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Dental News, Volume XXI, Number III, 2014


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CONGRESSES Effect of Fluoride-Based Prophylactic Agents on Titanium Corrosion Dr. Wiam El Ghoul, Dr. Mireille Rahi Dr. Ghassan Mostapha, Dr. Elias Smaira Pr. Khaldoun Rifai


May 29 - 31, 2014 USJ Dental School, Beirut, Lebanon

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Repair of an Implant-Supported Porcelain-Fused-to-Metal Restoration in Under-Occlusion Dr. Norma Ziadeh, Dr. Danielle El Hakim

JO 2014 11e JournĂŠes Odontologiques

IVOCLAR VIVADENT Monolithic Restoration Concepts June 14, 2014 London, UK


APDC 2014 36th Asia Pacific Dental Congress June 17 - 19, 2014 World Trade Center, Dubai, UAE


Role of Erupting Third Molars in Causing Dental Crowding Dr. Parmanand Dhanrajani Dr. Gregory Bellamy


The effect of aging and thermocycling on adhesive bonding to fluorosed enamel Dr. Wafa H. Alajam, Dr. Khalid M. Abdelaziz Dr. Mohamed M. Almoaleem





Oral Ulcers in Infants and Children Part II: Treatment Dr. Sawsan Nasreddine, Dr. Antoine Cassia

Dental News, Volume XXI, Number III, 2014



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w w Volume XXI, Number III, 2014 EDITORIAL TEAM Alfred Naaman, Nada Naaman, Jihad Fakhoury, Dona Raad, Antoine Saadé, Lina Chamseddine, Tarek Kotob, Mohammed Rifai, Bilal Koleilat, Mohammad H. Al-Jammaz COORDINATOR Elie Hajj ART DEPARTMENT Elie Hajj SUBSCRIPTION Micheline Assaf, Nariman Nehmeh ADVERTISING Josiane Younes PHOTOGRAPHY Albert Saykali TRANSLATION Gisèle Wakim, Marielle Khoury DIRECTOR Tony Dib ISSN 1026-261X

DENTAL NEWS IS A QUARTERLY MAGAZINE DISTRIBUTED MAINLY IN THE MIDDLE EAST & NORTH AFRICA IN COLLABORATION WITH THE COUNCIL OF DENTAL SOCIETIES FOR THE GCC. Statements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the Editor(s) or publisher. No part of this magazine may be reproduced in any form, either electronic or mechanical, without the express written permission of the publisher.

DENTAL NEWS – Sami Solh Ave., G. Younis Bldg. POB: 116-5515 Beirut, Lebanon. Tel: 961-3-30 30 48 Fax: 961-1-38 46 57 Email: Website:

JIDC 2014 - The 24th Jordanian International Dental Conference

October 21 - 24, 2014 at the Landmark Hotel in Amman, JORDAN Email: : Website:

AIDC 2014 - The 19th Alexandria International Dental Congress

October 22 - 24, 2014 Alexandria Int’l Dental Congress Alexandria, EGYPT Email: Website:

IQDAC 2014 - The 4th International Quintessence Dental Arab Congress

October 24 - 25, 2014 at the Riyadh Colleges, Riyadh, KSA Email: Website:

DFCIC 2014 - The 6th Dental-Facial Cosmetic International Conference

November 14 - 15, 2014 at the Jumeirah Beach Hotel, Dubai, UAE Email: Website: aesthetic2014

KDA 2014 - The 18th Kuwait Dental Association Conference

November 20 - 22, 2014 KUWAIT Email: Website:

SDA 2014 - The 8th Sudanese Dental Association Conference

December 2 - 4, 2014 SUDAN Email: Website:

SDS 2015 - The 26th Saudi Dental Society International Dental Conference

January 13 - 15, 2015 at the Riyadh International Convention & Exhibition Center, Riyadh, KSA Email: Website:

AEEDC 2015 - The 19th UAE International Dental Conference & Arab Dental Exhibition

February 17 - 19, 2015 at the Dubai International Conventional & Exhibition Center, Dubai, UAE Email: Website: Dental News App on both Appstore & Google play

This magazine is printed on FSC – certified paper. Dental News, Volume XXI, Number III, 2014

12 Implant Dentistry

Effect of Fluoride-Based Prophylactic Agents on Titanium Corrosion: A Literature Review and Clinical Implications Dr. Wiam El Ghoul Dr. Mireille Rahi

Dr. Ghassan Mostapha

Dr. Elias Smaira Pr. Khaldoun Rifai

Abstract Titanium is known to possess excellent biocompatibility as a result of corrosion resistance and lack of allergenicity when compared with many other metals. Fluoride is well known as a specific and effective caries prophylactic agent and its systematic application has been recommended widely over recent decades. Nevertheless, high fluoride concentrations impair corrosion resistance of titanium. The purpose of this paper is to discuss the current data regarding the influence of fluoride on titanium corrosion process in the last years. These data demonstrate noxious effects induced by high fluoride concentration as well as low PH in the oral cavity. Therefore, such conditions should be considered when prophylactic treatment is indicated with patients having dental implants or other dental devices.

Keywords Corrosion. Dental implants. Titanium alloys. Fluoride prophylactic agents. Titanium oxide layer. Oral cavity.

Introduction Titanium materials used for dental implants manufacturing are supposed to exhibit high corrosion resistance.1,2,3 Corrosion is defined as the process of interaction between a solid material and its chemical environment which leads to a loss of substance from the material, roughening of the surface, change in its structural characteristics, weakening of the restoration, loss of structural integrity, liberation of elements from the metal and toxic reactions.1,2,3 Many factors may influence corrosion in the oral environment such as type of materials, pH, temperature, humidity, oxygen and type of Dental News, Volume XXI, Number III, 2014

bacteria.4,5,6,7 High metal alloys used in dentistry are so stable chemically that they do not undergo significant corrosion in the oral environment.2 Most of commercially available implant systems are made of pure titanium or titanium alloy (Ti-6Al4V).8 Titanium and its alloys provide strength, rigidity, and ductility, similar to those of other dental alloys. Whereas, titanium and its alloy have excellent biocompatibility, low density, low thermal conductibility, good mechanical properties and greater corrosion resistance in saline and acidic environments.9,10,11 Another property of titanium is passivity, which is the formation of a thin layer of oxides TiO2, however this stable oxide layer is not inert to corrosion attack.11,12,13,14 Saliva contains several viruses, bacteria, fungi and food debris. Many Gram+ and Gram- bacterial species form a major part of the dental plaque around teeth and also colonize mucosal surfaces.2,15,16 These microorganisms affect corrosion of metals by forming of organic acids during glycolysis pathways from sugars, which will reduce the pH. A low pH creates a favorable environment for corrosion.2 Moreover, different products used in oral cavity have innumerous substances that can interact with titanium. Fluoride is one of these corrosive chemicals which are present at different concentrations in toothpastes, mouthwashes, and other sources like tablets, drops or chewing gums due to its evidence-based anticariogenic effect.7,17,18 The increasing use of various titanium-based materials for dental implants and orthodontic brackets raises the question of their corrosion resistance in presence of fluoride ions, which are present in toothpastes and mouth rinses.4,19

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14 Implant Dentistry Objectives The aim of this paper was to discuss published data on the role of fluoride on titanium corrosion in oral cavity and its clinical implications.

Materials and methods Search strategy: MEDLINE and PubMed searches were performed for articles written in English using the following terms: Corrosion process- Pure and Titanium alloys- Fluoride prophylactic agents- Fluoride corrosion- Titanium oxide layer- Saliva components- Oral cavity. References from 1990 to 2013 were consulted and reviewed for appropriate studies. Results: A total of 39 references were used, focusing on the effect of fluoride prophylactic agents on titanium corrosion, leading to 30 in-vitro studies, 1 invivo and 5 literature reviews.

The effect of fluoride on the corrosive process Dental use of fluoride has been considered the main method to protect the enamel and to reduce its dissolution; fluoride ions having the ability to interact with the enamel’s hydroxyapatite crystals forming fluorited hydroxyapatite or fluoroapatite. These minerals have greater lattice energy, higher crystallinity, and better resistance to dissolution than hydroxyapatite.19,20 However, corrosion behavior of pure titanium and titanium alloy investigated in artificial saliva are significantly affected by the presence of fluoride ions (added by NaF) as proven by electrochemical methods.4 Fluoride ions are very aggressive on the protective TiO2 film formed on titanium and titanium alloys. They incorporate into the oxide layer TiO2, and cause the breakdown of this protective passive layer.21,22,23 This contributes to the formation of a hydrofluoric acid,24,25,26 which results in morphological variations, such as increasing roughness leading to plaque accumulation3,11,13 and possibly inhibition of osseointegration.2,3 Siirila et al. (1991) reviewed the effect of topical fluoride on titanium and concluded that toothbrushes used in contact with titanium surfaces should be as non-abrasive as possible and that long lasting contamination with topical fluorides should be avoided.27 Licausi et al. (2013) proved that titanium alloys are subjected to different mechanical actions (sliding or fretting), thus resulting in a tribocorrosion system, which is an irreversible material degradation process due to the combined effect of corrosion and wear.10 Commercial dental gels and rinses contain fluoride from 200 to 20,000 ppm, and can affect corrosion behavior of titanium.6,21 Campus et al. (2003) proved that concentration of fluorides in saliva after brushing with toothpaste diminishes, still lower concentrations of fluoride are still found up to 24 hours.28 A critical fluoride concentration exists above which corrosion rates increases.10 Mimura et al. (1996) reported that titanium was not considered to have a high corrosion resistance in the solution containing 500 ppm at pH =4.29 Huang et al. (2002-2003) reported that the protectiveness of TiO2 formed on titanium and titanium alloy is degraded by fluoride ions when NaF concentration exceeds 0,1 % (fluoride ion close to 500 ppm) via the formation of a Ti-F complex compound leading to severe corrosion of metal.30,31 Toniollo et al. (2012) suggested that use of 0,05 % NaF solution on titanium is safe, whereas the 0,2 % NaF solution should be carefully evaluated in regard Dental News, Volume XXI, Number III, 2014

to its daily use.7 Fluoride concentration is not the only factor affecting corrosion process. It was also shown that pH value affects negatively this process. Reclaru et al. (1998) found that titanium and titanium alloys tested undergo a corrosive process, as soon as the pH drops below 3.5.32 Nakagawa et al. (1999-2005) revealed that titanium was corroded by existence of a small amount of NaF if pH was considerably low, and that titanium was corroded even at high pH if the NaF concentration was considerably high.6,33 Toniollo et al. (2009) reported that fluoridecontaining solutions (pH=7) used as mouthwashes do not damage the surface of cast pure titanium and can be used by patients with titanium-based restorations.5 Lelli et al. (2013) revealed that corrosion of titanium in the solution containing fluoride depends on the concentration of hydrofluoric acid HF. When HF was higher than 30 ppm, the passivation film of the titanium was destroyed.11 Rosalbino et al. (2012) have explained the active behavior for all the titanium alloys in fluoridated acidified saliva due to the presence of significant concentrations of HF that dissolve the spontaneous air-formed oxide film, giving rise to surface activation. However, an increase in stability of the passive oxide layer and consequently a decrease in surface activation are observed for the Ti-1M alloys (M=Ag, Au, Pd, Pt).8 Morphology changes in the surface of titanium were observed following fluoride corrosion. Correa et al. (2009) reported that the process of corrosion by fluoride on commercially pure titanium allowed greater streptocoque mutans adherence than in the absence of corrosion.3 Muguruma et al. (2011) investigated miniscrew implant, they observed pits and cracks formed on implant surfaces after immersion in 0,1 or 0,2 % NaF mouth rinse solutions. However, this should not cause deterioration of their torsional performance.34 Roselino et al. (2007) concluded that prolonged contact with fluoride ions is harmful to mechanical properties of titanium structures.18 To further elucidate the role of fluoride ion concentration on the corrosion behavior of titanium and Ti-6Al-4V implant alloys, when

