MALAYSIAN DENTAL JOURNAL

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Editor: AssociateProfessorDr.NgeowWeiCheong BDS(Mal),FFDRCSIre(OralSurgery),FDSRCS(Eng),AM(Mal) DepartmentofOral&MaxillofacialSurgery, FacultyofDentistry,UniversityofMalaya, 50603KualaLumpur,Malaysia. E-mail:[email protected]

Co-Editors: Dr. Seow Liang Lin Dr. Shahida SaidSecretary: Dr. Zamros YuzadiTreasurer: Dr. Lee Soon BoonEx-Officio: Dato’ Dr. Low Teong

EditorialAdvisoryBoard:We wish to express our sincere thanks to all members of the Editorial Advisory Board who gave their time willingly to review article as well as to assist with the editorial work of this journal.

Dr. Elise Monerasinghe Dr. Lam Jac Meng Professor Dr. Phrabhakaran NambiarDr. Chai Wen Lin Dr. Roslan Saub Dr. Nor Adinar Baharuddin Dr. Haizal Mohd Hussaini

Special acknowledgement to Prof. Dr. Michael Ong Ah Hup for his contribution in some of the editorial work of the Malaysian Dental Journal.

The Editor of the Malaysian Dental Association wishes to acknowledge the tireless efforts of the following referees to ensure that the manuscripts submitted are up to standard.

Prof. Dr. Toh Chooi Gait Prof. Dr. Ong Siew Tin Dato’ Prof. Dr. Hashim b. Yaacob Dr. Seow Liang Lin Prof. Zubaidah Abdul Rahim Prof. Dr. Phrabhakaran NambiarDr. Zamros Yuzadi Prof. Dr. Michael Ong Ah Hup Prof. Dr. Tara Bai Taiyeb AliDr. Haizal Mohd Hussaini Prof. Ling Booi Cie Prof. Dr. Rahimah Abdul KadirDr. Lau Shin Hin Dr. Fathilah Abdul Razak Prof. Dr. Nik Noriah Nik HusseinDr. Loke Shuet Toh Dr. Lam Jac Meng Assoc. Prof. Dr. Datin Rashidah EsaDr. Shahida Said Dr. Roslan Saub Assoc. Prof. Dr. Norsiah YunusDr. Zamri Radzi Dr. Chai Wen Lin Assoc. Prof. Dr. Tuti Ningseh Mohd DomDr. Norintan Ab. Murat Dr. Nor Adinar Baharuddin Assoc. Prof. Dr. Roszalina RamliDr. Siti Adibah Othman Dr. Siti Mazlipah Ismail Assoc. Prof. Dr. Roslan Abdul Rahman Dr. Nor Azwa Hashim Dr. Chew Hooi Pin Assoc. Prof. Dr. Nor Zakiah Mohd Zam ZamDr. Dalia Abdullah Dr. Wong Mei Ling Dr. Zeti Adura Che Abd. AzizDr. Wey Mang Chek Dr. Rohaya Megat Abdul Wahab

Malaysian Dental Journal (2007) 28(2) 67-68© 2007 The Malaysian Dental Association

MALAYSIANDENTALJOURNAL

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MalaysianDentalAssociationCouncil2007-2008President: Dato’ Dr. Low TeongPresident-elect: Dr. Sivanesan SivalingamImmediate Past President: Dr. Wong Foot MeowHon. General Secretary: Dr. Xavier JayakumarAsst. Hon. Gen. Secretary: Dr. Sorayah SidekHon. Financial Secretary: Dr. Lee Soon BoonAsst. Hon. Financial Secretary: Dr. Mohd Muzaffar HaminudinHon. Publication Secretary: Dr. Seow Liang LinChairman, Northern Zone: Dr. Neoh Gim BokSecretary, Northern Zone: Dr. Teh Tat BengChairman, Southern Zone: Dr. Steven Phun Tzy ChiehSecretary, Southern Zone: Dr. Leong Chee SanElected Council Member: Dr. Haja BadrudeenElected Council Member: Dr. Abu Razali bin SainiNominated Council Member: Dr. V. NedunchelianNominated Council Member: Dr. Hj. Marusah JamaludinNominated Council Member: Dr. Chia Ah ChikInvited Council Member: Dr. Raymond Chai

THE EDITORIAL BOARD OF THE MALAYSIAN DENTAL JOURNAL WISHES TO EXTEND ITS HEARTIEST CONGRATULATIONS TO DATO’ DR. LOW TEONG AND THE NEWLY ELECTED MALAYSIAN DENTAL ASSOCIATION COUNCIL FOR 2007-2008. WE BELIEVE THAT THE MDJ WILL GROW FROM STRENGTH TO STRENGTH WITH THEIR CONTINUOUS SUPPORT AND WITH THE APPOINTMENT OF NEW EDITORIAL BOARD MEMBERS.

ThePublisherThe Malaysian Dental Association is the official Publication of the Malaysian Dental Association. Please address all correspondence to:

Editor,MalaysianDentalJournal

MalaysianDentalAssociation54-2, (2nd Floor), Medan Setia 2, Plaza Damansara,

Bukit Damansara, 50490 Kuala LumpurTel: 603-20951532, 20947606, Fax: 603-20944670

Website address: http://mda.org.myE-mail: [email protected] / [email protected]

Cover page : Colony and cell morphology of microorganisms isolated from the supragingival plaque samples. Pictures courtesy of Dr. Fathilah Abdul Razak and Professor Dr. Zubaidah Abdul Rahim.

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AimAndScopeThe Malaysian Dental Journal covers all aspects of work in Dentistry and supporting aspects of Medicine. Interaction with other disciplines is encouraged. The contents of the journal will include invited editorials, original scientific articles, case reports, technical innovations. A section on back to the basics which will contain articles covering basic sciences, book reviews, product review from time to time, letter to the editors and calendar of events. The mission is to promote and elevate the quality of patient care and to promote the advancement of practice, education and scientific research in Malaysia.

PublicationThe Malaysian Dental Journal is an official publication of the Malaysian Dental Association and is published half yearly (KDN PP4069/12/98)

SubscriptionMembers are reminded that if their subscription are out of date, then unfortunately the journal cannot be supplied. Send notice of change of address to the publishers and allow at least 6 - 8 weeks for the new address to take effect. Kindly use the change of address form provided and include both old and new address. Subscription rate: Ringgit Malaysia 60/- for each issue, postage included. Payment in the form of Crossed Cheques, Bank drafts / Postal orders, payable to Malaysian Dental Association. For further information please contact :

ThePublicationSecretaryMalaysianDentalAssociation

54-2,(2ndFloor),MedanSetia2,PlazaDamansara,BukitDamansara,50490KualaLumpur

BackissuesBack issues of the journal can be obtained by putting in a written request and by paying the appropriate fee. Kindly send Ringgit Malaysia 50/- for each issue, postage included. Payment in the form of Crossed Cheques, Bank drafts / Postal orders, payable to Malaysian Dental Association. For further information please contact:

ThePublicationSecretaryMalaysianDentalAssociation

54-2,(2ndFloor),MedanSetia2,PlazaDamansara,BukitDamansara,50490KualaLumpur

Copyright© 2007 The Malaysian Dental Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by means of electronic, mechanical photocopying, recording or otherwise without the prior written permission of the editor.

