U.M.F. „GRIGORE T. POPA” IAŞI FACULTY OF DENTAL MEDICINE ABSTRACT PhD THESIS Scientific coordinator PROF.UNIV.DR. ANDRIAN SORIN PhD Student MOLDOVANU ANTONIA 2014
U.M.F. „GRIGORE T. POPA” IAŞI
FACULTY OF DENTAL MEDICINE
ABSTRACT
PhD THESIS
Scientific coordinator
PROF.UNIV.DR. ANDRIAN SORIN
PhD Student
MOLDOVANU ANTONIA
2014
U.M.F. „GRIGORE T. POPA” IAŞI
FACULTY OF DENTAL MEDICINE
PhD THESIS
CLINICAL, LABORATORY AND EXPERIMENTAL
STUDIES ON THE DIAGNOSTIC AND
THERAPY OF ROOT DENTAL CARIES
Scientific coordinator
PROF.UNIV.DR. ANDRIAN SORIN
PhD Student
MOLDOVANU ANTONIA
2014
1
SUMMARY OF PhD THESIS
GENERAL PART
I.Root surface dental caries. Generalities...................................................................................1
II.Epidemiological data of root dental caries.............................................................................5
III.Root dental caries ethiopathogeny......................................................................................11
III.1.Pathogeny of root dental caries........................................................................................11
III.2.Root dental caries microbiology.......................................................................................15
III.3.Favourising factors...........................................................................................................17
IV.Clinical and morphological factors:
IV.1.Morphological structure of dental tissues........................................................................25
IV.2.Clinical and morphological aspects.................................................................................29
V.Clinical-therapeutical management of root dental caries.....................................................35
V.1.Positive and differential diagnosis of root dental caries....................................................35
V.2.Therapeutical options:
V.2.A.Therapeutical and preventive measures.........................................................................37
V.2.B.Restorative approaches..................................................................................................55
PERSONAL RESEARCHES
VI.Reasons forthe choice of research theme. Methodology....................................................63
VII.Epidemiological and clinical study....................................................................................75
VIII.Research on the assessment of organic component changes following the treatment with
Carisolv....................................................................................................................................99
IX.Anatomical and clinical features of enamel-dentine junction – SEM study.....................129
X.The assessment of cario-preventive effect of some food supplied before the action of acid
beverages on exposed dental root surfaces.............................................................................151
XI.The assessment of status of giomer and resin-modified glass ionomer restorations used in
the treatment of root dental caries..........................................................................................171
XII.Conclusions......................................................................................................................209
References
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KEY WORDS: root cement, root dental caries, prevalence, enamel-dentine junction
PhD Thesis is structured as follows:
General part – five chapters (62 pages)
Personal researches – seven chapters (150 pages, 127 tables, 45 graphs, 5 images, 84 figures)
Note: the PhD abstract presents selective references and images
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I. ROOT DENTAL SURFACES. GENERAL ASPECTS.
The root dental caries is a major issue of oral health for old-aged
individuals. Three arguments support this assertion: life hope increased
significantly in developed countries, high prevalence of periodontal
diseases at old-aged patients, the preservation of high number of teeth
related to high number of root surfaces susceptible to dental caries.
The oral status of old-aged individuals has improved because of
high availability to oral health education, oral care improvement and large
scale use of fluoride toothpastes.
The number of old-aged patients with high number of natural teeth is significantly
higher comparing with past years and records a progressive increase.
The root dental caries dental caries are associated with exposed root surfaces
following gingival recession. Sumney et al. consider root dental caries as cavitated lesion
localised below enamel-cement junction and characterised by colour changes and reduced
consistency of cement and dentine (373, 167). Many authors proposed distinct criteria
regarding root dental caries, like localisation at the level of enamel-cement junction or root
cement (29), undermining of adjacent enamel (215), or extension to more than half of cement
surface (389).
The individual behaviour related to oral health is strictly correlated to age, with higher
effects for old-aged individuals. There is a direct relation between age and risk factors. The
use of sugar in tea or coffee associated with unregulated dental checking doubles the risk of
root dental caries for old-aged individuals.
The ethiology of root dental caries is complex, with bacterial factor as most important
risk factor. The old persons are most exposed to root dental caries because associated
systemic diseases. Many old-aged persons use medication that reduces salivary rate and
produces dry mouth.
The cavitary root dental caries can be easily diagnosed in clinical examen.
Despite many studies were performed regarding prevalence and associated factors,
our knowledges are limited. This should stimulate future researches focused on the ethiology,
treatment and prevention of root dental caries.
Each individual has a characteristic way of carious attack, influenced by different
factors, including number of type of natural teeth and their association with gingival
recessions. For old-aged persons, many missing teeth are, in fact, those teeth prediposed to
root dental caries. Katz et al. demonstrated that most root dental caries are localised on
mandibular molars, followed by premolars and incisives (215). Anterior maxillary teeth are
more affected of root dental caries than mandibular teeth. Both buccal and proximal surfaces
are affected by root dental caries, followed by oral surfaces. There are undefined specific oral
factors that can determine cariogenic attack patterns.
The bacteria implied in the ethiology of root dental caries are anaerobic facultative-
gram bacteria (streptococci, lactobacilli, actinomycetes) and anaerobic-gram bacteria
(Bacteroides, Prevotela, Saelenomonas, Fusobacterium, Leptotrichi, Capnocytophaga). Also
are implied favourising factors like bone alveolar recessions contributing to the exposure of
root surfaces to oral environment.
The enamel-cement junction is most vulnerable to dental caries because of thin and
weak mineralized cement layer covering the root dentine. This cement layer offers weak
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protection for the pulp-dentine complex and retention conditions for bacterial biofilm; more,
most areas are not accessible to the artificial self-cleaning especially when associated with
gingival inflammations and gingival hypertrophy.
The anatomy of enamel-cement junction is different as follows: cement covers enamel
for 60% individuals, cement in tight junction with cervical enamel for 30% individuals, thin
space between cement and cervical enamel for 10% individuals (overlap, meet, gap).
Most protective factors against cariogenic agents are localized in saliva and sulcular
fluid. The decrease of salivary secretion conducts to the increase of bacterial biofilm and
cariogenic bacteria. Patients with xerostomia present rampant dental caries also at the level of
root dental surfaces. If RFR is decreased and RFS is normal, salivary glands have a normal
response to external stimulus but do not produce adequate saliva during rest. In this situation,
teeth are covered by rest saliva for 14 hours daily and cariogenic activity significantly
increases.
The risk factors are as follows: low salivary flux, xerostomia, exposure of root
surfaces, chronic diseases, radiotherapy, manual ability limitation because of heart stroke,
artritis, or Parkinson, diseases like Alzheimer, Sjogren syndrom, diabetes, poor oral hygiene,
xerostomic medication. Potential risk factor is represented by previous carious experience
(treated or untreated root surfaces).
Old-aged individuals are associated with significant presence of systemic diseases.
Infections, autoimmune diseases, neoplasia can change normal response of immune system.
Also the salivary glands function must be considered as an important risk factor implied in
the assessment of old-aged patients.
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I.CLINICAL AND EPIDEMIOLOGICAL STUDY REGARDING ROOT SURFACE
DENTAL CARIES
The root dental caries represent a frequent pathology in old-aged
individuals (9). Proximal and buccal exposed root surfaces represent
risk areas for root dental caries (194). Despite low prevalence of root
dental caries for persons under age 60, this can increase to over 80%
for persons over age 60 (133). The root dental caries are related
especially to molars and bicusps for all age groups (23). The patients
with healthy periodontal tissues have low prevalence of root dental caries (4%), while
patients with gingivitis (15%) and patients with periodontal pockets (17%) have much higher
prevalence of root dental caries (389).
The epidemiological studies relate root dental caries with next factors: aged
population, high number of natural teeth, the increase of prevalence and severity of
periodontal disease, the increase of susceptibility for root dental caries of patients under
periodontal treatments (316).
THE AIMS OF STUDY:
The aims of study:
assessment of prevalence and distributions of root dental caries related to environment
factors, behavior factors and biological factors for patients included in study group
analisys of factors implied in the etiology of root dental caries and the assessment of
cariogenic risk for patients included in study group
data statistical analysis and establishment of possible correlation between the presence of
root dental caries and environment factors, behavior factors and biological factors
MATERIALS AND METHODS
The study group included patients with age between 45-85 years, selected from
patients treated in Clinical Base of Dental Learning „Mihail Kogălniceanu” and private dental
office in 2011-2012.
The research activities performed according to laws related to deontological norms of
research. The clinical examination was performed according to Law no.46, 21 januar 2003
related to patient rights. Written consent was obtained from patients included in study group.
The clinical examen used clasical probe and mirror associated with magnification means
(lens UK Loupes, x 3,5). The objectives were as follows:
1. Assessment of DMFT index
2. Assessment of root carious disease using Indices ICDAS II and CARS for root
surfaces (Pits&Ismail 2005)
3. Plaque index (Silness&Loe), cariogenic index of bacterial plaque (test Hardwick
J.L., Manly E.B.)
4. Root dental caries index Katze
5. Salivary function (buffer capacity (Dentobuff), RFR, RFS, saliva viscosity (Leus
P.A., Beliasov L.V), colorimetric test Snyder
6. The assessment of Mutans Streptococcus (Dentocult SM) and Lactobacilus
(Dentocult LB), 7. The assessment of cariogenic risk (educational level, systemic diseases, medication,
quest regarding foods type and content, carbohydrates consume frequency).
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RESULTS:
Regarding sex, the distribution was as follows: males 53%, females 47% (graph 7.1).
Regarding residence, 67% patients are from urban environment (graph 7.2.). In graph 7.3. is
presented the structure of study group related to age and sex. In study group the mean age is
63,17 years. Test Kolmogorov-Smirnov established the distribution related to age of study
group.
Table 7.I. Test Kolmogorov-Smirnov
Tests of Normality
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df p. Statistic df p.
age .116 192 .000 .954 192 .000
a. Lilliefors Significance Correction
The distribution is symetric and abnormal. The correlation between residence and age
was established using Pearson test. Chi-square was 42,928, freedom degrees were 3 and
significance two-tailed is 0,0001, (<0,05). The results validate a significant correlation
between age and residence.
Table 7.II. Pearson test (correlation between residence and age)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 41.928a 3 .000
Likelihood Ratio 42.254 3 .000
Linear-by-Linear Association 7.153 1 .007
N of Valid Cases 192
a. 0 cells (.0%) have expected count less than 5. The minimum expected
count is 6.33.
The coefficient chi-square was 88,992, freedom degrees 3. The significance two-
tailed is 0,0001, less than 0.05 shows a significant correlation between age and sex (table
7.III).
Table 7.III. Pearson test (correlation between sex and age)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 88.992a 3 .000
Likelihood Ratio 104.743 3 .000
Linear-by-Linear Association .589 1 .443
N of Valid Cases 192
a. 0 cells (.0%) have expected count less than 5. The minimum expected
count is 7.92.
The age group 55-64 years was most affected by root dental caries with ICDAS 01.
The test Pearson showed the existence of significant correlation between root dental caries
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with ICDAS 01 and age group (chi-square 87,085, freedom degree 6 and significance two-
tailed 0,0001<0,05) (table 7.IV).
Table 7.IV. Pearson test (correlation between ICDAS 01 and age group )
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 87.085a 6 .000
Likelihood Ratio 94.891 6 .000
Linear-by-Linear Association 58.536 1 .000
N of Valid Cases 128
a. 3 cells (25.0%) have expected count less than 5. The minimum
expected count is 2.25.
