in south-eastern anatolia, Turkey,” Journal of International Dental and Medical Research (JIDMR) 2009;2,40-4.

16. Rodriguez JG. Traumatic anterior dental injuries in Cuban preschool children. Dent Traumatol 2007;23:241-2.

17. Fried I, Erickson P. Anterior trauma in the primary dentition; incidence, classification, treatment methods, and sequelae: a review of the literature. ASDC J Dent Child 1995;62:256-61.

18. Kramer PF, Zembruski C, Ferreira SH, Feldens CA. Traumatic dental injuries in Brazilian preschool children. Dent Traumatol 2003;19:299-303.

19. Gondim JO, Moreira Neto JJ. Evaluation of intruded primary incisors. Dent Traumatol 2005;21:131-3.

20. Bassiouny MA, Giannini P, Deem L. Permanent incisors traumatized through predecessors: sequelae and possible management. J Clin Pediatr Dent 2003;27:223-8.

21. Skaare AB, Jacobsen I. Primary tooth injuries in Norwegian children (1-8 years). Dent Traumatol 2005;21:315-9.

22. Sandalli N, Cildir S, Guler N. Clinical investigation of traumatic injuries in Yeditepe Universty, Turkey during the last 3 years. Dent Traumatol 2005; 21(4):188-94.

23. Kahabuka FK, Plasschaert A, van’t Hof M. Prevalence of teeth with untreated dental trauma among nursery and primary school pupils in Dar es Salaam, Tanzania. Dent Traumatol 2001;17:109-13.

24. Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surgery 1972;1:235-9.

25. Galea H. An investigation of dental injuries treated in an acute general hospital. J Am Dent Assoc 1984;109:434-8.

26. Segura JJ, Poyato M. Tooth crow fracture in 3-year-old Andalusian children. J Dent Child 2003;70:55-7.

27. Walter LRF, Ferelle A, Issao M. Odontologia Para o Bebê. São Paulo: Ed. Artes Médicas, 1996.

28. Levin L, Samorodnitzky GR, Schwartz-Arad D, Geiger SB. Dental and oral trauma during childhood and adolescence in Israel: occurrence, causes, and outcomes. Dent Traumatol 2007;23:356359.

29. Wright G, Bell A, McGlashan G, Vincent C, Welbury RR. Dentoalveolar trauma in Glasgow: an audit of mechanism and injury.

Dent Traumatol 2007;23:226-31.

30. Wilson CF. Management of trauma to primary and developing teeth. Dent Clin North Am 1995;39:133-67.

31. Forsberg CM, Tedestam G. Traumatic injuries to teeth in Swedish Children living in an urban area. Swed Dent J 1990;14:115-22.

32. García-Godoy F, Morbán-Lauccer F, Corominas LR, Franjual RA, Noyola M. Traumatic dental injuries in preschool-children from Santo Domingo. Community Dent Oral Epidemiol 1983;11:127-30.

33. Otuyemi OD, Segun-Ojo IO, Adegboye AA. Traumatic anterior dental injuries in Nigerian preschool children. East Afr Med J 1996;73:604-6.

34. Hargreaves JA, Cleaton-Jones PE, Roberts GJ, Williams S, Matejka JM. Trauma to primary teeth of South African pre-school children. Endod Dent Traumatol 1999;15:73-6.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Dental Trauma in Preschool Children Ceyhan Altun et al

35. Llarena Del Rosario ME, Acosta Alfaro VM, Garcia-Godoy F. Traumatic injuries to primary teeth in Mexico City Children. Endod Dent Traumatol 1992;8:213-14.

36. Dale RA. Dentoalveolar trauma. Emerg Med Clin North Am 2000;18:521-38.

37. Arenas M, Barbería E, Lucavechi T, Maroto M. Severe trauma in the primary dentition-dignosis and treatment of sequelae in permanent dentition. Dent Traumatol 2006;22:226-30.

38. Sennhenn-Kirchner S, Jacobs HG. Traumatic injuries to the primary dentition and effects on the permanent successors-a clinical follow-up study. Dent Traumatol 2006;22:237-41.

Page 63

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Dental Waste Management in Ajman Raghad Hashim et al

EVALUATION OF DENTAL WASTE MANAGEMENT IN THE EMIRATE OF AJMAN, UNITED ARAB EMIRATES Raghad Hashim1*, Roaa Mahrouq2, Neam Hadi2 1. PhD Assistant Professor Ajman University, Ajman, United Arab Emirates.

2. DDS General Practitioner Ajman University, Ajman, United Arab Emirates.

Abstract Management of dental waste was investigated in Ajman, United Arab Emirates. A comprehensive survey was conducted for 49 of the 52 dental clinics available in the Emirate of Ajman to assess the current situation.

The focus was placed on hazardous waste produced by dental clinics and the handling, storage, disposal measures taken. Dentists were interviewed regarding their disposal of different dental waste. All the clinics segregated infectious waste from the main waste stream. Most of the segregation (75.5%) took place inside the clinics; Non contact amalgam was placed in trash in 47% of the clinics. Used fixer and developer poured down the drain by 93.9% of the clinics. About 83.7% of the clinics disposed the used X-ray films into regular waste.

The findings revealed that there is no proper separation of dental waste. Further research should be conducted, and construction of a training program constructed for the dentists and personnel who are in charge of waste management.

Clinical article (J Int Dent Med Res 2011; 4: (2), pp. 64-69) Keywords: Dental waste; management; United Arab Emirates.

Received date: 23 February 2011 Introduction Health care establishments (including dental clinics) are mainly concerned with providing high standard services to the community; this cannot be fully accomplished unless a proper waste handling policy that is consistent with the international regulations is strictly implemented. Even though dental clinics generate relatively small quantities of healthcare waste compared to the other medical facilities.

Nevertheless they are responsible for generating a certain amount of waste which can produce serious health and environmental hazards if not dealt with properly.

*Corresponding author: Dr. Raghad Hashim Assistant Professor, Head of Growth and Development Department Ajman University, P.O.Box 346 Ajman, UAE Phone: +9716 705 6394 E-mail: raghad69@yahoo.co.nz

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Accept date: 13 May 2011 The World Health Organization1 defines healthcare waste (HCW) as discarded (and untreated) materials from health care activities on humans or animals that have the potential of transmitting infectious agents to humans. These wastes include equipment or materials from the diagnosis, treatment and prevention of disease that have been in contact with blood and its derivatives, including tissues, tissue fluid or excreta, or waste from infection wards. According to Kizlary et al2, dental waste consists of three main categories: Infectious waste, non-infectious waste and domestic-type waste. Infectious waste contains materials contaminated with blood or other infectious fluid of the mouth, sharps and amalgam.

The common sources of major hazardous waste at dental clinics includes X-ray fixers and film, chemical disinfectants, dental amalgam, sharps and blood-soaked dressings, silver, lead, various solvent and other chemicals3.

The key to minimization and effective management of health care waste is segregation (separation) and identification of the waste.

Appropriate handling, treatment and disposal of Page 64

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

waste by type reduce costs and does much to protect public health4.

Although many developed countries have successfully managed to establish comprehensive systems for waste management, developing countries still tend to suffer from improper waste disposal5-7, insufficient financial recourses8, lack of awareness of health hazards and few data on health care waste generation and disposal9 were identified as the main reasons responsible for that problem.

Consequently, generated dental waste has the potential to be discharged into the waste water system and the majority of dental solid waste is dumped into household disposal sites and landfills without any recycling and separation processes. Since some of these wastes are hazardous in nature, this practice can create a potential risk to human health and to the environment10.

Currently, no study has investigated the generation and management of dental waste in the Emirate of Ajman. In the absence of such study, we investigated the handling and disposal of various types of dental waste generated on daily basis within the dental clinics throughout the Emirate of Ajman in United Arab Emirates.

Materials and methods There were a total of 52 registered dental clinics in the Emirate of Ajman distributed between governmental and private sectors. Out of those 52 clinics, 49 were private according to Ajman Municipality records in 2009. After preliminary construction of the questionnaire, it was distributed to six dentists to test its validity; their suggestions regarding some modifications in the design of some of the questions were taken into account.

Field visits to all dental clinics in the Emirate of Ajman were carried out over the month of March and April 2009.

Structured interviews lasting from 20 to 30 minutes were conducted, with the dentists using the pilot-tested questionnaire designed by the authors of this article. In each clinic, only 1 dentist was interviewed.

However, data could not be collected from 2 of the private clinics because the dentists serving these clinics were abroad at the time of the study.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Dental Waste Management in Ajman Raghad Hashim et al

The first part of the questionnaire (Appendix 1) included data on gender of the dentist, years of experience, number of staff at the clinic, and whether the dentist or their working staff were vaccinated against Hepatitis B. The last item was included due to the risks that are present for the health personnel who handle dental wastes, especially sharps; whether it was the dentist himself/herself or staff such as nurses, assistants or waste handlers. We have also included a question whether the person in charge of waste handling had received any professional training on dental waste management procedures before. In addition, the dentists were asked if they were aware of any documents outlining the clinics' waste management policy.

The second part of the questionnaire focused on the types of the clinical waste being segregated from the main waste stream on a daily basis, and where segregation and storage takes place in addition to the period of time the waste kept before removing it out of the clinic.

Amalgam waste question focused on the disposal of the old removed or extra newly placed amalgam fillings. Furthermore, dentists who used X-ray units in their clinics were asked about the disposal of the processing solutions and X-ray films.

Data were entered and analyzed using the statistical program SPSS (Statistical Package for the Social Sciences) Version 11.0. Descriptive statistics such as frequencies were utilized.

Results In this study 61% of participated dentists were male and 43% had more than 10 years experience. The majority of the dentists (96%) were vaccinated against hepatitis B virus. Most of the clinics (86%) had other personnel rather than the dentist (dental assistant, nurse…etc.), of those only 60 % were vaccinated against hepatitis B virus.

The waste handlers in 51.1% of the clinics were the persons in charge of waste collection, handling and storage (Table 1). Around half (51.1%) of the staff responsible for waste management did not receive any professional training on waste management. Concerning documents outlining waste management, 83.7% of the dentists were unaware of any document outlining the policy of waste management in the Emirate of Ajman.

Page 65

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Table 1. Status of personnel in charge of waste management.

Dental Waste Management in Ajman Raghad Hashim et al

The majority of these clinics (98%) used color coded bags/containers to segregate the waste. Non-contact amalgam was placed in trash in 47% of the clinics, while, in 20.4 % of the clinics it was returned to capsule and then trashed. Most of the segregation (78.5%) took place inside the clinic’s treatment area, waste was stored inside the clinic treatment area in 40.8% of the clinics, and in more than half the clinics (67.3%) it was kept for less than 5 days until the municipality collected it.

Regarding disposal of used fixer and developer 93.9% of clinics poured it down the drain. About 83.7% of the clinics disposed the used X- ray films into the regular waste. As for the lead foil, 81.6% of the dentists discarded it with the regular waste (Table 3).

All the clinics segregated infectious waste (blood soaked dressing, extracted teeth, sharps) from the main waste system, while 30.6% segregated infectious and heavy metal waste (amalgam mainly) and only 18.4% segregated infectious, heavy metal waste and chemical waste (cleaning solvents) as presented in table 2.

Table 3. Modes of disposal of X-ray related waste.

Discussion

Table 2. Segregation, storage, and disposal of dental waste.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

The validity and reliability of questionnaire based surveys can be influenced by design, question content, analysis and response rates.

The main limitation of this study is its crosssectional nature and the information collected represent a “snap-shot” of what the dentists are actually doing; this could perhaps have introduced some inaccuracies in reporting.

The 49 dental clinics included in this study represent about 94.2% of all Ajman dental clinics (49 out of 52) and the results showed that there is a clear shortfall in waste regulations if compared to the international standards.

Page 66

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

The majority of dentists had been vaccinated against hepatitis B virus, while 40% of the supporting staff at the clinics had not, which is alarming. Like any other health personal, dental care professionals are at risk of infection from blood borne pathogens. Therefore, it is strongly recommended that hepatitis B vaccination be administered to all dental health care workers as well as others who deal with medical waste.

Safe handling of hazardous waste is essential. All involved personal need to be aware of possible health hazards present and must be trained in the appropriate handling, storage and disposal methods. In this study, around half of personal dealing with dental waste did not receive any kind of professional training outlining this issue, although OSHA states that all employees with occupational exposure must receive initial and annual training11. The overall aim of training is to raise awareness and highlight roles of all personnel involved. It was disappointing to find that the majority of the dentists did not have any knowledge of any documents outlining waste management, which does not only jeopardize the safety of the workers, but also causes avoidable mishaps in handling of dental waste.

Sharps such as needles, syringes, and used ampoules are regarded as highly hazardous health care waste since they can cause injuries and transmitted diseases, especially to waste collection, treatment and disposal personnel11,12. These wastes must be segregated at the point of origin and packed in a rigid, leak-proof, puncture resistant container and the container must be specially labeled13. In the current study, all the clinics segregated infectious waste, were disposed off in the color coded yellow bags, with sharps placed in puncture resistant containers as outlined by the National Center for Chronic Disease Prevention and Health Promotion4. Studies conducted in Riyadh found that 72% of dental clinics in primary health care centers had containers for disposable needles and sharp instruments14 and 56% of dentists had special containers for sharp objects15.

On the other hand, one third of the clinics segregated heavy metals (amalgam mainly) but all were placed in the yellow bags for infectious wastes and ended up being incinerated which is not the best management protocol for amalgam16.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Dental Waste Management in Ajman Raghad Hashim et al

Research work has shown that improper disposal of mercury waste may be detrimental to the environment and public health. A variety of health problems linked to mercury intoxication range from joint pain to multiple sclerosis17.

The amalgam waste should remain in a properly labeled sealed container that is appropriate for storing contaminated amalgam waste and should be sent for the contents to be recycled18,19. Used and empty amalgam capsules may be disposed of as solid waste since they are non-hazardous. Most of the segregation 78.5% took place inside the dental clinic treatment room, as recommended by Pruss et al.11 where waste should always be segregated at site of generation, immediately. In the current study, 40.8% of the dental clinic store their waste inside the clinic, until the municipality collected it in less than 5 day intervals. As long as the waste is kept in appropriate receptacles complying with WHO recommendations and is inaccessible for vectors such as rats, rodents or cockroaches, it can be stored for a period not exceeding 30 days19.

Most of the used fixer and developer were poured down the drain, for used developer it is quit safe to be disposed down the drain20. Fixer is hazardous because of its high silver content.

Therefore, discarding of used fixer down the drain or into the garbage, as is done by dentists in the Emirate of Ajman, poses a serious threat to the environment and human health. This should be collected in a clearly marked container and should subsequently be recycled or treated as hazardous waste. The World Health Organization recommendations require a silver recovery unit to be installed at the end of the X-ray processing unit11.

The recovered silver can then be sold to a metal reclaimer and the treated fixer can be disposed of down a drain. As most dental clinics in Ajman and many developing countries produce small amount of waste individually, the silver recovery unit designed to these standards is needed rather than the more commonly designed units that handle larger and continuous quantities of waste. Furthermore, lead foil, used to shield the X-ray film, should be dealt with as hazardous waste and not disposed of with regular waste. It worth noting that none of the dental clinics surveyed uses the digital system of x-ray machines.

Training courses regarding waste management should be mandatory as it is crucial Page 67

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

for the upgrade of dental waste management practices. This should be part of a more comprehensive continuous education program for all dental personnel. The overall aim of training is to develop awareness of the health, safety, and environmental issues relating to health-care waste, and how these can affect employees in their daily work. Every dental clinic should have a written document explaining the dental waste management policy which should be understood by those who have to follow it taking in consideration those who do not have a good command of English or Arabic.

Conclusions This study might be considered as the first step in a more in depth research that should be performed in the future regarding the issue of dental waste management in specific and medical waste management in general. Such issues pose a high level of hazard to the community but are still over looked in most of the third world countries. Therefore, a national collaborative effort should be made to minimize the effects of solid and liquid wastes to the minimum, and to address these threats in comprehensive, effective ways.

An environmentally responsible dental office can help in restoring a healthier environment and can always make a difference.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

(Appendix 1) Dental Waste Management Questionnaire Gender: Male Female Years of experience: 1- Are you vaccinated against HBV? Yes No 2- Does the clinic have any personal other than the dentist?