MembershipandchangeofaddressAll matters relating to the membership of the Malaysian Dental Association including application for new member-ship and notification for change of address to and queries regarding subscription to the Association should be sent to Hon General Secretary, Malaysian Dental Association, 54-2 (2nd Floor) Medan Setia 2, Plaza Damansara, Bukit Damansara, 50490 Kuala Lumpur. Tel: 603-20951532, 20951495, 20947606, Fax: 603-20944670, Website Address: http://www.mda.org.my. Email: [email protected] or [email protected]

DisclaimerStatements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the editor(s), publishers or the Malaysian Dental Association. The editor(s), publisher and the Malaysian Dental Association disclaim any responsibility or liability for such material and do not guarantee, warrant or endorse any product or service advertised in this publication nor do they guarantee any claim made by the manufacturer of such product or service.

Malaysian Dental Journal (2007) 28(2) 69© 2007 The Malaysian Dental Association


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CONTENT

MDJ : The challenges ahead 71 Ngeow WC

Dentist’s Role as Smoking Cessation Counsellor 72 Asmaon AF, Ishak AR

An Immunohistochemical Study of p53 in Oral Epithelium Dysplasia and Squamous Cell Carcinoma. 78 Ma MS

A 5-Year Survey of Oral and Maxillofacial Biopsies in Hospital Kota Bharu and Universti Sains Malaysia, Kelantan: 1994-1998 83 Ghazali N, Zain RB, Samsudin AR, Abdul Rahman R, Othman NH

Predominant Supragingival Plaque Microflora in a Malaysian Population 92 Fathilah AR, Rahim ZHA, Othman Y

“The Expert Says………… Oral Microbiology, Periodontal Disease and Cardiovascular Disease” 97 Baharuddin NA

Management of an Unerupted, Dilacerated Maxillary Permanent Central Incisor by a Combined Surgical – Orthodontic Approach: A Case Report. 99 Sockalingam G, Ngah I

Cyclosporine-induced Gingival Overgrowth in a Patient with Hepatitis C Virus Infection - A Case Report 103 Subramaniam U

The Expert Says…….. Current Concept in Gingival Overgrowth 107 Ahmad Sharifuddin MA

A Pilot Radiographic Study on the Location of the Mandibular Canal in Malay Samples of Various Age-groups 112 Ngeow WC, Delitta D, Ishak H, Nambiar P

Reasons for Permanent Teeth Extraction at the Faculty of Dentistry, Universiti Kebangsaan Malaysia from June 1999-June 2001 118 Ibrahim N, Ahmad N, Nordin R, Ariffin F, Ramli R

Current Philosophies and Practices of General Dental Practitioners pertaining to Direct Restorations, Bleaching and Endodontics 122 Lim TW, Goh AC, Seow LL

CDE Self - Assessment in Clinical Dentistry Part XIX Section II 132 Wong FM

Answers for CDE Self - Assessment in Clinical Dentistry Part XIX Section II 136 Wong FM

Abstracts of The 64th MDA/FDI Scientific Conference 2007 140

Continuing Professional Development Quiz 151

Instructions to contributors 153



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If the readers can remember, in the 2006 No. 1 issue of the MDJ, you were informed of our efforts to gain international exposure. One of the approaches was by signing a non-exclusive agreement with EBSCO Publishing that year to sell our content to international libraries and institutions. I am glad to inform you that we had been successful in fulfilling our contract of providing EBSCO Publishing of providing them the latest content to 3 years (2005-2007) of the MDJ by the publication of this July-December 2007 issue.

In addition to that, I have been in contact with Scopus International, a subsidiary of Elsevier Publishing for possible evaluation to index the MDJ in the Index Medicus. I have sent in a formal application to Ms. Raja Leijting, the person in charge of Source Acquisition, Elsevier Bibliographic databases in Amsterdam, the Netherlands sometime in March 2007. As there is a change of guards that the MDA and MDJ level whereby Dr. Seow Liang Lin has taken over the task of the Honorary Publication Secretary as well as the Editor of the MDJ, she will now continue this effort of getting the MDJ indexed.

I am glad to inform the readers that the editorial office has been approached by the National Library of Congress of the United States of America through their representative office here in Kuala Lumpur to acquire copies of the MDJ. So far we have provided them some back issues of the MDJ and the editorial office plans to continue doing so in the future. We hope, with this mutual cooperation, this will be another way for the MDJ to gain more international exposure.

Lastly, may I congratulate Dr. Seow Liang Lin who will take over the helm of the Editor of this beloved journal. You will see her editorial in the next issue of the MDJ and I am sure she will have some surprises lining up for you. Happy reading.

Thank you.

Associate Professor Dr. Ngeow Wei Cheong,Editor, Malaysian Dental Journal.



MDJ:Thechallengesahead

Dentist’s Role as Smoking Cessation CounsellorAsmaon AF. BDS (Mal), MCD (Malaya). Dental Public Health Officer, Klinik Pergigian Datuk Keramat, 54200 Kuala Lumpur, Malaysia.

Ishak AR. BDS (Mal), DDPHRCS (Eng), MSc (Lond), PhD (Mal). Senior Professor, Department of Community Dentistry, Faculty of Dentistry, UMKL, Malaysia.

ABSTRACTThe aim of the study was to assess the potential role of dentists as smoking cessation counsellors in their practice. The target group comprised of all public and private sector dentists in the Federal Territory of Kuala Lumpur (FTKL) and Selangor. Data were collected via a twenty-six item questionnaire which was mailed to 831 dentists. A response rate of 67.1% was obtained. Results revealed that the majority of the respondents (97.8%) perceived that in addition to providing oral care, dentists should also be interested in their patients’ general health. Generally, about two-thirds of dentists (69.1%) and especially those from the public sector (76.4%) considered that they have an important role to play as smoking cessation counsellors. However, less than half of the respondents (40.3%) perceived that patients do not expect smoking cessation advice from their dentists. Yet, more than half of the respondents (55.1%) provided advice or helpful hints in order to motivate their patients to quit smoking. About 65% of the overall respondents did explain to their patients regarding the health risk due to smoking and its detrimental effects. Perceived obstacles to smoking cessation include lack of information between dentistry and smoking cessation (86.1%) followed by lack of training and lack of time.

Key words dentists, smoking, smoking cessation counsellor

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InTRoDuCTIon

Smoking remains a significant public health problem worldwide. The motivating factors that cause people to start smoking are difficult to determine and have been the subject of much research. Typically, tobacco use begins through social contacts, but the habit is reinforced by the development of physiological dependence, derived from the nicotine content of tobacco.1 The total global prevalence of smoking was 29% amounting to about 1.3 billion smokers.2 A study in the United Kingdom reported that there were 13 million adult smokers, which was 28% of the population in the UK3 whereas in the US,4 there were 46.2 million adults or 22.8% current smokers. In Malaysia, the national prevalence of smoking among adults over the age of 18 years was reported to be 24.8% with a prevalence of 49.2% in males and 3.5% in females.5 The extent of the damage smoking causes to health, society and the economy is often substantially underestimated. Smoking represents the single most important cause of premature death in the developed countries. Globally tobacco kills about 5 million people

per year. By the year 2020, it will kill 10 million people per year, of which 70% will be from developing countries.6 In addition to its detrimental effects to general health, tobacco use has many well recognized pathological effects on the oral tissues and oral cancers as well as precancers such as leukoplakia, increased severity of periodontal diseases and poor wound healing are the most significant effects of smoking on the mouth.7 Others include nasopharyngeal carcinoma, stomatitis nicotina, chronic candidiasis, median rhomboid glossitis and even severe teeth staining. Many smokers realize the hazards of smoking and the benefits of cessation, but quitting is made difficult as all tobacco products contain nicotine making it an addictive habit. Ultimately willpower is the only force that prevails. This requires motivation in the form of awareness that smoking is hazardous to health. As healthcare workers, dentists are in an ideal position to promote smoking cessation as they have unique knowledge and opportunity that enable them to encourage smoking cessation. They can play important roles in educating, counseling, ongoing support and other strategies, mainly to prevent more people from taking up

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the detrimental habit. Therefore, the aim of this study was to assess the potential role of public and private sector dentists as smoking cessation counselors in their practice.