The age group 55-64 years was most affected by root dental caries with ICDAS 02.
The test Pearson showed the existence of significant correlation between root dental caries
with ICDAS 01 and age group (chi-square 124,856, freedom degrees 9 and significance two-
tailed 0,0001<0,05) (table 7.V).
Table 7.V. Pearson test (correlation between ICDAS 02 and age group)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 124.856a 9 .000
Likelihood Ratio 147.585 9 .000
Linear-by-Linear Association 13.592 1 .000
N of Valid Cases 176
a. 3 cells (18.8%) have expected count less than 5. The minimum
expected count is 3.27.
Regarding root dental caries adjacent to composite resins fillings, 33,3% root dental
caries were incipient and 33,5% were deep caries. Regarding root dental caries adjacent to
amalgam fillings, 25% were deep root caries and 16,7% were incipient root caries (table
7.VI).
Tabelul 7. VI. Root dental caries adjacent to amalgam and composite resins fillings
Case Processing Summary
Cases
Valid Missing Total
N Percent N Percent N Percent
Age *filling .30 64 33.3% 128 66.7% 192 100.0%
Age * satisfactory amalgam
filling40
32 16.7% 160 83.3% 192 100.0%
Age *incipient adjacent root
dental caries 31
64 33.3% 128 66.7% 192 100.0%
Age * incipient root dental
caries adjacent to amalgam41
32 16.7% 160 83.3% 192 100.0%
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Age *incipient root dental
caries adjacent to composite
resin filling 32
64 33.3% 128 66.7% 192 100.0%
Age *deep root dental caries
adjacent to amalgam filling
42
48 25.0% 144 75.0% 192 100.0%
Regarding the distribution of incipient root dental caries adjacent to composite resins
fillings (CARS 31) related to age group, most affected were patients with age between 55-64
years, followed by age groups 45-54 and 74-85. Pearson test showed the existence of
significant correlation between incipient root dental caries adjacent to composite resins
fillings (CARS 31) and age group (chi-square 22,710, freedom degrees 3, significance two-
tailed 0,0001<0,05) (table 7.VII).
Table 7.VII. Pearson test (correlation between CARS 31 and age group.
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 22.710a 3 .000
Likelihood Ratio 29.036 3 .000
Linear-by-Linear Association .725 1 .395
N of Valid Cases 64
a. 4 cells (50.0%) have expected count less than 5. The minimum expected
count is .25.
Regarding the distribution of incipient root dental caries adjacent to composite resins
fillings (CARS 41) related to age group, most affected were patients with age between 55-64
years, followed by age groups 65-74 and 74-85. Pearson test showed the existence of
significant correlation between incipient root dental caries adjacent to composite resins
fillings (CARS 32) and age group (chi-square 59,710, freedom degrees 2, significance two-
tailed 0,0001<0,05) (table 7.VIII).
Table 7.VIII. Pearson test (correlation between CARS 32 and age group
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 59.000a 2 .000
Likelihood Ratio 64.498 2 .000
Linear-by-Linear Association 54.916 1 .000
N of Valid Cases 64
a. 3 cells (50.0%) have expected count less than 5. The minimum
expected count is .25.
Regarding the distribution of incipient root dental caries adjacent to composite resins
fillings (CARS 42) related to age group, most affected were patients with age between 55-64
years, followed by age groups 55-64 and 74-85. Pearson test showed the existence of
significant correlation between incipient root dental caries adjacent to composite resins
fillings (CARS 42) and age group (chi-square 48,00, freedom degrees 2, significance two-
tailed 0,0001<0,05) (table 7.IX).
Table 7.IX. Pearson test (correlation between CARS 42 and age group)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 48.000a 2 .000
9
Likelihood Ratio 61.105 2 .000
Linear-by-Linear Association 40.668 1 .000
N of Valid Cases 48
a. 2 cells (33.3%) have expected count less than 5. The minimum
expected count is .67.
The results of the assessment of cariogenic risk using Snyder test showed that all
patients from age group 45-54 have high cariogenic risk. For age group 55-64 high cariogenic
risk was associated with 50,5% patients, and for age group 75-84 high cariogenic risk was
associated with 84,2% patients. Pearson test showed the existence of significant correlation
between cariogenic risk and age group (chi-square 96,351, freedom degrees 6 and
significance two-tailed 0,0001<0,05) (table 7.X).
Tabelul 7.X. Pearson test (correlation between cariogenic risk and age group)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 96.351a 6 .000
Likelihood Ratio 119.270 6 .000
Linear-by-Linear Association 10.196 1 .001
N of Valid Cases 192
a. 2 cells (16.7%) have expected count less than 5. The minimum
expected count is 4.75.
The analysis of saliva viscosity showed that patients with root dental caries from age
group 45-54 years had good viscosity. Low viscosity was recorded for 50,5% patients in age
group 55-64 years , 64,6% patients from age group 65-74 years and 94,7% patients from age
group 75-84 years. Pearson test showed significant correlation between saliva viscosity and
age group (chi-square 73,461, freedom degrees 6, significance two-tailed 0,0001<0,05) (table
7.XI).
Table 7.XI. Pearson test (correlation between saliva viscosity and age group)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 73.461a 6 .000
Likelihood Ratio 87.835 6 .000
Linear-by-Linear Association 32.627 1 .000
N of Valid Cases 192
a. 3 cells (25.0%) have expected count less than 5. The minimum
expected count is 1.58.
Regarding biologic parameters, all patients from age group 45-54 years were
associated with cariogenic biofilm, 82,8% from patients in age group 55-64 years were
associated with cariogenic biofilm, 68,8% from patients in age group 65-74 years and only
10,5% ffrom patients in age group 75-84 years were associated with cariogenic biofilm.
Pearson test showed significant correlation between cariogenic biofilm and age group (chi-
square 56,804, freedom degrees 3, significance two-tailed 0,0001<0,05) (table 7.XII).
Table 7.XII. Pearson test (correlation between cariogenic biofilm and age group)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 56.804a 3 .000
10
Likelihood Ratio 58.131 3 .000
Linear-by-Linear Association 47.484 1 .000
N of Valid Cases 192
a. 1 cells (12.5%) have expected count less than 5. The minimum
expected count is 4.75.
For age group 45-54 years, half of patients were associated with low levels of
Streptococcus mutans, for the other half levels raised up to 100000 ufc\mL. For age group
55-64 years 33,3% from patients were associated with levels of Streptococcus mutans close
to 1000000 ufc\mL. For age group 65-74 years 64,6% from patients were associated with
levels of Streptococcus mutans close to 1000000 ufc\mL. 89,5% from patients in age group
75-84 years were associated with low levels of Streptococcus mutans in saliva. Pearson test
showed significant correlation between Streptococcus mutans in saliva and age group (chi-
square 126,355, freedom degrees 9, significance two-tailed 0,0001<0,05) (table 7.XIII).
Table 7.XIII. Pearson test (correlation between levels of Streptococus mutans in
saliva and age group)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 126.355a 9 .000
Likelihood Ratio 139.544 9 .000
Linear-by-Linear Association 4.578 1 .032
N of Valid Cases 192
a. 3 cells (18.8%) have expected count less than 5. The minimum
expected count is 3.17.
For age group 45-54 years, half of patients were associated with low levels of
Streptococcus mutans, for the other half levels raised up to 100000 ufc\mL. For age group
55-64 years 66,7% from patients were associated with low levels of Lactobacillus. For age
group 65-74 years 64,6% from patients were associated with levels of Lactobacillus had
mean levels. 84,2% from patients in age group 75-84 years were associated with low levels of
Lactobacillus in saliva, and only 10,5% had mean levels of Lactobacillus. Pearson test
showed significant correlation between Lactobacillus in saliva and age group (chi-square
185,174, freedom degrees 9, significance two-tailed 0,0001<0,05) (table 7.XIV).
Tabelul 7.XIV. Pearson test (correlation between levels of Lactobacillus in saliva and
age group)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 185.174a 9 .000
Likelihood Ratio 181.324 9 .000
Linear-by-Linear Association 39.348 1 .000
N of Valid Cases 192
a. 6 cells (37.5%) have expected count less than 5. The minimum
expected count is 1.58.
Regarding the assessment of nutritional factor, all patients in age group 45-54 years
has score 15. Same result was obtained for age group 65-74 years. For age group 55-64 years,
82,8% patients and 15,8% patients from age group 75-84 had score over 15. Pearson test
showed significant correlation between cariogenic level of nutritional factor and age group
(chi-square 78,430, freedom degrees 3, significance two-tailed 0,0001<0,05) (table 7.XV).
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Table 7.XV. Pearson test (correlation between cariogenic level of nutritional level
and age group)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 78.430a 3 .000
Likelihood Ratio 71.047 3 .000
Linear-by-Linear Association 26.908 1 .000
N of Valid Cases 192
a. 1 cells (12.5%) have expected count less than 5. The minimum
expected count is 3.17.
The assessment of systemic diseases were showed that most patients were affected by
hepatitis and articular diseases (13,64%), followed by hypertension and diabitis (9,09%),
heart stroke (8,81%)(graph 7.5).Most consumed xerostomic drugs was nitroglycerine and
diuretic drugs(13,1%), followed by antidepressants and beta-blockers(8,7%), digoxin (8,2%).
Pearson test showed significant correlation between xerostomic drugs consume and
age group (chi-square 277,316, freedom degree 24, significance two-tailed 0,0001<0,05)
(table VI.15).
Table 7.XVI. Pearson test (correlation between xerostomic drugs consume and age group)
Chi-Square Tests
Value df
Asymp. Sig. (2-
sided)
Pearson Chi-Square 277.316a 24 .000
Likelihood Ratio 331.492 24 .000
Linear-by-Linear Association 1.930 1 .165
N of Valid Cases 366
a. 8 cells (22.2%) have expected count less than 5. The minimum
expected count is 2.27.
DISCUSSIONS
The epidemiological studies show a large range of root dental caries prevalence
depending on the diagnostic criteria, studied population, aim of study. The probability that a
patient under 40 years have root dental caries is with 20% lower than age (96). Index RCI is
most used in epidemiological studies, with incidence rates: 1,5 – 4,3 root dental
caries/patient/year or 0.87 – 8,2 root dental caries/100 risk surfaces/year (32). The
epidemiological studies show the lack of consensus regarding definition and diagnostic
criteria of root dental caries. Only microbiological studies validate as single criteria the
consistency of cement (soft for active lesions, hard for inactive lesions).
The actual data show that root dental caries represents a real problem for old-aged
individuals, especially for those with systemic diseases. Regarding the composition of
bacterial biofilm localized on dental root surfaces, Van Houte J.et al. show that Streptococci,
Actinomyces, Veillonela represent 84,2%, 57,8%, 65,7% (388). Streptococus mutans and
Lactobacillus are not always present in bacterial biofilm from root dental surfaces.
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Poor oral hygiene of old-aged individuals is a risk factor for the development of root
dental caries. The retraction of periodontal tissues is associated with interdental areas hard to
be cleaned using classical means. Also the ability to learn new adequate tooth cleaning
methods is very low.
Vehkalalahti M. M. Et al. associated root dental caries with poor oral hygiene (OR
3,), low number of teeth (OR 2,3-2,7), old age (OR 2,1) (390).
The dental practice must insist on education and motivation regarding adequate oral
hygiene of patients.