Yes No If yes are they vaccinated against HBV? Yes No 3- Do they use any PPE –personal protective equipment - (gloves, mask, and lab coat)?

Yes No 4- Who is the person in charge of waste collection handling and storage at the clinic?  Dentist  Assistant  Nurse  Waste handlers

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Dental Waste Management in Ajman Raghad Hashim et al

5- Has she\he received any professional training on waste management?

Yes No 6- Are you aware of any document outlining dental waste management policy?

Yes No 7- Indicate which waste is segregated from the main waste stream?  Infectious waste only  Infectious waste & heavy metal waste  Infectious waste, heavy metal waste & Chemical waste 8- What types of containers\bags are used to segregate the waste?  Normal plastic bags  Color coded bags  Other 9- How do you deal with non contact amalgam?  Thrown in trash  In drain and trash  Returned to capsule then trash  Separate bottle 10- Where does the segregation take place?  Inside clinic  Outside clinic  Lab area (if present) 11- Where is the waste stored while awaiting removal from clinic or disposal?  Inside the clinic  Outside the clinic  Lab area (if present)  Other 12- How long is the waste kept before removing it out of the clinic\store area?  Less than 5 days  More than 5 days 13- How do you dispose the used fixer?  In the drain  Dumped in specific grounds  Given to recycling companies  Returned to manufacturing company 14- How do you dispose the used developer?  In the drain  Dumped in specific grounds  Given to recycling companies  Returned to manufacturing company 15- How do you dispose used x-ray films?  In the trash  Given to recycling companies  Medical waste bag 16- How do you dispose lead foil used in film packet?  In the trash  Given to recycling companies  Medical waste bag

Page 68

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Dental Waste Management in Ajman Raghad Hashim et al

References 1. World Health Organization (2004). Review of Health Impacts from Microbiological Hazards in Health – Care Wastes, Geneva, Switzerland, 2004.

2. Kizlary E, Losifidis N, Voudrias E, Panagiotakopoulos D. Composition and production rate of dental solid waste in Xanthi, Greece: variability among dentist group. Waste Management, 2005, 25:582-591.

3. Central of Disease Control, Hepatitis B fact sheet, July, 2007. http://www.cdc.gov/NCIDOD/Diseases/Hepatitis/b/bfact.pdf, (accessed 24 May 2008).

4. National Center for Chronic Disease Prevention and Health Promotion. Guidelines for Infection Control in Dental HealthCare Settings, CDC, USA, 2003.

5. Abdulla F, Qdais HA, Rabi A. Site investigation on medical waste management practices in northern Jordan. Waste Management, 2008, 28:450-458.

6. Shinee E, Gombojav E, Nishimura A, Hamajima N, Ito K. Health waste management in the capital city of Mongolia. Waste Management, 2008, 28:435-441.

7. Al-Khatib IA, Monou M, Mosleh SA, Al-Subu MM, Kassinos D. Dental solid and hazardous waste management and safety practices in developing countries: Nablus district, Palestine.

Waste Management Research, 2010, 28:436-44.

8. Tiynmaz E, Demir I. Research on solid waste management system: to improve existing situation in Corlu Town of Turkey.

Waste Management, 2006, 26:307-314.

9. Darwish IA, Al-Khatib IA. Evaluation of dental waste management of two cities in Palestine, Eastern Mediterranean Health Journal, 2006, 12:217-222 10. Farmer GM, Stankiewicz N, Michael B, et al. Audit of waste collected over one week from ten dental practices. A pilot study.

Australian Dental Journal, 1997, 42:114-117.

11. Pruss AE, Giroult E, Rushbrook P, eds. Safe management of wastes from health-care activities. WHO handbook. Geneva, World Health Organization, 1999, pp1-136.

12. Ozbek M, Dilek-Sanin FD. A study of the dental solid waste produced in a school of dentistry in Turkey. Waste Management, 2004, 24:339-345.

13. Treasure P, Treasure ET. An investigation of the disposal of hazardous wastes from New Zealand dental practices.

Community Dentistry and Oral Epidemiology, 1997, 24:328-331.

14. Kurdy S and Fontaine RE. Survey on infection control in MOH dental clinics, Riyadh. Saudi Epidemiol Bull, 1997, 3: 21-28.

15. Al-Rabeah A and Mohamed AG. Infection control in the private sector in Riyadh. Annals of Saudi Medicine, 2002, 22: 1:13-17.

16. Spencer AJ. Dental amalgam and mercury in dentistry.

Australian Dental Journal, 2000, 45:224-234.

17. Atesgaoglu A, Omurlu H, Ozcagli E, Sardas S, Ertas N. Mercury exposure in dental practice. Operative Dentistry, 2006, 31:666669.

18. Al-Qaroot Y. An environmental health study of medical waste in Nablus hospitals. Master thesis, Al Najah National University, Nablus, Palestine, 2001.

19. Palneik C. Hazardous waste management within dental practices. Journal of Ireland Dental Associate 2003, 49:103.

20. ADA Council on Scientific Affairs. Managing silver and lead waste in dental offices. Journal of American Dental Association; 2003, 134:1095-1096.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Page 69

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Reccurent Herpes Labialis Joslei Carlos Bohn et al

MANAGEMENT OF RECURRENT HERPES LABIALIS IN IMMUNOSUPPRESSED PATIENT – A CASE REPORT Joslei Carlos Bohn1, Lucimari Teixeira1, Cassiano Lima Chaiben1, Adriano Kuczynski1, Francisca Berenice Dias Gil2, Antonio Adilson Soares de Lima1* 1. Department of Stomatology, School of Dentistry, Universidade Federal do Paraná – UFPR, Curitiba/PR, Brazil.

2. Department of Dentistry, Hospital Oswaldo Cruz, Curitiba/PR, Brazil.

Abstract The clinical manifestations of herpes simplex virus (HSV-1 and -2) are found in both immunocompetent patients and in those immunocompromised. However, the typical lesions observed among immunosuppressed patients usually become more severe, long-lasting and require different interventions in individuals whose immune systems can not limit the infection.

Secondary or recurrent HSV-1 infection occurs through the reactivation of the virus, although many patients may present only asymptomatic infection in saliva.

The hallmark of the recurrent herpes labialis is characterized by burning sensation, itching, tingling or localized heat followed by the appearance of a rash before the onset of the bullous and vesicular lesions. The majority of cases are treated by antiretroviral drugs. For this reason, clinicians need to be aware of atypical cases which suggest a clinical immunosuppression that have not yet diagnosed.

The aim of this article is to report a case of recurrent herpes labialis of an immunosuppressed patient.

Case report (J Int Dent Med Res 2011; 4: (2), pp. 70-73) Keywords: Herpes Labialis, HIV, Immunosuppression, Lip. Received date: 10 June 2011 Introduction Among the various infectious diseases that may occur in the mouth, the most frequently observed for involves the HSV-1. The contact with this virus typically occurs before puberty.

When a patient is infected, the virus remains in its latent form within the regional neural ganglia indefinitely. Despite the initial infection is present in young patients, many individuals have signs and symptoms. Some individuals exhibit clinical symptoms such as malaise and possibly fever, while others develop primary herpetic gingivostomatitis1. Nonetheless, patients often *Corresponding author: Antonio Adilson Soares de Lima Curso de Odontologia - Departamento de Estomatologia da UFPR Rua Prefeito Lothário Meissner 632, Jardim Botânico 80170210 Curitiba – PR Brazil Phone: + 55 41 33604050 E-mail: aas.lima@ufpr.br

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Accept date: 18 July 2011 report pain, swelling, and cosmetic concerns associated with recurrent episodes and fear of transmitting herpes simplex virus (HSV) to others2.

Recurrent lesions appear throughout the life of an infected individual, usually at epithelial sites such as the eye (herpetic keratitis), skin, oral cavity (herpetic stomatitis), lips (herpes labialis), and orofacial complex (herpes facialis).

In an immunocompetent person, recurrences are generally limited and constrained to peripheral tissues innervated by the latently infected neurons3.

Recurrent herpes labialis is an infection of the lip by herpes simplex virus (HSV-1). Although most patients with recurrent herpes labialis have fewer than two episodes yearly, a small percentage of patients (5% to 10%) for reports frequent recurrences, defined as six or more episodes yearly 2. Common triggers that can reactivate the virus include fatigue, fever, ultraviolet radiation, chapping, abrasion, menses, skin trauma, and immunosuppression4-5. The small clusters of vesicles or ulcers involving a Page 70

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Reccurent Herpes Labialis Joslei Carlos Bohn et al

limited portion of the initially infected dermatome generally appear within two days of entry into the epithelium3.

Recurrent herpes labialis is characterized by small blisters (vesicles) filled with clear yellowish fluid. These injuries are manifested in a sudden, after numbness or itching of the lips during the 4-6 days. The vesicles break down leading to ulcers covered by crusts. The healing of injuries occurs between seven and ten days and leaves no scars1.

The diagnosis of HSV-1 or HSV-2 infection usually is based on the patient’s medical history, for symptomatology and clinical findings.

However, laboratory confirmation may be required when the clinical features are atypical or when patients are immunocompromised6. The aim of this article is to describe a case of recurrent herpes labialis in a patient with HIV disease.

Case Report A 36-year-old white male was referred to the Hospital Oswaldo Cruz in Curitiba (Brail) with symptoms of intense weight loss and with complaints of diarrhea, cough, sweats (particularly at night), painful vesicles and hemorrhagic crusts on the lips. The patient had decreased 14 Kg in last four months.

The patient’s medical history revealed a recent diagnosis of HIV infection and the use of illicit drugs. Initial laboratory investigation revealed normal liver and kidney function tests and blood sugar levels; complete hemogram showed anemia and leucopenia; and erythrocyte sedimentation rate: 110 mm. The CD4 count was 84 cells/µL and viral load was 287.256 cells.

Intraoral physical examination revealed oral candidiasis (thrush), gingivitis, dental caries, and some residual tooth roots. Furthermore, several yellow vesicles and ulcers covered by a slightly brownish crust in the upper and lower lip (Figure 1). Vesicles were also located in the skin around the lips.

According to the patient, these lesions appeared five days ago following high fever. The lesions were painful and causing discomfort due to aesthetic reasons. These lesions limited his oral hygiene and intake of food, but intravenous rehydration was not necessary. No regional lymph node involvement was found.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Figure 1. Vesicles and hemorrhagic crusts on the vermilion and around the lips.

Figure 2. Clinical appearance of patient after 7 days of treatment with Acyclovir.

Page 71

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

A complete medical evaluation for tuberculosis was done and the suspicion of pulmonary tuberculosis was ruled out. Serology tests confirmed that the patient was positive for HSV (IgG and IgM positive). The clinical features of the lesion reinforced one diagnostic hypothesis: recurrent herpes labialis.

The patient was treated with a 12-day course of acyclovir (600 mg/day) associated with topical acyclovir (ointment 5%). With this combined course of treatment, the disease was controlled. After 12 days of treatment, skin and lip lesions were controlled (Figure 2). Oral candidiasis was treated by fluconazol associated to topical nystatin. The lesions disappeared and the patient discharged from the hospital. In addition, the patient was treated by highly active antiretroviral therapy because of low CD4 count.

The patient was referred for outpatient and has shown no recurrence of HSV. Discussion The World Health Organization (WHO) identified HIV/AIDS as the world's most urgent public health challenge, because AIDS represents the greatest lethal epidemic in recent history. HIV infection is commonly associated with activation and dissemination of several other viral pathogens, including herpes simplex virus 1 and 2, human cytomegalovirus, human herpesvirus 8, Epstein-Barr virus, Varicella Zoster virus, and human papillomavirus, which behave as opportunistic agents and cause various diseases in immunocompromised hosts1,7.

The increased frequency and severity of diseases caused by these viruses in HIV-infected individuals is due mainly to dysfunction of both the adaptive and innate immune responses to viral pathogens8. Infections with herpes simplex virus type 1 and 2 (HSV-1 and HSV-2) are important, common, and worldwide in distribution9.

Ninety-eight percent of herpes simplex virus lesions are caused by reactivated disease and tend to be characterized by large, very painful ulcerative lesions throughout the mouth10.

In this case report, a bilateral recurrent herpes labialis was diagnosed around the lips of the patient. Several triggers may reactivate the virus, such as: fatigue, fever, ultraviolet radiation, chapping, abrasion, menses, skin trauma, and immunosuppression4-5. In this case, the low CD4 Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Reccurent Herpes Labialis Joslei Carlos Bohn et al

count should have been responsible for the reactivation of HSV, because the patient had a CD4 count = 84 cells/µL. Although the diagnosis of HSV infections is usually made clinically, Tzanck test, electron microscopy, viral culture and polymerase chain reaction (PCR) detection of HSV DNA can be utilized to verify the diagnosis11-12. Herpes simplex viruses type 1 (HSV-1) and 2 (HSV-2) cause a variety of medically significant infections, especially in immunosuppressed subjects. HSV also plays an important role in the disease progression of HIV infection. Chronic infection of HSV-1 has been regarded by the WHO as an important factor affecting the disease progression of HIV/AIDS. HSV-1 infection is usually transmitted during childhood and adolescence and is most often transmitted via nonsexual contact1.

Although this infectious disease has a predictable clinical course that progresses to an auto-regression, in this case, several lesions were widespread and severe in a region of the face which caused discomfort to the patient. In addition, laboratory tests revealed that the viral load was high and low CD4 count. HIV destroys CD4 lymphocytes gradually and the count relates inversely with the severity of the disease.

According to Duggal et al.13 the chances of oral lesions appear increase in patients a significantly higher viral load and lower CD4 count. However, any lesion in immunocompromised individuals must be immediately treated. Thus, a regimen that included topical and systemic drugs was established for the treatment of recurrent herpes labialis and oral candidiasis.

Acyclovir, valacyclovir hydrochloride, and famciclovir are the 3 antiviral drugs routinely used to treat symptomatic herpes simplex virus (HSV) infections14. CDC - Centers for Disease Control and Prevention has recommended the following treatment regimens for episodes of HSV-1 and HSV-2 infections: i) Acyclovir 400 mg orally three times a day for 7–10 days; or ii) Acyclovir 200 mg orally five times a day for 7–10 days or; iii) Famciclovir 250 mg orally three times a day for 7–10 days; or iv) Valacyclovir 1 g orally twice a day for 7–10 days. Treatment might be extended if healing is incomplete after 10 days of therapy. Intravenous (IV) acyclovir therapy should be provided for patients who have severe HSV disease or complications that necessitate hospitalization (e.g., disseminated infection, Page 72

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

pneumonitis, or hepatitis) or CNS complications (e.g., meningoencephalitis). The recommended regimen is acyclovir 5–10 mg/kg IV every 8 hours for 2–7 days or until clinical improvement is observed, followed by oral antiviral therapy to complete at least 10 days of total therapy.

Acyclovir dose adjustment is recommended for impaired renal function15. In our case, the patient was treated with a combination of topical and systemic acyclovir. Acyclovir therapy has proved safe for the long-term suppression of recurrent genital herpes infections and recurrent herpes labialis2,16,17.

Conclusion Recurrent herpes labialis is a lesion with unique clinical features but it can become exacerbated principally in immunocompromised patients. Thus, clinicians need to be aware of these situations lead to the diagnosis and treatment more appropriate.

Acknowledgements Dr Roberto Francisco Hoffman - Hospital Oswaldo Cruz (Curitiba/PR Brazil).

Reccurent Herpes Labialis Joslei Carlos Bohn et al

8. Tugizov SM, Webster-Cyriaque JY, Syrianen S, Chattopadyay A, Sroussi H, Zhang L, Kaushal A. Mechanisms of viral infections associated with HIV: workshop 2B. Adv Dent Res. 2011; 23(1): 130-6.

9. Langley RG. Famciclovir for the treatment of recurrent genital and labial herpes lesions. Skin Therapy Lett. 2005; 10(10): 5-7.

10. Schubert MM. Oral manifestations of viral infections in immunocompromised patients. Curr Opin Dent. 1991; 1(4): 38497.