MATERIALS AnD METHoDS

A postal questionnaire survey was undertaken among government and private dental practitioners with Annual Practising Certificate (APC) as of October 2003 in the Federal Territory of Kuala Lumpur (FTKL) and state of Selangor. Dentists working in purely administrative positions and those in universities were excluded. The questionnaire was designed based on reference to various types of questionnaires that were developed in other countries.8,9,10 Questions were added, modified or dropped to suit the objectives of the study. The questionnaire was then validated and modified before it

was pretested among ten public dentists. The questionnaire and a stamped addressed return envelope were sent to the target population, following which three reminders were sent at about a month interval in between. The Chi-square test was applied for testing statistical significance of differences between groups and a level of probability of p<0.05 was accepted as significant.

RESuLTS

A total of 558 (67.1%) dentists from the public and private sectors responded in this study. The response rate among public dentists was very good (99.0%) but it was considered above average (60.1%) among the private dentists. Their socio-demographic profiles are shown in Table 1.

Table 1: Socio-demographic characteristics of dentists (n=558)

ItemsRespondents

n (%)Sector type: Private Public

410148

73.526.5

Gender: Male Female

229329

41.059.0

Ethnic Group: Malay Chinese Indian Others

220 214 105 18

39.538.418.93.2

Work experience: 1-5 years 6-10 > 10

98 131 329

17.623.559.0

Smoking status: Never Once smoked but stopped Occasionally at present Daily at present

469 62 16 11

84.011.12.92.0

Overall, about three-quarters of the respondents were from the private sector. More than half (59.0%) of the respondents were female and the largest proportion of respondents were Malay (39.5%). The majority of the respondents have more than 10 years working experience (59.0%) and have never smoked (84.0%) Table 2 shows the belief and perception of dentists towards supporting smoking cessation among their patients.

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Dentist’s Role as Smoking Cessation Counsellor

The majority of the respondents (97.8%) perceived that dentists should also be interested in their patients’ general health other than merely providing oral care. About 69% believed that dentists have an important role as smoking counsellors. However, less than half of the respondents (40.3%) perceived that patients do not expect smoking cessation advice from their dentists. Significantly, more dentists in the public sector (76.4% versus 66.5%) believed that they have an important role to play as smoking counselors (p< 0.05). Table 2: Dentists’ belief and perception towards supporting smoking cessation

% of respondents in agreement OverallSector χ2

ρ-valuePublic Private1. Other than providing oral care, dentists should also be interested in their patients’ general health.

97.8 99.3 97.3 0.149

2. Dentists have an important role as smoking counsellors.

69.1 76.4 66.5 0.026

3. Patients do not expect smoking cessation advice from dentists.

40.3 40.5 40.2 0.950

4. Optimistic about own ability to effectively help patients to quit smoking.

25.3 25.7 25.2 0.906

5. Pessimistic about patients’ ability to change their smoking habit.

28.0 26.4 28.6 0.601

The extent to which dentists are engaged in smoking cessation interventions among their patients is shown in Table 3.

Table 3: Extent to which dentists are engaged in smoking cessation interventions


ρ-valuePublic Private1. Routinely record patients’ smoking status in patients’ card.

19.8 20.9 19.4 0.679

2. Explain to patients regarding the health risk due to smoking and its detrimental effects to health.

64.7 66.2 64.2 0.663

3. Provide advice or helpful hints to motivate patients to quit smoking.

55.1 55.4 55.0 0.938

4. Only discuss smoking with patients having poor subjective health.

65.6 72.3 63.2 0.047

5. Repeatedly make counselling attempts if patients continue to smoke.

22.9 17.6 24.8 0.072

6. Provide reading materials on smoking cessation in the waiting area of clinic.

9.0 11.5 8.1 0.216

7. Smoking is strictly not permitted in clinic or waiting area.

95.5 96.6 95.1 0.444

The majority of the respondents (95.5%) prohibited smoking in their clinics or waiting areas. About two thirds of the respondents (65.6%) only discussed smoking with patients having poor subjective health and 64.7% did explain to their patients regarding the health risk due to smoking and its detrimental effects to health. More than half of the respondents (55.1%) provided advice or helpful hints in order to motivate their patients to quit smoking. Significantly more public sector dentists (72.3% versus 63.2%) only discussed smoking with patients having poor subjective health (p= 0.047).

Table 4: Barriers faced by Dentists towards providing such interventions or advice

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Asmaon / Ishak


ρ-valuePublic Private1. Lack of information between dentistry and smoking cessation.

86.1 81.8 87.7 0.073

2. Constrained because lack of training in smoking cessation.

66.0 67.6 65.4 0.640

3. Counseling patients about smoking is not cost-effective to dental practice.

49.7 36.7 54.4 0.000

4. Lack of time in practice prevents from being involved in smoking cessation.

56.5 75.0 49.8 0.000

5. Fear smokers will leave practice if counseled to give up habit.

16.6 15.5 17.0 0.676

Table 4 shows the barriers that dentists encountered towards providing such interventions or advice to their patients by service sector. The most common barrier cited by dentists (86.1%) is lack of information between dentistry and smoking cessation followed by the lack of training in smoking cessation (66.0%). In contrast, the majority of respondents (83.4%) did not agree that by counselling or providing advice, smokers might leave their clinic. About three- quarters of the public sector dentists indicated lack of time in practice prevented them from being involved in smoking cessation, compared to only half of the private dentists (p< 0.001). The proportion of private dentists (54.4%) who expressed that counseling patients about smoking is not cost-effective for their dental practice is significantly (p < 0.001) higher than those in the public sector (36.7%).

Table 5: Recommendations that may assist dentists in their role in smoking cessation


ρ-valuePublic Private1. Smoking cessation counseling should be introduced into the dental school curriculum.

75.4 83.1 72.6 0.011

2. Will be interested if there is any continuing education seminar or workshop on smoking cessation skills.

60.0 80.4 52.6 0.000

3. Would be interested to send patient for further counseling on smoking (if needed) if dentist knows where to refer them.

73.4 86.5 68.7 0.000

4. With proper training, dental auxiliaries have an important role as smoking counselors.

72.4 85.1 67.7 0.000

The recommendations that may assist dentists in their role in smoking cessation are shown in Table 5. The most frequently quoted recommendation is that smoking cessation counselling should be introduced into the dental school curriculum (75.4%), followed by the referral of patients for further counselling on smoking (73.4%). Dental auxiliaries who are adequately trained (72.4%) are perceived to have an important role as smoking counsellors in assisting dentists. More than half of the respondents (60.0%) indicated interest in attending continuing education seminar or workshop on smoking cessation skills. Significantly, more dentists in the public sector were in favour of each of the recommendations that may assist them in their role in smoking cessation.