Most protective factors against cariogenic agents are present inside saliva and sulcular
fluid. The decrease of salivary secretion conducts to the increase of bacterial biofilm and
microbial flora changes. Patients with xerostomia are associated with rampant dental caries,
especially on root dental surfaces. Gastroesophageal reflux disease (GERD) maintains pH
under critical pH for many hours, submitting dental cement to demineralisation and
disolution followed by cavitary dental caries. Liver diseases influence immune system and
conduct to the lack of specific defensive agents like Ig A, M, G and determine the
development of cariogenic flora.
The correlation between diabetes and root dental caries can be explained by continous
elimination of glucose in saliva and development of cariogenic flora (especially
Streptococcus Mutans).
The xerostomic drugs and Parkinson disease can also affect the ability for adequate
hygiene of old-aged individuals. More, xerostomic drugs diminishes the rate of salivary flux
and reduces the protective effect of saliva.
CONCLUSIONS:
Prevalence of root dental caries is 68,7%.
Incipient root dental caries affect especially age group 55-64 years, followed by age
groups 45-54 years, 65-74 years, 75-84 years.
Age group 55-64 years was most affected by deep root dental caries, followed by age
groups 65-74 years, 45-54 years, 75-84 years.
Age group 55-64 years was most affected by root dental caries adjacent to composite
resins and amalgam fillings.
Most incipient and deep root dental caries, were adjacent to composite resins fillings,
followed by deep root dental caries adjacent to amalgam fillings.
Significant statistical correlations between salivary factors (rest and stimulated salivary
flux, buffer capacity, saliva viscosity) as well as biological microbial parameters (levels
of Streptococcus mutans and Lactobacillus, cariogenity of bacterial biofilm), nutritional
factor, systemic diseases, xerostomic drugs and root dental caries for old-aged patients.
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II. STUDY REGARDING THE ASSESSMENT OF CHANGES
RELATED TO ANORGANIC COMPONENT OF ROOT
DENTINE AFTER TREATMENT WITH CARISOLV
INTRODUCTION: Root dental caries represent an interesting issues for many dental
researches (167, 133,134, 214, 248, 283) as many individuals maintain their natural teeth at
advanced ages. Some controversial aspects are considered by many authors regarding the
development mechanisms and efficiency of preventive and therapeutical
methods.
An important objective of root dental caries therapy is the removal of
carious dentine. The chemo-mechanical method Carisolv is a viable solution
for this therapeutical stage.
Various methods and devices can offer qualitative and quantitative
informations regarding chemical elements and distributions of atoms and ions. Some
methods can offer only qualitative informations, other methods can offer both qualitative and
quantitative informations regarding type of chemical elements and concentrations. For
researches investigating surface status, analysis depth must be considered. There are
differences between methods that can analyse 100μm depth and methods that analyse 2μm
depth. Some features like porosity and hardness can influence accuracy of depth analysis.
Also an improper samples preparation can affect the results of chemical analysis.
THE AIM OF STUDY:
The aim of study was to assess the quantitative and qualitative chemical
composition (Ca, P ions) of root dental surfaces, following treatment with Carisolv.
MATERIALS AND METHOD:
The study group included 12 teeth extracted for periodontal reasons, with root dental
caries, associated with minimum one healthy surface. Teeth were stored in distilled water at
4°C. Teeth were divided in 2 halves using diamond discs (Komet Dental, Brasseler
GmbH&Co, Germania), under water cooling ; section plan separated the healthy root surface
from carious root surface. For each toot were performed two samples, one with carious root
surface (study group) and the other with healthy dentine surface (control group).
For each sample in study group, infected dentine was removed with Carisolv by a
single practitioner, accordingly to working protocol recommended by producer. Carisolv gel
covered carious dentine for 30 seconds; the softened dentine was removed using hand
instrument. The procedure was repeated until total removal of carious dentine, confirmed
with a probe touching hard dentine.
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Figure 8.10-8.13. Removal of carious dentine using Carisolv
The checking was performed using a dye Caries indicator (Vladmiva). The samples
with healthy dentine were considered control group.
The processed dentine samples were investigated by EDX method, using QUANTAX
QX2 ROENTEC (Bruker AXS Microanalysis GmbH, Germania):
assessment of qualitative and quantitative chemical composition,
mapping of chemical elements.
SEM microscope had the next parameters: resolution 3nm-30 KV, magnification 13-
1.000.000 X; 200 V, 30kV, scanning speed 200 ns-10 ms pixel-1.
RESULTS:
Using EDX analysis, spectrum of chemical elements was obtained from all dentine
samples allowing mapping of these elements on investigated dental surfaces. Also, EDX
method allowed quantitative analysis, expressing chemical composition as wt%.
An example is presented in graph 8.I, with higher percentages for oxygen, calcium and
phosphorus ions and lower percentages for Na, Mg, K (graph 8.I).
Graph. 8.I. Spectrum of chemical elements for a sample (group study) after removal of
carious dentine using Carisolv
Chemical composition (same tooth sample) is as follows: 58,01% wt% oxygen, 28,18 %
wt% calcium, P 13,22% wt%, K 1,03% wt%, Na 0,45% wt%, Mg 0,06% wt% (table 8.I.).
Table 8.I. Chemical composition for a sample (study group) after removal of carious
dentine using Carisolv
Element series [wt.-%] [norm. wt.-
%]
[norm. at.-%] Error in %
Calcium K-series 28,18901 28,47998 14,98967 0,882531
Phosphorus K-series 13,22548 12,99325 8,848761 0,563728
Sodium K-series 0,454188 0,446213 0,409417 0,072871
Potassium K-series 1,038483 1,020248 0,550435 0,063034
Magnesium K-series 0,063055 0,061947 0,053763 0,034233
Oxygen K-series 58,01711 56,99836 75,14795 8,960411
Sum: 101,7873 100 100
15
Figures 8.21-8.22. Mapping of chemical elements of analysed surfaces for samples in
study group a) calcium ions b) phosphorus ions
Chemical elements spectrum for control sample is presented in graph 8.II. Higher
percentages are observed for oxygen, calcium, phosphorus (graph 8.II).
Graph 8.II. Chemical elements of sample in control group
Chemical composition (same tooth sample) is as follows: 39,91% wt% oxygen, 28,42 %
wt% calcium, P 14,59% wt%, K 1,11% wt%, Na 1,02% wt%, Mg 0,42% wt% (table 8.I.).
Table 8.II. Chemical elements of sample in control group
(carious dentine removal using Carisolv)
For all investigated samples, only levels of calcium and phosphorus were considered,
as predominant chemical elements of dentine anorganic component. The results show levels
of calcium for samples with root dental caries between 23,09-28,18, and for control samples
between 23,18-28,42. The results show levels of phosphorus for samples with root dental
caries between 9,76-13,22, and for control samples between 9,88-14,59.
The mean of calcium ions was higher in control group (25,23), comparing with study
group (24,61). Same tendency was recorded for phosphorus ions, with a mean 10,84 in
control group and 10,52 in study group (table 8.IV).
Element series [wt.-%] [norm. wt.-
%]
[norm. at.-%] Error in %
Calcium K-series 28,42801 25,18514 13,62272 0,878865
Phosphorus K-series 14,59191 12,92737 9,047769 0,634063
Sodium K-series 1,025756 0,908745 0,856905 0,141928
Potassium K-series 1,112692 0,985764 0,546563 0,073081
Magnesium K-series 0,42306 0,3748 0,334294 0,072792
Oxygen K-series 39,91758 35,36405 47,91635 7,47444
Sum: 112,8761 100 100
16
Table 8.IV. Descriptive statistics. Mean values and standard deviations for Ca and P
levels in control group and study group
Descriptive Statistics
N Minimum Maximum Mean Std. Deviation Skewness Kurtosis
Statistic Statistic Statistic Statistic Statistic Statistic Std. Error Statistic Std. Error
Ca
study group
12 23.09 28.18 24.6167 1.35850 1.657 .637 3.963 1.232
Ca
control group
12 23.18 28.42 25.2325 1.41168 .712 .637 1.201 1.232
P
study group
12 9.76 13.22 10.5208 .95997 2.262 .637 6.058 1.232
P
control group
12 9.88 14.59 10.8467 1.25067 2.787 .637 8.754 1.232
Valid N (listwise) 12
The analysis of graph 8.V. shows that distribution of calcium ions in study group
deviates from normal curve and do not allow the use of parametrical test for statistical
comparisons.In graph 8.VI the distribution of calcium ions in control group deviates from
normal curve and do not allow the use of parametrical test for statistical comparisons.
The analysis of graph 8.VII. shows that distribution of phosphorus ions in study group
deviates from normal curve and do not allow the use of parametrical test for statistical
comparisons.In graph 8.VIII the distribution of phosphorus ions in control group deviates
from normal curve and do not allow the use of parametrical test for statistical comparisons.
The results of Mann-Whitney test (for the assessment of statistical differences)
showed the lack of significant statistical difference between the study groups and control
group regarding the levels of calcium and phosphorus ions (Mann-Whitney U = 48,500, z =
1.357, p = 0.175, respectiv Mann-Whitney U = 49,500, z = 1.300, p = 0.194) (tables 8.VI-
8.IX).
Tables 8.VI,8.VII. Mann-Whitney test (comparison between Ca ions levels)
Ranks
lot N
Mean
Rank
Sum of
Ranks
Ca Study
group
12 10.54 126.50
Control
group
12 14.46 173.50
Total 24
17
Mann-Whitney test shows the absence of significant statistical difference between the
scores of study group and control group, related to calcium ions levels (Mann-Whitney U =
48,500, z = 1.357, p = 0.175).
Mann-Whitney test shows the absence of significant statistical difference between the
scores of study group and control group, related to phosphorus ions levels (Mann-Whitney U
= 49,500, z = 1.300, p = 0.194).
DISCUSSIONS: The application of Carisolv gel facilitates the removal of carious dentine. The
chemical agents contain chloramines (NaOCl and aminoacids) with minimal adverse effects
on oral tissues and hard dental tissues. The final effects on dentine are not yet completely
explained.
Carisolv system removes the infected carious tissues due to the proteolitic action of an
organic complex (NaOCl 0,5% and three aminoacids: leucine, lisine, glutamic acid). Many in
vitro studies analyses the aspects, roughness, bacterial infiltrate degree, microhardness,
smear-layer, adhesion.
The aim of our study is to analyse the changes in mineral component of root dental
tissues after chemo-mechanical removal of carious dentine with Carisolv system. Because the
changes of mineral content can affect significantly the preventive and therapeutic strategy
addressed to root dental caries, some researchers are focused on the assessment of these
changes comparing carious dentine with healthy dentine (368, 370). Also Hamama HH et al.
(2013) assessed the changes of mineral content in carious lesions (159).
The quantitative methods can be invasive or non-invasive. Each method has a certain
correlation between measured parameters and mineral loss as well as reproductibility.
Our samples were examined under microscope SEM VEGA II LSH. The possibility to
use EDX system, QUANTAX QX2, allowed the mapping of the examined surfaces to
establish quantitative and qualitative chemical composition.
In a similar in vitro study (183) Hossain et al. assessed microhardness of dentine after
carious dentine removal using Carisolv, levels of Ca and P and repport CA/P, both on healthy
dentine adjacent to root dental caries and restant dentine. The authors concluded the lack of
significant statistical differences regarding (Ca%) and (P%), as well as the repport Ca/P
(p<0,01). SEM analysis revealed unregulated surface , roughness surface, covered on some
areas by smear-layer and other areas with open dentinal tubuli. The results indicated that
Carisolv do not produces adverse effects on treated dental surfaces, regarding dentine
composition in the examined carious cavities.
Also our results did not revealed significant statistical difference regarding chemical
composition of dentine before and after removal of carious dentine with Carisolv. However
further studies using higher number of samples are requested.