16 Implant Dentistry

coupled either metal/ceramic or all-ceramic superstructure, Anwar et al. (2011) examined this scenario by different electrochemical methods in artificial saliva solutions: they concluded that increased fluoride concentration leads to a decrease in the corrosion resistance of all tested couples.25

Discussion From above literature review, it is important to stress that described evidence of fluoride on titanium alloys derives mostly from in-vitro research, which includes oversimplifications in simulating oral environment.13 According to Lopez- Alias et al. (2006), it is difficult to predict the clinical behavior of any alloy from invitro studies, since such factors as changes in the quantity and quality of saliva, diet, oral hygiene, polishing of alloy, the amount and distribution of occlusal forces, or brushing with toothpaste can all influence corrosion to varying degrees.35 On the other hand, choice of materials to be used as suprastructures with titanium implants is crucial. Their galvanic corrosion behaviors should be evaluated in order to avoid any corrosive process.2 The concern of reducing implant corrosion might be addressed by different methods such as noble metal alloying additions, especially gold on the corrosion behavior of titanium; this could be ascribed to an incorporation of noble metal into the passive layer, resulting in increasing its dissolution resistance.8 Nakagawa et al. (2005) concluded that addition of a small amount of Pd or Pt to Ti to create an alloy proved to be very effective in improving the corrosion resistance of titanium in sodium fluoride (NaF) solutions of various concentrations up to 2 %.33 Ag and Au have excellent corrosion resistance in many aqueous solutions, and good in vivo biocompatibility.8 Zhang et al. (2009) clarified that addition of Ag was found to be effective in reducing corrosion current density and increasing the open circuit potential of titanium in artificial saliva environment.36 Shim et al. (2005) reported that Ti-Ag alloys with low Ag content (< 5 %) have better corrosion resistance than pure titanium in artificial saliva.37 Yamazoe et al. (2007) showed that Ti-0,5 Pt, Ti-6 Al- 4N -0,5 Pt, and Ti-6Al7Nb-0,5 Pt alloys had high corrosion resistance in a fluoride containing environment and high mechanical strength. Therefore, use fullness of these alloys as new implants or denture base materials was suggested.38 Design and texture of implant surface was also studied. The presence of pores in implant materials may be a source of corrosion problems. Foit and Joska (2013) showed that titanium implants with porosity of 24 and 33% initiated a local attack of the material.39 Moreover, the abnormal electrical currents produced during corrosion can convert any metallic implant into an electrode, and the negative impact on the surrounding tissues due to these extreme signals could be an additional cause of poor performance and rejection of implants. Electrical protection of the surfaces of the implants was proposed by Gittens et al. (2011) in order to reduce implant corrosion.15 On the other hand, innovative commercial mouthwashes and toothpastes during the last decade have replaced fluoride with biomimetic hydroxyapatite nanocrystals (CHA) as a remineralizing agent to avoid the effects of fluoride on human health.11 Dental News, Volume XXI, Number III, 2014

Conclusion The most favorable suprastructure/implant couple is the one capable of resisting the most extreme conditions that could possibly be encountered in oral cavity. Most studies were conducted in-vitro. Results showed that fluoride– containing products should be controlled and prescribed carefully, since increasing the use of such products can lead to alterations of implants and restoration surfaces, compromising the longevity of the treatment. In fact, fluoride ions seem to exert a negative influence on the corrosion resistance of pure titanium and titanium alloy Ti-6Al-4V, especially in the acidic artificial saliva which contained over 0,1% NaF (fluoride ions = 500 ppm). This may cause the breakdown of protective passivation layer that normally exists on titanium and titanium alloys, leading to severe corrosion.20,29,30,31 However, further in-vivo studies are warranted in order to elucidate corrosion resistance of titanium and titanium alloys exposed to fluoride agents in oral cavity.

References 1. Adya N, Alam M, Ravindranath T, Mubeen A, Saluja B. Corrosion in titanium dental implants: literature review. J Indian Prostho Soc 2005 July;5(3):128-131. 2. Chaturvedi TP. An overview of the corrosion aspect of dental implants (titanium and its alloys). Indian J Dent Res 2009 JanMar;20(1):91-8. 3. Correa CB, Pires JR, Fernandes-Filho RB, Sartori R, Vaz LG. Fatigue and Fluoride Corrosion on Streptococcus mutans adherence to Titanium-Based Implant/Component Surfaces. J Prostho 2009;18:382–387. 4. Milosev I, Kapun B, Selih VS. The effect of fluoride ions on the corrosion behavior of Ti metal, and Ti6-Al-7Nb and Ti-6Al-4V alloys in artificial saliva. Acta Chim Slov 2013;60(3):543-55. 5. Toniollo MB, Tiossi R, Macedo AP, Rodrigues RCS, Ribeiro RF, da Gloria M, de Mattos C. Effect of fluoride-containing solutions on the surface of cast commercially pure titanium. Braz Dent J 2009;20(3):201-4. 6. Nakagawa M, Matsuya S, Shiraishi T, Ohta M. Effect of Fluoride Concentration and pH on Corrosion Behavior of Titanium for Dental Use. J Dent Res 1999; September, 78(9): 1568-1572. 7. Toniollo MB, Galo R, Macedo AP, Rodrigues RCS, Ribeiro RF, da Gloria M, de Mattos C. Effect of fluoride sodium mouthwash solutions on cpTi: evaluation of physicochemical properties. Braz Dent J 2012 Sept/Oct;23(5):496-501. 8. Rosalbino F, Delsante S, Borzone G, Scavino G. Influence of noble metals alloying additions on the corrosion behaviour of titanium in a fluoride-containing environment. J Mater Sci Mater Med 2012; 23:1129–1137. 9. Canay S, Heresk N, Ulha AC, Bilgic S. Evaluation of titanium in oral conditions and its electrochemical corrosion behavior. J Oral Rehab 1998;25:759–764. 10. Licausi MP, Iguaz Munoz A, Amigo Borras V. Influence of the fabrication process and fluoride content on the tribocorrosion behavior of Ti6Al4V biomedical alloy in artificial saliva. J Mech Behav Biomed Mater. 2013 Apr;20:137-48.

17 Implant Dentistry 11. Lelli M, Marchisio O, Foltran I, Genovesi A, Montebugnoli G, Marcaccio M, Covani U, Roveri N. Different corrosive effects on hydroxyapatite nanocrystals and amine fluoride-based mouthwashes on dental titanium brackets: a comparative in vivo study. Int J Nanomed 2013;8:307-314. 12. Fovet Y, Gal JY, Toumelin-Chemla F. Influence of PH and fluoride concentration on titanium passivating layer: stability of titanium dioxide. Talanta 2001 Jan 26;53(5):105363. 13. Fragou S. Eliades T. Effect of topical fluoride application on titanium alloys: a review of effects and clinical implications. Pediatr Dent. 2010 Mar-Apr;32(2):99-105. 14. Perinetti G, Contardo L, Ceschi M, Antoniolli F, Franchi L, Baccetti T, Di Lenarda R. Surface corrosion and fracture resistance of two nickel-titanium-based archwires induced by fluoride, PH, and thermocycling. An in vitro comparative study. Eur J Ortho 2012;34:1-9. 15. Gittens RA, Olivaris RN, Tannenbaum R, Boyan BD, Scwartz Z. Electrical implications of corrosion for osseointegration of titanium implants. J Dent Res 2011;90(12):13891397. 16. Francisco Javier Gil FJ, Rodriguez A, Espinar E, Liamas JM, Padullés E, Juárez A. Effect of Oral Bacteria on the Mechanical Behavior of Titanium Dental Implants. Int J Oral Maxillofac Implants 2012;27:64–68. 17. Schiff N, Grosgogeat B, Lissac M, Dalard F. Influence of fluoride content and PH on the corrosion resistance of titanium and its alloys. Biomat 2002 May;23(9):1995-2002. 18. Roselino RAL, Noriega JR, Dametto FR, Vaz LG. Compressive fatigue in titanium dental implants submitted to fluoride ions action. J Appl Oral Sci 2007;15(4):299-304. 19. Duncan TB, Duncan WK, De Ball S. Fluoride: a review—Part II: Topical fluorides. Miss Dent Assoc J 1999:55(1):34-6. 20. Lee TH, Huang TK, LinSY, Chen LK, Chou MY, Huang HH. Corrosion Resistance of Different Nickel-Titanium Archwires in Acidic fluoride-containing Artificial Saliva. Angle Orthod 2010;80:547–553. 21. Noguti J, de Oliviera F, Peres RC, Claudia A, Renno M, Ribeiro DA. The role of fluriode on the process of titanium corrosion in oral cavity. Biomat 2012;25:859-862. 22. Khoury ES, Abboud M, Bassil-Nassif N, Bouserhal J. Effect of two-year fluoride decay protection protocol on titanium brackets. Int Orthod 2011 Dec;9(4):432-51. 23. Srivastava K, Chandra PK, Kamat N. Effect of fluoride mouth rinses on various orthodontic archwire alloys tested by modified bending test; an in vitro study. Indian J Dent Res 2012;23(3):433-434. 24. Walker MP, White RJ, Kula KS. Effect of fluoride prophylactic agents on the mechanical properties of nickel-titanium-based orthodontic wires. Am J Orthod Dentofacial Orthop 2005 June;127(6):662-9. 25. Anwar EM, Kheiralla LS, Tammam RH. Effect of fluoride on the corrosion behavior of Ti and Ti6Al4V dental implants coupled with different superstructures. J Oral Implantol 2011 Jun;37(3):309-17. 26. Mane PP, Pawar R, Ganiger C, Phaphe S. Effect of fluoride prophylactic agents on the surface topography of NiTi and CuNiTi wires. J Contemp Dent Pract 2012 May 1;13(3):285-8. 27. Siirila HS, Kononen M. The effect of oral topical fluorides on the surface of commercially pure titanium. Int J Oral Maxillofac Implants 1991;6:50-54. 28. Campus G, Lallai MR, Carboni R. Fluoride concentration in saliva after use of oral hygiene products. Caries Res 2003;37:66-70. 29. Mimura H, Miyagawa Y. Electrochemical corrosion behavior of titanium castings: part 1. Effects of degree of surface polishing and kind of solution. Jpn J Dent Mater Dev 1996;15:283-295. 30. Huang HH. Effects of fluoride concentration and elastic tensile strain on the corrosion resistance of commercialy pure titanium. Biomat 2002 Jan;23(1):59-63. 31. Huang HH. Effects of fluoride and albumin concentration on the corrosion behavior of Ti-6Al-4V alloy. Biomat 2003;24:275-282. 32. Reclaru L, Meyer JM. Effects of fluorides on titanium and other dental alloys in dentistry. Biomat 1998 Jan-Feb;19(1-3):85-92. 33. Nakagawa M, Matono Y, Matsuya S, Udoh K, Ishikawa K. The effect of Pt and Pd alloying additions on the corrosion behavior of titanium in fluoride-containing environments. Biomat 2005;26:2239-2246. 34. Muguruma T, Iijima M, Brantley WA, Kyung HM, Mizoguchi I. Effects of sodium fluoride mouth rinses on the torsional properties of miniscrew implants. Am J Orthod Dentofacial Orthop 2011;139(5):588-593. 35. Lopez-Alias JF, Martinez-Gomis J, Anglada JM, Peraire M. Ion release from dental casting alloys as assessed by a continuous flow system: nutritional and toxicology implications. Dent Mater 2006;22:832-7. 36. Zhang BB, Zheng YF, Liu y. Effect of Ag on the corrosion behavior of Ti-Ag alloys in artificial saliva solutions. Dent Mater 2009;25(5):672-677. 37. Shim HM, Oh KT, Woo JY, Hwang CJ, Kim KN. Corrosion resistance of titanium-silver alloys in an artificial saliva containing fluoride ions. J Biomed Mater Res B 2005;73:252-257. 38. Yamazoe J, Nakagawa M, Matono Y, Takeuchi A, Ishikawa K. The development of Ti alloys for dental implant with high corrosion resistance and mechanical strength. Dent Mater J 2007;26:260-267. 39. Foit J, Joska L.. Influence of porosity on corrosion behaviour of Ti-39Nb alloy for dental applications. Biomed Mater Eng 2013;23(3):183-95. Dental News, Volume XXI, Number III, 2014



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20 Prosthetic Dentistry

Repair of an Implant-Supported Porcelain-Fused-to-Metal Restoration in Under-Occlusion: A Case Report Dr. Norma Ziadeh Dr. Danielle El Hakim

Abstract This paper presents an indirect intraoral repair procedure that may be used to overcome an under-occlusion defect on an implant-supported porcelain-fused-to-metal (PFM) fixed partial denture. In the present technique, onlay ceramic restorations were adhesively bonded to the original PFM. The reparation was quick, relatively affordable and easier than removing the bridge and making a new one. This procedure provided good aesthetic and functional results.