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Dentist’s Role as Smoking Cessation Counsellor

DISCuSSIon

The total response rate among eligible respondents in the present study was 67.1%. The response rate was almost comparable to the 73.1% obtained in a national sociodental study carried out among dentists by Razak11 in 1990. Significantly higher percentage of public sector dentists as compared to private practitioners (99.0% and 60.1% respectively) responded to the questionnaire. This allows generalization to be made for the target population especially those in the public sector. The majority of dentists, especially those from the public sector (76.4%) seem to consider that they have an important role as smoking counsellor. This concurs with the study done in Oxford, United Kingdom12 in which a very high proportion (88.6%) of dentists thought that they should encourage smokers to stop the habit. Dentists however can be effective in counselling patients to reduce their tobacco use by being role model. A study done among Alberta dentists13 indicated that over 90.0% of them perceived that they should show leadership and set a good example. In this present study, about 95.0% of dentists are not current smokers and that 84.0% had never smoked. In spite of this, only 25.3% of the overall respondents were optimistic about their effectiveness in encouraging patients to stop smoking. In contrast, the dentists in United Kingdom were more optimistic (42.2%) in their ability to advice patients to stop smoking.12

In the present study, one of the possible reasons why dentists doubted their effectiveness is that most patients do not expect smoking cessation advice from their dentists as perceived by about 40.0% of the respondents. This is also reflected in the result of a survey done in Canada,13 whereby 61.5% of dentists perceived their patients did not expect tobacco intervention from them, when in fact, 58.5% of their patients actually expected dentists to provide such a service. In addition, 28.0% of dentists in this study are pessimistic about their patients’ ability to change their smoking habit. However, studies in the United States14-15 showed even higher levels of pessimism (64.0% and 100.0% respectively). In a US national survey,16 33.0% of the dental practitioners asked most or nearly all patients whether they smoked and 66.0% advised smoking patients to stop the habit, which is consistent with the present study that shows more than half of the respondents (55.1%) provided advices or helpful hints in order to motivate their patients to quit smoking. In comparison, a study carried out among UK dentists,17 although half of the responding dentists had asked their clients about their smoking habits, only 30.0% of them provided brief advice to help patients quit tobacco use. Among the respondents in the present study, 64.7% did explain to their patients regarding the health risk due to smoking and its detrimental effects. A study carried out in Iowa18 reported that about 90.0% of their practitioners discussed the negative health effects of tobacco, whereas only 64.0% advised their smokers to quit. In a survey among Alberta dentists,13 it was found that most dentists had limited their counselling efforts to discussing about the hazards of smoking and benefits of quitting, which is

consistent with the present study. This is in contrast to the findings of Tomar19 where 40.0% of dentists do not routinely ask about tobacco use and 60.0% do not routinely advise tobacco users to quit. The finding that 95.5% of the respondents felt that smoking should not be allowed in dental office reception areas in this study, is consistent with the 90.0% response obtained in a study by Fried and Cohen.20 This finding is not surprising given that many offices have already adopted smoke-free policies and that patients probably expect a smoke-free office environment. The National Cancer Institute in the United States had also suggested removing of all ashtrays; displaying “no smoking” signs and either removing magazines that contain cigarette advertisements or crossing out the advertisements with a large red X, which might further enhance or support a tobacco-free office environment.21

Most studies that provided baseline data on counselling patients clearly suggested that dentist were not adequately communicating to their patients the importance of quitting smoking.22 Another survey of dentists and physicians in San Francisco15 showed that about 70.0% of them agreed that counselling about smoking is actually frustrating and that 76.0% of dentists would only spend more time counselling if they are paid by the health insurance. While providing advice or smoking cessation interventions, the most common barrier cited by dentists (86.1%) in this study is the lack of information between dentistry and smoking cessation. This may also be one of the reasons why 62.0% of Minnesota dentists who claimed that they were not well prepared to assist patients in quitting smoking.23 In addition, a study done among Alberta dentists,13 found that 44.0% of the respondents felt that there was a lack of coordination between dentistry and tobacco cessation services. Related to this, about 6 out of 10 dentists in this study felt constrained by their lack in smoking cessation training. The importance of skills training was emphasized in a study among Australian dentists by Bell et al.24 who found that some dentists use ineffective advice. In the same study, over half of the respondents reported an interest in receiving free training. Apart from inadequate counselling training, Warnakulasuriya22 also stated that the lack of reimbursement as a major constraint in most dentists’ surveys. This is consistent with the present study where dentists claimed that counselling patients about smoking is not cost-effective to their dental practice. Therefore, dentists need to be apprised of the less obvious economic benefits that accrue from tobacco-use interventions efforts. These include a healthier patient population. About three quarters of the public sector dentists and half of the private dentists in this study indicated that lack of time prevented them from being involved in smoking cessation. This is also reflected in the study of Warnakulasuriya17 who stated that only 30.0% of the dentists routinely provided brief health education advice concerning tobacco counselling in a busy schedule. This is despite the suggestion by Fiore25 that only three minutes or less of a clinician time is required for a brief intervention. A failed attempt at implementing a smoking cessation programme involving dental offices in Ontario, Canada13

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Asmaon / Ishak

cited lack of time and fear of alienating patients as their major reasons. This is in contrast to the present study where the majority of respondents (83.4%) did not agree that counselling or providing advice might encourage smokers to leave their clinics. This is in accordance with a survey done by Bell et al.,24 which indicated that most dental patients (61.0%) would not change to another dentist if asked about smoking at every visit.

RECoMMEnDATIon

Based on the findings in this study, the following recommendations are proposed:

1. There is a need to incorporate smoking cessation counselling techniques and other health promotion activities into the dental school curriculum.

2. There is a need to assist health care providers to be able to communicate effectively with their patients about the hazards of smoking. An appropriate protocol is needed to assist dentists in smoking cessation strategies in their clinical settings as a basic guideline to help their patients quit smoking.

3. Dental auxiliaries can be adequately trained to play an important role as smoking counsellors in assisting dentists. This should also be reflected in their training curriculum.

ACKnoWLEDGEMEnTS

The authors wish to thank the Director General of Health, Malaysia for his permission to publish this article. This study was undertaken as a partial fulfillment for the degree of Master of Community Dentistry, Faculty of Dentistry, University of Malaya.

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16. Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg R. Tobacco control activities in U.S. dental practices. J Am Dent Assoc. 1997;128:1669-79.

17. Warnakulasuriya KAAS, Johnson NW. Dentists and oral cancer prevention in the UK: opinions, attitudes and practices to screening for mucosal lesions and to counseling patients on tobacco and alcohol use: baseline data from 1991. Oral Dis. 1999;5:10-4.

18. Logan H, Levy S, Ferguson K, Pomrehn P, Muldoon J. Tobacco-related attitudes and counseling practices of Iowa dentists. Clin Prev Dent. 1992;14: 19-22.

19. Tomar SL, Husten CG, Manley MW. Do dentists and physicians advice tobacco users to quit? J Am Dent Assoc 1996;127:259-65.