The results of our study and literature data show the absence of Carisolv
disadvantages, excepting a significant decrease of adhesion to healthy dentine, if separate
etching and dual composite resins are used for coronal restoration (132).
For cervical and root dental caries it is difficult to obtain minimal excavation
(restricted to carious infected dentine) due to difficulties in moisture control and location of
pulp room. For this category of dental caries, chemo-mechanical methods as well as air-
abrasion and laser have are advantageos alternatives to classical mechanical method for the
removal of carious dentine. More, root dental caries are accessible for Carisolv system. Our
results sustain conclusions expressed by Ericson et al. (1999) (114). The mean time for the
removal of carious dentine was 6,9±2,8 minutes for Carisolv and 3,8±2,0 minutes for
mechanical method. In another study, 78% patients treated with Carisolv perceived equal or
18
less time for Carisolv comparing with mechanical method (115). Even the disadvantage of
longer working time is balanced by the lack of anesthesia and higher patient comfort.
The use of NaOCl 10% improves the potential of remineralisation due to proteolitic
action of NaOCl. Literature data show the increase of root dentine permeability to fluor ions
after treatment with NaOCl.
The anorganic content of cement (45-50%) is lower comparing to bone (65%),
enamel (96%) or dentine (70%). This composition makes high susceptibility of cement to
demineralization. The lack of uniform percentages for calcium and phosphorus ions
complicates the use of laboratory methods for the investigation of chemical structure.
For our study, microanalysis of chemical composition for healthy and affected
dentine after Carisolv, did not highlighted any significant changes of anorganic structure.
CONCLUSIONS:
1. The chemical elements microanalysis by EDX, regarding changes induced in vitro in
the structure of healthy dentine and restant dentine after treatment with chemo-
mechanical method Carisolv, offers orientative informations regarding potential for
structural changes of mineral component of root dental tissues after the action of
Carisolv.
2. The method Carisolv did not conducted to significant quantitative and qualitative
changes of anorganic component of root restant dentine comparing with healthy
dentine surfaces.
3. În restant dentine after the action of Carisolv, values of Calcium ions varied between
23.09 and 28.18, values for Phosphorus ions varied between 9.81 and 13.22.
4. For healthy dentine, Calcium ions varied between 23.18-28.42, Phosphorus ions
varied between 9.88 -14.59.
19
III. SEM STUDY REGARDING THE FEATURES OF
ENAMEL/CEMENT/DENTINE JUNCTION
INTRODUCTION: Old-aged patients have a significant problem with exposed
dental surfaces thar are vulnerable to root dental caries, especially if these patients have
systemic diseases that affect protective salivary environment (391, 389). Literature data (82,
218) demonstrate direct correlation between depth of periodontal pocket and quantity of
bacterial biofilm and calculus. ECJ (enamel-cement junction) is area associated with high
quantity of bacterial biofilm and calculus. However this issue remains controversial both for
periodontists and general dentists (314).
This study aimed to assess the various anatomical relations between enamel, dentine,
cement at the level of ECJ, on different dental groups, buccal, oral, proximal surfaces. The
ECJ anatomy influences the bacterial biofilm and calculus retention as well as possible
biological and clinical implications. The specific morphology of root carious areas constitutes
a factor that favourises the localization of root carious lesions on these surfaces, when patient
presents high cariogenic risk related to diverse ethiological factors.
The presence of enamel-cement junction exposed to oral cavity cariogenic factors on
patients with gingival recession, is considered as most susceptible cariogenic area. The
cement layer has less thickness than enamel, less mineralization degree than enamel and
dentine. The root cement offers weak protection for pulp-dentine complex; also offers
retention conditions for bacterial biofilm considering the lack of accesibility and artificial
cleaning due to gingival hypertrophia and gingival inflammations.
The relation between root cement and enamel in ECJ was approached in many studies
using polarized light microscopy, SEM microscopy, nanoindentation technique,
prophylometry, electronic probe analysis, morphopatological studies (81, 37). The issue
remains incompletely understood due to numerous variables that interfere.
Choquet (1899) published first study about ECJ, further studies showed great
variability regarding relation between enamel and cement near to ECJ (81).
The issue related to ECJ anatomy became an important issue due to high prevalence
of cervical and root dental caries as well as noncariogenic lesions (erosion, abfraction,
cervical abrasion) and periodontal diseases.
In our study we proposed to interpret the result as to highlight some useful
conclusions for practitioner regarding prevention and treatment of root surface
carious lesions.
THE AIM OF STUDY:
The study aimed to identify anatomical and pathological features of tissues relations
of ECJ, by SEM microscopy as well as the changes following diverse therapeutical
procedures applied at the level of ECJ.
Objectives:
1. Description of ECJ tissue repports;
2. Identification of ECJ potential for accumulation of bacterial biofilm and calculus.
MATERIALS AND METHOD:
The study group included 16 extracted teeth (IC, IL, C, PM1, PM2, M1, M2, M3)
with healthy cervical area. The teeth were stored in distilled water at 4°C The teeth were
divided in 4 halves (buccal, oral, mesial, distal), and sectioned using diamond discs (Komet
20
Dental, Brasseler GmbH&Co, Germania), under water cooling. The section plan was selected
as to preserve ECJ. For each tooth were performed 4 samples.
The dental samples were analysed regarding morphology with SEM microscope
VEGA II LSH (TESCAN, Cehia). The parameters of microscope were as follows: resolution
3nm-30KV, magnification 30-1.000.000 X, acceleration tension 200 V-30 kV, scanning
speed 200 ns-10 ms per pixel.
The types of ECJ were analysed regarding morphological aspects and retention degree
for bacterial biofilm and calculus.
RESULTS:
The results are presented in figures 1 and 2:
- maxillary teeth, on surfaces as follows: buccal(B), oral(O), mesial(M), distal(D).
central incisive: highest frequency for “head-to-head” ECJ (B,D), followed bu
exposed dentine (O) and ECJ with cement covering enamel (M).
lateral incisive: highest frequency for exposed dentine (B, D), followed by cement
covering enamel (O), and enamel covering cement (M).
canins: highest frequency for exposed dentine (B,O), followed by “head-to-head”
ECJ (M), enamel covering cement (D).
bicusps:
PM 1: distribution similar to canines
PM2: highest frequency for exposed dentine (O,M), followed by
cement covering enamel (D) and “head-to-head” ECJ (V).
molars:
M1: highest frequency for cement covering enamel (B,O,D), followed by
“head-to-head” (M).
M2, highest frequency for cement covering enamel (B,O), followed by
exposed dentine (D)
M3, highest frequency for cement covering enamel (B,O), followed by
exposed dentine (M), and enamel covering cement (D).
- Mandibular teeth on surfaces as follows: buccal (B), oral (O), mesial (M) şi
distal (D).
central incisives: highest frequency for cement covering enamel (O, D), followed
by “head-to-head” (B), and enamel covering cement (M).
lateral incisives: highest frequency for „head-to-head” (B, M), followed by cement
covering enamel (O) and enamel covering cement (D).
canines: similar results with central incisives.
bicusps:
PM1, highest frequency for „head-to-head” (B, M), followed by cement
covering enamel (O), and enamel covering cement (D).
PM2, highest frequency for „head-to-head” (B, D), followed by cement
covering enamel (M), and enamel covering cement (O).
molars,
M1 highest frequency for „head-to-head” (B, M), followed by cement
covering enamel (O), and enamel covering cement (D).
M2, highest frequency for cement covering enamel (B), followed by “head-to-
head” (D), and enamel covering cement (O).
M3 highest frequency for „head-to-head” (B,M), followed by cement covering
enamel (O), and enamel covering cement (D).
21
There are various situations regarding surface patterns of enamel, exposed dentine and
cement as well as structure of ECJ seems to contribute to the attachment of bacterial biofilm
and calculus (Fig. 9.1-9.19). The unregulated topography allows the development of bacterial
biofilm as to request significant scaling to eliminate all residual deposits. CEJ is frequently
located near to restorations that hinder adequate action of scaling instruments. The borders of
restorations present retention areas with bacterial biofilm and even calculus. Highest retention
degree was associated to ECJ with exposed dentine between enamel and cement.
Figures 9.1-9.3.Aspects of ECJ “head-to-head”.
The aspects of ECJ “head-to-head” are presented in SEM images 9.1.-9.3. with
enamel in tight contact with cement.
Figures 9.4-9.6. Aspects of ECJ with thin space between enamel and cement exposing dentine
The aspects of ECJ with spaces between cement and enamel are presented in SEM
images 9.4-9.6, with exposed dentine.
Figures 9.7-9.8. Aspects of ECJ with cement covering cement.
The aspects of ECJ with cement covering enamel are presented in SEM images 9.7-
9.8., with absence of space between enamel and cement.
22
Figure 9.9-9.11. Aspects of ECJ with enamel covering cement.
Figure 9.12. Deposits of bacterial biofilm and calculus near to ECJ.
Statistical analysis: I. Results for maxillary teeth:
The correlation coefficient is – 0,4530, with significance level 0,009. There is a
significant negative correlation between „cement covering enamel” and „ECJ with exposed
dentine” (Table 9. IV). Table 9.IV. Results of correlation coefficient between ECJ for maxillary teeth
Correlations
Cement
covering enamel
ECH “head-
to-head”
ECJ with
exposed dentine
Enamel
covering cement
Spearman's
rho
Cement
covering enamel
Correlation
Coefficient
1.000 -.237 -.453**
-.236
Sig. (2-tailed) . .192 .009 .193
N 32 32 32 32
“Head-to-head” Correlation
Coefficient
-.237 1.000 -.160 -.026
Sig. (2-tailed) .192 . .382 .887
N 32 32 32 32
Exposed dentine Correlation
Coefficient
-.453**
-.160 1.000 -.274
Sig. (2-tailed) .009 .382 . .130
N 32 32 32 32
Enamel
covering cement
Correlation
Coefficient
-.236 -.026 -.274 1.000
Sig. (2-tailed) .193 .887 .130 .
N 32 32 32 32
**. Correlation is significant at the 0.01 level (2-tailed).
23
Statistical analysis was performed related to ECJ category, tooth category, surface
category. The non-parametrical Kruskal-Wallis test was performed.
1.a).ECJ category: Table 9.V. Kruskal-Wallis, related to ECJ category (maxillary teeth)
Ranks
ECJ N Mean Rank
Variable Cement covering enamel 32 66.00
ECJ “head-to-head” 32 66.00
ECJ with exposed dentine 32 70.00
ECJ with enamel covering dentine 32 56.00
Total 128
Table 9.VI. Kruskal-Wallis test for maxillary teeth (ECJ category).
Test Statisticsa,b
Variable
Chi-Square 4.335
df 3
Asymp.
Sig.
.228
a. Kruskal Wallis Test
b. Grouping Variable:
joncţiune
The results of statistical test is expressed as chi-square (4,335) with 3 freedom degrees
and p = 0.228 > 0.05; the results show lack of significant statistical difference (Table 9.VI).
1.b. Teeth category Table 9.VII. Kruskal-Wallis test for maxillary teeth (teeth category)
Ranks
Tooth type N Mean Rank
Variabile central incisive 16 64.00
lateral incisive 16 64.00
canine 16 64.00
bicusp1 16 64.00
bicusp2 16 64.00
molar1 16 64.00
molar2 16 68.00
molar3 16 64.00
Total 128
24
Table 9.VIII. presents the results regarding the presence or absence of significant
statistical differences.
Table 9.VIII. Kruskal-Wallis test for maxillary (teeth category).