Introduction Fracture of porcelain is a frequent mechanical complication in implant-supported prosthesis. The reparation can present difficult challenges to the practitioner. Due to the brittle nature of the porcelain and its fabrication process requiring firing, new porcelain can hardly be added to an existing restoration intra-orally.1 Intra-oral repair options provide the possibility of repairing the porcelain in the patient’s mouth preventing replacement of the complete restorations.1,3 Repair alternatives are classified in two categories: the direct and the indirect techniques.4 In the direct technique, composite resin is applied directly to the fractured restoration with the aim to reestablish function and aesthetics. Several articles2-4 have been published describing the indirect technique whereby the remainder of the restoration is prepared and a lab-fabricated restoration is cemented or bonded on the remaining substrate. This technique is more appropriate for large fractured surfaces, in posterior areas with heavy functional load, or where aesthetic result is important; however, it requires a second appointment.2-4 Dental News, Volume XXI, Number III, 2014

No previous publications have reported the use of this approach to adjust the occlusal plane. This paper describes an indirect intraoral repair technique for an implant-supported porcelainfused-to-metal fixed partial denture in underocclusion. CAD/CAM onlay ceramic restorations were used to treat the defect.

Case-report A 45-year old woman came to the dental office complaining of unaesthetic smile and poor chewing ability on the left side. Clinical examination revealed a disharmony of the occlusal plane, poor restorations, missing teeth and a 4 unit implant-supported PFM bridge in the lower left area in under-occlusion (fig 1). Fig 1

Fig.1: Clinical view showing the under-occlusion in the lower left mandible.

Radiographic examination (fig 2) showed the presence of radiolucency around one implant (the third most distal) and an unfamiliar screw element in the last implant all this with good

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22 Prosthetic Dentistry clinical and radiographic adaptation of the prosthesis. Probing of the third implant was executed, of 5mm depth, no pus or bleeding signs were found around it. A slight redness on the gingival margins around the implants due to plaque retention caused by poor mouth hygiene.

Fig 3

Fig 2

Fig.3: Preparation of the ceramic. A 1 mm depth and 1.5 mm height with fine grit 25micron rounded shoulder burs. Fig 4 Fig.2: Initial radiographic examination. Note the presence of radiolucency around the third most distal implant and an unfamiliar screw element in the most distal implant. (right to the photo)

A full-mouth rehabilitation was indicated, changing all the deteriorated restorations and crowns, placing implants in edentulous areas, to adjust the occlusal plane including 2 implants in upper maxilla facing the 4 unit implant supported PFM’s. The patient was informed about his problem and treatment alternatives; After all options discussion, a deep scaling of the implant surface in question was implemented and an indirect repair was decided without removing the existing 4-element restoration. Since removal of the bridge could potentially result in deterioration of the abutments especially the most distal one where an unknown metallic screw is used to fix the abutment, which may lead to loosing the last implant as well as the implant with bone resorption and the inability to place 2 other implants in this site because of the insufficient bone height above the inferior dental nerve.

Repair technique Study casts were mounted in articulator and a full wax-up was carried out to evaluate the height or space to be corrected. Buccal, palatal, mesial and distal preparations of 1 mm depth and 1.5 mm height were created using fine grit 25 micron burs (Komet Dental, Lemgo, Germany) to prevent cracks in the prepared ceramic. With the occlusal present defect, no occlusal reduction was needed (fig 3). A provisional restoration was made using a silicon key as mold copying the morphology of the wax-up. The temporary used between the two appointments (fig 4) helped in testing the new occlusion. A one-step polyether impression (ImpregumTM PentaTM medium-bodied and ImpregumTM GarantTM L DuoSoftTM light-bodied consistency) (3M ESPE, Germany) in custom tray was taken for the fabrication of the master cast. Bite Dental News, Volume XXI, Number III, 2014

Fig.4: Provisional restoration from wax up



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24 Prosthetic Dentistry registration, shade selection was done to match the new onlays with the existing bridge. The plaster cast was scanned with the indirect in lab technique and CAD/CAM onlays were milled (IPS e.max CAD, Ivoclar Vivadent, Schaan, Liechtenstein). The onlays were tried in mouth and checked for marginal adaptation and final outcome prior to bonding. Internal surfaces of the IPS e.max onlays were etched with 9.5% hydrofluoric acid for 20 seconds. For control of the oral cavity humidity and patient protection due to the inherent risks of the hydrofluoric acid, field isolation was obtained with the aid of a rubber dam, a lip expander and the use of a protection eyewear. The prepared surface of the feldspathic restoration was etched for 2 minutes with the same acid (fig 5). After rinsing with water for 30s and drying the ceramics with an air stream, a one bottle silane coupling agent (Monobond S, Ivoclar Vivadent, Schaan, Liechtenstein) was applied on both surfaces, left undisturbed for 1 minute and then air dried. Fig 5

After 6 months of treatment, the full-mouth rehabilitation was completed and the patient reestablished function and esthetics. The comfort in chewing food was expressed by the patient in the one-year follow up. The prosthesis has been in the mouth for 2 years (fig 7), and no visible alterations have been observed so far.

Discussion Other treatment modalities could have been considered in this case; Total replacement of the bridge or, even more, replacement of the defected implant(s). This would have made the treatment extremely expensive and time-consuming, besides leaving the patient vulnerable to a more complicated situation. The CAD/CAM restorations allow less stress on the ceramic to ceramic interface and more accuracy of fit. IPS e. max CAD is a high-strength Fig 7

Fig.5: Use of a rubber dam for etching and bonding

Finally, the ceramic onlays were adhesively bonded to the prepared surface using the dual-curing luting composite, Variolinc N (Ivoclar Vivadent, Schaan, Liechtenstein), and the interface margin was polished (fig 6). At the end of the bonding session, occlusal contact points Fig 6 were verified with 12 Microns articulating paper (Arti-fol, Bausch, Koln, Germany), for any occlusal or lateral prematurity contacts, to achieve a harmonic distribution of the occlusion. After the contacts adjustments a ceramic polishing kit (Komet Dental, D端sseldorf, Germany) was used with 3 progressive granulometries and a polishing paste (Intensive Unigloss Paste, Intensiv, Montagnola, Switzerland)

Fig.6: Final occlusal view, onlays bonded Dental News, Volume XXI, Number III, 2014

Figure 7: Radiographic examination and clinical view after 2 years.



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26 Prosthetic Dentistry lithium-disilicate-based glass ceramic with high edge stability. With strength of 360 to 400 MPa, the material is suited to the fabrication of fully anatomical and partially reduced anterior and posterior crowns.10 When repair of ceramic restorations is considered, a strong and durable bond between the crown and repairing ceramic must be achieved. A strong resin bond relies on micromechanical interlocking and chemical bonding to the silanized ceramic and bridge surfaces, which requires roughening (HF) and cleaning for adequate surface activation.4 Several considerations should be accounted for when choosing the material of the repair onlay restorations. Feldspathic ceramics, used as veneering porcelain in PFM restorations and lithium disilicate onlays are both glass-ceramic materials3 allowing etching process. Ceramic-ceramic compatibility is important for enhanced esthetic outcome and better bond. Successful material combinations should have close thermal expansion coefficients to avoid any thermal stresses that may lead to a future cracking or debonding. It is known that lithium disilicate is a brittle material but it gets its strength when bonded correctly. Many studies were published describing how to prepare the surface of a fractured restoration for intraoral repair.1-4 For glass-ceramic surfaces, the use of silane seems to be essential, whereas an appropriate etching and a mechanical treatment depend on the kind of the ceramic. Hydrofluoric (HF) etching can achieve a proper surface roughness, because the glassy matrix is selectively removed and crystalline structure is exposed.3-7 For instance, with the lithium disilicate, 9,5% HF acid applied for only 20 seconds is successful to provide a proper etch, while for the feldspathic ceramic,8,9 a 2-2.5 minutes is needed (9,5% HF). Intraoral use of hydrofluoric acid is controversial because of its hazardous properties.1,3,4 Therefore, clinicians should never use it without a rubber dam and eyewear protection. Chemical bonding is achieved by application of a silane.3-6,11 Silane solutions are bifunctional molecules that bond silicone dioxide (SiO2) with hydroxyl groups on the ceramic surface and silane is a crutial agent for a satisfying resin bond to glass ceramics; it has also a functional group that co-polymerizes with the organic matrix of the resin. Additionally, silanization increases the wettability of the bonded surface. As a general rule, for most systems, fresh chemically active silane (one to two coats) should be applied and allowed to dry for a minimum of 30 seconds to 1 minute in room temperature followed by a gentle warm-air drying (for 60 seconds). To be noted that extended time of silanized ceramic could lead to losing the bonding properties by chemical transformation of silane into siloxane (inactive saturated formula). VariolinkN is a dual-curing luting composite product for adhesive luting of glass-ceramic, lithium disilicate and composite restorations. It is composite resin cement,5 with modified formula and has the advantages of high strength, high adhesion, low solubility, and aesthetic results. This allows it to be used with brittle, esthetic restoration types such as glass-ceramics and indirect composite or in cases where retention is critical. The ultimate success and longevity of intraoral porcelain reparations is a multifactor chain. The extent of the repair, occlusal forces applied on it, and the patient’s oral habits, oral hygiene, and esthetic demands are some of the factors that might contribute to the survival of the reparation. The use of a rubber dam is essential to provide adequate isolation for the adhesive steps, and the Dental News, Volume XXI, Number III, 2014

occlusion must be carefully adjusted after the bonding. This technique was never described in the litterature.

Conclusion The replacement of a multi-unit implant supported bridge with under-occlusion problem may not necessarily be the most suitable solution because of added cost, chair time required and related removal complications. Indirect intraoral reparation using ceramic onlays restorations may offer appropriate therapeutic alternative with short-term clinical success. Further clinical cases and long term follow up are needed in order to implement this technique as a long term solution for under-occlusion metal ceramic prosthesis.

References 1. Ozcan M. Evaluation of alternative intra-oral repair techniques for fractured ceramic-fused-to-metal restorations. J Oral Rehabil 2003; 30:194-203. 2. Galiatsatos AA. An indirect repair technique for fractured metal-ceramic restorations: a clinical report. J Prosthet Dent 2005; 93:321-323. 3. Kimmich M, Stappert CFJ. Intraoral treatment of veneering porcelain chipping of fixed dental restorations. A review and clinical application. J Am Dent Assoc 2013; 144:31-44. 4. Hammoud BD, Swift Jr EJ, Brackett WW. Intraoral repair of fractured ceramic restorations. J Compil 2009; 21:275-284. 5. Blatz MB, Sadan AS, Kern M. Resin-ceramic bonding: a review of the literature. J Prosthet Dent 2003; 89:268–274. 6. Alex G. Preparing porcelain surfaces for optimal bonding. Compend Contin Educ Dent 2008;29:324–335. 7.Vidotti HA, Garcia RP, Conti PCR, Pereira JR, Valle ALd. Influence of low concentration acid treatment on lithium disilicate core/ veneer ceramic bond strength. J Clin Exp Dent. 2013; 5:157-162. 8. Santos Jr GC, Santos MJMC, Rizkalla AS. Adhesive cementation of etchable ceramic esthetic restorations. J Can Dent Assoc 2009; 75:379-384. 9. Soares CJ, Soares PV, Pereira JC, Fonseca RB. Surface treatment protocols in the cementation process of ceramic and laboratoryprocessed composite restorations: a literature review. J EsthetRestor Dent 2005; 17:224-235. 10. Reich S, Fischer S, Sobotta B, Klapper HU, Gozdowski S. A preliminary study on the short-term efficacy of chairside computer-aided design/computer-assisted manufacturing- generated posterior lithium disilicate crowns. Int J Prosthodont. 2010 May-Jun; 23(3):214-6. 11. Culp L, McLaren EA. Lithium disilicate: the restorative material of multiple options. CompendContinEduc Dent 2010; 31:716-725.