11. Whitley RJ, Roizman B: Herpes simplex virus infections. Lancet 2001; 357:1513–1518.

12. Ozcan A, Senol M, Saglam H, Seyhan M, Durmaz R, Aktas E, Ozerol IH: Comparison of the Tzanck test and polymerase chain reaction in the diagnosis of cutaneous herpes simplex and varicella zoster virus infections. Int J Dermatol 2007; 46:1177–1179.

13. Duggal MS, Abudiak H, Dunn C, Tong HJ, Munyombwe T. Effect of CD4+ lymphocyte count, viral load, and duration of taking anti-retroviral treatment on presence of oral lesions in a sample of South African children with HIV+/AIDS. Eur Arch Paediatr Dent. 2010; 11(5): 242-6.

14. Cernik C, Gallina K, Brodell RT. The treatment of herpes simplex infections: an evidence-based review. Arch Intern Med. 2008; 168(11): 1137-44.

15. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Sexually transmitted diseases: treatment guidelines 2010.

Available at: http://www.cdc.gov/std/treatment/2010/genital-ulcers.htm#hsv.

Accessed June 2, 2011.

16. Straus SE, Croen KD, Sawyer MH, Freifeld AG, Felser JM, Dale JK, et al. Acyclovir suppression of frequently recurring genital herpes. Efficacy and diminishing need during successive years of treatment. JAMA. 1988; 260: 2227-30.

17. Kaplowitz LG, Baker D, Gelb L, Blythe J, Hale R, Frost P, et al.

Prolonged continuous acyclovir treatment of normal adults with frequently recurring genital herpes simplex virus infection.

JAMA. 1991; 265: 747-51.

Declaration of Interest All authors disclose that there was no conflict of interest that could inappropriately influence in this report of case.

References 1. Neville B, Damm DD, Allen CM, Bouqout J, eds. Viral infections.

In: Oral and Maxillofacial Pathology. 2nd ed. St. Louis: Saunders; 2002: 213-252.

2. Rooney JF, Straus SE, Mannix ML, Wohlenberg CR, Alling DW, Dumois JA, Notkins AL. Oral acyclovir to suppress frequently recurrent herpes labialis. A double-blind, placebo-controlled trial. Ann Intern Med. 1993; 118(4): 268-72.

3. Miller CS, Danaher RJ, Jacob RJ. Molecular Aspects of Herpes Simplex Virus I Latency, Reactivation, and Recurrence. Crit Rev Oral Biol Med. 1998 9: 541-562.

4. Habif TP. Herpes simplex. In: Baxter S, ed. Clinical dermatology: a color guide to diagnosis and therapy. 3rd ed. St. Louis. Mosby-Year Book, 1996: 325-44.

5. Corey L. Herpes simplex virus. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 5th ed. Philadelphia. Churchill Livingstone, 1998: 1564-80.

6. Brown RS, Eiland D. Palatal lesions in an otherwise healthy patient. J Am Dent Assoc. 2010; 141(4): 429-32.

7. He N, Chen L, Lin HJ, Zhang M, Wei J, Yang JH, Gabrio J, Rui BL, Zhang ZF, Fu ZH, Ding YY, Zhao GM, Jiang QW, Detels R. Multiple viral coinfections among HIV/AIDS patients in China.

Biosci Trends. 2011; 5(1): 1-9.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Page 73

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Cornelia de Lange Syndrome Michele Callea et al

BIFID UVULA AND SUBMUCOUS CLEFT PALATE IN CORNELIA DE LANGE SYNDROME Michele Callea1*, Marco Montanari2, Franco Radovich1, Gabriella Clarich1, Izzet Yavuz3 1. Institute for Maternal and Child Health - IRCCS “Burlo Garofolo”- Trieste, Italy.

2. Unit of Dentistry for Disables, Department of Oral Science, Alma Mater Studiorum, University of Bologna, Italy.

3. Dicle University, Faculty of Dentistry, Department of Pediatric Dentistry, Diyarbakir, Turkey.

Abstract Cornelia de Lange syndrome is a rare congenital disease characterized by growth and psychomotor retardation, peculiar facial feature as skeletal and craniofacial deformities, gastrointestinal and cardiac problems and malformation of the upper limb. The prevalence is estimated around 0.6/100000 in the population1.

The diagnosis is based on clinical findings and the etiology is still unclear. We present a case of a 17-year-old patient, who came to our attention for dental pain. After an oral examination carried out under general anesthesia the patients presented most of the charactericts described in the literature as micrognathia , high arched palte, delayed aruption, missing of some teeth. The most peculiar findings were the bifid uvula and the submucous cleft palate. The entity of clefting can be determined only with a Magnetic Resonance Imaging which should be carried out under general anesthesia .

Caries and periodontal disease were present and the entire dental treatment has been carried out in one sitting without any anestesiologic problems2-5.

Case report (J Int Dent Med Res 2011; 4: (2), pp. 74-76) Keywords: Bifid Uvula, Submucous Cleft Palate, Cornelia De Lange Syndrome.

Received date: 31 May 2011 Introduction Cornelia De Lange Syndrome (CdLs) is an autosomal dominant disorder6, a rare syndrome of multiple congenital anomalies and multisystemic disease, also called Brachmann-de Lange syndrome.

Brachmann had firstly described a child with similar features in 19167.

CdLs is classically characterized by typical features, such as microbrachycephaly, mental deficiency, abnormal speech development, seizures and hypotonia. Behavioral problem as regurgitation, projectile vomit, difficulties in chewing and swallowing are *Corresponding author: Dr. Michele Callea Unit of Oral and Maxillofacial Surgery, Department of Odontology IRCCS Burlo Garofolo Maternal and Child Health Hospital, Trieste, Italy

Accept date: 01 August 2011 reported. The facial phenotype overrides racial characteristics.

Eyebrows are often confluent. Micrognatia is a very common feature. Delayed tooth eruption and microdontia, wide spaced teeth and cleft palate are other features reported in Literature8.

Usually the hands and feet are small.

Hirsutism is generalised, nipples and humbelicus are often hypoplastic.

Around 20% of the affected patients have a congenital heart defect3.

Diagnosing classic cases of Cornelia de Lange syndrome is usually straightforward, however, diagnosing mild cases may be challenging, even for an experienced clinician7.

We report a case of an affected patient in which we made an intraoperatory identification and diagnosis of bifid uvula and submucous cleft palate.

The diagnose of CdLs was made at the age of 4 years old based upon clinical findings and multi-specialistic examination.

E-mail: mcallea@gmail.com Phone: +39 -040-3785675

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Page 74

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Case Report We report a case of a 17-year-old girl who came to our attention , in the unit of Pediatric Dentistry and Maxillo Facial Surgery of our Institute because of dental pain.

She presented low posterior hairline, long eyelashes, thin lips, downturned angle of the mouth, small hands, feet with short digits, hirsutism, small nipples. The neck was short and thick.

The oral examination has been impossible to carry out in the dental office because of poor collaboration.

Radiographic examination, intraoral and orthopantomography could not be carry out due to lack of cooperation of the patient. The dental treatment has been carried out under general anesthesia (Figure 1).

Cornelia de Lange Syndrome Michele Callea et al

Severe gingivitis was present, therefore an accurate ultrasound scaling ablation has been carried out, polishing of old fillings, and extraction of still present primary canines and the permanent maxillary left canine was done and detersion of the socket, presenting granular infective tissue allowing us to eradicate the cause of the referred oral pain by parents.

Figure 2. Dental status revaeling severe gingivitis.

Figure 1. The patient has been intubutaded endotracheally.

After a total disinfection of the operatory field, an oral examination was made , which revealed missing of some teeth probably because of non-erupted anchilosed teeth or in ectopic position with still chance for a delayed eruption .

Old amalgam and composite restaurations were present due to a previous operation carried out under general anesthesia, but more important bifid uvula and a submucous cleft palate was identified, not so severely significant for a surgical operation and correction of the submucous clefting, along with the consideartion of the difficulty of devices which requires any kind of impressions9.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

The operation has been carried out in an hour and 45 minutes, and after that, the patient who was staying in the hospital under DH regime has been placed in the department of Pediatric Surgery.

Instruction for good oral hygiene was given to the parents, and post operatory control and follow up established. After 6 months we observe an improoved dental status health of the patient affected by CdLs, confirmed after 12 months consultation.

To our knowledge this is a particular and special case which allowed the dental and maxillo-facial staff to carry out a complete dental treatment leading to a clinical identification and diagnosis of bifid uvula and submucous cleft palate after an accurate inspection, noticing the difficulty of the approach which always require general anesthesia for any examiantion or clinical investigation in patients affected by CdLs. Discussion CdLs is a rare disease which requires a multisciplinary careful approach. Fetal Alcohol Syndrome and tetrasomy 18p10 should be considered for differential diagnosis.

Page 75

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

CdLs is a genetical and usually sporadic disease. In the past few years it has been shown that CdLs is caused by gene mutations affecting proteins involved in sister chromatid cohesion.

Studies in model organisms, and more recently in human cells, have revealed, somewhat unexpectedly, that the developmental deficits in CdLS likely arise from changes in gene expression11.

Aitken DA et al. reported that secondtrimester maternal serum pregnancy associated plasma protein-A measurements may be of value as an adjunct to ultrasonography in the prenatal diagnosis of Cornelia de Lange syndrome12.

As reported in the literature caries and periodontal disease are typical dental features in these patients.

Bifid uvula and not severe submucous clefting were not unusual finding still rare, along with the rarity of the disease. Cleft palate is present in 20% of the diagnosed cases13.

This case is particular for the accuracy of the examination which led to the identification of the bifid uvula and submucous cleft palate and the complete dental treatment.

Phonation, speech , mastication might be compromised because of clefting, still, its mild manifestation do not require an immediate maxillo-facial and plastic surgeon correction, especially not prior a strumental examination as a CT (Computer Tomography) or MRI (Magnetic Resonace Imaging) to carry out absolutely under general anesthesia, which can reveal the entity of the submucous cleft until now only clinically diagnosed.

Cornelia de Lange Syndrome Michele Callea et al

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Liu J, Baynam G. Cornelia de Lange syndrome. Adv Exp Med Biol. 2010; 685: 111-23.

2. Washington V, Kaye AD. Anesthetic management in a patient with Cornelia de Lange syndrome. Middle East J Anesthesiol.

2010; 20(6): 773-8.

3. Robert J. Gorlin, M. Michael Cohen Jr., Raoul C.M. HENNEKAM SYNDROMES of the HEAD and NECK 4th EDITION Int J Oral Maxillofac Surg. 1993; 22(3): 171-2.

4. Takeshita T, Akita S, Kawahara M. Anesthetic management of a patient with Cornelia De Lange syndrome. Anesth Prog. 1987; 34(2): 63-5.

5. O'Donnell D, Davis PJ, King NM Management problems associated with Cornelia de Lange syndrome. Spec Care Dentist.

1985; 5(4): 160-3.

6. Liu J, Baynam G. Cornelia de Lange syndrome. Adv Exp Med Biol. 2010; 685: 111-23.

7. Brachmann W. Ein Fall von symmetrischer Monodaktylie durch Ulnadefekt, mit symmetrischer Flughautbildung in den Ellenbeugen, sowie anderen Abnormalitaten. Jahr Kinderheilkunde. 1916; 84: 225-35.

8. Toker AS, Ay S, Yeler H, Sezgin I. Dental findings in Cornelia de Lange syndrome. Yonsei Med J. 2009; 50(2): 289-92.

9. Chate RA. Respiratory arrest during an orthodontic impression of a cleft palate, in a baby with Brachmann-de Lange syndrome. J R Coll Surg Edinb. 1994; 39(2): 121-3.

10. G Borck, R Redon, D Sanlaville, M Rio, M Prieur, S Lyonnet, M Vekemans, N P Carter, A Munnich, NIPBL mutations and genetic heterogeneity in Cornelia de Lange syndrome. L Colleaux, V Cormier-Dair. J Med Genet 2004; 41: 128.

11. Dorsett D, Krantz ID. On the molecular etiology of Cornelia de Lange syndrome. Ann N Y Acad Sci. 2009; 1151: 22-37.

12. Aitken DA, Ireland M, Berry E, Crossley JA, Macri JN, Burn J, Connor JM. Second-trimester pregnancy associated plasma protein-A levels are reduced in Cornelia de Lange syndrome pregnancies. Prenat Diagn. 1999; 19: 706-10.

13. Yamamoto K, Horiuchi K, Uemura K, Shohara E, Okada Y, Sugimura M, Yoshioka A. Cornelia de Lange syndrome with cleft palate. Int J Oral Maxillofac Surg. 1987; 16(4): 484-91.

Conclusions Thorough oral examination evaluation by dental health professionals the diagnosis of Cornelia de Lange syndrome is based on clinical findings and the etiology is still unclear.

The most peculiar findings are the bifid uvula and the submucous cleft palate. Health care workers must be able to recognize the disease and treatment way.

Acknowledgements We would like to thank the family for allowing the publication of clinical data and imagines.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Page 76

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Extruded Maxillary Molars Julia Elodie Vlachojannis and Margherita Santoro

A NOVEL TREATMENT APPROACH FOR EXTRUDED MAXILLARY MOLARS Julia Elodie Vlachojannis1*, Margherita Santoro2 1. Dr. Med. Dent., M. Sc., Lofou 4A Ekali, Athens 14578, Greece.

2. D.D.S., M.A., Division of Orthodontics, Columbia University, School of Dental and Oral Surgery, 635 W 168th St, P&S Box 20, New York, NY 10032, US.

Abstract Two approaches are currently used to correct overerupted/extruded posterior teeth, the “prosthodontic” and the “orthodontic” one. This report presents a novel orthodontic approach for selective molar intrusion.

In two females (26 and 20 years), a modified transpalatal arch (TPA, equivalent to a couple with a 30 g net force) was used to move the tooth bodily. A 50 g force was applied to the overerupted maxillary second molar by means of a short length elastomeric chain from the helix to the palatal sheath and replaced every three weeks. Sufficient intrusion of the maxillary second molar was obtained within two months.

For intrusion of a single tooth, a modified TPA together with a short length elastomeric chain is a non-invasive and cost-effective alternative to traditional edgewise mechanics, temporary anchorage devices, or removable appliances.

Case report (J Int Dent Med Res 2011; 4: (2), pp. 77-86) Keywords: Case report, unopposed molar, selective molar intrusion, modified transpalatal arch appliance.

Received date: 14 May 2011 Introduction Unopposed molar teeth are frequently subject to overeruption, and are believed to be related to impaired masticatory function and to development of temporomandibular disorders.1 In a longitudinal study over 10 years with 12 adults, Christou and Kiliaridis found that unopposed molars showed more vertical displacement (0.8mm) than opposed molars (0.4mm). They concluded that the observed changes were either the result of late growth remodeling or a consequence of altered dental equilibrium following antagonist tooth loss.2 Two approaches are currently in use to correct overerupted (extruded) posterior teeth.

The prosthodontic approach reduces the vertical height of the crown of the extruded tooth; however, depending on the amount of extrusion *Corresponding author: Julia Elodie Vlachojannis, Dr. Med. Dent., M. Sc. Lofou 4A Ekali, Athens 14578, Greece E-mail: jvlachojannis@gmail.com

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Accept date: 08 August 2011 prior endodontic treatment might be necessary.

The orthodontic approach aims to intrude the tooth; however, due to the great root surface area of molars, the resistance to intrusion forces is high. A good anchorage system is necessary to counteract the unwanted effect of extrusion on the adjacent tooth. This report presents two cases successfully treated with an orthodontic approach using a modified transpalatal arch (TPA) for selective molar intrusion.

Biomechanical Background Intrusion is described as an apical movement in the direction of its long axis into the alveolus in the same direction that forces are imposed by physiologic occlusion by means of positive tension and positive pressure applied to the contents of the periodontal apparatus.

The periodontal ligament system is most resistant to orthodontic forces applied in vertical direction towards the apex of the root due to the unique combination of simultaneous hydraulic pressure and fibrous tension applied to the periodontal ligaments. Very light continuously applied forces are most effective. They result in small increases in fiber tension without elevating Page 77

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

hydraulic pressures beyond the physiologic level and thus preventing the compressed tissues to be traumatized.3 Positive continued tension stretches the periodontal ligaments in a semi-elastic way.