Test Statisticsa,b
Variable
Chi-Square .284
df 7
Asymp. Sig. 1.000
a. Kruskal Wallis Test
b. Grouping Variable: tipul dintelui
The results of statistical test are as follows: chi-square (0,284) with 7 freedom degree,
p = 1.000 > 0.05; the results show the absence of significant statistical differences (Table
9.VIII).
1.c).Surface category:
Table 9.IX. Kruskal-Wallis test for maxillary teeth (surface category).
Ranks
Surface category N Mean Rank
Variable Buccal 32 62.00
Oral 32 66.00
Mesial 32 64.00
Distal 32 66.00
Total 128
.
Table 9.X. Kruskal-Wallis test for maxillary teeth (tooth surface).
Test Statisticsa,b
Variable
Chi-Square .446
df 3
Asymp. Sig. .931
a. Kruskal Wallis Test
b. Grouping Variable: tipulsuprafetei
The results of statistical test are as follows: chi-square (0,446) with 3 freedom
degrees, p = 0.931 > 0.05; the results show significant statistical differences (Tabel 9.X).
1. Results for mandibular teeth:
Correlation coefficient between ECJ (Table 9.XI):
- 0,558, significance level 0,001. Significant negative correlation between „head-to-
head” and „cement covering enamel”. Significant statistical correlation.
– 0,3578, significance level 0,045. Significant negative correlation between „enamel
covering cement” and „cement covering enamel”. Significant statistical correlation.
–0,438, significance level 0,012. Significant negative correlation between „head-to-
head” and „enamel covering cement”. Significant statistical correlation.
25
Table 9.XI . Results of correlation coefficient between ECJ for mandibular teeth
Correlations
Cement
covering enamel
Head-to-
head
Exposed
dentine
Enamel
covering
cement
Spearman's
rho
Cement
covering
enamel
Correlation
Coefficient
1.000 -.558**
-.174 -.357*
Sig. (2-tailed) . .001 .341 .045
N 32 32 32 32
“Head-to-head” Correlation
Coefficient
-.558**
1.000 -.214 -.438*
Sig. (2-tailed) .001 . .241 .012
N 32 32 32 32
Exposed
dentine
Correlation
Coefficient
-.174 -.214 1.000 -.137
Sig. (2-tailed) .341 .241 . .456
N 32 32 32 32
Enamel
covering
cement
Correlation
Coefficient
-.357* -.438
* -.137 1.000
Sig. (2-tailed) .045 .012 .456 .
N 32 32 32 32
**. Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2-tailed).
The statistical analysis (non-parametrical test Kruskal-Wallis) regarding ECJ category,
tooth category, surface category
2.a). ECJ category (mandibular teeth).
Table 9.XII. Kruskal-Wallis test related to ECJ (mandibular teeth).
Ranks
ECJ N Mean Rank
Variabile Cement covering enamel 32 68.50
“head-to-head” 32 74.50
Exposed dentine 32 52.50
Enamel covering cement 32 62.50
Total 128
Table 9.XIII. Kruskal-Wallis test for mandibular teeth related to ECJ.
Test Statisticsa,b
Variable
Chi-Square 10.914
Df 3
Asymp. Sig. .012
a. Kruskal Wallis Test
b. Grouping Variable:
ECJ
26
The results of statistical test are as follows: chi-square (10,914) with 3 freedom
degrees, p = 0.012 < 0.05; results show significant statistical difference.
There are significant statistical differences between the investigated ECJ (Table
9.XIII.).
2.B). Teeth category
Table 9.XIV. Kruskal-Wallis test for mandibular teeth (teeth category).
Ranks
Teeth category N Mean Rank
Variable central incisive 16 64.50
lateral incisive 16 64.50
canine 16 64.50
bicusp1 16 64.50
bicusp2 16 64.50
molar1 16 64.50
molar2 16 64.50
molar3 16 64.50
Total 128
Table 9.XV. Kruskal-Wallis test for mandibular teeth (teeth category).
Test Statisticsa,b
Variable
Chi-Square .000
df 7
Asymp. Sig. 1.000
a. Kruskal Wallis Test
b. Grouping Variable:
tipuldintelui
The results of statistical test are as follows: chi-square (0,000) with 7 freedom
degrees, p = 1.000 > 0.05; results show the lack of significant statistical difference (Table
9.XV).
2.c). Surface category
Table 9.XVI. Kruskal-Wallis test for mandibular teeth (surface category).
Ranks
Surface
category N Mean Rank
Variable buccal 32 64.50
oral 32 64.50
mesial 32 64.50
distal 32 64.50
Total 128
27
Table 9.XVII. Kruskal-Wallis test for mandibular teeth (surface category).
Test Statisticsa,b
Variable
Chi-Square .000
df 3
Asymp. Sig. 1.000
a. Kruskal Wallis Test
b. Grouping Variable:
tipulsuprafetei
The results of statistical test are as follows: chi-square (0,000) with 3 freedom
degrees, p = 1.000 > 0.05; results show the lack of significant statistical difference (Table
9.XVII).
DISCUSSIONS:
The ECJ morphology represents an area with high clinical and therapeutical
significance due to the association with tooth hypersensibility and susceptibility to cervical
dental caries and non-cariogenical lesions.
Most root dental caries are localised on exposed surfaces, but 10-20% are localised
subgingivally (362). Banting et al. (30) consider that most root dental caries are localised near
to gingival margins, but Ravald et al. (315) identify as risk areas the borders of direct
restorations (51%), ECJ (25%) for patients under periodontal therapy (315). Katz et al.
repport the localisation of root dental caries at the level of buccal and interdental surfaces of
posterior mandibular teeth, followed by interdental surfaces of maxillary posterior teeth and
interdental surfaces of anterior mandibular teeth (215). Heegard et al.(168) repported that
most root dental caries are localised on buccal surface teeth. Imazato et al. (192) consider that
canines and first bicusps are most affected by root dental caries, while Kularatne et al. (230)
prove that molars are most frequently associated with root dental caries.
In our study ECJ of teeth before extraction were covered by gingival tissues, but
further exposure to oral environment is expected with age. From that moment, ECJ will be
exposed to various chemical and physical factors that will alter its morphology.
Our study proved that most encountered ECJ category is „head-to-head”, result that is
sustained by other literature data. The presence of space between enamel and cement is most
frequent to maxillary teeth, most predisposed to pathological changes following therapeutical
periodontal sessions or bleaching techniques.
Our results show that distribution of enamel, dentine and cement in cervical area is
unregulated and non-predictible. Preventive or therapeutical acts can generate dental or
periodontal damage with negative results in future (87).
The attachment of bacterial biofilm to the cervical enamel or root surface represent
key elements in initiation of periodontal disease or root dental caries. However subgingival
biofilm can present significant variations regarding quantity and accumulation rate, due to
host factors like xerostomia, surface nature, host genetics, oral hygiene variation and bacterial
composition (360,156). The adherence of bacterial biofilm is significantly influenced by
texture and composition of dental surface.
Quirynen M. et al.. prove that surface roughness facilitates the bacterial adhesion and
is correlated with free surface energy. The dental surfaces with higher roughness have higher
surface energy that facilitate the bacterial adherence.
Many researches confirmed (87) that, despite the efficiency of scaling and root
planning, they do not eliminate completely the bacterial biofilm and calculus from
subgingival root dental surfaces.
28
CONCLUSIONS:
There are four ECJ categories as follows: cement covering enamel (32.8%), urmată de
“head-to-head” (29,68%), exposed dentine due to space between cement and enamel
(20,31%) and enamel covering cement (17,1%).
Each tooth can have variations of ECJ on different surfaces (buccal, oral, mesial,
distal).
JSC represents a significant clinical challenge influencing the initiation and
development of root dental caries
The unregulated margins between enamel and cement, the presence of development
defects, enamel hypoplasia, represent retentive areas with risk for the accumulation of
biofilm and calculus.
Unregulated topography of ECJ can influence the results of scaling and root planning,
but overinstrumentation can produce enamel fracture associated with more retentive
ECJ and higher accumulation of bacterial biofilm and calculus.
29
IV. ASSESSMENT OF CARIOPREVENTIVE EFFECT OF FOODS
SUPPLIED PREVIOUS TO THE ACTION OF BEVERAGE
DRINKS ON THE EXPOSED ROOT SURFACES
INTRODUCTION: The literature data show high prevalence of cervical and
root dental caries of old-aged patients. This pathology is favourised by the systemic
diseases associated with old-aged individuals. Most implied factors are food acids
(253, 255) and intrinsic acids (36, 338).
Many clinical and epidemiological researches confirmed relation between
carbohydrates and dental caries (169, 267, 409, 203). The etiopathogeny of dental
caries is influenced by mineral elements. 100 mineral elements are divided in two
categories: macroelements (C, H, O, N, P, S, Na, K, Cl, Ca, Mg) and microelements
(Zn, Fe, Cu, Ca, I, F, Cr, Mn, Mo, Se, V, etc.). Calcium is in highest quantity in
organism (1100-1400 g), 95% in bones and teeth. Old-aged individuals have lower
adsorption of calcium. There are food factors that increase the adsorption of calcium
(vitamins C and D, lactose, lactic acid excess of proteins) and food factors that
decrease the calcium adsorption (oxalic acid from chocolate, cacao, excess of fats
and phosphaţis, food fibres).
Milk and milk products offer high levels of calcium
(57,225,200). Milk has 120 mg/l calcium, cow cheese has 250
mg/100g, 900-1000mg/100g in cheeses type Olanda and
Schweitzer and 1300mg/100g. In Parmezan.
Vegetables (broccoli, cabbage) and fruits contain low
quantities of calcium. Meat has very low levels of calcium as
well as grains. High levels of calcium have oceanic fish and marine algae (ex:
wakame algae, 1380mg/100g).
Gedalia (42) et al. and Lewinstein et al. (243) researched in situ efectele the
effects of milk and cheese on enamel demineralisation following consume of acidic
beverages (cola). Kato, Sales-Peres and Buzalaf proved the role of iron ions in
cervical dental erosions (280, 105, 211, 212). As liver is an important source of iron
(224) also broccoli is rich in iron (272); thus the consume of broccoli can have a
protective effect on dental demineralisation. The studies mentioned previously
demonstrate the existence of remineralisation processes associated with consume of
milk, cheese, broccoli, on demineralised dental surfaces.
The potential of milk and some foods to protect teeth against demineralisation
is an issue that worth more attention from the research groups.
AIM OF STUDY:
Our study aimed to assess the cariopreventive effect of milk, cheese and algae
after the action of acid beverage on exposed root dentine.
MATERIALS AND METHOD:
The study group included 20 healthy extracted teeth, for orthodontic reasons.
The teeth were sectioned with diamond discs (Extec Corp, Enfield, CT, Statele Unite
ale Americii), under water cooling. The study group included 40 sections of buccal
and oral root surfaces with lenght 4 mm, width de 4 mm and grossness 3 mm.
The research was performed by assessment of prepared dental surfaces and
prophilometry of acidic erosion degree following the action of acidic beverage
(Sprite).
30
The samples were divided in four groups:
I – milk action
II –cheese extract action
Lot III –algae Wakame action
Lot IV –control group, no protective action following the effect of acidic
beverage (Sprite).