20. Fried JL, Cohen LA. Maryland dentists’ attitudes regarding tobacco issues. Clin Prev Dent. 1992;14:10-6.

21. WHO. National cancer control programmes, policies and managerial guidelines – 2nd Editions. Geneva: WHO 2002.

22. Warnakulasuriya KAAS. Effectiveness of tobacco counseling in the Dental Office. J Dent Ed. 2002;66:1079-87.

23. Hastreiter RJ, Bakdash B, Roesch MH, Walseth J. Use of tobacco prevention and cessation strategies and techniques in the dental office. J Am Dent Assoc. 1994;125:1475-84.

24. Bell GR, Donnelly N, Ward J. Preventive dentistry: what do Australian patients endorse and recall of smoking cessation advice by their dentists? Br Dent J. 2003;194:159-64.

25. Fiore MC. A Clinical Practice Guideline for treating tobacco use and dependence. A US Public Health Service Report. J Am Med Assoc. 2000;283:3244-54.

Address for correspondence:

Professor Dato’ Dr. Ishak Abdul Razak BDS (Malaya), DDPHRCS (Eng), MSc (London), PhD (Malaya).Senior ProfessorDepartment of Community Dentistry, Faculty of Dentistry, University Malaya, 50603 Kuala Lumpur, Malaysia.Tel +603-79674800 Fax +603-79674809Email: [email protected]

An Immunohistochemical Study of p53 in Oral Epithelium Dysplasia and Squamous Cell Carcinoma.Ma MS. BDS(Mal), MDentSci(Leeds), FDS RCS(Eng). Oral Pathologist, Armed Forces Dental Centre, Kem Kementah, Jalan Padang Tembak, 50634 Kuala Lumpur, Malaysia.

ABSTRACTSquamous cell carcinoma (SCC) is the commonest cancer in the mouth. Multiple risk factors, such as smoking, alcohol consumption, irradiation, viruses infection and chronic irritation are thought to be responsible for the formation of oral squamous cell carcinoma. Although SCC can develop through a series of precancerous stages manifested as various degrees of epithelial dysplasia, this is not always the case. p53 is the commonest mutated gene in human cancers. Mis-sense mutation of the gene or complexing of the protein with viral or cellular proteins prolongs its half-life and leads to its detection by immunohistochemistry. This study was designed with the aim of demonstrating any possible relationship between p53 and oral squamous cell carcinoma by immunohistochemical staining techniques. A total of 66 specimens from the oral cavity (10 normal mucosa, 11 hyperkeratosis without dysplasia, 11 mild dysplasia, 11 moderate dysplasia, 10 severe dysplasia and 13 SCC) were examined for the presence of p53. The results show p53 was not expressed in normal mucosa, but was found with increasing frequency in increasingly severe dysplasia and SCC. In conclusion, this study shows p53 mutation is common in oral squamous cell carcinoma and probably occurs early in the multisteps of oral carcinogenesis.

Key words oral cancer, dysplasia, tumour markers, p53, risk

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InTrODuCTIOn

Squamous cell carcinoma accounts for more than90 % of all carcinomas in the oral cavity. It is wellacknowledged thatcarcinogenesis is amulti-stepprocessin which carcinogens induce genetic damage in certaincellsandifthesecellsarenotidentifiedbyDNArepairingmechanism,selectivegrowthadvantagemaydevelopandformatumour.1Despiteadvancesinetiologyandepidemiology,theexactmechanisms involved in oral carcinogenesis remainunknown. Results of current researches suggest that p53mutation may play a role in the development of oralsquamouscellcarcinoma.2 Expression of p53 has beenreported in a majority of invasive carcinoma includingthosefromoralmucosa,andinanumberofdysplasiasandinsitucarcinomas. p53geneislocatedonchromosome17.Itencodesa 53-kd nuclear phosphoprotein known to regulate cellgrowthandreplication.3Geneticstudiesofhumancancerhaveshownthatp53isthemostcommonmutatedgeneinhumancancerwith60-65%of all humancancershavingmutationatthep53locus.4

Current researches suggest that p53 can sense damageor potential damage to DNA and invoke a protectiveresponseeitherbyblockingthecellcycleorinducingcellapoptosis.5,6 Obviously, loss of this function of the genecan lead to propagation of genetic imperfect cells anddevelopmentofcancer. The majority of p53 mutations are missensemutationwhichislocalizedtothecentral190aminoacidsof the protein.3 These mutant proteins are produced inlargeamount in tumourcellssuggesting that theycanbeusedasamarkerofmalignancyandatargetoftherapy.7

Mutatedp53canbedetectedbyoneofthefollowingways:

a. polymerasechainreaction(PCR)ofDNAorRNAb. Immunohistochemistry

Wild-typep53hasashorthalflifeofabout20-30minutes.Mutationleadstoalongerhalflifeandaccumulationinthetissue.Asaresult,mutantp53canbedetectedbyapplyingimmunohistochemicalmethodtotheaffectedtissues.

c. singlestrandedconformationpolymorphism(SSCP)analysis

MALAYSIAn DEnTAL JOurnAL

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Ma

Thishasasensitivityandspecificityof90%indetectingp53mutations.7

d. directsequencing

Thisisthemostprecisemethodtotracemutatedp53.Itcanbe performed on tissue biopsies or tumour cells in bodyfluidssuchasurineorsputum.Howeverthistechniqueistimeandlabourconsuming.7

MATErIAL AnD METHODS Sixtysix(66)consecutiveandunselectedformalinfixed paraffin embedded blocks of tissues which werediagnosedbyoralpathologistasSCCorkeratoseswithorwithoutdysplasiawere retrievedfromthehistopathologylaboratory fileofLeedsDental Instituteandused for thestudy.Specimenswithepithelialdysplasiawereclassifiedintomild,moderateandsevereaccordingtoWorldHealthOrganization (WHO) classification.8 There were 11hyperkeratosis without dysplasia; 11 hyperkeratosis withmilddysplasia;11hyperkeratosiswithmoderatedysplasia;10hyperkeratosiswithseveredysplasiaand13SCCs. Inaddition, 10 normal mucosa were included to serve ascontrolsofthestudy. Specimens from patients who have been treatedwithradiotherapywereexcludedfromthestudyasthismayinfluencethestabilityofp53protein.Threeserial4micronsectionsweremountedonAPES(3-aminopropyltriethoxy-saline) slides and dried overnight in 37ºC incubator.One of these sections was subjected to haematoxylinand eosin staining, while the other was subjected to p53immunostaining. The remaining section was used as anegativecontrolforthestainingprocedure. Foreachbatchofimmunostaining,anSCCknowntostainpositivewithp53antibodywasincludedaspositivecontrols. The negative control section went through thesamestainingprocedureasthestudiedsectionsbutinsteadofbeingincubatedwithprimaryantibody,thesectionwasonlyincubatedwithnormalgoatserum.Streptavidinbiotin

complex method was used for all the immunostainingprocedures. The sections were dewaxed with xylene andhydrated through different grades of alcohol. Slideswere then immersed in methanol to block endogenousperoxidaseactivity.NormalGoatSerum(NGS)(DakoX-0907Denmark)attheconcentrationof1/5wasappliedonthesectionsandleftinahumidchamberfor5minutestoblockthenon-specificbindingsites. Mouse anti-p53 monoclonal antibody (ChemiconInternationalIncMAB-4054USA)withadilutionof1/50was thenapplied to thesectionsexceptnegativecontrolsandleftforonehourinthehumidchamber. ThesectionswerethenwashedinTBS(tris-bufferedsaline0.05M,pH7.6)withagitationfor20minutes.10ulof biotinylated goat anti-mouse/rabbit immunoglobulin(Dako Strept ABComplex/ HRP Duet, mouse/rabbit K-0492Denmark)wasaddedto1000ulTBSandappliedtothesectionsfor30minsinahumidchamber. SectionswerethenwashedinTBSwithagitationfor20minsandStreptABCwasappliedtosectionsandleftfor30minsinahumidchamber.SectionsweredevelopedinDAB (3,3’-diaminobenzidine-tetrahydrochloride) (SigmaD-5637Germany)for5minutesandcounterstainedwithMeyershaemotoxylin,andmountedwithDPX.