Small forces are required to maintain the extension until the fibers fatigue.3 Positive pressure on the bone results in resorption. A continuous intrusive light force of 0.5N was also associated with significantly reduced basal blood flow in the pulp in 13 incisors (p<0.05).4 After resorption of the bone, the tooth will move into the space closest to the tooth. The whole cycle is then repeated several times during orthodontic treatment.3 It is most important to know the center of resistance of the tooth to be intruded. This center is dependent on root length and morphology, number of roots and level of alveolar bone support. This center is usually located at about one-fourth to one-third the distance from the cemento-enamel junction to the root apex.5 On upper incisors the center of resistance is located at 0.24 times the root length measured apically to the level of alveolar crest.6 Due to the delicate balance of the periodontal ligament fiber systems, the force applied needs to be well chosen, keeping in mind that these calculations are only approximate in individual cases. A force is equal to mass times acceleration (F = ma) and is measured either in Newton or clinically in gram x millimeter (mm). If the force passes through the center of resistance the tooth translates without tipping (so-called bodily movement). The further away the point of force application is from the center of resistance, the greater are the rotational and the linear moments; the rotation moment is to be determined by multiplying the magnitude of force by the perpendicular distance of the line of action to the center of resistance. The ratio between the net moment and net force on a tooth (M/F ratio) with reference to the center of resistance determines the center of rotation.7 An M/F ratio of 10:1 generally produces sole translation with the center of rotation located at infinity.8 The force presents magnitude (size) and direction and is described as a vector with a line of action and point of application. The magnitude of the moment force has 2 variables: the magnitude of the force and the distance from the center of resistance. Common ways of obtaining Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Extruded Maxillary Molars Julia Elodie Vlachojannis and Margherita Santoro

orthodontic forces are the deflection of wires, the activation of springs and auxiliaries such as elastics.8 An intrusive force on the molars’ buccal tube creates a moment tipping the crown buccaly (Figure 1).

Figure 1. The intrusive force on the molar creates a moment tipping the crown buccaly.

An orthodontic force of higher magnitude will be required on molars than on incisors because of the larger area of periodontal attachment. There is a general agreement that this force should not exceed 100 gm.9 Forces in conventional orthodontics are transmitted through the archwire. A very stiff archwire has a steep load-deflection curve with a high initial force that decays rapidly even with small tooth movements. The study by Kohno and co-workers suggests that molar movements induced by light forces with modern clinical appliances are close to physiological movements.5 Intrusion of a tooth will result in unwanted effects: (i) extrusion of the adjacent tooth, often seen when engaging an archwire while brackets height differs. This is associated with clockwise rotation of the mandible and an anterior open bite when the extrusion takes place in the molar area (Figure 2);9 (ii) molar transversal width expansion when the intrusion is caused by a high pull headgear. This can be counteracted by constricting the inner bow of the high pull headgear or by using a TPA.9 Page 78

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Extruded Maxillary Molars Julia Elodie Vlachojannis and Margherita Santoro

adjusted by cutting it in half and a helix was bent parallel to the roof of the palate. The removable palatal bar was then adjusted to a 60-90° angle so that the helix laid at the height of the center of resistance of the extruded molar. The helix was kept open facing the gingiva, just enough to activate the appliance by slipping through a power-chain or other elastomeric auxiliaries of choice. In combination with a main guiding stainless steel archwire 0.022′′ or 0.022” x 0.028” (which is run through the buccal tube) a balanced force system was achieved to create an equilibrium between buccal and palatal root torque (Figure 3).

Figure 2. This step bend between the two terminal molars produces extrusion and lingual tipping of the first maxillary molar and intrusion combined with buccal tipping of the second maxillary molar. It does not only create couples in the same direction (green) but also distal tipping of the terminal molar with a 25° vertical force vector. Since the forces are applied to the buccal tube, it is important to compare equivalent force systems at the center of resistance in order to predict tooth movement. The resultant vector is indicated (orange). The unilateral extrusion of the adjacent maxillary first molar can cause an open bite if this unwanted effect is not sufficiently controlled.

This study proposes a different approach to molar intrusion and displays more anchorage than conventional biomechanics in which the risk of extruding the adjacent posterior tooth is prevalent. It can be considered a modification of previous designs, such as the Kucher and Weiland’s appliance that uses similar biomechanics in combination with a transpalatal arch to reduce the prominence of the palatal cusp of the upper second molar.18 Materials and methods Appliance fabrication & design: An impression was taken of the arch with the extruded molar. The teeth were bonded/banded with edgewise fixed appliances. A band was fit on the adjacent molar including a soldered palatal attachment for a prefabricated removable palatal bar (GAC International Inc., Islandia, NY).

The removable palatal bar was made of 0.036′′ stainless steel round wire and was Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Figure 3 A. Palatal view of force system: At the palatal sheath (B) we connected an elastomeric auxiliary to the helix from the semi-palatal arch appliance (located at the height of the center of resistance to obtain pure translation). Note that during intrusion the height of the hook became more incisal and a couple is being created which brings the center of rotation from infinity toward the tooth. If this couple is large enough relative to the forces the amount of translation could become negligible in comparison to the tipping and the center of rotation would be near the center of resistance.

Forces: When representing a vector as an arrow, the point of application is indicated as the origin of the arrow and the length of the arrow is proportional to the magnitude of the force and is arbitrary. The arrowhead indicates the direction and the body indicates the line of action. All forces have the same scale. Our two applied Page 79

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

forces acted on three planes of space as illustrated in the two-dimensional graph (Figure 2). To determine the single net force or resultant affecting the maxillary second molar, both applied net-effect forces had to be combined.

The two vectors acted as sides of a parallelogram and the resultant was the diagonal.

Its length indicated the magnitude of the resultant force on the same scale as the original force. The final movement of the maxillary molar was identical to the resultant.

The two vectors had their point of application in point A – the buccal tube and in point B – the palatal sheath (Figures 3A and 3B): On point A we used a step bend, which created a moment tending to rotate the tooth and also created two couples in the same direction regardless of the step bend location between the brackets. As the line of action did not pass through the center of resistance, tipping of the maxillary second molar was expected. We applied 45 gm force on the tube 6 mm from the center of resistance and produced 270 gm-mm moment (Mf – moment of the force), tipping the tooth.

Extruded Maxillary Molars Julia Elodie Vlachojannis and Margherita Santoro

This force system was equivalent to a couple with a 30 gm net force to move the tooth bodily (Figure 3 A). Note that during intrusion the height of the hook became more incisal and a couple was being created which moved from infinity to a more incisal position. If this couple was large enough relative to the forces the amount of translation could become negligible in comparison to the tipping and the center of rotation would be near the center of resistance (Figure 3 C).10

Figure 3 C. Molar cut view and application of the force: The resultant vector (green) indicates a slight palatal crown tipping.

In our model, we obtained an intrusive force of 92.8 gm combined with clinically negligible distal and palatal crown tipping each of less than 15° (Figure 3 B). However, according to the individual environment, each clinical application might produce other unwanted effects.

Figure 3 B. Resultant vector (thin red arrow) in combining all forces (orange arrows) at the center of resistance: An intrusive force combined with slight distal and palatal crown tipping is obtained.

To obtain bodily movement we needed to create a moment of the couple (Mc) equal in magnitude and opposite in direction to the original movement. On point B we used a hook at the height of the center of resistance to obtain pure translation. We applied 50 gm force on the tube 6 mm from the center of resistance and produced 300 gm-mm moment (Mf – moment of the force), tipping the tooth very slightly palatally.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Figure 4 A1.

Pre-treatment assessment, buccal view.

intra-oral

Page 80

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Extruded Maxillary Molars Julia Elodie Vlachojannis and Margherita Santoro

Patient A.J. A 26 year 10-months-old female patient was referred by a general dentist for orthodontic evaluation. Her chief complaint was the missing tooth in the lower right arch. She presented with mild upper and lower anterior crowding, missing mandibular right second molar and extruded maxillary right second molar (Figures 4 A1 and A2).

Figure 4 B2. Appliance in place (occlusal view).

After 2 months of intrusive force we obtained space for implant placement of mandibular right second molar (Figures 4 C - F).

Figure 4 A2. assessment.

Pre-treatment

study

model

After evaluating the patient’s periodontal health condition, the following treatment plan was designed: Full-arch-bonding with edgewise appliances, including the modified semi-palatal bar appliance for intrusion of maxillary right second molar, mandibular right second molar implant placement and retention of the maxillary right second molar in its new position.After the patient’s treatment plan approval, the semipalatal bar appliance was placed (Figure 4 B1) and an Ormco Power Chain (Ormco, Glendora, USA) was tied palatally from the palatal sheath of the maxillary right second molar through the semi-palatal bar helix and back onto the sheath (Figure 4 B2).

Figure 4 C. Lateral view 2 months post orthodontic intrusion.

Figure 4 D. Occlusal view 2 months post orthodontic intrusion.

Figure 4 B1. Appliance in place (buccal view).

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Cephalometric and panoramic evaluation indicate the successful intrusion (Figures 5 A and B and Figures 6 A and B). The cephalometric superimposition along the palatal plane registered at ANS shows successful intrusion of Page 81

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Extruded Maxillary Molars Julia Elodie Vlachojannis and Margherita Santoro

the second molar (Figure 7 A) and no measurable extrusion of the adjacent molar that was used as anchorage (Figure 7 B).

Figure 4 E. Lateral view after implant placement and temporary crown insertion.

Figure 5 B. Post-treatment cephalogram.

Figure 6 A. Pre-treatment panoramic radiograph of patient 1.

Figure 4 F. Lingual view after implant placement and temporary crown insertion.

Figure 6 B. Post-treatment panoramic radiograph with implant placement of patient 1.

Figure 5 A. Pre-treatment cephalogram.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Figure 7 A. Cephalometric superimposition along the palatal plane registered at ANS shows Page 82

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

successful intrusion of upper second molar in patient 1.

Extruded Maxillary Molars Julia Elodie Vlachojannis and Margherita Santoro

and panoramic evaluation indicate the successful intrusion. The cephalometric superimposition shows no measurable extrusion of the adjacent molar used as anchorage. Both maxillary right first and second molar were slightly mesially displaced.

Figure 7 B. Cephalometric superimposition along the palatal plane registered at ANS shows no measurable extrusion of the adjacent upper first molar in patient 1.

Patient D.S. A 20-year-old female patient presented in 2000 for surgical treatment evaluation of her Cl III malocclusion. After performing orthodontic decompensation, her maxillary right second molar was bucally tipped out of the arch and needed intrusion and correct alignment before performing mandibular setback surgery (Figure 8 A).

Figure 8 B. Post-treatment occlusal view of clinical successful intrusion of UR7 in patient 2.

Figure 8 C. Palatal view of clinical successful intrusion of UR7 in patient 2.

Figure 8 A. Pre-treatment occlusal view of decompensated maxillary arch in patient 2.

The semi-palatal bar appliance was placed and a power-chain was tied palatally from the palatal sheath of maxillary right second molar through the semi-palatal bar helix and back onto the sheath. After 2 months of intrusive force the correct alignment was achieved. Clinical (Figures 8 B and C), cephalometric (Figures 9 A and B) Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Figure 9 A. Cephalometric superimposition along Page 83

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

the palatal plane registered at ANS shows successful intrusion of upper second molar in patient 2.

Figure 9 B. Cephalometric superimposition along the palatal plane registered at ANS shows no measurable extrusion of the adjacent upper first molar in patient 2.

Results Our results confirm that the modified TPA technique is an alternative to conventional methods for selective molar intrusion. In detail, patient A.J. showed an intrusion of 3.5 mm and patient D.S. an intrusion of 1.5 mm over 2 months and 3 appointments.

Discussion In 2001, Daimaruya examined molar intrusion in dogs through a skeletal anchorage system. Canine mandibular molars intruded by an average of 3.4 mm over the 7 months of observation.11 The intrusion of about 3.5 mm observed in our patient A.J. is in accordance with previous observations and also with the intrusion observed by Moon and co-workers12 who achieved first and second molar intrusion in selected patients by the more invasive means of corticotomy and orthodontic skeletal anchorage.

Our proposed method includes full arch bonding to gain a solid anchor during treatment.

The previously extruded tooth should be maintained for 6 months in its new position to allow the periodontal ligament fibers to restructure. During treatment, the intrusion surrounding gingival tissue and bony structures were clinically monitored and remained healthy.

Permanent retention needs to be preserved by the restorative substitution of the opposing teeth. Based on cephalometric Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Extruded Maxillary Molars Julia Elodie Vlachojannis and Margherita Santoro

superimpositions, the expected extrusive force on the adjacent tooth - in this cases the first molar - was not observed in our patients. This may be due to occlusal forces, the stabilizing effect of the buccal guiding archwire, and the use of light force generated by the power chain over an extended period of time. The intrusion of a single tooth concentrates on a small area at the apex. Only extremely light and continuous forces (5 to 15 gm per tooth) should be employed with the line of action of the force directed through or close to the tooth’s center of resistance.13,14 There is general agreement that forces on posterior teeth should not exceed 100 gm.15,16 Maintaining a light force application may avoid other unwanted effects of intrusion, e.g. the resorption of the intruding tooth in the apical third.

In an animal skeletal anchorage system model, Daimaruya and coworkers found a minimum root resorption of 0.1 mm ± 0.1 mm (mean ± SD) after 7-months of treatment. Root resorption reached the dentin at one-third of the apical area of the roots.11 Thus, even minimum external apical root resorption can be considered aggressive when localized at the apical region. We could not detect root resorption in our patients; however a much larger number of patients will be needed to exclude unwanted effects generated by this appliance.

Auxiliary anchorage has been used to control the intrusive force, e.g. a base arch (rectangular stainless steel archwire), which includes all teeth except the extruded tooth, together with a buccal intrusion arch. The intrusion arch is segmentally attached to the base appliances. To achieve pure molar intrusion it is necessary to position the point of application of the force more anteriorly (Figure 10).14

Figure 10. Example of an intrusion arch: this Page 84

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

arch is not inserted into the posterior brackets and unwanted effects are a large tip back moment and a small extrusive force at the incisors.

The extrusive force on incisors can be counteracted by an anterior bite plate, by occlusal forces and / or by an anterior vertical pull (J-hook) headgear.17 Intrusion of teeth adjacent to the molar may occur as unwanted effect, when those teeth are not connected to the appliances.18 Orthodontic intrusion of posterior teeth is difficult to achieve in adults due to missing growth compensation, histological changes in the alveolar bone, smaller marrow spaces and a reduced blood supply when compared with growing patients.19 To improve anchorage, a combination of corticotomy, miniplates and orthodontic miniscrews has been proposed.5 Corticotomy was performed by incising the cortical bone surrounding the tooth to reduce resistance during intrusion. The method is expensive, rarely covered by dental plans and associated with pain, swelling and infection. By combining corticotomy with rare earth magnets, Hwang and Lee achieved an intrusion of 3.5 mm during 2 months of treatment without observing adverse events such as discomfort, root resorption and/or extrusion of the adjacent teeth.20 Temporary anchorage devices (TAD) are preferable because they provide maximum anchorage control and minimize the need for full arch appliances. The success rate of more than 75% has been considered favorable.21 Putative adverse events of TAD’s include pain, infection, trauma of anatomical and vascular structures, fracture, dislodgement and gingival overgrowth.22,23 Use of 2 TADs to successfully correct an overerupted upper first molar was described by Kravitz and coworkers.24 In another study using TADs, overerupted maxillary first molars were intruded by 3 to 8mm over 7.5 months (about 0.5-1.0 mm per month), without loss of tooth vitality, adverse periodontal response or radiographically evident root resorption 25,26 In order to reduce the risk of extruding the adjacent posterior tooth, we employed a modification of previous appliances, such as the Kucher and Weiland’s appliance that used similar biomechanics in combination with a TPA to Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Extruded Maxillary Molars Julia Elodie Vlachojannis and Margherita Santoro

reduce the prominence of the palatal cusp of the upper second molar.27 In contrast to this appliance we could eliminate the laboratory step.

Gianelly had employed a removable appliance, which anchored on the remaining dentition, pulling from the buccal and the palatal side. He concluded that this type of anchorage was inadequate for restoring an occlusal plane when the overerupted tooth is a terminal tooth.