The samples were covered on half of surface with varnish resistent to acid
(Farmec ultrarezistent, Farmec S.A. România.) that was applied in two layers; the
uncovered half was submitted to the action of investigated protective foods. The
samples were immersed in cheese extract (Forgrana, Parmezan Grana Padano, Italia),
algae Wakame Flakes (ClearSpring, Japonia), milk (Zuzu, S.C.Albalact S.A.,
România) for 5 minute (32 ml/sample) previously to the immersion in Sprite (pH
3,4). Between erosive cycles the samples were immersed in artificial saliva
Fusayama - Mayer (pH 7) (32 ml/sample) at room temperature.
În control group, the samples were submitted for 72 hours to 9 cycles (3 cycles in
24 hours) of demineralisation by immersion in Sprite, (Coca Cola, Romania), for 5
minutes (32 ml/sample). In periodes between immersions the samples were
maintained in artificial saliva. The wear of root surfaces submitted to acidic cycles
was determined by prophilometric method with rugosimeter TAYLOR HOBSON-
Surtronic25.
RESULTS:
For all the investigated samples roughness profiles were recorded for root dental
surfaces. It was recorded mean value of profile deviation related to mean line (Ra).
The results for all samples from study groups and control group are presented in
table 9. II.
Table 10.II. Erosions values related to food categories Suprafeţe radiculare
Milk Cheese Algae Control
1 0,787 0,512 0,424 1,370
2 0,581 0,483 0,479 1,110
3 0,770 0,415 0,462 1,714
4 0,641 0,509 0,501 1,298
5 0,512 0,498 0,521 1,684
6 0,591 0,531 0,439 1,433
7 0,589 0,547 0,547 1,786
8 0,627 0,469 0,487 1,769
9 0,659 0,509 0,533 1,862
10 0,574 0,545 0,499 1,674
31
I. Study group I (Milk)
Table 10. III. Values of surface erosions for study group Milk
Graph 10.1. Values of surface erosions for study group Milk
II. Study group II (Cheese)
Table 10. IV. Values of surface erosions for study group Cheese
Graph 10.2. Values of surface erosions for study group Cheese
III. Study group III (Algae)
Tabel 10.V. Values of surface erosions for study group Algae.
Graph 10.3. Values of surface erosions for study group Algae
IV. Control group
Table 10.VI. Values of surface erosions for control group
Graph 10.4. Variations of surface erosions for control group
32
Results for statistical analysis:
Table 10.VII. Descriptive statistics
milk cheese algae control
N Valid 10 10 10 10
Miss 0 0 0 0
Mean .63310 .50180 .48920 1.57000
standard errors of mean .027444 .012449 .012528 .078911
Standard deviation .086786 .039367 .039617 .249538
Mean value of „algae” study group (0.48920) is lower than mean value of
erosion for „cheese” study group (0.50180), but lower than mean value of „milk” study group
(0.63310), that is lower than mean value of „control” group (1.57000).
Graph 10.5. Variations of mean values for erosion in all study groups
Frequencies distribution
The results of homogeneity analysis of distributions for the study groups are presented in
table 10.VIII.
Test Shapiro-Wilk has p (sig.) >0,05 for all groups, resulting normal distributions.
Table 10.VIII. Results of homogenity analysis for all study groups (Shapiro-Wilk).
Tests of Normality
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
Milk .186 10 .200* .899 10 .211
Cheese .173 10 .200* .911 10 .290
Algae .098 10 .200* .974 10 .928
Control .262 10 .051 .906 10 .252
a. Lilliefors Significance Correction
*. This is a lower bound of the true significance.
Table 10. IX.Results of Levene for all study groups
Test of Homogeneity of Variances
Erosion
Levene Statistic df1 df2 Sig.
19.901 3 36 .000
Test Mann-Whitney is used to determine the presence or absence of significant
statistical differences between study groups.
33
Study groups „Milk” versus „Cheese”
Table 10. X . Comparison of erosion between „Milk” and „Cheese”.
Ranks
lot N Mean Rank Sum of Ranks
erosion Milk 10 15.15 151.50
Cheese 10 5.85 58.50
Total 20
Table 10. XI . Mann-Whitney test for study groups „Milk” versus „Cheese”.
Test Statisticsb
eroziune
Mann-Whitney U 3.500
Wilcoxon W 58.500
Z -3.518
Asymp. Sig. (2-tailed) .000
Exact Sig. [2*(1-tailed Sig.)] .000a
a. Not corrected for ties.
b. Grouping Variable: lot
Mann-Whitney test shows value U 3.5000, p = 0.001 < 0.05. There are significant
statistical differences between the values of erosions for „milk” and „cheese” study groups.
Study groups „Milk” versus „Algae”
Table 10. XII . Comparison of erosion between study groups „Milk” and „Algae”
Ranks
lot N Mean Rank Sum of Ranks
Erosion milk 10 15.20 152.00
algae 10 5.80 58.00
Total 20
Table 10. XIII . Mann-Whitney test for study groups „Milk” versus „Algae”
Test Statisticsb
eroziune
Mann-Whitney U 3.000
Wilcoxon W 58.000
Z -3.553
Asymp. Sig. (2-tailed) .000
Exact Sig. [2*(1-tailed Sig.)] .000a
a. Not corrected for ties.
b. Grouping Variable: lot
Mann-Whitney test shows value U 3.0000, p = 0.001 < 0.05. There are significant
statistical differences between the values of erosions for „milk” and „algae” study groups.
34
Study groups „Milk” vs „Control” Table 10.XIV . Comparison of erosion between study groups „Milk” and „Control”
Ranks
N Mean Rank Sum of Ranks
erosion Milk 10 5.50 55.00
Control 10 15.50 155.00
Total 20
Table 10.XV. Mann-Whitney test for study groups „Milk” versus „Control”
Test Statisticsb
eroziune
Mann-Whitney U .000
Wilcoxon W 55.000
Z -3.780
Asymp. Sig. (2-tailed) .000
Exact Sig. [2*(1-tailed Sig.)] .000a
a. Not corrected for ties.
b. Grouping Variable: lot
b. Grouping Variable: lot
Mann-Whitney test shows value U 0.0001, p = 0.001 < 0.05. There are significant
statistical differences between the values of erosions for „milk” and „control”.
Study groups „Cheese” vs „Algae”
Table 10. XVI . Comparison between study groups„Cheese” versus „Algae”
Ranks
lot N Mean Rank Sum of Ranks
eroziune branza 10 11.45 114.50
alge 10 9.55 95.50
Total 20
Table 10. XVII . Mann-Whitney test for study groups „Cheese” versus „Algae”
Test Statisticsb
eroziune
Mann-Whitney U 40.500
Wilcoxon W 95.500
Z -.719
Asymp. Sig. (2-tailed) .472
Exact Sig. [2*(1-tailed Sig.)] .481a
a. Not corrected for ties.
b. Grouping Variable: lot
Mann-Whitney test shows value U 40.500, p = 0.472 > 0.05. There are not significant
statistical differences between the values of erosions for „cheese” and „algae”.
Study groups „Cheese” versus „Control”
Table 10. XVIII. Comparison of erosion between study groups „Cheese” versus „Control”
Ranks
lot N Mean Rank Sum of Ranks
erosion cheese 10 5.50 55.00
control 10 15.50 155.00
Total 20
35
Table 10.XIX. Mann-Whitney test for study groups „Cheese” versus „Control”.
Test Statisticsb
erosion
Mann-Whitney U .000
Wilcoxon W 55.000
Z -3.781
Asymp. Sig. (2-tailed) .000
Exact Sig. [2*(1-tailed Sig.)] .000a
a. Not corrected for ties.
b. Grouping Variable: lot
Mann-Whitney test shows value U 0.0001, p = 0.001 <0.05. There are significant
statistical differences between the values of erosions for „cheese” and „control”.
Study groups „Algae” versus „Control”
Table 10. XX . Comparison of erosion between study groups „Algae” versus „Control”
Ranks
lot N Mean Rank Sum of Ranks
erosion algae 10 5.50 55.00
control 10 15.50 155.00
Total 20
Table 10. XXI . Mann-Whitney test for study groups „Algae” versus „Control”.
Test Statisticsb
eroziune
Mann-Whitney U .000
Wilcoxon W 55.000
Z -3.780
Asymp. Sig. (2-tailed) .000
Exact Sig. [2*(1-tailed Sig.)] .000a
a. Not corrected for ties.
b. Grouping Variable: lot
Mann-Whitney test shows value U 0.0001, p = 0.001 <0.05. There are significant
statistical differences between the values of erosions for „algae” and „control”.
DISCUSSIONS:
The demineralization and remineralisation cycles are complex processes that alternate
daily and represent a natural component of dynamic behavior of dental tissues under the
action of a local factors complex (saliva, anatomy and mineral content of teeth, food factor,
pH of bacterial biofilm, fluor bioavailability).
Our study aimed to study the erosive potential on root surface to understand better the
ultrastructural surface changes of root dental caries.
The control group is associated with high levels of minerals loss in the cement areas,
comparing with minerals loss in coronal areas, recorded by other studies. This phenomenon is
explained by the lower mineralization and hardness of cement. This explains faster evolution
of root dental caries comparing with coronal carious lesions.
Heitor Marques Honório et al. (2010) and other studies researched erosive processes
in cervical enamel and root tissues on animals teeth. (177). In our study we preffered human
36
teeth because animals teeth are more porous and more susceptible to erosive processes. The
assessment included three cycles of acidic pH to simulate the daily consume of acidic
beverages and foods.
For acidic beverages the time needed for saliva to buffer the acids will increase. The
content of calcium and phosphates influences the local environment at the level of dental
surface; thus, the addition of calcium and phosphates is an efficient anti-erosive strategy.
West Nx. et al. (2003) compared, by prophilometry, the effects of acidulated drinks
with high content of calcium with the effect of orange juice, after 20 days of consuming 250
ml, four times daily (399). The conclusions was that consume of acidic drinks with content of
calcium reduced significantly the minerals loss, comparing with orange juice.
The consume of milk protects the enamel due to calcium and phosphate ions, despite
the possible low pH.
The immersion of dentine samples in remineralisation solutions (250 ppm, 2000 ppm)
for one minute, showed an increase of resistance to erosion in direct relation with content of
fluor (18). The immersion of enamel samples in AMF gels presents a significant protective
effect against erosions and abrasion (18).
In conditions of neutral pH, hydroxiapatite is in chemical balance with saliva rich in
calcium and phosphate ions; as pH decreases under the action of external and internal acids,
the saturation degree decreases till critical pH associated with unsaturated saliva. The
demineralisation provoked by acidulated beverages, is influenced by remineralisation of
acquired pellicle. Remineralisation is slowly and can take a few hours. The acidic drinks and
foods increase the level of H+ ions, level that can be measured only for disociated ions.
However undisociated form has an important role in the initiation of erosive processes. The
total acidic level is important as determine the quantity of (H+) ions that interact with dental
surface. pH indicates only the initial values of (H+) ions.
In our study the loss of dental tissues by acidic demineralisation was used as response
variable as is able to measure the dental tissues loss following pH cycles. Even if probe used
in prophilometric tests, would deteriorate the dental surface, this phenomenon appears on all
samples and could not influence the results of the statistical tests. The resolution of
prophilometer is 0,4 um, allowing accurate measurements by erosion, as mean values of
erosion depth is higher than error limit of device.
CONCLUSIONS:
The cariopreventive effect of foods must be considered in analysis regarding
risk of root dental caries..
Root dental surfaces can benefit by the protective action of foods rich in
minerals (calciumCa, P).
Milk, cheese and algae consumed before acidic beverages, have the possibility
to protect and reduce the erosive potential of root dental surfaces.
The surface roughness of root cement is lower if protective foods are
consumed before the action of acidic beverages.