rESuLTS

Allthenormalmucosaand11hyperkeratosiswithoutdysplasiashownegativestainingwithp53antibody.Onlyone (9%) keratosis with mild dysplasia scored positive.For moderate dysplasia, three (27%) stained positive,whereas 30% of keratosis with severe dysplasia stainedpositive. In five of the margins studied, one (20%) haspositivereactivity.Inthe13SCCsstudied,10(77%)havepositivestaining.Onlyoneoutof10(10%)marginsscoredpositive.ThepercentageofpositivelesionsincreaseswiththeseverityofepitheliumdysplasiawiththehighestscoreinSCC(Figure1).

Figure 1: Percentage of p53 in lesions and margins

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An Immunohistochemical Study of p53 in Oral Epithelium Dysplasia and Squamous Cell Carcinoma.

DISCuSSIOn

It is known that leukoplakia and erythroplakiamay progress to SCC. It is also well acknowledged thatepithelialdysplasiaisrelatedtothepotentialofmalignanttransformation. However, many investigators foundthat dysplasia grade seems to be unreliable as the onlyindicatorinpredictingcancerdevelopment.Moreover,thehistological grading of epithelial dysplasia is subjectedto individual experience even among senior pathologist.Therefore, a method which can accurately predict thepotential malignant transformation of leukoplakia orerythroplakia is required to help the surgeons in planingtheir treatments for patients. Recently, p53 has beeninvestigateddeeplyanditisthoughtthatitcanservethispurpose.OnafollowupstudybyKikegawa,982%(nineout 11) leukoplakia were positive for p53 even beforemalignanttransformation.Kantolaet al.10noticedapoorerprognosis on SCC of tongue without overexpression ofp53proteins althoughTNMwas still themost importantprognostic factor. However, study by Karpranos et al.11showsp53expressionwasnotsignificantlyrelatedtotheprognosisofheadandneckcancer. In the present study, result of p53 expression indysplastic epithelium is in accordance with study byGirod et al.,12 Shintani et al.,13 Sulkowska et al.14 andKikegawa,9inwhichthepercentageofp53overexpressioninoralpreneoplasticandneoplasticlesionsisrelatedtothedegreeofepitheliumdysplasiaand lossofdifferentiationofSCC. p53positivityhasbeenreportedin34to81%ofOSCCthat studied by using immunohistochemistry.15,16,17,8,18,19,20In contrast, reports regarding p53 positivity in normaloral mucosa are controversial, it was detected in somestudies21,22 but not in others13,14,24 with a range of 0% to58%. Overexpression of p53 in normal oral mucosawhichisnotassociatedwithtumourbuthasbeenexposedto tobacco and/or alcohol has been reported.15,16,23,25Thismay indicates the epithelium is at increased risk ofmalignant transformation. The cellular response to thesecarcinogens may consist of accumulation or stabilizationofwild-typep53proteintopreventcellsfromenteringG1inorder toallowDNArepair,or toavoid theadditionofoncogenicmutation.5Inourstudy,allthenormalmucosadoesnotoverexpressp53.Thisisprobablyalloursamplesarenon-smokersandhavenotbeenexposedtoalcoholorthelevelofexposuretotobaccoandalcoholarebelowthatwhichcancausestabilizationofwildtypep53.Ourresultof negative p53 reactivity in normal and hyperkeratoticmucosaisconsistentwiththestudiesofOdgenet al.23andShintaniet al.13 Findingofp53 innormal epitheliumwhich isnotassociatedwithcarcinomabuthasbeenexposedtotobaccoand/or alcohol would be significant since this indicatesthat the epithelium is at increase risk for transformationinto carcinoma.25 Therefore, the determination of p53expressioninthesehighrisksgroupindividualscouldhelptoassessthepotentialforredevelopmentofcarcinoma.This

isprobablythereasonwhyp53onlydetectableinsomeofthepreneoplasticlesions,assumingincaseswherep53isdetectable, it is due to tobacco and/or alcohol exposureas not all dysplastic lesions in the mouth are caused bytobacco and/or alcohol. However, whether this increasedof p53 expression in preneoplastic lesions is a result ofgene mutation or a cellular checkpoint reaction to toxicexposureisnotcertainedandremainstobedetermined.Ourstudyshowsagradualincreaseofp53overexpressionas the grade of epithelial dysplasia increase from mildto severe (Table 1), which is 9% and 30% respectively,indicates that p53 could be a marker for classifying thedegree of epithelium dysplasia. This is supported by thestudy of Shintani et al.13 and Kikegawa9 in which theyfound a significant correlation between histopathologicalclassificationandp53positivityofleukoplakia.

Table 1: Percentage of p53 detected in lesions and margins.

p53 (%)Disease Lesion MarginNormalMucosa 0 0Hyperkeratosis 0 0MildDysplasia 9 0ModerateDysplasia 27 0SevereDysplasia 30 20SCC 77 10

p53 is only detected in certain percentage ofthe preneoplastic samples studied, indicating that in themultistepprocessofcarcinogenesis,p53mutationoccursas an early event probably only in a subset of SCCs. Inthe other SCCs, the reverse may be true.27Alternatively,p53 mutation could be a random event in the process ofcarcinogenesis.27 In fact, the stage at which p53 has itseffect remainsunclear,28 and inheadandneck studiesofsquamous carcinoma, overexpression of p53 have beenrelatedtobothearlyandlatestagesofmalignancy. Mutationofp53mayoccurbeforethemorphologicalchangescouldbedetectedbylightmicroscopeassuggestedbythep53positivityinhistologicalnormalepithelialcelladjacent to the tumour. This again indicates that p53mutationmayoccurearlyincarcinogenesisandsuggestedthat it could be used as an indicator in predicting themalignant potential of epithelium dysplasia. Study byRegeziandcolleagues29todetectp53proteinexpressioninsequentialbiopsiesoforaldysplasiaandin situcarcinomasupportsthishypothesis. The reports of p53 expression in the histologicalnormalepitheliumadjacent tocarcinomavarydependingon the techniques used to treat antigens. The use of anantigenretrievaltechniqueeitherbymicrowaveboilingorautoclavingofsectionsinsaltorureasolutioncanlowerthethresholdfordetectionofp53byanuncertainunderlyingmechanism which could hydrolysis cross-linkage formedbyformaldehydeorproteindenaturation.17 In the studydonebyShinet al.,25 45%ofSCCs