Due to the fact that the occlusal plane is restored by a combination of extrusion / intrusion and extrusion was an easier and quicker movement to be produced orthodontically, Gianelly preferred surgery instead of restoring the occlusal plane.18 The use of removable appliances instead of fixed appliances may be the cause of the discrepancy between the results of our study and previous studies.

Some intrusive forces on the adjacent molar have also been observed by Gianelly18, and could be justified by the presence of the horizontal periodontal fibers attached apically to the crown. However, this phenomenon is only noticeable when the adjacent molar is not the direct source of anchorage, in which case extrusive forces will prevail. In our study, the first molar was the direct source of anchorage, and was stabilized by a separate archwire system encompassing the whole maxillary arch. Intrusion was not observed on the maxillary first molars, and extrusion was not observed either.

Another reaction to the intrusion force is that the periodontal pocket might deepen.

Caution must be given to the presence of periodontal diseases as these may aggravate and lead to periodontal damage.13,14 In case of normal intrusion the periodontal fibers are expected to build a junctional epithelium at best, but there is no basis for expecting true reattachment of the periodontal fibers in response to orthodontic treatment. Melsen et al. described the formation of a tight epithelial cuff in histological slides of a dog’s lower first premolar that was first extruded and then intruded.28 With our patients, the position of the gingiva relative to the crown was left unchanged while periodontal probing depths did not increase.

Conclusions Extruded upper second molars are often encountered in adult patients. The modified TPA appliance presents a clinically elegant, nonPage 85

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

invasive and cost-effective procedure.

The TPA is rapidly bent in the office and is cost-effective because it does not require laboratory work. This appliance can be inserted in one session chair-side.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Lyka I, Carlsson GE, Wedel A, Kiliaridis S. Dentists' perception of risks for molars without antagonists. A questionnaire study of dentists in Sweden. Swed Dent J 2001;25(2):67-73.

2. Christou P and Kiliaridis S. Three-dimensional changes in the position of unopposed molars in adults. Eur J Orthod 2007;29(6):543-9.

3. Thurow RC. Tissue adaptation to functional and orthodontic stresses: Edgewise Orthodontics. 4th ed. St Louis, Mo: CV Mosby Co; 2001:91-106.

4. Sano Y, Ikawa M, Sugawara J, Horiuchi H, Mitani H. The effect of continuous intrusive force on human pulpal blood flow. Eur J Orthod 2002;24(2):159-66.

5. Kohno T, Matsumoto Y, Kanno Z, Warita H and K. Experimental tooth movement under light orthodontic forces: rates of tooth movement and changes of the periodontium. J Orthod 2002;29(2):129-136.

6. Tanne K, Koenig HA, Burstone CJ. Moment to force ratios and the center of rotation. Am J Orthod Dentofacial Orthop 1988;94(5):426-31.

7. Smith RJ, Burstone CJ. Mechanics of tooth movement. Am J Orthod 1984;85(4)294-307.

8. Nanda R. Principles of biomechanics. In: Biomechanics in Clinical Orthodontics. ed. R Nanda, Philadelphia: WB Saunders Co; 1996:3-7.

9. Natali AN. Appliance configuration. Dental Biomechanics, 1st ed.

CRC; 2003:202-205.

10. Smith RJ, Burstone CJ. Mechanics of tooth movement. Am J Orthod 1984;85:294-307.

11. Daimaruya T, Nagasaka H, Umemori M, Sugawara J, Mitani H. The influences of molar intrusion on the inferior alveolar neurovascular bundle and root using the skeletal anchorage system in dogs. Angle Orthod 2001;71(1)60-70.

12. Moon CH, Wee JU, Lee HS. Intrusion of overerupted molars by corticotomy and orthodontic skeletal anchorage. Angle Orthod 2007;77(6):1119-25.

13. Melsen B, Agerbaek B, Markenstam G. Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod 1989;96:232241.

14. Proffit WR, Fields HW. Biomechanics and Mechanics. In: Contemporary Orthodontics. 3rd ed. Missouri: MOSBY; 2000:668.

15. Thurow RC. Tissue adaptation to functional and orthodontic stresses: Edgewise Orthodontics. 4th ed. St Louis, Mo: CV Mosby Co; 2001;91-106.

16. Smith RJ, Burstone CJ. Mechanics of tooth movement. Am J Orthod 1984;85(4):294-307.

17. Natali AN. Appliance configuration. Dental Biomechanics, 1st ed.

CRC; 2003:202-205.

18. Gianelly A. Adult Orthodontics. Bidimensional technique. Theory and Practice. Central Islip, NY: GAC International; 2000:238.

19. Melsen B. Limitation in adult orthodontics. In: Melsen B, editor.

Current controversies in orthodontics. Chicago: Quintessence; 1991:147-80.

20. Hwang HS, Lee KH. Intrusion of overerupted molars by corticotomy and magnets, Am J Orthod Dentofacial Orthop 2001;120(2):209-16.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Extruded Maxillary Molars Julia Elodie Vlachojannis and Margherita Santoro

21. Crismani AG, Bertl MH, Celar AG, Bantleon HP, Burstone CJ. Miniscrews in orthodontic treatment: review and analysis of published clinical trials. Am J Orthod Dentofacial Orthop 2010;137(1):108-13.

22. Papadopoulos MA, Tarawneh F. The use of miniscrew implants for temporary skeletal anchorage in orthodontics: a comprehensive review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(5):6-15.

23. Park HS, Jeong SH, Kwon OW. Factors affecting the clinical success of screw implants used as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2006;130(1):18-25.

24. Kravitz ND, Kusnoto B, Tsay PT, Hohlt WF. Intrusion of overerupted upper first molar using two orthodontic miniscrews. A case report, Angle Orthod 2007;77(5):915-22.

25. Kravitz ND, Kusnoto B, Tsay TP, Hohlt WF. The use of temporary anchorage devices for molar intrusion. J Am Dent Assoc 2007;138(1):56-64.

26. Yao CC, Wu, CB, Wu HY, Kok SH, Chang HF, Chen YJ. Intrusion of the Overerupted Upper Left First and Second Molars by Mini-implants with Partial-Fixed Orthodontic Appliances: A Case Report. Angle Orthod 2004;74(4):550-7.

27. Kucher G and Weiland FJ. Goal-oriented positioning of upper second molars using the palatal intrusion technique. Am J Orthod Dentofac Orthop 1996;110:466-8.

28. Melsen B. Tissue reaction following application of extrusive and intrusive forces to teeth in adult monkeys. Am J Orthod 1986;89(6):469-75.

Page 86

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Occupational Hazards Among Dentists Prashant Babaji et al

OCCUPATIONAL HAZARDS AMONG DENTISTS: A REVIEW OF LITERATURE Prashant Babaji1*, Firoza Samadi2, JN Jaiswal3, Anju Bansal4 1. Dr, MDS, Reader, Department of Pedodontics, Sardar Patel Postgraduate Institute of dental and medical science. Lucknow, Utter Pradesh, India.

2. MDS, Professor & HOD, Department of Pedodontics, Sardar Patel Postgraduate Institute of dental and medical science. Lucknow, Utter Pradesh, India 3. MDS, Professor & Director, Department of Pedodontics, Sardar Patel Postgraduate Institute of dental and medical science. Lucknow, Utter Pradesh, India 4. MDS, Senior Lecturer, Department of Pedodontics & Preventive Dentistry, Budha Institute of Dental College & Hospital. Patna, Bihar, India.

Abstract Occupational hazard refers to a risk or danger as a consequence of the nature or working conditions of a particular job. Dental surgeons are exposed to a number of occupational hazards in their professional work. With advent of advanced technology, no matter how beneficial it is, can exert a negative impact also on some members of the population.

This article highlights on occupational hazards like physical, chemical, biological, psychological, musculoskeletal disorders and their effects. The aim of this paper is to increase the level of awareness of occupational hazards among the dental surgeons and also to provide information on the ways in which hazards can be reduced.

Review (J Int Dent Med Res 2011; 4: (2), pp. 87-93) Keywords: Dental, occupational hazards, physical, psychological, musculoskeletal disorder.

Received date: 03 February 2011 Introduction

Dentists are usually exposed to a number of occupational hazards during their professional work. These cause the appearance of various ailments, specific to the profession, which develop and intensify with years.

In many cases they result in diseases and disease complexes, some of which are regarded as occupational illnesses1.

Ocuupational hazards can be defined as a risk to a person usually arising out of employment. It can also refer to a work *Corresponding author: Dr.Prashant Babaji MDS, Reader Department of Pedodontics Sardar Patel Postgraduate Institute of dental and medical science Lucknow, Utter Pradesh, India Phone: 8009058818/ 09880707506 E-mail: babajipedo@rediffmail

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Accept date: 23 March 2011

material, substance, process or situation that predisposes, or itself causes accidents or disease, at a work place. Beradino Ramazzini is referred to as father of occupational medicine2.

Occupational hazards can occur in the form of biohazards, neuro-muscular skeletal disorders, health hazards (disruption of the respiratory and cardio-vascular system) hearing impairment, visual problems, allergies and skin diseases1,3.

Dentists during clinical practice exposes to variety of work related hazards.

These occupational hazards can be classified into five types: “physical, chemical, biological, psychological and musculoskeletal disorders”.

1) Physical The dentists are at risk of physical injuries during many dental procedures. Poor illumination causes eye pain, eye strain, headache, eye fatigue where as excessive brightness leads discomfort, and visual Page 87

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

fatigue. Eyes may be affected with conjunctivitis and keratitis while using dental curing light, computer and lasers.

Moreover use of high-speed turbines, compressor, suction and ultrasonic dental scaler results temporary or permanent hearing loss, fatigue, interface with communication by speech and decreased efficiency. Dentist can expose to both ionizing and nonionising radiation. Chronic exposures to radiation can results, somatic (body) or genetic changes.

The radiation effects are cumulative and this damage is totally painless yet life threatening, it may cause acute erythema, dermatitis, chronic skin cancer, bone marrow suppression, damaged to eye including cornea, lens and retina. Safety shields and use of eye glasses helps to protect from radiation damage4. Glassware and sharp needles, lancets, B.P blades, broken ampoules , test tubes are hazardous and can cause cuts, scratches, abrasions which are potential locations for infections2,5,6.

Needle stick injuries and cuts from sharp objects have been reported 1-15 % of surgical procedures2. Sharp instruments should be handled carefully to avoid injuries.

Aerosols were defined as particles less than 50 micrometers in diameter. The smaller particles of an aerosol (0.5 to 10 μm in diameter) can penetrate through smaller passages of the lungs and are thought to carry the greatest potential for transmitting infections.

The dental literature shows that many dental procedures produce aerosols and droplets that are contaminated with bacteria and blood. These aerosols represent a potential route for disease transmission.

Splatter was defined by Micik and colleagues as airborne particles larger than 50 μm in diameter. These particles or droplets are ejected forcibly from the operating site and are too large to become suspended in the air and are airborne. Airborne infection in dentistry ususally comes comes from aerosols due to their ability to stay airborne Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Occupational Hazards Among Dentists Prashant Babaji et al

and potential to enter respiratory passages.

Ultrasonic scaler has been shown to produce the greatest amount of airborne contamination, followed by the air-driven high-speed handpiece, the air polisher and various other instruments such as the air water syringe and prophylaxis angles.7,8,9 The use of personal barrier protection such as masks, gloves and eye protection will eliminate much of the danger inherent in splatter droplets arising from the operative site. While preprocedural rinses will reduce the extent of contamination. The most frequently mentioned methods of removing airborne contamination from the air of the treatment room are the use of a high efficiency particulate air or HEPA (high efficiency particulate arresting) filter and the use of ultraviolet chambers in the ventilation system.9 2) Chemical Dentists are exposed to various types of chemicals that are hazardous while providing care. They include mercury, beryllium, silica and powdered natural rubber latex (NRL). Most dangerous of these agents is mercury. These chemicals act by local action, inhalation and ingestion.

Mercury use in dental amalgam has potential occupational exposure to dentists.

The maximum level of exposure considered to be safe is 50 µg/ cc of air7,8. The active component in mercurial vapour has a particular affinity for brain tissue.

Mercury poisoning can be characterized by tumours of the face, arms or legs and may be associated with progressive, tremulous illegible handwriting with slurred speech4,10.

The exposure risks from mercury can be minimized by careful handling, collecting the waste part of amalgam in closed container and subjecting it to recycling, use of proper evacuation system and avoiding the direct physical contact. The research conducted at the University of Calgary Faculty of Medicine found that exposure to Page 88

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

mercury caused the formation of "neurofibrillar tangles," which are one of the two diagnostic markers for Alzheimer's disease. In February, 1998, a group of the world's top mercury researchers announced that mercury from amalgam fillings can permanently damage the brain, kidneys, and immune system of children.

Dental amalgam fillings have been found to affect DNA. This later can leads to cancer.

Damage in human blood cells based on a number of studies in Sweden, the World Health Organization review of inorganic mercury in 1991 determined that mercury absorption is estimated to be approximately four times higher from amalgam fillings than from fish consumption.10 Inhalation of dust containing free silica or silicon dioxide in ceramic laboratories leads to silicosis. Some of the dental alloys contain beryllium and if it inhaled while working on items such as dental crowns, bridges, and partial denture framework, they can cause chronic beryllium disease (CBD).

As per Occupational Safety and Health Administration (OSHA) specification, employees cannot be exposed to more than 2 microorganisms of beryllium per cubic Meter of air for an 8 hour time weighted average8.

Formaldehyde is one of the chemical agents routinely used in the clinical set up mainly for disinfection of operatory area.

Liquid and vapour forms of formaldehyde may cause severe abdominal pain, nausea, vomiting and eye irritation5. Occupational Safety measures should be followed to minimize the side effects due to chemical agents.

Latex gloves (dusted with cornstarch powder) form an efficient barrier against most pathogens. Unfortunately most of the professionals are allergic to latex content of gloves. The powder in latex gloves itself is not the allergen. It only provides binding sites for latex protein, and aids in carrying the protein into the skin. It has also been reported that airborne powder particles can Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Occupational Hazards Among Dentists Prashant Babaji et al

cause asthmatic allergic reactions or even anaphylaxis. Dental personnel should also note that latex is present in other personnel protective equipments like masks, eyewear, and clinical gowns. The clinical symptoms of latex allergies include: urticaria, conjunctivitis accompanied by lacrimation and swelling of eyelids, mucous rhinitis, bronchial asthma and anaphylactic reaction. Most allergic reactions can be managed by self medication, prescribed medication. Sufferers from latex allergy are advised to work in latex free environment and use vinyl, nitrile or 4H gloves.1,3 Dental products such as acrylics, resins and polymer materials used in restorative dentistry represent a major advance in dentistry; but these products may act as allergens in part of the population4,9.

Because allergy is a reality, dentists have to deal with it, so dental personnel should be familiar with the major signs and symptoms of allergic reactions, including anaphylaxis.

Allergic patch test can be done to determine type of allergen.

Dental personnel should always keep records of dental materials used, if allergic reaction occurs, backtracking is necessary in order to identify the specific allergen. Avoid direct contact of material which cause allergy.

Local exhaust ventilation systems can significantly reduce the peak concentration of acrylate vapour in the breathing zone of dental technicians.

However, the local exhaust ventilation is not efficient in reducing the concentration of airborne acrylic dusts3,7.

3) The biological hazards The biological hazards are constituted by infectious agents of human origin and include viruses, bacteria and fungi.

Transmissible diseases currently of greatest concern to the dental professional are HIV, HBV, HCV and Mycobacterium tuberculosis.

A dentist can become infected either directly or indirectly, i.e by a cut or wound, needle stick injury, aerosols of saliva, gingival fluid and natural organic dust particles.

Page 89

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

The following are the main entry points of infection: epidermis of hands, oral epithelium, nasal epithelium, epithelium of upper airways, bronchial tubes, alveoli and conjunctival epithelium. In order to overcome from the infection spread, a thorough knowledge about the infection, mode of transmission and safety measures is necessary. During many dental procedures, the use of a rubber dam will eliminate virtually all contamination arising from saliva or blood1.