The surface roughness of root cement had lower value for „algae” (0.48920),
followe by „cheese” (0.50180) and „milk” (0.63310); all study groups values
mean values are lower than mean value of „control” (1.57000).
37
VI. ASSESSMENT OF GIOMER AND RESIN-MODIFIED
GLASSIONOMER IN ROOT DENTAL CARIES THERAPY
INTRODUCTION: The prevalence of root dental caries is high, especially for old-
aged persons. Remains incompletely known both etiological factors and possibilities to stop
these carious lesions. The morphological and structural particularities of ECJ area represent a
challenge dor dental practitioner. Both techniques and materials contribute to the success of
direct restorations in this area. The ideal material must be resistant, esthetic, biocompatible
and must have ability to prevent marginal secondary caries. One new material produced for
these types of restorations is giomer (Beautifil, Shofu, Japan).Many studies analyse and
propose optimal solutions, but cervical and root surfaces restorations remains an questionable
issue.
Giomers are hybrid materials that combine resin with prepolymerized glassionomer
particles (Prereacted Glass Ionomer). Producers claim that giomers have superior properties
comparing with resin-modified glassionomer cements (RMGC). Giomers have both the
advantages of composite resins (esthetics, resistance) and glassionomer cements
(biocompatible, fluor release, good adhesion in cervical area).
The cervical and root dental areas raise problems related to adhesion due to cervical
margins of restorations close to gingival tissues and hypersensitivity to thermic, chemical,
mechanical stimulus.The choice of an optimal materials is critical to obtain restoration
longevity. The adhesion of ECJ area is inferior to adhesion to enamel. The materials used for
these type of restorations are glassionomer cements (CGI), resin-modified glassionomer
cements (RMGC), giomers (G) and composite resins (RC). Conclusions of studies that
assessed the behavior of these materials in ECJ area are various, some supporting composite
resins (58), other supporting RMGC (276). Some studies highlight the culour alterations for
RMGC (127, 411). Data literature offer informations regarding behavior on periodes of 1-8
years (148,149, 403). A few studies compared the qualities of composite resins and giomers
used in the treatment of cervical and root dental caries.
AIM OF STUDY:
Scopul acestui studiu este de a evalua longitudinal performanţele clinice de restaurare
a cariilor radiculare pe o perioadă de 24 luni, a două materiale din categoria cimenturilor
glassionomere modificate cu răşini (CGMR) şi Giomeri (G).
MATERIALS AND METHOD:
The study group included 30 patients (18 women, 12 males) , selected from patients
treated in Clinical Base of Dental Learning „Mihail Kogălniceanu” and
private dental office in 2011-2012.The research activities performed
according to laws related to deontological norms of research. The clinical
examination was performed according to Law no.46, 21 januar 2003 related
to patient rights. Written consent was obtained from patients included in
study group. The clinical assessment and treatment were performed by a
single pratitioner to avoid inter-examinators errors. Before treatment all patients were
submitted to professional teethbrushing and scaling. The study group included Fuji II LC,
GC (Japonia) and Beautifil II, Shofu (Japonia). 40 cavities were prepared, that were divided
randomly in two study groups (n=20).The culour choice was performed using Vita SYSTEM
3D-MASTER and isolation was performed with Ultrapac (ULTRADENT).After 24 hours the
restorations were finished with diamond burs (Micro Diamond Technologies) and finishing
discs (3M ESPE) and polishing paste Super Polish (KERR).The assessment of qualities
parameters was performed after 1, 12, 24 months by a single examinators with mirror and
probe. The assessment was performed using assessment criteria FDI 2010 (Tables 11.II-
11.IV). Three categories of criteria were used: A. esthetics, B. funcţional, B. biologic.
38
Table 11.II. FDI Assessment criteria for direct restorations.
A. Estethic criteria 1. Surface status; Roughness
2. Colour: a) surface b) marginal.
3. Culour correspondence and translucency
4. Anatomic form (estethics)
B. Functional criteria
5. Restoration fracture and retention
6. Marginal adaptation 7. Occlusal contour.
8. Proximal contact point
9. Radiographic examen
10. Patient opinion: a) esthetics, b) function
C. Biological criteria 11. Reccurence of carious lesions
12. Tooth fracture; retention
13. Effect on periodontal tissues
In statistical analysis were included next criteria::
1. Surface status; Roughness
2. Colour: a) surface b) marginal.
3. Restoration fracture and retention
4. Marginal adaptation 5. Patient opinion: a) esthetics, b) function
6. Effect on periodontal tissues
RESULTS:
All 30 patients were assessed after 1, 12, 24 months. The results of the criteria
assessment were noted as clinically excellent (CE), clinically acceptable (CA), clinically
satisfactory (CS), clinically unsatisfactory (CUS), clinically unacceptable (CUA).
Figure 11.4-11.7. Giomer restorations (before, after, after 12 months, after 24 months)
39
Figure 11.8 -11.11. Glassionomer cement restorations (before, after, after 12 months,
after 24 months)
1. Surface status; Roughness:
The results after 1 years are presented in tables 11.VII, 11.IX:
Giomer 85% score 1 (clinically excellent), 10% score 2 (clinically acceptable), 5% score
3 (clinically satisfactory)
RMGC: 75% score 1 (clinically excellent), 10% score 2 (clinically acceptable), 10%
score 3 (clinically satisfactory), 5% score 4 (clinically unsatisfactory).
The results after 2 years are presented in tables 11.VII, 11.X:
Giomer 80% score 1 (clinically excellent), 15% score 2 (clinically acceptable), 5% score
3 (clinically satisfactory)
RMGC 70% score 1 (clinically excellent), 15% score 2 (clinically acceptable), 10% score
3 (clinically satisfactory), 5% score 4 (clinically unsatisfactory).
The result of homogenity analysis is presented in table 11.XI. Test Kolmogorov-Smirnov has
p (sig.) <0,05 and do not sustain normal distribution for the two study groups.The test Mann-
Whitney will be applied for significant statistical differences after 12 and 24 months.
Table 11.XI. Results of homogenity analysis for distributions in study groups G vs. RMGC
for roughness and surface status
Tests of Normalityb,c
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
G12months .499 20 .000 .447 20 .000
G24months .475 20 .000 .522 20 .000
RMGC12months .444 20 .000 .583 20 .000
RMGC24months .413 20 .000 .635 20 .000
a. Lilliefors Significance Correction
b. G1month is constant. It has been omitted.
c. RMGC1lmonth is constant. It has been omitted.
Table 11.XII. Mann-Whitney test for surface status and roughness.
Ranks
cement N Mean Rank Sum of Ranks
12months G 20 19.38 387.50
RMGC 20 21.63 432.50
Total 40
24months G 20 19.33 386.50
RMGC 20 21.68 433.50
Total 40
40
Table 11.XIII. Mann-Whitney test for surface status and roughness
Test Statisticsb
luna12 luna24
Mann-Whitney U 177.500 176.500
Wilcoxon W 387.500 386.500
Z -.872 -.839
Asymp. Sig. (2-tailed) .383 .402
Exact Sig. [2*(1-tailed Sig.)] .547a .529
a
a. Not corrected for ties.
b. Grouping Variable: ciment
12 months, U 177,5, p = 0.383 > 0.05.
24 months U 176,5, p = 0.402 > 0.05.
Scores for study groups „G” and „CGMIR” do not present significant statistical
differences.
2. Colour: a) surface; b) margins
After one year:
Giomer: 85% score 1 (clinically excellent), 10% score 2 (clinically acceptable),
5% score 3 (clinically satisfactory),
RMGC: 80% score 1 (clinically excellent), 10% score 2 (clinically acceptable),
10% score 3 (clinically satisfactory), 2% score 2 (clinically non-satisfactory).
After 2 years:
Giomer: 80% score 1 (clinically excellent), 10% score 2 (clinically acceptablel),
10% score 3 (clinically satisfactory),
RMGC: 75% score 1 (clinically excellent), 10% score 2 (clinically acceptable),
5% score 3 (clinically satisfactory), 10% score 2 (clinically non-satisfactory).
The results of homogenity analysis of distributions for study groups are presented in table
11.XIX. Kolmogorov-Smirnov test has p (sig.)<0,05 for both study groups and distribution is
abnormal. Test Mann-Whitney will be applied to analyse if there are significant statistical
differences between study groups.
Table 11.XIX. Homogenity analysis for distributions related to colour: a) surface b)
margins.
Tests of Normalityb,c
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
G12months .499 20 .000 .447 20 .000
G24months .476 20 .000 .515 20 .000
RMGC12months .476 20 .000 .515 20 .000
RMGC24months .441 20 .000 .564 20 .000
a. Lilliefors Significance Correction
b. G1month is constant. It has been omitted.
c. RMGC1lmonth is constant. It has been omitted.
41
Table 11.XX. Mann-Whitney test for colour: a) surface; b) margins.
Ranks
cement N
Mean
Rank
Sum of
Ranks
12
mont
hs
G 20 19.95 399.00
RMGC 20 21.05 421.00
Total 40
24
mont
hs
G 20 19.85 397.00
RMGC 20 21.15 423.00
Total 40
Table 11.XXI. Mann-Whitney test for colour: a) surface; b) margins.
Test Statisticsb
luna12 luna24
Mann-Whitney U 189.00
0
187.000
Wilcoxon W 399.00
0
397.000
Z -.450 -.482
Asymp. Sig. (2-tailed) .653 .630
Exact Sig. [2*(1-tailed
Sig.)]
.779a .738
a
a. Not corrected for ties.
b. Grouping Variable: ciment
The results of Mann-Whitney test (Table 11. XXL):
12 months U 189, p = 0.653 > 0.05,
24 months U 187, p = 0.630 > 0.05.
The scores for study groups „G” and „RMGC” do not present significant statistical
differences.
3. Restoration fracture and retention
After 1 year:
Giomer: 80% score 1 (clinically excellent), 5% score 2 (clinically acceptable),
10% score 3 (clinically satisfactory), 5% score 4 (clinically non-satisfactory).
After 2 years:
RMGC: 75% score 1 (clinically excellent), 10% score 2 (clinically
acceptable), 10% score 3 (clinically satisfactory), 5% score 4 (clinically non-
satisfactory).
The results of homogenity analysis of distributions for study groups are presented in table
11.XXV. Kolmogorov-Smirnov test has p (sig.)<0,05 for both study groups and distribution
is abnormal. Test Mann-Whitney will be applied to analyse if there are significant statistical
differences between study groups.
42
Table 11.XXV. Homogenity analysis of distributions for study groups G and RMGC
after 12 and 24 months, for restoration fracture and retention
Table 11.XXVI. Mann-Whitney test for study groups G and RMGC after 12 and 24
months, for restoration fracture and retention.
.
Table 11.XXVII. Mann-Whitney test for study groups G and RMGC after 12 şi 24
luni, for restoration fracture and retention.
Test Statistics
b
12months 24months
Mann-Whitney U 198.500 198.500
Wilcoxon W 408.500 408.500
Z -.058 -.058
Asymp. Sig. (2-tailed) .954 .954
Exact Sig. [2*(1-tailed Sig.)] .968a .968
a
a. Not corrected for ties.
b. Grouping Variable: ciment
The results of Mann-Whitney test:
12 monthsU 198,5, p = 0.954 > 0.05.
24 monthsU 198,5, p = 0.954 > 0.05.
The score for study group „G” and „RMGC” do not present significant statistical
differences.