28 Oral Surgery

Role of Erupting Third Molars in Causing Dental Crowding

Dr. Parmanand Dhanrajani Oral surgeon Dr. Gregory Bellamy Chief dental officer

HCF Dental Centre Sydney, Australia

Despite numerous attempts to clarify the role of third molars in causing late anterior crowding, the issue remains controversial. This has been extensively reviewed in the literature with different conclusions.1,2 Moreover, orthodontic patients and their parents are often concerned that third molars will threaten the stability of orthodontic results, and frequently cite the eruption of third molars as causing redevelopment of their malocclusion in the form of anterior crowding.3 Being in the field of oral surgeon for more than two decades it becomes difficult to answer patient as to whether the wisdom teeth will cause crowding of anterior teeth or not. Recently my colleague referred a 22 years old young man for the removal of left both upper and lower third molars due to crowding on the left side, the patient complaint was of left anterior crowding. The patient reported a history of orthodontic treatment, his right upper and lower third molars were removed 3 years previously. On examination, 28 and 38 were impacted and he had crowding of anterior teeth on left side more on lower jaw (fig 1). Orthopantomogram

Fig 1

Fig 2

Fig.2: Photograph showing anterior crowding on left side

showed mesioangular 38 and impacted 28 high (fig 2). Patient had the 18 and 48 removed after orthodontic treatment but did not have the 28 and 38 removed until he was referred again this time. Clinical and orthopantomogram findings were very suggestive of erupting third molars having a definitive role in causing anterior crowding. Although this is a single case but we cannot ignore the finding of these clinical implications. We leave to clinicians to decide whether to remove, prophylactically, erupting third molars after orthodontic treatment.

References 1. Sidlauskas A, Trakiniene G. Effect of the lower third molars on the lower dental arch crowding. Stomatologija, Baltic Dental and Maxillofacial Journal 2006; 8:80-84. 2. Lindauer SJ, Laskin DM, Tufekci E, Taylor RS, Cushing BJ, Best AM. Orthodontists and surgeons opinions on the role of third molars as a cause of dental crowding. AM j Orthod Dentofac Orthop. 2007; 132:43-48. 3. Tufecki E, Svensk D, Kallunki J, Huggare J, Lindauer SJ, Laskin DM. Opinions of American and Swedish orthodontists about the role of erupting third molars as a cause of dental crowding. Angle Orthod. 2009; 1139-1142.

Fig.1: Orthopantomogram showing impacted left lower third molars with anterior crowding Dental News, Volume XXI, Number III, 2014

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Good brushing technnique can be enhanced with the use of a specially designed dentifrice to help maintain good gingival health.18,19

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In vitro studies have shown that the hydroxyapatite-like layer starts building from the first use7-9* and is up to 50% harder than dentine.9,14 The hydroxyapatite-like layer binds firmly to collagen within exposed dentine10,15 and has shown in in vitro studies to be resistant to daily physical and chemical oral challenges,9,14-17 such as toothbrush abrasion16 and acidic food and drink.14-17

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Baseline 6 weeks NovaMin® containing dentifrice

Baseline 6 weeks Placebo control

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In vitro studies show that a hydroxyapatite-like layer forms over exposed dentine and within the dentine tubules:7,9,10,12,13 Hydroxyapatite-like layer over exposed dentine

Hydroxyapatite-like layer within the tubules at the surface

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References: 1. Du MQ et al. Am J Dent 2008; 21(4): 210−214. 2. Pradeep AR et al. J Periodontol 2010; 81(8): 1167−1113. 3. Salian S et al. J Clin Dent 2010; 21(3): 82-87. Prepared November 2011, Z-11-496. 4. Tai BJ et al. J Clin Periodontol 2006; 33: 86-91. 5. Devi MA et al. Int J Clin Dent Sci 2011; 2: 46-49. 6. GSK data on file (study 23690684) 7. LaTorre G, Greenspan DC. J Clin Dent 2010; 21(3): 72-76. 8. Edgar WM. Br Dent J 1992; 172(8): 305-312. 9. Burwell A et al. J Clin Dent 2010; 21(Spec Iss): 66–71. 10. Efflandt SE et al. J Mater Sci Mater Med 2002; 26(6): 557-565. 11. de Aza DN et al. J Mat Sci: Mat in Med 1996; 399–402. 12. Arcos D et al. A J Biomed Mater Res 2003; 65: 344–351. 13. Earl J et al. J Clin Dent 2011; 22[Spec Iss]: 62-67. (A) 14. Parkinson C et al. J Clin Dent 2011; 22(Spec Issue): 74-81. 15. West NX et al. J Clin Dent 2011; 22(Spec Iss): 82-89. 16. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 68-73. (B) 17. Wang Z et al. J Dent 2010; 38: 400−410. 18. “Dentifrices” Encyclopedia of Chemical Technology 4th ed. vol 7, pp. 1023-1030, by Morton Poder Consumer Products Development Resources Inc. 19. van der Weijen GA and Hioe KPK. J Ciul Periodontal 2005; 32 (Supp 1.6): 214-228. Date of Preparation: July 2013, Code: CHSAU/CHSENO/0008/13

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30 Restorative Dentistry

The effect of aging and thermocycling on adhesive bonding to fluorosed enamel Dr. Wafa H. Alajam, BDS, MDSc, PhD. Assistant Professor, Department of Restorative Dental sciences, College of Dentistry, King Khalid University, Abha, KSA

Dr. Khalid M. Abdelaziz, BDS, MDSc, PhD. Associate Professor in Dental Biomaterials, Department of Restorative Dental sciences, College of Dentistry, King Khalid University, Abha, KSA

Dr. Mohamed M. Almoaleem, BDS, MDSc, PhD. Assistant Professor, Department of Prosthodontics, College of Dentistry, Jazan University, Jazan, KSA

Abstract Background Adhesive bonding to tooth surfaces could be affected by aging and structural abnormalities of tooth tissues. This study evaluated the shear bond strength of 2 contemporary adhesives to fluorosed tooth enamel following wet aging and thermocycling.

Materials and Methods Two groups (n=40 each) of extracted premolars were respectively selected with mild and moderate fluorosis. Another 40 premolars with no fluorosis served as control. Cylinders of nanofilled composite were bonded in two subgroups onto buccal enamel of all teeth using AdperTM Single Bond 2 (ASB) and Adper Prompt L-Pop (ALP) adhesive systems (n= 20 each). Before testing the shear bond strength of all groups, 10 specimens from each of their subgroups were subjected to 6 months of wet aging in distilled water at 37±1oC and thermocycling at 5, 37 and 60oC with 30s dwelling time for 5000 cycles (Class 1). The other 10 were tested after 24h of wet storage with no thermocycling (Class 2). Both one-way ANOVA and Tukey’s comparisons (α =0.05) were then used to statistically analyze the collected data. The fracture surfaces of all specimens were also inspected to determine the common mode of bond failure.

Results No differences were detected between bonding values of both adhesives to normal and fluorosed enamel (P>0.05). Wet aging and thermocycling has no effect (P>0.05) on the bonding values. The reported bond failures were mainly belonged to admixed and adhesive modes. Dental News, Volume XXI, Number III, 2014

Conclusion Both ASB and ALP adhesives provide comparable bonding values to normal and fluorosed tooth enamel. Wet aging and thermocycling have no adverse effect on the adhesive bonding to tooth enamel with different degrees of fluorosis.

Keywords Adhesive bonding, aging, enamel, fluorosis, thermocycling.

Introduction The esthetic perception of teeth is seriously affected in presence of dental fluorosis.1 This condition usually alters the normal structure of tooth enamel that, in some instances, requires dental intervention to restore teeth esthetic and function.2 The restoration process mostly utilizes resin composites that normally retain micromechanically to the etched enamel surfaces,3,4 in spite of the expected difficulty to etch the hypermineralized, fluorosed enamel.5,6 Originally, the standard 15-60s enamel etching7,8 looks not enough to provide an acceptable shear bond strength of resin composites to fluorosed teeth enamel.2,3,9 However, grinding some of surface enamel improves the bonding values.10 Sometime ago, dental manufacturers introduced a variety of self-etch, 1 and 2- step adhesives aiming to reduce the number of application steps and to save the operators’ time accordingly. However, the performance of these adhesives in presence of fluorosed enamel still not affirmed yet.11-14 Shida et al.15 reported that water fluoridation has an adverse influence on the etching efficacy of the self-etching adhesives. More researchers correlated the noted reduction in the bond strength of these to the

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32 Restorative Dentistry severity of enamel fluorosis,16 although others deduced no difference in the bond strength to normal or fluorosed enamel surfaces.17 To date, a contradiction is obvious between the results of some studies. Some studies10,18 showed better bonding of acid-etch adhesive systems to fluorosed enamel in comparison to self-etching adhesive. Other investigators19 encountered the reverse results as the 2-step self-etching adhesives provided higher bond strength values to fluorosed enamel than that obtained by the other types of adhesives. Moreover, no study concerned about the effect of aging and thermocycling on the bond strength of contemporary adhesive to the fluorosed enamel of patients in endemic areas like Saudi Arabia. Depending on the proceedings, this in vitro study aims to evaluate the shear bond strength of both total and self-etching dental adhesives to enamel surfaces with mild and moderate fluorosis following wet aging.

Materials and methods Two groups of extracted premolars with mild and moderate fluorosis (n=40 each) were selected for this in vitro study. Another 40 premolars with no fluorosis served as control. All teeth were collected out of Saudi orthodontic patients by 2 investigators following the clinical criteria of Thystrup and Fejerskov.20 Teeth scored 0 were considered normal, while those scored 1-3 and 4-6 were respectively classified as mildly and moderately-fluorosed (Table 1). After cutting their roots off, selected teeth were embedded horizontally into auto-polymerizing acrylic resin blocks (Meliodent, Heraeus Kulzer, Hanau, Germany) with their buccal surfaces up. The exposed buccal surfaces together with the acrylic top surfaces were then flattened up using 220-800 grit sandpaper discs (Wetordry, 3M Collision Repair, St. Paul, MN, USA). Cylinders of nanofilled composite restorative (Filtek Z350, 3M ESPE, St. Paul, MN, USA) were incrementally-built-up in a rubber mold, 3mm in both diameter and height, and bonded to the prepared buccal surfaces of teeth in each group using either a total or a self-etching adhesive system (n= 20 each) .

In subgroup 1, an Adper Single Bond 2 (ASB) adhesive (3M ESPE, St. Paul, MN, USA) was rubbed in 2 coats against the buccal enamel surfaces following a standardized 15s etching (Scotchbond etchant, 3M ESPE, St. Paul, MN, USA). The adhesive material was left undisturbed for 15s, air thinned, and light cured (LEDition, Ivoclar Vivadent, Schaan, Liechtenstein) for 15 more seconds before building the composite cylinders up. The single-step Adper Prompt L-Pop (ALP) (3M ESPE, St. Paul, MN, USA) self-etching adhesive system was used to bond composite cylinders to the non-etched enamel surfaces in subgroup 2. Pouches contents were mixed together for 5s with aid of the supplied brush. The mixed material was then rubbed onto enamel surfaces in 2 coats. The material was left in contact with enamel without disturbance for 15s, air thinned and cured for another 15s. Before testing the shear bond strength of all groups, 10 specimens from each of their subgroups were subjected to 6 months of wet storage in distilled water at 37±1oC and thermocycling at 5, 37and 60oC with 30s dwelling time for 5000 cycles (Class 1). The other 10 were tested after 24h of wet storage with no thermocycling (Class 2). The shear bond strength of all test specimens was tested on a universal testing machine (WP 300 universal material tester, G.N.U.T Gerätebau GmbH, Fahrenberg, Germany) running at a

Table 1. Clinical findings of teeth with different degrees of fluorosis Type of fluorosis No fluorosis

TFI scores 0

Clinical findings Normal enamel translucency following prolonged drying

Mild fluorosis


Smooth surface enamel usually shows pronounced lines or areas of opacities. Similar areas of opacities are notable on the occlusal surface and accompanied sometimes with worn areas circumscribed by a rim of opaque enamel.