Prevention from contamination and cross-infection can be done by effective sterilization of instruments using autoclave before and after use. Legnani et al. made an assessment of the aerosol contamination resulting from dental procedures. Air contamination was measured by means of the Surface Air System method and the “plate” method (Air Microbial Index). It was proved that during working hours the average air bacterial load increased over three times, and the air load levels were 1.5 times (aerobic bacteria) and 2 times (anaerobes) greater as compared to the initial load.11 The Occupational Safety and Health Administration (OSHA) has published Controlling Occupational Exposure to Bloodborne Pathogens in Dentistry. These OSHA guidelines are designed to protect the employee, not the patient. The OSHA bloodborne pathogen standard is a comprehensive rule that sets forth specific requirements.

OSHA guidelines are designed to prevent the transmission of blood-borne diseases to employees. It includes requirements for an exposure control plan, exposure control precautions, laundry procedures, mandatory hepatitis B vaccinations, housekeeping standards, and waste disposal regulations.12 4) Psychological Hazards a. Stress Dentists encounter numerous sources of professional stress, beginning in dental clinic.

Stress can be defined as the biological Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Occupational Hazards Among Dentists Prashant Babaji et al

reaction to any adverse internal or external stimulus physical, mental or emotional that tends to disturb the organism’s homeostasis.

Dentists perceive dentistry as being more stressful than other occupations.

Coping with difficult or uncooperative patients, over workload, constant drive for technical perfection, underuse of skills, low self-esteem and challenging environment are important factors contributing to stress among dentist. Dunlap J and Stewart J in their survey on 3,500 dentists found that 38 percent were frequently worried or anxious, 34 percent of the respondents felt physically or emotionally exhausted, and 26 percent said they always or frequently had headaches or backaches.1,13,14 b. Professional burnout One of the possible consequences of chronic occupational stress is professional burnout. Meslach and Jackson (1986) define burn out as: “A syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals who do people work of some kind.” Burnout is best described as a gradual erosion of the person.Prolonged experience of burn out may lead to depression, so early recognition of the symptom is important14. In a study of three dental specialities Humphris et al reported that general dentists and Oral surgeons had the highest levels of burnout and that orthodontists had the lowest levels of burnout.15 c. Anxiety disorder and Depression Anxiety disorders are chronic and relentless and can grow progressively worse if not treated. Two common and potentially overlapping anxiety disorders are panic disorder and generalized anxiety disorder, or GAD. In panic disorder, feelings of extreme fear and dread strike unexpectedly and repeatedly for no apparent reason They are accompanied by intense physical symptoms like feeling sweaty, weak, faint, dizzy, flushed or chilled; having nausea, chest pain, smothering sensations, or a tingly or numb Page 90

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

feeling in the hands. GAD is characterized by chronic exaggerated worry and tension, even though little or nothing has provoked it.14 Depressive disorder often occurs with anxiety disorders and substance abuse.

Major depression is an illness that involves the body, mood and thoughts. It affects the way people eat, sleep, feel about themselves and think about things. Studies have indicated that both anxiety and depressive disorders are observed frequently in dentists.14 Coping with Psychological hazards The goal of coping with stress is to offset the negative effects of stress by using appropriate coping strategies. Coping can be done by, participating in activities that make to feel better, going to movies or participating in religious, social or other activities.

Stress management workshops focusing on stress relievers may include deep breathing exercises; progressive effective relaxation of areas of the body; listening to audiotapes of oral instructions on how to relax; meditation; information on the topics of practice and business management, time management, communication and interpersonal skills.

These workshops should be structured to help improve dentists’ coping skills and equip them to deal more effectively with the stressors intrinsic to the profession.14 Physical exercise, such as regular walking or working out at a health club, cannot be underestimated as a stress reliever. Such activities result in burning up the additional supply of adrenaline thoses results from stress, and they allow the body’s functions to return to a more normal state.

Physical exercise helps develop greater selfesteem, self-control and self-discipline.

People’s personalities and temperaments have a significant impact on their perceptions of stress. Those who have strong, positive self-images and know how to relax so as to reduce mental and emotional Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Occupational Hazards Among Dentists Prashant Babaji et al

pressures also cope better with stress, as do people who are open to being helped by others.

Stressors such as failing to meet personal expectations, seeing more patients for financial reasons, working quickly to see as many patients as possible for financial reasons, earning enough money to meet lifestyle needs and being perceived as an inflictor of pain are all stress-producing situations and has to be taken care. Break the large task into small ones. Application of relaxation, hypnosis and desensitization technique helps in stress management.

Anxiety disorder and depression can be treated with antianxiety or antidepressant drugs and psychotherapy16.

5) Musculoskeletal disorder Muskuloskeletal disorders are common health problems reported among dentists. Its prevalence reported to be between 38-82%.

Musculoskeletal disorders are a group of conditions that involves: Nerves ,Tendons , Muscles and supporting structures such as intervertabral discs1.

It has been reported that young and less experienced dentists experience more musculoskeletal disorders compared to older and experienced one4.

Common musculoskeletal problems are, low back pain, shoulder pain, headache, hand and wrist pain. Low back pain is more prevalent than other types. The cause of musculoskeletal problem is due to, repeated unidirectional twisting of the trunks, working in one position, prolonged static periods and operators flexibility4,17,18.

At work, the dentist assumes a strained posture (both while standing and sitting close to a patient who remains in a sitting or lying position), which causes an overstress of the spine and limbs.

Back pain syndromes diagnosed in dental workers originate from spine degeneration in its different phases. The posture of the dentist at work, with the neck bent and twisted, an arm abducted, repetitive Page 91

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

and precise movements of the hand are frequent cause of the neck syndrome and of pain within the shoulder and upper extremities19.

Puriene A et al20 reported Fatigue and back pain as most common prevalent and chronic physical complaints among Lithinium dentists.

The dentist makes constant monotonous movements, which stress the wrist and elbow joints. Also of consequence are mechanical vibrations. A number of dental doctors suffer from a defect of the median nerve and of the cubital nerve. A consequence of the defected median nerve in the carpal canal is the so-called tunnel syndrome. Its early phase is dominated by paroxysmal paraesthesiae of the thumb and index finger, which occur almost without exception at night and which are accompanied by sensomotor disorders of the thumb and index finger 21.

Pains of the epicondylus, appearing at first during strain and special movements, gradually intensifying and radiating along the forearm, point to an inflammation of the epicondylus of the humeral bone. Operations carried out during extractions stress not only the elbow joint and the wrist joint but may result in chronic tendon sheath 19 inflammation .

Prevention includes maintaining correct body posture while treating patients, taking adequate rest, doing some exercises.

Common musculoskeletal disorders occurring among dentists. Following are the classification of some of the musculoskeletal disorders seen commonly among dental practitioners.19 (Table 1).

Organization for Safety and Asepsis Procedures (OSAP) The Organization for Safety and Asepsis Procedures (OSAP) is the only evidence-based, non-governmental organization in the world that concentrates solely on the provision of information, education and publications on the subject of Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Occupational Hazards Among Dentists Prashant Babaji et al

dental infection control and occupational safety and health. OSAP also has a unique constituency comprised of three major categories: clinicians, educators and trainers, and the dental industry. All three groups are represented on the Board of Directors and play a role in developing well reasoned, science-based, practical solutions to the world's complex infection control and safety issues.12

Table 1. Classification of some of the musculoskeletal disorders.

Page 92

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Recommendations for occupational hazards in dentistry Dentist has to upgrade his existing knowledge by participating in continuing dental education. Universal precaution has to be taken while practicing to prevent occupational hazards.

Dental clinic design has to be made with, sufficient lighting, ventilation, engineering control measure and equipped with appropriate personal protective.

Conclusions

Occupational health risks are present in every profession. Dentists are one such professional group. In spite of these hazards we cannot refrain from providing care and serving community. Sufficient knowledge and adequate information regarding occupational hazards and its prevention will contribute in providing quality care to patients without any doubt.

Occupational Hazards Among Dentists Prashant Babaji et al

13. Dunlap J, Stewart J. Survey suggests less stress in group offices. Dent Econ 1982; 72 : 46-54.

14. Rada RE, Johnson-Leong C. Stress, burnout, anxiety and depression among dentists J Am Dent Assoc. 2004; 135: 78894.

15. Humphris G. A review of burnout in dentists. Dent Update 1998; 25 : 392-96.

16. Regier DA, Roe DS, Narrow WE, Kaelber CT, Schatzberg AF. Prevalence of anxiety disorders and their co-morbidity with mood and addictive disorders. Psychiatry Suppl.1998; 34: 2428.

17. Abiodun-Solanke IM, Agbaje JO, Ajayi DM, Arotiba JT. Prevalence of neck and back pain among dentists and dental auxiliaries in South-western Nigeria. Afr J Med Med Sci. 2010; 39: 137-42.

18. Puriene A, Janulyk V, Musteikyte M, Bendinskaite R. General health of dentists.Litetrature review. Stomatologija. Baltic Dental and Maxillofacial Journal. 2007; 9: 10-20.

19. Rundcrantz BL, Johnsson B, Moritz U: Pain and discomfort in the musculoskeletal system among dentists. A prospective study. Swed Dent J. 1991; 219-28.

20. Puriene A, Aleksejuniene J, Petrauskiene J, Balciuniene I, Janulyte V. Self reported occupational health issue among Lithinium dentists. Industrial Health 2008; 46: 369-74 21. Ostrem CT: Carpal tunnel syndrome. A look at causes, symptoms, remedies. Dent Teamwork. 1996; 9: 11-15.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Jolanta S. Occupational Hazards of Dentistry. Ann Agric Environ Med. 1999; 6: 13- 19.

2. Fasunlaro A, Owatode FJ. Occupational hazards among clinical Dental staff. J Contemp Dent Pract. 2004; 5: 134-52.

3. Tošić G. Occupational hazards in dentistry – part one:allergic reactions to dental restorative materials and latex sensitivity .Working and Living Environmental Protection 2004; 2: 317-24.

4. Leggat PA, Kedjarune U, Smith DR. Occupational health problems in modern dentistry: a review. Industrial Health. 2007; 45: 611-21.

5. Chopra SS, Pandey SS .Occupational Hazards among Dental Surgeons. Medical Journal Armed Forces India 2007; 63:23-25.

6. Fasunloro A. Occupational Hazards among Clinical Dental Staff. J Contemp Dent Pract. 2004; 52: 72-76.

7. Micik RE, Miller RL, Mazzarella MA, Ryge G. Studies on dental aerobiology: bacterial aerosols generated during dental procedures. J Dent Res 1969; 48: 49-56.

8. Miller RL, Micik RE. Air pollution and its control in the dental office. Dent Clin North Am 1978; 22: 453-76.

9. Harrel SK , Molinari J. Aerosols and splatter in dentistry: A brief review of the literature and infection control implications. J Am Dent Assoc 2004; 135: 429-37.

10. Mutter J. Is dental amalgam safe for humans? The opinion of the scientific committee of the European Commission. Journal of Occupational Medicine and Toxicology. 2011 ;6: 1-17.

11. Legnani P, Checchi L, Pelliccioni GA, D’Achille C: Atmospheric contamination during dental procedures. Quintessence Int 1994; 25: 435-39.

12. Miller. Review of Bloodborne Pathogens Standard clarifies OSHAs expectations of dental offices. Dental Ecnomicschris.

2009; 99: 12-15.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Page 93

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Effects of Magnetic Field Fadel Mohammed Ali et al

EFFECTS OF EXPOSURES TO A MIX OF FAST NEUTRONS AND 50Hz, 0.05mT MAGNETIC FIELD ON RAT TESTES” (IN VIVO STUDY) Fadel Mohammed Ali1*, Wafaa Nemat Allal Ahmed2, Samira Abdel Hamid3, Eman Sayed Abd EL–Fattah2, Mona Ahmed3 1. Biophysics Dept., faculty of science, cairo university.

2. National Institute for Standers, Cairo. Egypt.

3. Faculty of Science, Faculty of Girls Ain Shams university.

Abstract In the present work; the effect of whole body exposure of rats to mixed radiation (MR) from fast neutrons (FN) and 50Hz, 0.05mT magnetic field (MF) on the structural functions of the animal testis were investigated.

For this; 100 white albino rats were divided equally into four groups namely A, B, C and D. Animals of group A were used as control, groups B and C were exposed to 50Hz, 0.05mT MF and fission neutrons from 252Cf source at a dose rate 10 µSv/h respectively for a period of 4 weeks at a rate of 8h/day and 5 days/week. Group D was exposed to fission neutrons and MF at the same field strengths and dose rates for the same period as groups B and C. At the end of the exposure period, blood was collected, animals were sacrificed and testes were removed for histopathological examination.

The results indicated highly significant decrease (p<0.0001) of testosterone hormone level (THL) in blood for animals from all groups as compared to control. Moreover; highly significant increase (p<0.0001) in the creatine phosphokinase (CPK) enzyme in sera was measured for all exposed animals. Results were analyzed depending on the probable mechanisms of interaction of these types of radiation with biological tissue. It was concluded from the present findings that the induced damage of the testis and the dramatic elevated CPK enzyme levels are higher for exposure to mixed radiation as compared with exposure to a single field.

Experimental article (J Int Dent Med Res 2011; 4: (2), pp. 94-99) Keywords: Magnetic Field, Testis, Rat, Fast Neutrons.

Received date: 17 July 2011 Introduction There is long scientific history on the biological effects of ionizing radiation (IR) and the safe limits of exposures1. Damage by IR, such as X- rays, γ- rays, and ultraviolet, have been extensively and thoroughly investigated and are well established, monitored and confirmed2 as a significant risk for carcinogenic events3,4.

On the other hand; questionable consequences of everyday exposure to extremely low frequency magnetic field (ELFMF) pollution has become of great concern and *Corresponding author: Dr. Wafaa N. Ahmed.

National Institute for Standards, Cairo- Egypt.

E-mail: dr.wafaa.neamatallah@gmail.com

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Accept date: 05 August 2011 debate. Moreover, exposure to a mixture of both ionizing and non-ionizing radiation do exist for occupational exposures from nuclear generating facilities such as nuclear accelerators in medicine, manufacture, research and the use of nuclear reactors for generating electric power.

Exposure to electric and magnetic fields may increase the incidence of various types of cancers5,6.

Alterations in the erythrocyte’s membrane elasticity and permeability in addition to changes in the hemoglobin molecular structure and heart injuries were detected after one month whole body exposure of rats to 50Hz, 0.2mT magnetic fields.7 In addition; possible cytotoxic and/or cytostatic effects on differentiating spermatogonia after 50Hz, 1.7mT magnetic fields for 28 days of mouse were reported8.

Atrophy of the seminiferous tubules (ST) and renal necrosis due to 50Hz, 0.207µT Page 94

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

magnetic field exposure were detected9.

Furthermore; sub-fertility and infertility of the reproductive system of rats exposed to 50Hz were also observed10, 11. Other complications such as significant decreased THL and main tissue changes in some ELFMF exposures12and degeneration similar to apoptosis in spermatogenic cells in mice after continuous exposure to 60Hz 14 µT magnetic field were detected13.

The damage of the male rat’s ST after short term MF- 50Hz, 50 and 100µT exposure was attributed to the increased level in the Follicle Stimulating Hormone (FSH) in serum14.

Other studies reported that exposure to MF, either strong or weak, may damage the testis function by inducing injury to ST, Leydig cells and sperms15. Moreover; single exposure to 60Hz 6 mT for 30 min. resulted in DNA double-strand breaks and apoptosis16. It was also concluded that prolonged exposure to 50 Hz, 1G MF is biologically toxic on testes17.

Therefore, this study is carried out to investigate the effects of a mixed exposure of extremely low frequency magnetic field (ELF-MF) in the presence of fast neutrons (FN) on rats' testis functions.

Effects of Magnetic Field Fadel Mohammed Ali et al

wires connected in parallel. Cf252 point source of 50µgm (original activity 27 mCi), purchased from Amersham radiochemical center (UK) with present yield 5.4x104 n/s was used. The source was put in a special housing fixed on the inner top wall at the center of the solenoid chamber to allow average homogeneous fields of FN during MF exposure (Figure 1).