Tests of Normalityb,c
Kolmogorov-Smirnov
a Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
G12months .475 20 .000 .523 20 .000
G24months .475 20 .000 .523 20 .000
RMGC12months .467 20 .000 .509 20 .000
RMGC24months .467 20 .000 .509 20 .000
a. Lilliefors Significance Correction
b. G1month is constant. It has been omitted.
c. RMGC1month is constant. It has been omitted.
Ranks
ciment N Mean Rank Sum of Ranks
month12 G 20 20.58 411.50
RMGC 20 20.43 408.50
Total 40
month24 G 20 20.58 411.50
RMGC 20 20.43 408.50
Total 40
43
4. Marginal adaptation
After 1 year:
Giomer: 85% score 1 (clinically excellent), 10% score 2 (clinically
acceptable), 5% score 3 (clinically satisfactory),
RMGC: 80% score 1 (clinically excellent), 10% score 2 (clinically
acceptable), 10% score 3 (clinically satisfactory), 2% score 4
(clinically non-satisfactory).
After 2 years:
Giomer: 80% score 1 (clinically excellent), 10% score 2
(clinically acceptable), 10% score 3 (clinically satisfactory),
RMGC: 75% score 1 (clinically excellent), 10% score 2
(clinically acceptable), 5% score 3 (clinically satisfăctory), 10% score
4 (clinically non-satisfactory).
The results of homogenity analysis of distributions for study groups are
presented in table 11.XXXIII. Kolmogorov-Smirnov test has p (sig.)<0,05 for both study
groups and distribution is abnormal. Test Mann-Whitney will be applied to analyse if
there are significant statistical differences between study groups.
Table 11. XXXIII. Homogenity analysis of distributions for marginal adaptation.
Kolmogorov-Smirnov test.
Tests of Normalityb,c
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
G12months .499 20 .000 .447 20 .000
G24months .476 20 .000 .515 20 .000
RMGC12months .476 20
.000 .515 20 .000
RMGC24months .441 20 .000 .564 20 .000
a. Lilliefors Significance Correction
b. G1lmonth is constant. It has been omitted.
c. RMGC1lmonth is constant. It has been omitted.
Table 11. XXXIV. Mann-Whitney test for marginal adaptation.
Ranks
cement N Mean Rank Sum of Ranks
12months G 20 19.95 399.00
RMGC 20 21.05 421.00
Total 40
24months G 20 19.85 397.00
RMGC 20 21.15 423.00
Total 40
44
Table 11. XXXV. Mann-Whitney test for marginal adaptation. Test Statisticsb
12months 24months
Mann-Whitney U 189.000 187.000
Wilcoxon W 399.000 397.000
Z -.450 -.482
Asymp. Sig. (2-tailed) .653 .630
Exact Sig. [2*(1-tailed Sig.)] .779a .738a
a. Not corrected for ties.
b. Grouping Variable: ciment
The results of Mann-Whitney test:
12 months, U 189, p =0.653 > 0.05.
24 months, U 187, p = 0.630 > 0.05.
The scores for study groups „G” and „RMGC” do not present significant statistical
differences.
5. Patient opinion
After 1 year:
Giomer: 90% score 1 (clinically excellent), 10% score 2 (clinically
acceptable).
RMGC: 85% score 1 (clinically excellent), 5% score 2 (clinically
acceptable), 5% score 3 (clinically satisfactory), 5% score 4 (clinically
non-satisfactory).
After 2 years:
Giomer: 85% score 1 (clinically excellent), 5% score 2
(clinically acceptable), 10% score 3 (clinically satisfactory),
RMGC: 75% score 1 (clinically excellent), 5% score 2
(clinically acceptable), 15% score 3 (clinically satisfactory), 5% score
4 (clinically non-satisfactory).
The results of homogenity analysis of distributions for study groups are presented in table
11.XIX. Kolmogorov-Smirnov test has p (sig.)<0,05 for both study groups and distribution is
abnormal. Test Mann-Whitney will be applied to analyse if there are significant statistical
differences between study groups.
Table 11.XLI. Homogenity analysis of distributions for patient opinion.
Kolmogorov-Smirnov test.
Tests of Normalityb,c
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
G12months .527 20 .000 .351 20 .000
G24lmonth .502 20 .000 .440 20 .000
RMGC12months .496 20 .000 .441 20 .000
RMGC24months .451 20 .000 .587 20 .000
a. Lilliefors Significance Correction
b. G1month is constant. It has been omitted.
c. CGIMR1month is constant. It has been omitted.
45
Table 11.XLII. Mann-Whitney test for patient opinion Ranks
cement N Mean Rank Sum of Ranks
12months G 20 19.90 398.00
RMGC 20 21.10 422.00
Total 40
24months G 20 19.40 388.00
RMGC 20 21.60 432.00
Total 40
Table 11.XLIII. Mann-Whitney test for patient opinion. Test Statisticsb
luna12 luna24
Mann-Whitney U 188.000 178.000
Wilcoxon W 398.000 388.000
Z -.565 -.853
Asymp. Sig. (2-tailed) .572 .393
Exact Sig. [2*(1-tailed Sig.)] .758a .565a
a. Not corrected for ties.
b. Grouping Variable: ciment
The results for Mann-Whitney test:
12 months, U 188, p = 0.572 > 0.05.
24 months, U 178, p = 0.393 > 0.05.
The scores for study groups „G” and „RMGC” do not present significant statistical
differences.
6. The effect of restoration on periodontal tissues
After 1 year:
Giomer: 85% score 1 (clinically excellent), 10% score 2 (clinically acceptable), 5%
score 3 (clinically satisfactory),
RMGC: 85% score 1 (clinically excellent), 5% score 2 (clinically acceptable), 5%
score 3 (clinically satisfactory), 5% score 4 (clinically non-satisfactory).
After 2 years:
Giomer: 85% score 1 (clinically excellent), 5% score 2 (clinically acceptable), 10%
score 3 (clinically satisfactory),
RMGC: 80% score 1 (clinically excellent), 10% score 2 (clinically acceptable), 5%
score 3 (clinically satisfactory), 5% score 4 (clinically non-satisfactory).
The results of homogenity analysis of distributions for study groups are presented in
table 11.XIX. Kolmogorov-Smirnov test has p (sig.)<0,05 for both study groups and
distribution is abnormal. Test Mann-Whitney will be applied to analyse if there are
significant statistical differences between study groups.
46
Table 11.XLIX. Homogenity analysis for distributions for effect of restoration on
periodontal tissues. Kolmogorov-Smirnov test. Tests of Normalityb,c
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
G12months .499 20 .000 .447 20 .000
G24months .502 20 .000 .440 20 .000
CGIMR12months .496 20 .000 .441 20 .000
CGIMR24months .467 20 .000 .509 20 .000
a. Lilliefors Significance Correction
b. G1month is constant. It has been omitted.
c. RMGC1month is constant. It has been omitted.
Table 11.L. Mann-Whitney test for effect of restoration on periodontal tissues
Ranks
cement N Mean Rank Sum of Ranks
12months G 20 20.40 408.00
RMGC 20 20.60 412.00
Total 40
24months G 20 20.00 400.00
RMGC 20 21.00 420.00
Total 40
Table LI. Mann-Whitney test for effect of restoration on periodontal tissues.
Test Statisticsb
luna12 luna24
Mann-Whitney U 198.000 190.000
Wilcoxon W 408.000 400.000
Z -.087 -.409
Asymp. Sig. (2-tailed) .931 .683
Exact Sig. [2*(1-tailed Sig.)] .968a .799
a
a. Not corrected for ties.
b. Grouping Variable: ciment
The results of Mann-Whitney test (table LI):
12 months, U 198, p = 0.931> 0.05.
24 months, U 190, p = 0.683> 0.05.
The scores for study groups „G” and „CGMIR” do not present significant statistical
differences.
DISCUSSIONS:
The clinical studies indicate that success of material is related to clinical performance
in oral cavity and longevity. ADA indicates a minimal retention of 95% after 6 months, and
90% after 18 months, to accept a dental material or adhesive system.
The retention of adhesive materials (composite resins, giomers, compomers) depends
on the strenght of their adhesive systems that confront with compressive stress (in restoration
mass) and breaking stress (to the adhesive interface).The lost of marginal adaptation is main
reason that produces the replacement of cervical restorations. RMGC materials avoid
adsorption and lost of “free water” and major changes during setting reaction acid/base.
RMGC has the advantage of hydric balance due to setting reaction acid-base and to HEMA
47
polimerisation by photosensible activators. Thus, for RMGC materials despite the limits of
photoactivation, chemical setting reaction will continue for complete setting of restoration
mass. The link of HEMA to poliacrilic acid allows protection of restoration during setting
reaction. The adsorption of water will be hindered after photoactivation. It can be a difference
regarding physical differences between areas completely photopolimerized and some areas
with residual HEMA, incompletely photopolimerized. luminoasã. These incompletely
photopolimerized areas benefit by the chemical polimerisation. However HEMA is hidrophil
and can adsorp some low quantitis of water and contribute to the restoration expansion and
lower resistance to abrasion and erosion as well as colour changes for patients with poor oral
hygiene. RRMGC materials include Fuji II LC, Photac-fil, Vitremer. For Fuji II LC (GC) and
Vitremer (3M/ESPE), ionic changes with dentine and additional chemical setting reaction
improve physical properties and chemical adhesion to the dentinal tissues (204). The limits of
these materials are represented by culour changes and vulnerability to erosion and abrasion
for patients with frequent consume of acidic beverages and patients with high cariogenic risk.
However the absence of secondary marginal caries at the margins of RMGC restorations is
highlighted in studies. Sunico et al. observed a 80% success rate after 2 years for cervical
restorations with S-PRG 80%, and only 71% for F-PRG (374).Giomers have the advantages
of high resistance to abrasion and erosion,fluor release and high esthetics. Yap et al. observed
that giomers release low levels of fluor ions both on short and long term (412.). Our study assessed RMGC and giomer root-cervical restorations , after 1, 12 and 24
months, using FDI criteria (2010). Or results are similar with other studies (374, 150). The
result regarding retention after 24 months is rather disappointing, due to 8% restorations with
non-acceptable score, result that is similar for RMGC and giomers. Regarding esthetic
criteria, giomer restorations do not suffer significant changes after 12 months and most are
acceptable after 24 months, due to surface status. The esthetic changes of RMGC restorations
are important after 24 months for smokers or those patients consuming tea or coffee, but
without significant statistical differences. Good adhesion to dental tissues is proved by the
absence of posttreatment hypersensitivity for those teeth presenting cervical hypersensitivity
before treatment. Adhesive system of giomers (FL Bond II LC) has satisfactory marginal
adaptation, while RMGC have chemical adhsesion to dentine.
CONCLUSIONS:
Resin-modified glassionomer cements (RMGC) and Giomers (G) used in the
therapy of cervical and root dental caries have retention rates over 90% if
adequate technique is applied and cariogenic risk is controlled as well as the
traumatic occlusal contacts are removed.
After 24 months, most giomer restorations present clinically excellent scores for
functional and biological criteria; poor scores were associated with marginal
adaptation.
After 24 months, most of resin-modified glassionomer cement restorations present
acceptable clinical scores regarding esthetic and biologic criteria and satisfactory
scores regarding functional criteria.
The status of surfaces is superior for giomer comparing with RMGC restoartions.
Giomer and RMGC are not susceptible to surface coloration, marginal coloration
or dental hypersensitivity.
RMGC is inferior to giomer regarding marginal adaptation, but no significant
statistical differences were recorded between the investigated materials.
The retention rates are similar for both materials after similar periodes of time.
Surface status is similar for giomer and RMGC, despite the superiority to giomer
related to behaviour to finishing sessions.
48
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