Moderate fluorosis


Marked opacity or chalky-white appearance of enamel is obvious on smooth tooth surfaces. Opacity of occlusal enamel is usually accompanied with pronounced attrition or pitting 2-3mm in diameter.

Sever fluorosis


Loss of outermost smooth surface enamel involving ≥ ½ of entire surface. Marked occlusal attrition and deviation from normal tooth configuration are obvious. A cervical rim of normal enamel is usually noticed.

• TFI= Thystrup and Fejerskov index20 Dental News, Volume XXI, Number III, 2014

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34 Restorative Dentistry crosshead speed of 0.5 mm/min. All specimens were mounted horizontally in a specially-designed metal jig. A knife-edged rod attached to the moving upper member of the testing machine aided in stressing the enamel-composite adhesive junction. The maximum force at fracture was recorded for each specimen and the shear bond strength was then calculated in reference to the bonded surface area. The recorded bond strength data were then analyzed statistically using both one-way ANOVA and Tukey’s HSD comparisons (α =0.05) to stand on the significance of differences detected between different classes of test specimens. The fracture surfaces of each specimen were inspected at X10 (A. Kruss Optronic GmbH, Hamburg, Germany) under low angle illumination in order to categorize the mode of bond failure. The adhesive type of bond failure was recorded when a complete separation was detected at either adhesivetooth or adhesive-composite interface, while the cohesive one was recorded when the separation was entirely detected within composite or enamel bulk. The admixed type of bond failure was recorded when the debonding pattern showed signs of both previously described adhesive and cohesive failures. To confirm the recorded findings, a further instrumental assessment of some fracture surfaces belonging to the 3 different categories of bond failure was carried out using scanning electron microscope (SEM) (JEOL, JCM-5000, NeoScope, JEOL Ltd, Tokyo, Japan) at X100 original magnification.

Results Shear bond strength data are summarized in Table 2. The initial statistical testing of the collected shear bond strength data indicated some differences

between the 12 tested classes of specimens (ANOVA, P= 0.001086). Further analysis using Tukey’s comparisons showed that most of the tested classes have no differences either from the controls or between each other (P> 0.05). Considering each group of specimens, no difference was noticed between bond strengths of both adhesives to normal and mildly-fluorosed enamel surfaces (Groups 1 and 2) even when aging and thermocyling were considered. However in group 3 (Moderately-fluorosed enamel), both the non- aged ASB and the aged ALP classes of specimens showed lower bond strength values when compared with ALP control class (ALP bonded to normal enamel with no aging) (Tukey’s comparisons, P= 0.03474 and 0.03835), although they were not different from each other (Tukey’s comparisons, P=1). The same 2 classes also showed lower bond strength values than that recorded for the nonaged ALP class of specimens of group 2 (ALP bonded to mildly-fluorosed enamel with no aging) (Tukey’s comparisons, P= 0.01786 and 0.01986) .

Table 2. Shear bond strength values (MPa) to normal and fluorosed tooth enamel Normal enamel


Mildly-fluorosed enamel

Moderately-fluorosed enamel







No aging

16.16± 0.65 (control)

16.82± 3.34 (control)

15.73± 0.98

16.99± 3.36

14.14± 0.85 #$

16.30± 1.17

Aging and thermocycling

16.45± 0.55

16.72± 1.24

15.55± 1.93

15.89± 1.87

14.98± 0.73

14.16± 0.52#$

• ASB = Adper Single Bond 2, ALP= Adper Prompt L-Pop • # Significantly different from ALP bonded to normal enamel with no aging (control). (Tukey’s comparisons, P= 0.03474 and 0.03835) • $ Significantly different from ALP bonded to mildly-fluorosed enamel with no aging. (Tukey’s comparisons, P= 0.01786 and 0.01986)

Table 3. Incidence (%) of different modes of bond failure Grouping

Failure mode

No aging

Normal enamel

Mildly-fluorosed enamel

Moderately-fluorosed enamel







Adhesive Cohesive Admixed

40 0 60

40 0 60

60 10 30

50 0 50

50 0 50

50 0 50

Adhesive Aging and thermocycling Cohesive

40 20 40

50 10 40

70 0 30

50 0 50

40 0 60

30 0 70


• ASB = Adper Single Bond 2, ALP= Adper Prompt L-Pop Dental News, Volume XXI, Number III, 2014


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36 Restorative Dentistry Inspection of fracture surfaces (Table3) indicated that both adhesive and admixed types are the commonly detected modes of bond failure for specimens bonded with either ASB or ALP in all groups and subjected to no aging. On the other hand, subjecting the bonded specimens to wet aging and thermocycling helped the adhesive mode of bond failure to be dominant on expense of the admixed one. The SEM images also confirmed that most of the bond failures belonged to the admixed and adhesive modes (Figures 1-4), although very few surfaces showed evidence of cohesive failure within the composite body (Figure 5).


fluorosed enamel surfaces (Table 1). This finding could be related to the enamel’s preparation procedure done at the time of bonding. The grinding and flattening of enamel helps, in some way, get rid of the enamel layer that normally resists etching due to its abnormal structure. In spite of the detected non-meaningful differences, the two adhesive systems, ASB and ALP, showed no logical differences when bonded to Fig 3

Fluorosis of tooth enamel is usually associated with histologic changes that reflect on the normal tooth esthetic.1 Adhesive bonding of composite restorative is considered a time-saving approach to restore the fluortic defects,2 in spite of the known difficulties of enamel etching.21,18 This fact displays evident controversies about the bonding performance of different types of contemporary adhesive systems to fluorotic enamel.3,5,6,21 Accordingly, this in vitro study was designed to evaluate the bonding values of a total-etch, 2-step and 1-step, selfetching adhesives before and after wet storage and thermocycling. For standardization, the selection of fluorosed teeth was done according to the detected clinical characteristics following the modified Thylstrup and Fejerskov index20 shown in Table 1. On the other hand, testing the shear bond strength was found to have close proximity to the actual dislodging forces that normally act on adhesive veneers. The outer 0.5 mm of mid-labial enamel surface was ground away creating flat enamel surfaces in order to mimic the clinical preparation characteristics for veneering restoration, and to help standardize and measure the bonding surface area. In disagreement with Weerasinghe et al.,21 results of this study showed no differences in the bonding values of the selected adhesives to normal and

Fig. 3: Admix mode of bond failure of Adper Single Bond 2 in aged moderately-fluorosed enamel specimen. Fig 4

Fig 1

Fig. 4: Adhesive mode of bond failure of Adper Prompt L-Pop in aged moderately-fluorosed enamel specimen.

Fig. 1: Admix mode of bond failure of Adper Single Bond 2 in non-aged normal enamel specimen.

Fig 5

Fig 2

Fig. 2: Admix mode of bond failure of Adper Single Bond 2 in aged mildy-fluorosed enamel specimen. Dental News, Volume XXI, Number III, 2014

Fig. 5: Cohesive mode of bond failure (composite bulk) of Adper Single Bond 2 in non-aged mildfluorosed enamel specimen.

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38 Restorative Dentistry enamel surfaces with mild and moderate fluorosis (Table 2). These data indicated that the investigated self-etching adhesive system is as effective as those utilizing phosphoric acid etching and come, accordingly, in coincidence with those of Pashley and Tay, and Tay et al.,22,23 They postulated that the severity of etching does not affect the values of adhesive bond strength to tooth enamel, although this thought is currently in conflict with the deduction of Ateyah and Akpata.6 Some investigators24 believe that the lower acidity (higher pH) of self-etch adhesive in comparison to the commonly used 35% phosphoric acid etchant (pH=0.7) could suppress their etching power. Therefore, this study utilized a self-etch adhesive with comparable acidity (pH=0.8-0.9) to that of regular etchants and this could be attributed to its efficient bonding to tooth enamel.24,25 In contrary, Ostby et al.25 noticed acceptable bonding of the self-etch adhesives with higher pH (2.7) to tooth enamel and deduced minimal importance of this factor accordingly. An additional debate over the performance of different adhesive systems bonding to fluorotic enamel was also noticed between some previous studies. Waidyasekera et al.26 reported higher bond strength of self-etching adhesives to fluorosed tooth tissues in comparison to total-etch adhesives, while Ertugrul et al.27 stated that the use of etch-and-rinse dentin bonding technique produced higher bond strengths of the resin composite tested to fluorotic and nonfluorotic enamel compared to self-etching techniques. As the restoration ages in service, the bond quality usually shows a sort of deterioration as a result of the mechanical and thermal stresses that continuously develop at the bonding interfaces.28 Both water storage and thermocycling are procedures usually used to simulate clinical aging. In this study and in agreement with Khoroushi and Rafiei,29 5000 cycles of thermocycling at 5, 37 and 60oC together with 6 months aging in wet environment had no significant effect on the recorded shear bond strength data (Table 2); although the mode of bond failure has obviously altered in response (Table 3). The reported bond failures respectively showed admix and adhesive characteristics, with the adhesive mode becoming dominant among aged samples. Accordingly, further photo-micro-graphical studies are required to clarify the effect of aging on the interfacial junction between resin adhesive and fluorosed tooth enamel.

Conclusion Both Adper Single Bond 2 and Adper Prompt L-Pop adhesive systems provided comparable bonding values to normal and fluorosed tooth enamel. Wet aging and thermocycling have no adverse effect on the adhesive bonding to tooth enamel with different degrees of fluorosis.

References 1. Lawson J, Warren JJ, Levy SM, Broffitt B, Bishara SE. Relative esthetic importance of orthodontic and color abnormalities. Angle Orthod 2008; 78(5):889–94. 2. Al-Sugair MH, Akpata ES. Effect of fluorosis on etching of human enamel. J Oral Rehabil 1999; 26(6): 521–8. 3. Adanir N, Türkkahraman H, Güngör AY. Effects of fluorosis and bleaching on shear bond strengths of orthodontic brackets. Eur J Dent 2007; 1(4): 230–5. 4. Buonocore MG. A simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J Dent Res 1955; 34(6): 849–53. 5. Opinya GN, Pameijer CH. Tensile bond strength of fluorosed Kenyan teeth using the acid etch technique. Int Dent J 1986; 36(4): 225–9. 6. Ateyah N, Akpata E. Factors affecting shear bond strength of composite resin to fluorosed human enamel. Oper Dent 2000; 25(3): 216-22. 7. Retief DH, Woods E, Jamison HC. Effect of cavosurface treatment on marginal leakage in class V composite resin restorations. J Prosthet Dent 1982; 47(5): 496-501. Dental News, Volume XXI, Number III, 2014

8. Barkmeier WW, Shaffer SE, Gwinnett AJ. Effects



60 Oper


second enamel acid conditioning on adhesion and morphology.