A

Materials and methods One hundred adult male Albino rats of average weights 200 ±10g were divided into four equal groups namely; A, B, C and D. Animals of group A were used as control, groups B and C animals were exposed to 50Hz, 0.05mT MF and fission neutrons from 252Cf source at a dose rate 10 µSv/h respectively for a period of 4 weeks at a rate of 8h/day and 5 days/week. Group D was exposed to a mixed radiation of 252Cf fission neutrons and magnetic field at the same field strengths and dose rates for the same period as groups B and C. The total neutron dose received by the animals during the exposure period was 1.6 mSv. The animals were kept in special cages that permit normal ventilation, daylight and suitable environmental conditions, cleaning and changing water was done for all animals twice daily.

Irradiation Facilities The MF exposure system has been already described in details elsewhere7, 17.

It is composed of 4 solenoids of copper Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

B

C Figure 1. Irradiation facility for mixed neutron and magnetic fields (A) show the solenoid, (B and C) show cross section at the mid of the solenoid showing the position of 252Cf source.

Page 95

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

The average neutron dose rate delivered to the animals was 10µSv/h as measured by a neutron monitor model NM2, manufactured by Nuclear Enterprises, England. The irradiation facilities of the animals were done in the Biophysics Department, Faculty of science, Cairo University. At the end of the exposure period, animals were individually weighed and the weights were recorded to the nearest 0.5/gm, and then blood samples were collected from the eye vein for biochemical CPK enzyme and THL investigation.

The animals were then directly sacrificed; both testicles were removed, weighted and prepared for histopathological investigations.

There are no restrictions in Egypt for the use of experimental animals for scientific research, but the international ethics were followed in the present work.

For THL estimation; blood samples were spun at 3000 rpm for 10 minutes and serum was decanted. Sera were decanted, placed in glass bottles with rubber caps, labeled and stored at 60C until quantification of testosterone.

Quantitative determination of testosterone in serum samples was performed using a commercially available radioimmunoassay (RIA) kit for testosterone according to the manufacturer’s specifications. Results are expressed as nano-grams per milliliter (ng/ml).

For histological investigations; testes were fixed in 10% formal saline and subsequently processed for Microtomy at 6 μ thick. For Histopathological study, paraffin sections were routinely stained in Harris’s Haematoxylin and Eosin (HE). The sections were photographed using an Image Analysis SystemCompact Video Microscope (CVM); SN. 1148JAPAN. For biochemical sera analysis; total creatine phosphokinase (CPK) was performed at the Autoanalyser Unit, National Research Center (NRC) Cairo-Egypt using an Olympus Chemical Auto-analyzer, Model, Au400; GmbH. Wendenstr, 14-18, D-20097. Hamburg, Germany.

Statistical Analysis The Microsoft Excel was used for data analysis, and P value of 0.05 or less taken as (*P < 0.05, **P < 0.01, ***P < 0.001) for all statistical tests (with Student’s t-test).

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Effects of Magnetic Field Fadel Mohammed Ali et al

Results At termination of exposure, rats were investigated for body and testicular weights, THL and total CPK; these data are presented in Table 1.

Table 1. Alterations in body weight, testicular weight and testosterone hormone level. *significant (p<0.05), **highly significant (p<0.001), ***highly highly significant (p<0.0001) Gp. (A): is the control. Gp. (B): is whole body exposed to 50 Hz, 0.05 mT magnetic field for 4 weeks, 10 µSv/h, 8 hours/day and 5 days/week. Gp. (C): is whole body exposed to fast neutrons from 252Cf source to receive a maximum dose of 1.6 mSv distributed over a period of 4 weeks, 10 µSv/h, 8 hours/day and 5 days/week. Gp. (D): is exposed to a complex of both ionizing (FN) radiation and non-ionizing ELF-MF exposure over a period of 4 weeks, 10 µSv/h, 8 hours/day and 5 days/week.

Histological Observations: In control group (Gp. A), testes generally showed normal testicular weight and architecture with an orderly arrangement of differentiating spermatogenic and Sertoli cells in the wall of the seminiferous tubules (ST) and Leydig cells in the interstitial space (Figure 2.1).

Figure 2.1 Exposed animals to MF (Gp. B) showed marked pathological lesions in the interstitial connective tissues in the form of edematous and hemorrhagic areas with excessive accumulation of intensely eosinophilic ground substance among the tubules (Figure 2.2).

Page 96

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Effects of Magnetic Field Fadel Mohammed Ali et al

processes of wax impedance, cutting, staining and section investigations were repeated twice (Figure 2.5).

Figure 2.2 Inflammatory cells were observed within the inter-tubular spaces where atrophy, Leydig cell hyperplasia, congested and dilated blood vessels, ST deterioration, degenerated germ cells and focal sloughing were also observed (Figure 2.3).

Figure 2.4

Figure 2.5

Figure 2.3 Animals of (Gp. C) showed severe lesions in the form of ST inflammatory reactions and interstitial tissues, damaged spermatogenic cells, basement membrane disruption, Leydig cell edema and hypoplasia of interstitial tissue.

Depleted germ cells, hyalinization, calcification and necrotic in the seminiferous tubules were frequent (Figure 2.4).

Exposure to mixed radiations (Gp. D) resulted in distortion of the ST and degeneration of Leydig cells. Marked increase of fibrous interstitial tissues were observed that difficulties emerged during cutting paraffin blocks, staining, and investigating the sections for this phase that the Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Figure 2.6 Fibrous interstitial tissue, edema, and hypoplasia of Leydig cells were seen. Moreover; hyalinization and calcification were abundant Page 97

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

(Figure 2.6), normal ST were hardly seen for some sections (Figure 2.7).

Figure 2.7 Figure 2. (Gp.A),1: Testis histology of control rat, showing normal seminiferous tubules and interstitial tissues;(X250). (Gp.B),Rat exposed to magnetic field; 2: Degenerated and depleted germ cells (star),eosinophilic ground substances (curved arrow), edematous, hemorrhagic and hyperplasia of interstitial tissues (arrow); (X400). 3: Atrophy and focal sloughing tubule (curved arrow); loss of spermatogenic substances (stars);and Leydig cell hyperplasia(arrow); (X250). (Gp.C), Rat exposed to fission neutrons; 4: Disrupted tubules (arrows); hemorrhage (star); and marked severe hypoplasic interstitial tissues (X100). (Gp.D), Rat exposed to mixed fields; 5: Abnormal ST (arrow); infibrous interstitial tissues (star); and hemorrhage(X100). 6: Hyalinization and calcification of seminiferous tubules within fibrous interstitial tissues (arrows); (X250).7: Abundantnecrotic ST, hemorrhages of interstitial tissues and Leydig cells and edema (stars), and blood vessel dilation (arrow); normal ST are hardly seen (X400)[H&E]

Discussion Despite of the large number of both experimental and epidemiological studies that were extensively carried out on (ELF-MFs), the interaction mechanisms with biological systems are still unclear. However, the mechanisms of interaction of fast neutrons with biological systems is completely different than ELF-MFs since the average energy associating 50 Hz MF is around 1013eV while it is 2x106eV for fission neutrons18. Therefore, it seems logic to carry the discussion of the present findings depending on the basic possible interactions of each type of Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Effects of Magnetic Field Fadel Mohammed Ali et al

radiation with the biological system. The most probable interaction of FN with biological system is the formation of highly energetic nuclear recoils resulting from neutron elastic scattering with the nuclei forming the biological macromolecules. Hydrogen nuclei have the highest scattering cross-section and the average logarithmic energy transferred per collision (unity) for fast neutrons. These highly energetic nuclear recoils migrate in the hydrocarbon network resulting in deficient regions, highly energetic active species and free radicals17.

The radiative capture of chlorine nuclei to neutrons share considerable source of damage to the biological system since all electrolytes are in the form of chlorides. The basic interaction mechanism of MF with moving ions is the formation of perpendicular forces on the ions which cause their shift from target directions.

Since all metabolic functions are run through ionic currents and potentials, the application of MFs will result in the disturbance of these metabolic activities and the formation of free radicals. These free radicals can cause oxidative cell damage at the cellular level, interfering with the protein synthesis to finally result in acute inflammation, cellular destruction and tissue edema19,10,11.

According to the fore-mentioned interaction mechanisms of the MFs and FN with the biological tissues; one can analyze the present findings. The observed hyperplasia of the interstitial tissues and Leydig cells of the exposed animals to 50Hz MF in addition to the degenerated spermatogonia (Figure 2.2) and the highly significant decreased testosterone level in blood; all represent structural and functional changes in the testis.

One may speculate that; the normal tilting movement of the phospholipid bilayer macromolecules forming the cellular membrane could be disrupted under the influence of the MF which may lead to the changes in the packing properties of these molecules and hence the intermolecular forces of cellular membrane. This analysis could be supported by the observed atrophy of the ST, hemorrhage, hyalinization and calcification (Figures 2.5, 2.6, 2.7).

Moreover; the highly significant increased CPK level in the blood is mainly attributed to the damage of the cellular membrane in cells of different organs. On the other hand; the observed hypoplasia of the interstitial tissues and the Page 98

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

disrupted ST (Figure 2.4) are indication for the direct damaging mechanisms carried by the fast neutrons to the macromolecules forming the cellular membrane. Exposure of animals to both types of radiation caused more cellular damage as well as the highly significant increased CPK level in blood.

Conclusions It may be concluded from the present findings that; 1. Exposure to either fast neutron doses within the limits recommended by ICRP-60 is harmful to the testis.

2. Whole body exposure to 50 Hz, 0.5 G magnetic field is harmful to the body and decreases the fertility of the animal.

3. It seems necessary to reconsider the permissible dose limits recommended by the ICRP-60 in case of exposures to mixed radiation with 50Hz magnetic field.

Acknowledgements Appreciation and gratitude are expressed to Dr. Mahmoud S. Morsy, professor and head of Textile Division, National Institute for Standards; Cairo-Egypt, for technical assistance in providing the photographing imaging system.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

Effects of Magnetic Field Fadel Mohammed Ali et al

7. Fadel MA, Wael SM, MostafaRM. Effect of 50 Hz, 0.2 mT magnetic fields on RBC properties and heart functions of albino rats, Bioelectromagnetics 2003; 24(8): 535-45.

8. Raffaele De Vita, Delia Cavallo, Luigi Raganella, PatriziaEleuteri, Maria G Grollino, Alberto Calugi. Effects of 50Hz magnetic fields on mouse spermatogenesis monitored by flow cytometric analysis. Bioelectromagnetics 2005; 5(16): 330– 334.

9. Zare S, Alivandi S, Ebadi AG. Histological studies of the low frequency electromagnetic fields effect on liver, testes and kidney in guinea pig. World Applied Sciences Journal 2007; 2(5): 509-511.

10. Khaki AA, Tubbs RS, Shoja MMet al. The effects of an electromagnetic field on the boundary tissue of the seminiferous tubules of the rat: a light and transmission electron microscope study. Folia Morphol 2006; 65(3): 188-94.

11. Khaki AA, Zarrintan S, Khaki A, Zahedi A. The effect of electromagnetic field on the microstructure of seminal vesicles in rat: a light and transmission electron microscope study. Pak J BiolSci 2008; 1; 11(5): 692-701.

12. Farkhad SA, Zare S, Hayatgeibi H, Qadiri A. Effects of extremely low frequency electromagnetic fields on testes in Guinea pig. Pak. J BiolSci2007; 15; 10(24): 4519-22.

13. Yoon-WK, Hee SK, Jin SL et al. Effects of 60Hz 14µT magnetic field on the apoptosis of testicular germ cell in mice.

Bioelectromagnetics 2009; 30(3): 66-72.

14. Akram A, HadiF M, Mohammad J,Tahmasebi B, Hajieh S, Mohammad B. Hypothalamic- pityitary- gonadal axis responses of the male rats to short and long term alternative magnetic fields (50 Hz) exposure. JRMS 2009; 14(4): 231-238.

15. Cao Y, Zhang W, Lu MX et al. 900-MHz microwave radiation enhances gamma- ray adverse effects on SHG44 cells. J Toxicol Environ Health A 2009; 72(11-12): 727-32.

16. Jiyeon K, Chang SH, Hae JL, Kiwon S. Repetitive exposure to a 60-Hz time-varying magnetic field induces DNA double-strand breaks and apoptosis in human cells. Biochemical and Biophysical Research Communications 2010; 400(4): 739-44.

17. Islam MS, Fadel MA, Hamada MM, El-Badry AA. Reproductive Impacts from Exposure of Male Albino Rats to 50Hz, 1 Gauss Magnetic Field Effects of Exposure to 50Hz, 1 Gauss Magnetic Field on Reproductive Traits in Male Albino Rats. ACTA VET. BRNO 2011, 80: 107–111.

18. David O. Carpenter, Sinerik Ayrapetyan. Biological Effects of Electric and Magnetic Fields. 1994; Volume 1, Ch. 2.

19. Khaki AA, Choudhry R, Kaul JK et al. Montazam H. Effect of electromagnetic field on Sertoli cell of rat testes. A light and transmission electron microscope study. JIMSA 2004; 17: 136– 140.

References 1. ICRP-60, Recommendations of the International Commission on Radiological Protection. ICRP-Publication 1990: 60, Pergamon Press.

2. Chung HC, Kim SH, Lee MG et al. Mitochondria dysfunction by gamma- irradiation accompanies the induction of cytochrome p450 2E1 (CYP2E1) in rat liver. Toxicology 2001; 161(1-2): 7991.

3. Jones JA, Casey RC, Karouia F. Ionizing Radiation as a Carcinogen. Comprehensive Toxicology 2010; (Second Edition) 14: 181-228.

4. Adachi S, Ryo H, Hongyo Tet al. Effects of fission neutrons on human thyroid tissues maintained in SCID mice. Mutat Res 2010; 696(2): 107-13.

5. ClearySF. A review of in vitro studies: low-frequency electromagnetic fields. Am. Ind. Hyg. Assoc. J.1993; 54(4): 17885.

6. Bowman JD, Thomas DC, LondonSJ, Peters JM. Hypothesis: the risk of childhood leukemia is related to combinations of power-frequency and static magnetic fields.

Bioelectromagnetics1995; 16(1): 48-59.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Page 99

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Mosaic Turner Syndrome Selda Simsek et al

A MİDDLE AGED WOMAN WİTH MOSAIC TURNER SYNDROME: A CASE REPORT Selda Simsek1*, Ahmet Yalinkaya2, Diclehan Oral1, Aysegul Turkyilmaz1, Selahattin Tekes1, Turgay Budak1 1. Dicle University Medical Faculty Department of Medical Biology, Diyarbakir, Turkey.

2. Dicle University Medical Faculty Department of Obstetrics and Gynecology, Diyarbakir, Turkey.

Abstract Turner syndrome is a disorder of females is characterized by the absence of all or part of a normal second sex chromosome. Turner syndrome occurs in 1 in 4000 live-born girls and approximately 5 to 10 percent of them have mosaic isochromosome 45,X/46,X,i(Xq).

Turner syndrome is associated with reduced adult height and with gonadal dysgenesis, leading to insufficient circulating levels of female sex steroids and to infertility. Osteoporosis and high risk of fractures are features in adults with Turner syndrome.

In this study, we present a delayed case of Turner syndrome with primary amenorrhea, short stature, osteoporosis and high risk of fractures. This case has ignored due to social and economic conditions, therefore we think that the patient can be considered for publication.

Case report (J Int Dent Med Res 2011; 4: (2), pp. 100-103) Keywords: Turner syndrome; isochromosomes, primary amenorrhea, Osteoporosis.

Received date: 25 April 2011 Introduction Turner syndrome, a disorder of females is characterized by the absence of all or part of a normal second sex chromosome, leading to a constellation of physical findings that often includes congenital lymph edema, short stature, and gonadal dysgenesis.1,2,3 Turner syndrome occurs in 1 in 4000 liveborn girls. The most frequent chromosome constitution in Turner syndrome is 45,X without second sex chromosome. However, about 50 percent of cases have other karyotypes. About one quarter of Turner syndrome cases involve mosaic karyotypes, in which only a proportion of cells are 45,X. The most common karyotypes and their approximate relative prevalences are as follows; 50 percent of cases 45,X, 15 percent of cases 46,X,i(Xq), 15 percent of cases 45,X/46,XX, about 5 percent of cases 45,X/46,X i(Xq), about 5 percent of cases 45,X, other X *Corresponding author: Dr. Selda Simsek Dicle University Medical Faculty Department of Medical Biology, Diyarbakir, Turkey.