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expressedp53and21%ofthesamplesexpressedp53inhistologicallynormalepitheliumadjacent to the tumours.They suggested that this is due to exposure of theepitheliumtotobaccoand/oralcoholasnormalepitheliumtaken from cancer-free, non-smoking individuals did notexpress p53. This is supported by Cruz et al.30 whonoticed p53 immunostaining pattern were related to thesmokinghabitsofthepatients.Inourstudy,p53isdetectedin 20 % of histologically normal epithelium adjacentto severe dysplasia and 10 % of ‘normal’ epitheliummargins adjacent to SCC which is low compared toGonzalez-Moles31 but consistent with Cruz et al.32 Sucha low percentage of expression of p53 in histologicallynormalepitheliumadjacenttopreneoplasticandneoplasticlesionsmayduetomutationofp53genein thisareahasnot stabilized the protein sufficiently to be detected byimmunohistochemistry. Recent reports of p53 positivity in the normalmucosa adjacent to head and neck SCCs have beenconsideredasevidenceoffieldcancerizationandthereforepotentialforfurthercarcinomadevelopment.21

In our study, all the normal epithelium adjacentto carcinoma with p53 positivity have p53 expressionin their corresponding tumour. This is contrast to thestudy of Nakanishi et al.20 and Odgen et al.22They bothdetectedp53positivity in thenormalepitheliumadjacenttop53negativetumour.Odgenet al.22alsodemonstratedthat tumour can arise in either p53 positive or negativenormal epithelium adjacent to the tumour.And thereforetheyconcluded thatoverexpressionofp53 in thenormalepitheliumadjacent to tumourdoesnotnecessarypredictafurthertumour.Conversely,Shintaniet al.13noticedthatoverexpression of p53 adjacent to carcinomas was onlyobserved in those specimens that exhibited detectablep53 in the tumours and there was no p53 expressionin the epithelium surrounding p53 negative tumours, aresult consistent with ours. The immunostaining in non-malignant mucosa of the margins of SCC could serve avaluablepredictorfor localrecurrenceandthereforemayhaveimplicationsonthemanagementofpatients. In our study, p53 could not be detected in 23 %ofSCC,suggesting thatp53mutation isnotessential fortumourtransformation.Inadditiontothefactorsoutlinedabove,thiscouldbeareactiontootheraetiologicalfactorsthat may responsible for the development of tumour, oralternativelystabilizationofp53decreasedasotherfactorsintervening. In those cases where p53 were detected ineither thepremalignantormalignant lesions, thepatientsmay have a genetic susceptibility to react in that way topotentialcarcinogensasdemonstratedbyFoulkeset al.34Itiscertainlynotduetoanatomicalvariations,13althoughvery rarely all epithelial cells can overexpress p53 incertain individuals.35 Immunohistochemical detection ofp53mayindicateatissueresponsetoanaetiologicalagentwhich is not yet recognized or to an endogenous factorassociatedwiththetumouritself.22Therefore,detectionofp53inSCCdoesnotnecessarilyindicateithasacausativerole in carcinogenesis. It could be that other aetiological

agent(s), either external or internal, cause a stabilizationofp53after interactingwith it.Otherexplanationofp53negative tumour are that such SCC may contain no p53geneduetobialleliclossofthegene,averylowlevelsofwild-typeormutantp53(pointmutationdoesnotstabilizetheproteinsufficientlytothedetectablelevels),oratypeofp53mutationwhich isnotrecognizedby theantibodyused.Furthermore,p53inductionshowsdoseresponseandtimecourses.Thisindicatesthatoverexpressionofp53isprobablyatransientphenomenon.33

An increased in stabilityofp53 isnotnecessarilyduetop53mutationsbutcanalsobeduetobindingofthewild-typep53tootherproteinsandanalteredp53turnoverat the epigenitical level.36 Therefore, detection of p53by immunohistochemistry does not necessarily indicatemutation.37 It could be non-functional accumulation ofp53, or alternatively increase stabilization as a result ofUV light, radiation or cytotoxic therapy. However, noneofthesefactorsexistinoursamples.Conversely,absenceofp53expressiondoesnotnecessarilyindicatethereisnomutation; it couldbe thatmutationofp53 exists but didnotresultinastableform,oralternativelyp53expressionis degraded after forming complex with viral proteinsand hence appears absent. Also, immunohistochemistryonly detects mis-sense mutation which result inconformational change and stabilization of the translatedprotein, nonsense and frame shift mutation do not causeprotein stabilization, hence, less likely to be detected byimmunohistochemistry.38 Insummary,theneedtointerprettheresultsofp53overexpressionbyimmunohistochemistrytechniqueswithcautious cannot be overemphasized since this dependsgreatlyonstabilizationandhalf-lifeofpointmutatedp53.

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2. WernerG&SummerlinDJ.Therelationshipofp53andhumanpapillomavirusinoralcarcinomain-situ.OralSurgOralMedOralPatholOralRadiololEndod.1996;82:(abstract)

3. LaneDP.P53andhumancancers.BrMedBull.1994;50:582-99.

4. LevineAJ.Thetumoursuppressergenes.AnnRevBiochem.1993;62:623-51.

5. Lane DP. p53, guardian of the genome. Nature. 1992;358:15-6.

6. LaneDP.Adeathinthelifeofp53.Nature.1993;358:15-6.7. Velculescu VE, El-Deiry WS. Biological and clinical

importanceof thep53 tumoursuppressergene.ClinChem.1996;42:858-868.

8. WHO Collaborating Center for Oral Precancerous lesions.efinitionofleukoplakiaandrelatedlesions:anaidtostudieson oral cancer. Oral Surg Oral Med Oral Pathol. 1978;46:518-39.

9. Kikegawa A. Immunohistochemical analysis of the p53tumorsuppressorgeneproductinoralleukoplakia.KokubyoGakkaiZasshi.2001;68:51-9.

10.Kantola S, Parikka M, Jokinen K, Hyrynkangs K, SoiniY,

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AlhoOP,SaloT.Prognosticfactorsintonguecancer–relativeimportance of demographic, clinical and histopathologicalfactors.BrJCancer.2000;83:614-9.

11.KarpranosN,StathopoulosGP,ManolopoulosLetal..p53,p21andp27proteinexpressioninheadandneckcancerandtheirprognosticvalue.AnticancerRes.2001;21:521-8.

12.GirodSC,KruegerG,PapeHD.p53andKi67expressioninpreneoplasticandneoplasticlesionsoftheoralmucosa.InJOralMaxillofacSurg.1993;22:285-8.

13.Shintani S, Yoshihama Y, Emilio ER, Matsumura T.Overexpressionofp53isanearlyeventinthetumourigenesisof oral squamous cell carcinomas. Anticancer Res.1995;15:305-8.

14.Sulkowska M, Falmuski W, Chyczewski L, SulkowskiS. Evaluation of p53 nad bcl-2 oncoprotein expressionin precancerous lesions of the oral cavity. Neopalsma.2001;48:94-8.

15.Langdon JD, Partridge M. Expression of the tumoursuppresser gene p53 in oral cancer. Br J Oral MaxillofacSurg.1992;30:214-20.

16.LavieilleJP,BramillaE,Riva-LivieilleC,ReytE,CharachonR, Bramilla C. Immunohistochemical detection of p53proteininpreneoplasticlesionsandsquamouscellcarcinomaoftheheadandneck.ActaOtholaryngol.1995;115:334-9.

17.Dowell SP, Odgen GR. The use of antigen retrieval forimmunohistochemical detection of p53 over-expression inmalignantandbenignoralmucosa:acautionarynote.JOralPatholMed.1996;25:60-4.