Dent 1986; 11(3): 111-6 9. Gungor AY, Turkkahraman H, Adanir N, Alkis H. Effects


fluorosis and self etching primers on shear bond strengths of orth-

odontic brackets. Eur J Dent 2009; 3(3): 173–7. 10. Ermis RB, De Munck J, Cardoso MV, Coutinho E, Van Landuyt KL, Poitevin A, Lambrechts P, Van Meerbeek B. Bonding to ground versus unground enamel in fluorosed teeth. Dent Mater 2007; 23(10): 1250-5. 11. Bouillaguet S, Gysi P, Wataha JC, Ciucchi B, Cattani M, Godin CH, Meyer JM. Bond strength of composite to dentin using conventional, one-step and self-etching adhesive systems. J Dent 2001; 29(1): 55–61. 12. Van Meerbeek B, Vargas M, Inoue S, Yoshida Y, Peumans M, Lambrechts P, Vanherle G. Adhesives and cements to promote preservation dentistry. Cavex products 2001; Supplement 6: 119–44. Available at: research/437. 13. Swift EJ Jr. Dentin/enamel adhesives: review of the literature. Pediatr Dent 2002; 24(5): 456-61. 14. Torii Y, Itou K, Hikasa R, Iwata S, Nishitani Y. Enamel tensile bond strength and morphology of resin-enamel interface created by acid etching system with or without moisture and self-etching priming system. J Oral Rehabil 2002; 29(6): 528-33. 15. Shida K, Kitasako Y, Burrow MF, Tagami J. Micro-shear bond strengths and etching efficacy of a two-step self-etching adhesive system to fluorosed and non-fluorosed enamel . Eur J Oral Sci 2009; 117(2): 182–6. 16. Neme AL, Evans DB, Maxson BB. Evaluation of dental adhesive systems with amalgam and resin composite restorations: comparison of microleakage and bond strength results. Oper Dent 2000; 25(6): 512–9. 17. Ratnaweera PM, Nikaido T, Weerasinghe D, Wettasinghe KA, Miura H, Tagami J. Micro-shear bond strength of two all-in-one adhesive systems to unground fluorosed enamel. Dent Mater J 2007; 26(3): 355-60. 18. Torres-Gallegos I, Martinez-Castañon GA, Loyola-Rodriguez JP, Patiño-Marin N, Encinas A, Ruiz F, Anusavice K. Effectiveness of bonding resin-based composite to healthy and fluorotic enamel using total-etch and two self-etch adhesive systems. Dent Mater J 2012; 31(6): 1021–7. 19. Waidyasekera PG, Nikaido T, Weerasinghe DD, Tagami J. Bonding of acid-etch and self-etch adhesives to human fluorosed dentine. J Dent 2007; 35(12): 915-22. 20. Thylstrup A, Fejerskov O. Clinical appearance of dental fluorosis in permanent teeth in relation to histologic changes. Community Dent Oral Epidemiol 1978; 6(6): 315-28. 21. Weerasinghe DS, Nikaido T, Wettasinghe KA, Abayakoon JB, agami J. Micro-shear bond strength and morphological analysis of a self-etching primer adhesive system to fluorosed enamel. J Dent 2005; 33(5): 419-26. 22. Pashley DH, Tay FR. Aggressiveness of contemporary selfetching adhesives. Part II. etching effects on unground enamel. Dent Mater 2001; 17(5): 430–44. 23. Tay FR, Pashley DH, King NM, Carvalho RM, Tsai J, Lai SC, Marquezini L Jr. Aggressiveness of self-etching adhesives on unground enamel. Oper Dent 2004; 29(3):309–16. 24. Suyama Y, Lührs AK, De Munck J, Mine A, Poitevin A, Yamada T, Van Meerbeek B, Cardoso MV. Potential smear layer interference with bonding of self-etching adhesives to dentin. J Adhes Dent. 2013; 15(4): 317-24. 25. Ostby AW, Bishara SE, Denehy GE, Laffoon JF, Warren JJ. Effect of self-etchant pH on the shear bond strength of orthodontic brackets. Am J Orthod Dentofacial Orthop. 2008; 134(2): 203-8. 26. Waidyasekera PG, Nikaido T, Weerasinghe DD, Tagami J. Bonding of acid-etch and self-etch adhesives to human fluorosed dentine. J Dent 2007; 35(12): 915-22. 27. Ertugrul F, Türkün M, Türkün LS, Toman M, Cal E. Bond strength of different dentin bonding systems to fluorotic enamel. J Adhes Dent 2009; 11(4): 299-303. 28. Yun X, Li W, Ling C, Fok A. Effect of artificial aging on the bond durability of fissure sealants. J Adhes Dent 2013;15 (3): 2518. 29. Khoroushi M, Rafiei E. Effect of thermocycling and water storage on bond longevity of two self-etch adhesives. Gen Dent 2013; 61(3): 39-44.

Dentures contain surface pores in which microorganisms can colonise.1 Corega速 cleanser is proven to penetrate the biofilm* and kill microorganisms within hard-to-reach surface pores.2

Help your patients eat, speak and smile with confidence with the Corega速 denture care regime. SEM images of denture surface. *In vitro single species biofilm after 5 minutes soak References: 1. Glass RT et al. J Prosthet Dent. 2010; 103(6): 384-389. 2. GSK Data on File, Lux R. 2012. Date of preparation: June 2014. Ref: CHSAU/CHPLD/0008/14c

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40 Oral Pathology

Oral Ulcers in Infants and Children Part II: Treatment

Dr. Sawsan Nasreddine, BDS, DESS Pediatric Dentistry, DESS Public Health Dentistry, Department of Public Health Dentistry. Dr. Antoine Cassia, Dr. Chir. Dent., Dr. Sc. Odont., DUPRMF, Associate Professor and Former Chairperson, Department of Oral Pathology and Diagnosis, Director of LASER Unit.

Lebanese University School of Dentistry, Beirut.



Many treatments have been advocated for oral ulcers. These may be preventive, symptomatic and etiologic. They may be local or systemic and based upon antiseptics, antibiotics, corticosteroids, antirheumatics, anti-inflammatory, hormone therapy, antiviral, colchicine, thalidomide, interferon, hyaluronic acid, laser, cautery, cryotherapy, bioadhesives, homeopathy, vitamins as well as sundry other management strategies and combinations of various medications. Systemic treatment may be appropriate for severe and resistant cases.

Most injuries to the oral mucosa are painful and are a common reason for patients to choose selftreatment or to seek professional dental help. Whether caused by mucosal trauma or common aphthous ulcer, these benign lesions are source of acute pain that can disturb daily activities. Many products are available for the treatment of oral soreness. Over-the-counter products indicated for oral ulcers include different formulations and different active compounds.1


It consists to prevent the appearance of the ulcer, especially traumatic ulcer, like: - Using film cover. (Fig.1) - Hydration of the cotton roll before removing it. - Taking care when you put the suction tip. - Advise patient with alveolar nerve block analgesia to stop eating and sleeping for two hours, and for children who did analgesia for the first time to be for two hours under supervision of an adult.

Preventive treatment, symptomatic treatment, laser treatment and etiologic treatment.


Fig 1

Modalities of treatment a. Preventive treatment

b. Symptomatic treatment Fig.1-a: traumatic ulcer related to radiographic film


Symptomatic treatment is a must even if we are searching for the etiology of ulcers. It consists simply in reducing, even disappearance of symptoms, mainly pain. It can be local or systemic.

Local treatment

Fig. 1-b: film cover Dental News, Volume XXI, Number III, 2014

It consists to cover the ulcer like putting gel which sticks to it and to get it to adhere firmly: this gel should form a protective layer over the ulcer to help make it comfortable2 (Fig.2). Usually, the treatment should be instaured 15 minutes before any painful situation like eating

42 Oral Pathology Fig 2

or speaking by applying on dried lesions (3 to 5 times daily), or according to the manufacturer.

Gel and paste Dental adhesive paste - Solcoseryl速 active ingredients: . Calf blood extract protein-free 2.125mg . Lauromacrogol 400 10mg/g

Dental analgesic paste mainly anesthetic - Emla速 5% cream contains two amide-type local anesthetics, lidocaine 2.5% and prilocaine 2.5% (Fig.3). Prilocaine and lidocaine are classified as amidetype local anesthetics for which serious adverse effects include methemoglobinemia. Although the hydrolyzed metabolites of prilocaine (o-toluidine) and lidocaine (2,6-xylidine) have been suspected to induce methemoglobinemia. When the parent compounds (prilocaine and lidocaine) were incubated with human liver microsomes (HLM), methemoglobin (Met-Hb) formation was lower than when the hydrolyzed metabolites were incubated with HLM.3 - Medijel速 gel active ingredients: . lidocaine hydrochloride and aminoacridine hydrochloride. . Apply Medijel to the painful area. Fig 3

Age and body weight requirements

Maximum total dose of Emla cream

Maximum application area

Maximum application time

0 up to 3 months or < 5 kg


10 cm2

1 hour

3 up to 12 months and > 5 kg


20 cm2

4 hours

1 to 6 years and > 10 kg

10 g

100 cm2

4 hours

7 to 12 years and > 20kg

20 g

200 cm2

4 hours

Fig.3 maximum prescription of Emla 5% cream related to age and body weight requirements as recommended by manufacturer. Dental News, Volume XXI, Number III, 2014

44 Oral Pathology - Orabase® product characteristics: . 20% benzocaine. . Orabase® gives maximum strength pain relief for canker. - Ginvapast® components consist of calcium gluconate, cetylpyridinium chloride and procaine hydrochloride. We can do our own “cocktail” by mixing dental adhesive paste with dental analgesic paste like: Solcoseryl® + Emla® 5% or Orabase® + Solcoseryl®

Dental anti-inflammatory paste - Kenalog® in Orabase (AIS) Kenalog (triamcinolone acetonide 1mg/g) in Orabase 0.1%. It is the theoretical advantage of incorporating a corticosteroid in an adhesive base.4 The active ingredient of Kenalog in Orabase for mouth ulcers relieves pain by reducing the swelling around the ulcer and it speeds up the healing process. The treatment is effective because the active ingredient is a unique paste - Orabase - which keeps the medicine in direct contact with the ulcer. Orabase also helps to prevent the pain because it covers the ulcer, protecting the tender exposed nerves from further irritation. - Pyralvex® Although it is neither a paste nor a gel it contains a few ingredients; however there are two main ingredients: They are the rhubarb extract and salicylic acid. The rhubarb extract is a genuine (natural) extract while the salicylic acid is an acid similar to aspirin.

Patch - RemeSense® It’s a patch active ingredients: . Hyaluronic acid: helps to reform oral tissues . Bark extract of the red mangrove: forms an impervious protective layer over the affected area . Cellulose: creates a strong barrier The patch automatically dissolves after a few hours. - Urgo® active ingredients: Ibuprofen.

Mouthwash • Protective action - Aloclair® Aloclair contains the film-forming agent, polyvinylpyrrolidone. Dosage and administration: . Fill the measuring cap provided to the 5 ml or 10 ml indicator mark. . Rinse the mouth with the liquid for at least 60 seconds. . Gargle and spit out. . Use as needed, up to 3-4 times a day. . May be used by children who are old enough to follow the instructions. • Sodium bicarbonate diluted in warm water • Analgesic and antiseptic - Trachisan® (chlorhexidine gluconate, lidocaine hydrochloride) • Antiseptic - Eludril® Eludril mouthwash contains two active ingredients, chlorhexidine gluconate at 0.20% and chlorbutanol hemihydrate. - Paroex® (chlorhexidine gluconate 0.12%)

- Pansoral® Pansoral contains cetalkonium chloride 0.1mg/g and choline salicylate 87mg/g

- Dologel® Dologel contains Choline Salicylate and Lidocaine Hydrochloride. (AI) Dosage: 8.7% gel: Apply as directed Contraindication: children <12years. Dental News, Volume XXI, Number III, 2014

- Cariax® (chlorhexidine gluconate 0.12%, sodium fluoride) Alcohol-free mouthwashes will generally be more comfortable for the patient to use.5

Systemic treatment Antipyretics/Analgesics Paracetamol/Acetaminophen: 30mg/kg/d every 4 hours - Panadol® 125mg/5ml

:»ŸÉ©dG »`°SÉ«≤dG ºbôdG á``ÄdÉe OGƒ``e % 87

VOCO øe IQƒ£àŸG ƒfÉædG á«æ≤J º««≤àd Gk ójóL kÉ«©Lôe i k ƒà°ùe äOó q M AGOC’G á«dÉY âjRƒÑªμdG ´GƒfCG :(kÉfRh) % 87 á``ÄdÉŸG OGƒŸG áÑ°ùf