E-mail: seldatsimsek@gmail.com

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Accept date: 13 July 2011 abnormality and about 5 percent of cases other 45,X/? Mosaics.1,2,4 Osteoporosis, reduced volumetric bone mineral density (vBMD), and an increased risk of fracture have been reported as features of Turner syndrome (TS) not only in adults but also in children. Osteoporosis may result from an inherited bone structure defect associated with other skeletal and connective tissue anomalies of the syndrome or, more likely, from estrogen deficiency. Estrogen replacement and treatment of short stature with GH were reported to optimize bone mass in Turner syndrome girls .5,6 It will be reported a delayed case of Turner syndrome with primary amenorrhea, short stature, osteoporosis and high risk of fractures.

This case has ignored due to social and economic conditions, therefore, we think that the patient can be considered for publication.

Case Report A 39 years old patient with primary amenorrhea was referred to Dicle University Medical Faculty Department of Genetics for karyotype analysis. According to information of her family; as his father’s second marriage. She had five brothers and four sisters. She belonged to a very poor socioeconomic background.

Page 100

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

On gynecologic and ultrasound examination of the patient that was performed in the department of obstetrics and gynecology by the gynecologist vaginal development was normal. 54x31cm size of uterus and ovaries could not be evaluated. Pelvic MRI also revealed the same. She was short statured with 136cm in height and 40kg in weight. She had not attained menarche. Development of her breasts was infantile. Her pubic and axillary hair was infantile.

The measurement of hormone level revealed an increase in the FSH level 95,9 mIU/ml, LH level 21,42 mIU/ml, estradiol level was low that 5 mIU/ml. The measurement of the other hormones level were found as 2,97pmol/L for plasma TSH level, 5,71 pmol/L for T3 level, 15,26 pmol/L for T4 level, 4,22ng/ml for prolactin level, 14,98 µg/dL for cortisol level, 57,25pg/mL for PTH level and 3,14pg/mL for ACTH level.

Higher fracture risk and osteoporosis was evaluated for femur on whole body bone densitometry of the patient. Also the patient was complaining about hearing impairment.

Audiologically findings of the patient; with very mild symptoms in the left ear and mild hearing loss mixed type in the right ear.

The chromosomal analysis done by Peripheral Blood Lymphocyte Culture and Gbanded. Chromosome analysis was performed on 100 metaphase plate and mosaic 45,X[%66] / 46,X,i(Xq)[%34] karyotype was detected (Figure 1 and 2).

Mosaic Turner Syndrome Selda Simsek et al

Figure 2. Karyotype showing chromosomal complement.

46,X,i(Xq)

Materials and methods We obtained chromosome preparations from routine peripheral blood lymphocyte cultures.

At least five GTG banded metaphases (minimal 500 band level) were evaluated for couple.

Karyotypes were recorded according to The Recommendations of The International Standing Committee on Human Cytogenetic Nomenclature 2000.

Peripheral blood cultures were set up in F-10 nutrient media and with 20% fetal bovine serum. The cultures were stimulated with phytohaemagglutinin (PHA-M) and incubated for 72h at 37 o C. The cultures were arrested with colchicine (10 mg/ml) at 70,5th h and treated with 0.075 M KCl. The cultures were fixed with cornoy fixative (methanol: Acetic acid, 3:1).

The chromosomes were prepared on prechilled slides and stored for three days at room temperature for ageing of the slides. The chromosome preparations were subjected to GTG-banding using standard procedure. Briefly, the slides treated with trypsin-EDTA in Sorensen's buffer for 30 seconds and stained with giemsa stain. At least 100 well-spread and banded metaphases were analyzed under microscope and karyotyped according to ISCN 2000.

Discussion

Figure 1. Karyotype showing 45,X chromosomal complement.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Two pathogenic mechanisms, which have been described in the literature, lead to monoclonal monosomy X: meiotic nondisjunction and chromosomal lag or loss.

Page 101

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

The incidence rate of 45,X in spontaneous abortions is high. This single abnormality is present in an estimated 1 to 2 percent of all conceptuses; survival to term is a rare outcome, and more than 99 percent of such fetuses abort spontaneously.

The single X is maternal in origin in about 70 percent of cases; in other words, the chromosome error is usually paternal. The basis for the unusually high frequency of X or Y chromosome loss is unknown. Furthermore, it is not clear why the 45,X karyotype is usually lethal in utero but is apparently fully compatible with postnatal survival.

The missing genes responsible for the Turner syndrome phenotype must reside on the X and Y chromosomes. It has been suggested that the responsible genes are among those that escape X inactivation.

The basis for isochromosome formation is not precisely known, at least two mechanisms have documented: mid-division through the centromere in meiosis II and, more commonly, exchange involving one arm of a chromosome and its homolog at the proximal edge of the arm, adjacent to the centromere.1 The Xq isochromosome is associated with autoimmune disorder but not congenital abnormalities. The clinical picture of Turner syndrome varies from case to case.7 Phenotype is not well predicted by genotype, particularly in the case of mosaicism.

This is particularly true of the various mosaicisms when the picture depends on the ratio of the different cell populations and their distribution in various tissues and organs.8 Hearing loss and middle ear diseases are often reported in some of patients with Turner syndrome. Hearing loss in women with Turner syndrome is not clinically apparent in most of the cases; this fact reflects the need of early evaluation and further monitoring of hearing organ in those patients.2,9,10,11 Parkin and Walker recommended that Turner Syndrome is associated with a high incidence of middle ear disease so, individuals with Turner syndrome should be screened for onset and progression of hearing loss.10 Several authors have documented an association between Turner Syndrome and an increased risk of fracture in patients with Turner Syndrome.

Although these researchers recommended in their clinical studies that Estrogen supplementation is essential to improve Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Mosaic Turner Syndrome Selda Simsek et al

BMC (Bone Mineral Density) accrual during growth in Turner syndrome.5,6,12 Kannan TP et al. reported that the delay in the diagnosis of Turner syndrome in their studies could be attributed to the lack of antenatal screening and early neonatal screening.

The institution of societies and referral centers to cater exclusively to the needs of the Turner syndrome patients will also help them seek advice and improve their outlook towards the society. Hence, establishing early diagnosis, educating and increasing awareness among doctors, as well as prenatal diagnosis, would be an effective measure in alleviating the social trauma related to Turner syndrome patients in their population.8 Also, some researchers emphasized that the importance of delay in the diagnosis of Turner syndrome.2,13 Conclusions Early diagnosis will enable early intervention and early psychological counseling to the patient as well as the parents, which in turn will help enhance their quality of life.

Declaration of Interest The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Nussbaum RL. Thompson and Thompson Genetics in Medicine.

Six edition, WB.Saunders Company, 2001:172-175.

2. Noor M, Abdullah S, Mahmood S. Turner’s Syndrome. Gomal Journal of Medical Sciences 2007;5(1):33-37.

3. Güneş S, Kara N, Sürücü B et al. Two Turner Syndrome Patients with the Mosaic 45,X/46,X,i(Xq) Karyotipe:Case Report. Turkiye Klinikleri J Med Sci 2008, 28(2):236-238.

4. Pamuji S.E, Dasuki D. Nonmosaic 45, XO karyotype in a woman with Turner syndrome without any cognitive, psychosocial or behavioral deficiencies (A Case report). Berkala Ilmu Kedokteran 2007,39(3): 138-143.

5. Bakalov V.K, Michael M.L, Baron J, et al. Bone Mineral Density and Fractures in Turner Syndrome. The American Journal of Med 2003, 115(4):259-64.

6. Högler W, Briody J, Moore B, et al. Importance of Estrogen on Bone Health in Turner Syndrome: A Cross-Sectional and Longitudinal Study Using Dual-Energy X-Ray Absorptiometry.

The Journal of Clinical Endocrinology & Metabolism 2004, 89(1):193–199.

7. Ferrero S, Bentivoglio G. Adenomyosis in a patient with mosaic Turner’s syndrome. Arch Gynecol Obstet 2005, 271(3): 249–250.

8. Kannan T.P, Azman B.Z, Ahmad Tarmizi A.B et al. Turner syndrome diagnosed in northeastern Malaysia. Singapore Med J 2008, 49(5): 400-404.

9. Gawron W, Wikiera B, Rostkowska-Nadolska B et al. Evaluation of hearing organ in patients with Turner syndrome. Int J Pediatr Otorhinolaryngol 2008, 72(5):575-9.

Page 102

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Mosaic Turner Syndrome Selda Simsek et al

10. Parkin M, Walker P. Hearing loss in Turner syndrome. Int J Pediatr Otorhinolaryngol 2009, 73(2):243-7.

11. Güngör N, Böke B, Belgin E, Tunçbilek E. High frequency hearing loss in Ullrich-Turner syndrome. Eur J Pediatr 2000, 159(10):740-744.

12. Holroyd C. R, Davies J. H, Taylor P, et al. Reduced cortical bone density with normal trabecular bone density in girls with Turner syndrome. Osteoporos Int 2010, 21(12):2093–9.

13. Chander N.V, Ahmed E.M, Turner’s Syndrome Variant with Three Cell Line Mosaicism and Ring X Chromosome (45, X /46,X r(X)(p21 q25)/46,Xx) in A Saudi Patient. Bahrain Med Bull 2001, 23(1):42-44.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Page 103

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

Cardiac Arrest Adnan Tufek et al

A CARDIAC ARREST ASSOCIATED WITH DOUBLE LUMEN ENDOBRONCHIAL TUBE: CASE REPORT Adnan Tufek1*, Feyzi Celik1, Orhan Tokgoz1, Haktan Karaman1, Refik Ulku2, Zeynep Baysal Yildirim1, Gonul Olmez Kavak1 1. Department of Anesthesilogy and Reanimation, Dicle University, School of Medicine, Diyarbakir, Turkey.

2. Department of Thoracic Surgery, Dicle University, School of Medicine, Diyarbakir, Turkey.

Abstract Double lumen tubes are used frequently in operations of Thorax Surgery Department.

This case report presents a cardiac arrest towards the end of surgery in patient with placement of left bronchial double lumen tubes.

Unexplained perioperative cardiac arrest may be due to obstruction of pulmonary artery flow associated with double lumen tube in thorax surgery.

Case report (J Int Dent Med Res 2011; 4: (2), pp. 104-105) Keywords: Double lumen tube, Cardiac arrest.

Received date: 30 June 2011 Introduction Although there are alternative pulmonary isolation techniques in thorax surgery, double lumen tubes (DLT) are still frequently used.1 This case report presents an immediate cardiac arrest just after surgery in patient with left DLT. Case Report 55-year-old, 70 kg male patient had chest pain and dyspnea for 6 months. Right lower lobectomy was planned after diagnosis of lung cancer. Computerized tomography of lung revealed a mass localized to superior segment of lower lobe in right lung. Preoperative examination was normal without any other pathologies.

Premedication was given with iv 0.05 mg/kg midazolam. After standard anesthesia monitorization (ECG, SpO2, NIBP), epidural catheter was placed between thoracic 7-8 intervertebral space for postoperative analgesia. *Corresponding author: Assist. Prof. Dr. Adnan Tüfek Department of Anesthesilogy and Reanimation, Dicle University, School of Medicine, Diyarbakır, Turkey Phone: +90 532 5183496 E-mail: adnantufek@hotmail.com

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

Accept date: 01 August 2011 Catheter was fixed with approximately 4 cm inside. Anesthesia induction was performed with 2 mg/kg propofol, 2 µg/kg fentanyl and 0,6 mg/kg rocuronium. After adequate muscle relaxation, intubation was done with 35 numbered left Robertshaw tube successfully at first attempt.

Tube position was confirmed with fiberoptic bronchoscope.

Anesthesia was maintained with %2 sevoflurane and %50 O2-air intraoperatively. Right radial artery was catheterized then right internal jugular vein was also catheterized for central venous monitorization. Left lateral decubit position was given, then position of DLT was controlled again at this position. Surgery commenced thereafter.

Right lower lobectomy procedure was performed successfully with right thoracotomy.

However, suddenly bradycardia and cardiac arrest was observed during closure of pleura.

The cardiopulmonary resuscitation (CPR) was performed with internal cardiac massage. Firstly, cardiac tamponade and tension pneumothorax were ruled out.

Arterial blood gas analysis (ABG) was also done. Then, patient was brought to the supine position and external cardiac massage was started. ABG analysis revealed no metabolic disorder to explain sudden cardiac arrest. (pH:7.35, pCO2: 50 mmHg, pO2: 120 mmHg, HCO3: 25 mEq/L, BE: -3). When there was no positive response at the 15th minute of CPR, Page 104

Journal of International Dental and Medical Research ISSN 1309-100X http://www.ektodermaldisplazi.com/journal.htm

DLT was exchanged to single lumen tube. When cardiac rhytym turned to ventricular fibrillation (VF), defibrillation was performed with 360 J. Sinus rhytym was achieved, heart rate was 110/min and arterial blood pressure was 65/40 mmHg. Dopamin infusion (10 µg/kg/min) was started and patient was transferred to Reanimation ICU unit with mechanical ventilation and supportive treatment. At the 12th hour of ICU stay, he gained his consciousness back. At the 4th day, he was extubated when his spontaneous ventilation was adequate. Hemodynamics followup was stabile and there was no neurological sequele. At the 7th day of ICU, he was transferred to Thorax surgery department wards.

Cardiac Arrest Adnan Tufek et al

Similarly in our case, after 15 minutes of CPR and exchanging of DLT with single lumen tube, cardiac arrest rhytym returned to normal sinus. Therefore, we consider that left DLT compressed the pulmonary artery outflow, this caused cardiac arrest.

Conclusions Unexplained cardiac arrest in thorax surgery may be associated with obstruction of pulmonary artery outflow by DLT, therefore CPR should be continued until exchanging of DLT with single lumen tube.

Declaration of Interest

Discussion Thorax surgery cases have highest mortality and cardiovascular complications constitute the second most cause of morbidity after respiratory complications.2 Adverse events due to DLT are seen mostly during intubation and due to one-lung-ventilation.1 Perioperative bradycardia may be seen generally because of central mechanisms, psychological stress, pain or reduced venous return.2,3 Unexplained cardiac arrest is rare at the end of surgery. Generally, pericardial tamponade and tension pneumothorax are the main causes of cardiac arrest which are seen at perioperative period and reversible associated with surgical manipulation.4 Our case had sudden cardiac arrest; pericardial tamponade and tension pneumothorax are ruled out, ABG analysis was normal. In spite of CPR, there was no electrical activity on ECG. This was interpreted as a complication of DLT. Therefore, DLT was exchanged with single lumen tube and soon, patient's rhythm turned from asystole to ventricular fibrillation.

Douglas G Wells et al.5 presented a case underwent right thoracotomy because of excision of bronchogenic cyst. After anesthesia induction, sudden cardiac dysrhytmia and cardiac arrest was reported. Left Robertshaw tube displaced the bronchogenic cyst, obstructed pulmonary artery flow. Only after removal of cyst and exchanging of DLT with single lumen tube, cardiac arrest rhytym returned to normal sinus.

Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011

The authors report no conflict of interest and the article is not funded or supported by any research grant.

References 1. Cohen E. Recommendations for airway control and difficult airway management in thoracic anesthesia and lung separation procedures. Are we ready for the challenge? Minerva Anestesiol 2009; 75: 3–5.

2. Kinsella SM, Tuckey JP. Perioperative bradycardia and asystole: relationship to vasovagal syncope and the BezoldJarisch reflex. Br J Anaesth. 2001; 86 (6): 859-68.

3. Doyle DJ, Mark PW. Reflex bradycardia during surgery. Can J Anesth 1990; 37: 219-222.

4. Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G; European Resuscitation Council. European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation. 2005; 67 Suppl 1: 39-86.

5. Douglas G Wells, Zelcer J, Podolakin W, Baker TG, Wilson AC, White AL. Cardiac arrest from pulmonary outflow tract obstruction due to a double-lumen tube. Anesthesiology. 1987; 66(3): 422-3.

Page 105