AGÎgÓd á≤FÉa áehÉ≤e • »©«Ñ£dG ø°ù∏d πKɇ …QGôM Oó“ • äGhOC’ÉH ¥É°üàd’G ΩóY ,π«μ°ûàdG ádƒ¡°S) á≤FÉa πeÉ©J ádƒ¡°S • (π«μ°ûàdG ó©H ΩGƒ≤dG ≈∏Y á¶aÉÙGh • ójóe ʃd QGô≤à°SG :óeC’G á∏jƒW á«dÉY á«dɪL •

ák fQÉ≤e %50-%30 `H πbCG »éæJGôdG ÖdÉ≤dG áÑ°ùf :ájó«∏≤àdG äRƒÑªμdG ´GƒfCÉH

(kɪéM) %1^57 kGóL ¢†Øîæe »Ñq∏°üJ ¢ü∏≤J • »`dÉY …ƒ``«M π```qÑ≤J • Ò°üb ≥«Ñ£J øeõH á«dɪ÷G á«dÉY äɪ«eÎd AÉHô◊G á«°UÉN •


46 Oral Pathology - Adol® 250mg/5ml

Systemic antibiotics can be used to prevent secondary infectious.4 Other modalities have been used with some success: excision with primary closure, cryosurgery, and topical application of tetracycline followed by cortisone ointment and injection of cortisone directly into the lesion in combination with systemic administration of cortisone.6

Laser treatment Laser technology in pediatric dentistry is a viable treatment modality for children and adolescents. The laser can be thought of as an alternative instrument that sometimes completes and, at other times, substitutes for the traditional techniques. Because of their well documented surgical and clinical advantages, lasers are commonly used on soft tissues in oral pathology. The laser offers a minimally painful treatment option that allows fast healing. Different laser wavelengths can be used with sub-ablative power both to detoxify and dehydrate the ulcer as well as to induce analgesic and bio-stimulating effects.7 Different wavelengths interact differently with a variety of chromophores (e.g. hemoglobin, water, hydroxyapatite) contained in several types of target tissues (e.g. mucosa); therefore, the choice of laser is regulated by the different optical affinity and coefficient of absorption of the tissues for each particular wavelength. Thus, lasers are classified according to their use on the soft tissues exclusively, on soft and hard tissues.7 The low level laser therapy or ‘soft laser therapy’ is effective for some specific applications in dentistry such as in treatment of ulcers. Along with the primary benefit of being nonsurgical, it promotes tissue healing and reduces edema, inflammation and pain. 810, 940 and 980 nm diode laser can be used for the treatment of minor aphthous ulcers and herpetiform aphthous ulcers; both being clinical variants of aphthous ulcers.8 The wound should be cleaned and dried prior to application. At first, laser should be applied in the center of the lesion, in a punctual manner and scanning along lesion at a distance of 5mm, with 2 J/cm² and move to the edges of the wound in a circular scanning manner with 2 to 4 J/cm², according to the extension of the lesion.9 Application frequency: 2-3 applications weekly, with a 24-hour interval, until improvement of painful symptomatology and total tissue repair (Fig.3).


Fig. 3-a,b: Banding laser (courtesy Oral pathology and Oral diagnosis department – LU) Dental News, Volume XXI, Number III, 2014


The performance therapy of laser consists in banding laser. Banding laser consist on the elaboration of a protective layer on the surface of a lesion related to thermal energy (Ray 2005). The erbium family is certainly the most important for its versatility in application. The erbium family includes the erbium-chromium-doped yttrium scandium gallium garnet (Er,Cr:YSGG) and the erbium-doped yttrium aluminum garnet (Er:YAG) lasers. The wavelengths of the two erbium lasers have a lot of clinical overlap in their application but with a more superficial interaction for the Er:YAG, which is primarily absorbed by the water.7 In cases where higher energies are required, amplifiers have to be employed.10 The erbium lasers are indicated in soft tissue treatment when the tissue is lightly vascularized.7 In medical applications, and especially in dentistry, the Erbium lasers represent highly developed commercial lasers with very high yield and efficiency in tissue removal.10 (Fig.4-a,b,c).


Fig 4



Fig 3

Fig. 4-a, Aphthous ulcer can be irritating to patient and can delay treatment. b, ulcer was exposed to laser erbium. c, post operation vision. Courtesy Oral pathology and Oral diagnosis department – UL.

47 Oral Pathology Biopsy must precede laser therapy when there has been an ulcerated area for more than two or three weeks or there is doubt regarding the diagnosis.9

Etiologic treatment It is necessary to eliminate all diseases that can be accompanied by Crohn’s disease and Behçet’s syndrome. We should try to treat the etiology of the ulcer in that case, the treatment is related to each kind of lesion and eventually underlying systemic disease.

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In case of:

Recurrent aphthous ulcers The course of these ulcers varies from few days to over 2 weeks, but usually their duration is of the order of 10 days. Minor aphthae heal without scar formation.11,12 Major aphthous ulcers are difficult to treat. The patients often have had these non healing ulcers for months.5 They can persist for ≥ 6 weeks and commonly leave scars.12 It requires good oral hygiene. Systemic corticosteroids only in most severe cases.13,14 Herpetiform ulcer seems to respond best to tetracycline mouthwash.14 - Ask the patient to change his toothpaste to another one without SLS (Sodium Lauryl Sulfate) when recurrent aphthous ulcers are suspected to relate to SLS components as: . Pronamel (Sensodyne) . Orosafe junior . Oral Balance (Biotène) - Ask the patient blood test if anemia is suspected . Folic acid . Ferritin . Vitamin B12

Primary herpetic gingivostomatitis Normally, the primary herpes simplex infection is self-limiting and the child will recover within 10 days. Children having these lesions decrease their food intake, and it is advisable to adopt a support therapy, which should include: - increase the liquid’s intake - the use of dietary supplements - highly nutritious cold liquid diet 15,16 Systemic antibiotics can be used to prevent secondary infections.6 In severe cases, hospitalization and/or the use of antiviral agents are necessary.16 Active ingredients: - Acyclovir 2 used 3 times per day as: . Zovirax® cream 5% Dental News, Volume XXI, Number III, 2014

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Dental News, Volume XXI, Number III, 2014

49 Oral Pathology . Cyclovax® cream 5% . Supraviron® - Valacyclovir used 3 times per day as: . Valatex® (maximum dose is 1000mg 3 times daily) Valacyclovir is an oral antiviral drug which is active against the herpes viruses. It is used to treat infections with shingles (herpes zoster), and chickenpox (varicella zoster). It belongs to a class of drugs called nucleoside analogs that mimic one of the building blocks of DNA. It stops the spread of herpes virus in the body by preventing the replication of viral DNA that is necessary for viruses to multiply. Valacyclovir, therefore, is active against the same viruses as acyclovir, but Valacyclovir has a longer duration of action than acyclovir, and, therefore, can be taken fewer times each day. Valacyclovir was approved for use by the FDA in 1995.

Traumatic ulcer Most traumatic ulcers heal within 10 days. Oc-

Dental News, Volume XXI, Number III, 2014

casionally, however, a lesion persists for some weeks because of continued traumatic insults or continued irritation by the oral liquids or because of the development of a secondary infection.5 Parents should be warned and children reminded not to bite their lips after mandibular block anaesthesia.14 We should remove the cause of the ulcer in case of denture, orthodontic treatment or a tic.

Factitious ulceration (self-inflicted oral lesions) Frequently the diagnosis can be confirmed only by discrete observation after admission to hospital. The patient’s family doctor should be told of the need for specialist psychiatric accessment.2 No local anesthesia is used as the patient’s pain perception is altered. Non-contingent reinforcement therapy is successfully used to reduce self inflicted oral lesion.17

Viral and bacterial infections Varicella (chickenpox) The virus is extremely contagious and is generally contracted as a childhood infection between 18 months and 5 years of age. The virus is effectively spread by direct contact and even as an airborne infection. The infection generally resolves within 2 weeks.18 Analgesic and antipyretic are often beneficial and refer the patient.

50 Oral Pathology Herpangina

Tuberculosis ulcer

The systemic symptoms resolve within few days and the oral ulcers usually take seven to ten days to heal. In patients with atypical presentations, laboratory confirmation may be required: - Viral cultures from early vesicular lesions or stool specimen analysis are the best techniques in patients with only oral lesions. Viral cultures of the ulcerative lesions will usually be negative. - Serological tests for rising enterovirus antibody titers between the acute and convalescent stages can be done to confirm the diagnosis in questionable cases. In most cases, the infection is self-limiting and without complications. Therapy for these patients is directed toward symptomatic relief. Non-aspirin antipyretics and topical anesthetics are often beneficial19 and the patient should be referred.

Diagnosis is confirmed by biopsy, chest radiography and a specimen of sputum. Myobacterial infection is confirmed by culture. Oral lesions clear up rapidly if vigorous multi drug chemotherapy is given for the pulmonary infection. No local treatment is required,2 the patient should be referred.

Hand, foot and mouth disease Serological confirmation of the diagnosis is possible but rarely necessary as the history, especially of other cases. The disease typically resolves within a week.2 Culture of cutaneous lesions is best for hand, foot and mouth disease.19 Analgesic and antipyretic are usually prescribed and refer the patient.

Malignant ulcers

Squamous cell carcinoma Treatment Rare in children, the detection of this type of ulcer is important because the tumor has a good prognosis if accessible and diagnosed at an early stage. Health professional should educate patients to recognize suspicious lesions and to know the risk factors. A biopsy (or second opinion) should obtain for suspicious lesions and ulcers that persist after the removal of possible causal agents, as these

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52 Oral Pathology







Recurrent Aphthous


Refer the patient





Primary herpetic gingivostomatitis











Hand, Foot and Mouth









Tuberculosis Squamous cell carcinoma are the only reliable methods for establishing a definite diagnosis.4 Indications for biopsy of an oral ulcer: - Of unknown origin that remains without signs of healing after 2 weeks. - Of probable known aetiology (after clinical examination and diagnostic tests) that do not respond to appropriate treatment after 2 weeks - Believed to be caused by precipitant factors, which do not show signs of healing 2 weeks after removal of these factors.4 In small ulcers (<5mm in diameter) an excisional biopsy is recommended (including 2mm of perilesional tissue), whereas in larger ulcers (>5mm in diameter) an incisional biopsy is preferred. The specimen must include part of the ulcer and the perilesional tissue, including the unaffected surrounding epithelium. The centre of the ulcer alone usually does not show diagnostic features. Scalpel or punch biopsies are preferred; other techniques (e.g. lasers, electrical scalpels) are not recommended.4

Conclusion It is essential to review the patient to assess his progress and response to any treatment instituted. It is important that patients are aware of the limitations of treatment.20 An ulcer without pain can be a chronic ulcer, a healing ulcer or a malignant ulcer. A painful ulcer is usually benign.

References 1. Descroix V., Coudert A.E., Vigé A., Durant J.P., Touenay S., Molla M., Pompignoll M., Missika P., Allaert F.A. Efficacy of topical 1% lidocaïne in the symptomatic treatment of pain associated with oral mucosal trauma or minor oral aphthous ulcer: a randomized, double-blind, placebo-controlled, parallel-group, single-dose study. Journal of Orofacial Pain. 2011, Vol.25, nbr 4:327-332. 2. Cawson R.A., Odell E.W. Diseases of the oral mucosa: introduction and mucosal infections. Oral pathology and oral medicine. 8th edition, 2008: 206-216. 3. Higuchi R., Fukami T., Nakajima M., Yokoi T. Prilocaine- and lidocaine-induced methemoglobinemia is caused by human carboxylesterase-, CYP2E1-, and CYP3A4-mediated metabolic activation. Jun 2013, 41(6):122030 4. Fishman S.L., Nisengard R.J., Blozis G.G. Generalized red conditions and multiple ulcerations differential Dental News, Volume XXI, Number III, 2014

X diagnosis of oral lesions.

USA, Mosby, 4th edition, 1991:83-87 5. Munoz-Corcuera M., Esparza-Gomez G., Gonzalez-Moles M.A., Bascones-Martınez A. Oral ulcers: clinical aspects. A tool for dermatologists. Part II. Chronic ulcers clinical and experimental dermatology. 2009, 34:456-461 6. Wood N.K., Goaz P.W. Differential diagnosis of oral lesions. USA, Mosby, 4th edition, 1991:195-221 7. Olivi G., Margolis F.S., Genovese M.D. Pediatric laser dentistry, a user’s guide. Chicago, Quintessence Publishing Co,2011,15-26 8. Tharwani B. Use of soft laser therapy in treatment of aphthous ulcers. Guident, your guide on the path of dentistry. Dec 2012:109-111 9. Brugnera A. jr, Garrini dos Santos A. E. C., Bologna E. B., Pinheiro Ladalardo Th. Ch. C. G. Atlas of laser therapy applied to clinical dentistry, Chicago, quintessence Editora, 2006:34-35 10. Moritz A. Oral laser application. Berlin, Quintessenz VerlagsGmbH, 2006:52-88 11. Field E.A., Allan R.B. Review article: oral ulceration, aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic. Aliment pharmacol ther. 2003, 18:942-962. 12. Munoz-Corcuera M., Esparza-Gomez G., Gonzalez-Moles M.A., Bascones-Martınez A. Oral ulcers: clinical aspects. A tool for dermatologists. Part I. Acute ulcers, clinical and experimental dermatology. 2009, 34:289-294 13. M. M. S. Nico, A. E. Brito, L. E. A. M. Martins, P. Boggio and S. V. Lourenco Oral ulcers in an immunosuppressed 5-year-old boy clinical and experimental dermatology. 2008, 33:367-368 14. Cameron A.C., Widmer R.P. Pediatric oral medicine and pathology; ulcerative and vesiculobullous lesions. Handbook of Pediatric Dentistry. Edinburgh, Mosby, 3rd edition, 2008:177-180 15. Scully C., Felix D.H. Oral medicine-update for the dental practitioner aphthous and other common ulcers British Dental Journal. 2005, Vol.199, No 5:259-264 16. Koch G., Poulsen S. Oral mucous lesions and minor oral surgery. Pediatric Dentistry (a clinical approach). Copenhagen, Munksgaard, 2nd edition, 2009:298-307 17. Medina A. C., Sogbe R., Gomez-Rey A.M., Mata M. Factitial oral lesions in an autistic paediatric patient International Journal of Paediatric Dentistry. 2003, 13:130-137 18. Sällberg M. Oral viral infections of children. Periodontology 2000, 2009, Vol.49:87-95 19. Lewis M. Herpangina: an enteroviral febrile associated vesiculobullous disease. Oklahoma Dental Association Journal. March 2008:32-34 20. Talacko A.A., Gordon A.K., Alfred M.J. The patient with recurrent oral ulceration. Australian Dental Journal. 2010, 55 (1 Suppl):14-22

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2014 54




May 29 - 31, 2014 USJ Dental School Beirut, Lebanon

More Pictures Available On

Monsieur le Recteur, Messieurs les ministres et députés, Chers invités et collègues Je tiens à remercier, le Recteur et les vice-recteurs pour leur appui inconditionnel à l’organisation de ces journées, les présidents de l’ordre, les doyens et directeurs, pour leur présence avec nous. Je souhaite la bienvenue dans notre pays, aux doyens des Facultés de chirurgie dentaire des pays arabes, aux conférenciers spécialistes étrangers venus très nombreux pour participer à la réussite de notre congrès biannuel: les 11èmes journées odontologiques et j’espère, au-delà des préoccupations d’ordre professionnel, qu’ils emporteront du pays des cèdres un souvenir agréable. Nous en sommes à la 11ème édition des Journées Odontologiques, la première ayant eu lieu en 1991 au sortir de la guerre. Si cette tradition des journées s’est perpétuée, c’est d’abord parce qu’elle a su rester fidèle à ses principes fondateurs: assurer grâce à la participation des praticiens libanais une mise à jour de l’exercice de la profession. Bien que fortement impliquée dans les préparatifs du congrès, je ne peux que souligner la très grande qualité du programme scientifique, la variété des thématiques, l’ampleur de l’exposition. Le président du comité d’organisation a rappelé l’importance de la formation continue. Je vais aborder les activités de la Faculté qui n’a pas arrêté de se développer depuis 1919 date de la création de l’école dentaire. Nous avons actuellement 450 étudiants: entre le doctorat d’exercice, les Masters spécialisation et recherche et le Doctorat. Malgré le nombre important de praticiens au Liban, nous avons remarqué


icture Dental News, Volume XXI, Number III, 2014

of the Audience during the

que l’attrait qu’exerce la profession sur les jeunes libanais augmente toujours. Pour terminer, je voudrais saluer l’engagement du conseil de Faculté, des enseignants et du personnel, remercier le comité d’organisation et son président le Dr Ghassan Yared, qui témoigne de son dévouement pour la Faculté et pour la profession. À vous toutes et tous, praticiens étrangers et libanais, je voudrais vous souhaiter de tout coeur trois belles journées sur ce campus centenaire des sciences médicales et infirmières. Pr. Nada Naaman Doyen de la Faculté de Medecine Dentaire

Opening Ceremony

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,M , Badawi, Azar, Mr. Abela, Hage, Mokbel

rs News, ader egarbane Dental Volume XXI, Number III, 2014

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Dr. Yared, Dr. Moukarzel, Rector Dr. Dakkash

Dr. Fadi Karam, President Elie Maalouf, Dr. Ammar Houry, Dr. Nizar Kady


Pr. Hardan, Dr. Maciel Jr, Dr. Abi Sleiman

Pr. Zbouny, Mr. Baraka, Mr. Genini, Dr. Kamachi

Dr. Zarazir, Dr. Dib, Pr. Mhanna, Dr. Stempf, Mr. Khattar

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Ivoclar Vivadent hosts the 2nd International Expert Symposium in London Endorsed by the King’s College London Dental Institute, Ivoclar Vivadent hosted the International Expert Symposium ‘The Quality of Esthetics’ in London. World-renowned specialists discussed the latest materials and advanced clinical concepts to an audience of 750 delegates on 14th June 2014. Robert Ganley, CEO of Ivoclar Vivadent AG and Darryl Muff, Managing Director Ivoclar Vivadent Ltd. UK & Ireland opened proceedings with a welcoming address, highlighting their commitment to connect with clinicians and technicians through the continued dissemination of knowledge and education. Dr James Russell and Rob Lynock (UK) looked at ethics in esthetics, illustrating how through close teamwork the clinician and technician can ensure patients are provided with highly esthetic restorations, whilst ensuring minimal preparation and preserving the tooth’s healthy structure. Bart van Meerbeek (Belgium) discussed research into the most effective bonding approach, concluding that in most cases a combination of the self-etch approach and the etch & rinse approach is necessary, even though the self-etch approach is often regarded as the most effective, with its ease-of-use and low-failure rate. Dr Eric van Dooren (Belgium) and technician Murilo Calgaro (Brazil) discussed the general principles of ingot and shade selection with the IPS e.max system, placing great emphasis on lithium discillicate (LS2) with low translucency (LT) and medium opacity (MO) ingots for optimal, esthetic results, whilst technician Michele Temperani (Italy) discussed all-ceramics and CAD/CAM technology as an ideal combination for greater esthetic success. Dr Markus Lenhard (Switzerland) demonstrated how Tetric EvoCeram Bulk Fill layering technique has revolutionised composite restorations to make procedures quicker and simpler. Van P. Thompson (USA) discussed monolithic crown CAD/CAM materials, looking at silicate and oxide ceramics, the problems of cone cracks and radial fractures, and why Zirconia has become the material of choice.

Focusing on ultra-thin ceramic restorations, Dr Stefan Koubi (France) emphasised that keeping some of the dyschromia and working closely with the technician to achieve the ideal colour match was key. Supporting this, Dr Rafael Piñeiro Sande (Spain) stressed that diagnosis is most important part of treatment when aiming for the best esthetic results, whilst Oliver Brix (Germany) demonstrated the experience with the IPS e.max system, exploring the limits in innovative dental design and how to work with nature. Prof Daniel Edelhoff (Germany) concluded the programme by looking at how to solve the problem of accelerated tooth wear due to dentine exposure, before Josef Richter, Chief Sales Officer of Ivoclar Vivadent AG, closed the Symposium by announcing Madrid, Spain, as the next venue for the 2016 Expert Symposium.

APDC 2014




June 17 - 19, 2014 World Trade Center, Dubai, UAE

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Dr. Aisha Sultan surrounded by the Representatives of the APDF His Highness Sheikh Hamdan Bin Rashid Al Maktoum. Deputy Ruler of Dubai, Minister of Finance and President of Dubai Health Authority. Excellencies, Distinguished guests, Peace and Allah’s mercy and blessing be upon you. Since its establishment in 1981, the Emirates Medical Association has always been a strong supporter of the health sector in UAE. It helped provide everything that serves this sector through the dissemination of health awareness among the people and keeping up the dental community with all that is new in the field of dentistry. And the Dental Society as an active member of the Emirates Medical Association have worked hard during the past 30 years of its existence in organizing and promoting dozens of scientific conferences in the different fields of dentistry across the country. Many of these events were organized in association with various international dental societies making UAE a favorable world destination for scientific gatherings. Your Highness, Dear guests, To be “number one” has become a state motto and our leadership has set the goal to be number one in everything we do. Our duty as members of the dental community in UAE is to fulfil the vision of our beloved country in attracting international dental associations and federations to join us in the global promotion of dental health education. To bring Dental News, Volume XXI, Number III, 2014

this goal into reality, 4 years ago, the Dental Society of the Emirates Medical Association submitted its proposal to host the 36th Asia Pacific Dental Congress 2014. Several other member nations of the Asia Pacific Dental Federation have joined the race and after a lengthy screening and inspecting process, UAE was granted the honor of hosting this congress here in Dubai. It is the first time for the Asia Pacific Dental Congress to come to this part of Asia since its inauguration in Japan in 1955. From the time it was officially declared as host nation, efforts from all Dental Society members, government agencies, academic institutions and private sectors in the country have come together to help bring this event into success. Today the name of UAE will be carved in gold as the first state in the Middle East and Gulf region to host this event and for the First Emirati Lady Dentist to become the President of the Asia Pacific Dental Congress for the cycle 2014 – 2015.

Dr. Aisha Sultan President of the Asia Pacific Dental Federation

Dental News, Volume XXI, Number II, 2014


APDC 2014



Flag Holders during the Opening Ceremony

Dr. AlOrayedh, Dr. Debaybo, Dr. Zakia, Dr. Dib, Pr. Shammery, Dr. Jishi, Dr. Kowash

Meeting of the Delegates of the Asia Pacific Dental Federation

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ITENA Clinical’s nanohybrid composite Reflectys Reflectys is one of the bestselling products of the French laboratory, ITENA CLINICAL. This anterior and posterior nanohybrid light-cured composite is recommended for all classes & cavities. Confident of the products performance, ITENA had a clinical evaluation performed by the independent American organization, Dental Advisor; which provides objective clinical reports. It was tested by 24 consultants on a variety of factors: aesthetics, non-stickiness to instruments, finishing & packaging. Reflectys received a 91% clinical rating after 740 uses; thereby giving it a great score of 4 ½ stars. Its polishing properties and its universal use were particularly appreciated. The composite is available in 16 shades that can be mixed including two opaque shades, enamel and incisal shades, and a pedo shade. Sold in syringe or capsules, Reflectys is also available in a flowable version - ideal for areas with difficult access thanks to an excellent thixotropy. website: Dental News, Volume XXI, Number III, 2014


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The Bluephase Style polymerization light from Ivoclar Vivadent wins the bronze award The Bluephase Style curing light from Ivoclar Vivadent won the bronze medal at one of the most prestigious design competitions in the medical technology industry. With the bronze award of the esteemed «Medical Design Excellence Awards 2014», the polymerization light holds one of the top positions in the category «Dental Instruments, Equipment and Supplies». Criteria for the assessment of the product features were the degree of technological innovation, design and development progress. Furthermore, the patient and the economic benefits as well as the contribution to the health system were considered. website: Dental News, Volume XXI, Number III, 2014


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Dental News, Volume XXI, Number I, 2014