18.PenhallowJ,SteingrimsdottirH,ElaminF,WarnakulasuriyaS, Farzaneh F, Johnson N, Tavassoli M. p53 alterationsand HPV infections are common on oral SCC: p53 genemutationscorrelatewiththeabsenceofHPV16-E6DNA.IntJOncol.1998;12:58-68.

19.Yanamoto S, Kawasaki S, Yoshitomi I, Mizuno A. p53,mdm2,andp21expressioninoralsquamouscellcarcinomas:relationship with clinicopathologic factors. Oral Surg OralMedOralPatholOralRadiolEndod.2002;94:593-600.

20.PandeP,SoniS,KaurJ,AgarwalS,MathurM,ShuklaNK,RalhanR.Prognosticfactorsinbetelandtobaccorelatedoralcancer.OralOncol.2002;38:491-9.

21.Nakanishi Y, Noguchi M, Matsuno Y. P53 expression inmulticentric squamous cell carcinoma and surroundingsquamousepitheliumoftheupperaerodigestivetract.Cancer.1995;75:1657-62.

22.Odgen GR, Chisholm DM, Morris AM, Stevenson JW.Overexpressionofp53innormaloralmucosaoforalcancerpatientsdoesnotnecessarilypredictfuturemalignantdisease.JPathol.1997;182:180-4.

23.OdgenGR,KiddieRA,LunnyDP,LaneDP.Assessmentofp53proteinexpressioninnormal,benignandmalignantoralmucosa.JPathol.1992;166:389-94.

24.Minawaer,Ahmatjan,SuzukL.DetectionofHPVtype16,18infectionsandp53proteinoverexpression inoralsquamouscell carcinoma. Zhonghua Kou Qiang Yi Xue Za Zhi.2001;36:451-3.

25.Shin DM, Kim J, Ro JY, et al.. Activation of p53 geneexpression in premalignant lesions during head and necktumourigenesis.CancerRes.1994;54:321-6.

26.ShahnawazSA,RegeziJA,BradleyG,DubeID,JordanRC.p53genemutationsinoralepithelialdysplasiaandsquamouscellcarcinoma.JPathol.2000;190:417-22.

27.ChibaI,ShindohM,YasudaMetal..Mutations in thep53

gene and human papillomavirus infection as significantprognostic factors in squamous cell carcinomas of the oralcavity.Oncogene.1996;12:1663-8.

28.LeungKW,PedlarJ,HighAS.Decreasingp53overexpressioninsequential,recurrentoralsquamouscellcarcinoma.BrJofOral&MaxillofacSurg.1996;34:225-9.

29.Regezi JA, Zarbo RJ, Regev E, Pisanty S, Silverman S,Gazit D. p53 protein expression in sequential biopsies oforal dysplasia and in situ carcinomas. J Oral Pathol Med.1995;24:18-22.

30.Cruz I, Snijders PJ, Van Houten V, Vosjan M, van DerWaal I, Meijer CJ. Specific p53 immunostaining patternsare associated with smoking habits in patients with oralsquamouscellcarcinomas.JClinPathol.2002;55:834-40.

31.Gonzalez-Moles MA, Galindo P, Gutierrez J, Rodriguez-ArchillaA,Ruiz-AvilaI,Sanchez-FernandezE.Significanceof p53 expression in non-tumoral epithelium adjacent tooral squamous cell carcinomas. J LaryngolOtol. 2002;116:355-8.

32.CruzIB,MeijerCJ,SnijdersPJ,SnowGB,WalboonersJM,van Der Waal I. p53 immunoexpression in non-malignantoral mucosa adjacent to oral squamous cell carcinoma:potential consequences for clinical management. J Pathol.2000;191:132-7.

33.Odgen GR, Hall PA. Field change, clonality, and earlyepithelial cancer: possible lessons from p53. J Pathol.1997;181:127-9.

34.Foulkes WD, Brunet J-S, Sieh W, Black MJ, Shenouda G,NarodSA.Familial riskofsquamouscellcarcinomaof thehead and neck: retrospective case-control study. Br Med J.1996;86:1681-4.

35.BarnesDM,HanbyAM,GilletCE,etal..Abnormalexpressionofwild-typep53protein innormalcellsofacancer familypatient.Lancet.1992;340:259-63.

36.Wynford-ThomasD.P53intumourpathology:canwetrustimmunocytochemistry?JPathol.1992;166:329-30.

37.Hall PA, Lane DP. P53 in tumour pathology: can we trustimmunohistochemistry?Revisited!JPathol.1994;172:1-4.

38.Raybaud-DiogèneH,TétuB,MorencyR,FortinA,MonteliRA. P53 overexpression in head and neck squamous cellcarcinoma: review of literature. Oral Oncol, Eur J Cancer.1996;32B:143-9.

39.Gonzalez-Moles MA, Galindo P, Gutierrez-Fernandez J,Sanchez-Fernandez E, Rodriguez-Archilla A, Ruiz-AvilaI, Bravo M. p53 protein expression in oral squamouscell carcinoma, survival analysis.Anticancer Res. 2001;21:2889-94.


Dr. Ma Mei SiangBDS(Mal) MDentSci(Leeds) FDS RCS(Eng)Pusat Pergigian Angkatan TenteraKem Kementah Jalan Padang Tembak50634 Kuala Lumpur, Malaysia.Tel: 012-3990925E-mail address: [email protected]

A 5-Year Survey of Oral and Maxillofacial Biopsies in Hospital Kota Bharu and Universti Sains Malaysia, Kelantan: 1994-1998Ghazali N. Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.

Zain RB. Department of Oral Pathology, Oral Medicine & Periodontology, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.

Samsudin AR. Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Universiti Sains Malaysia (USM), Kelantan, Malaysia.

Abdul Rahman R. Department of Oral Surgery, Kota Baru Hospital, Ministry of Health, Kelantan, Malaysia.

Othman NH. Department of Pathology, Faculty of Medicine, USM, Kelantan, Malaysia.

ABSTRACTA review of incident oral and maxillofacial biopsies in Kelantan from January 1994 to December 1998 was carried out to evaluate the scope of pathological lesions managed by the two main oral and maxillofacial units in this state. A total of 357 biopsy reports from incident cases of pathological lesions were reviewed. The biopsies were mainly from intra-oral sites (n=326, 91.3%). Females had more frequent oro-facial lesions compared with males (male:female ratio is 0.8:1). The Bumiputera ethnic group had the most number of biopsies (n=321; 90%). The three most commonly observed histopathological groups were the connective tissue hyperplasia (n=90; 25.2%), epithelial dysplasia and neoplasia (n=68; 19%) and salivary gland cysts/mucocele (n=56; 15.7%). The top five most frequent diagnoses were mucocele (n=56; 15.7%), squamous cell carcinoma (n=45; 12.6%), epulides (n=31; 8.7%), pyogenic granuloma (n=25; 7.0%) and fibroepithelial polyp (n=19; 5.3%). Oro-facial malignancies made up almost one-fifth of all diagnoses and squamous cell carcinoma was the most common sub-type. Lymphomas in the oro-facial region (n=8; 11.4%) were more common than basal cell carcinoma (n=7; 10%) and salivary gland malignancies (n=6; 8.5%). Epithelial jaw cysts consisted of 8.7% (n=31) of all diagnoses, where inflammatory types were more common than the developmental types. Odontogenic tumours consisted of 5.6% (n=20) of all diagnoses and ameloblastoma was the predominant type.

Key words Oral pathology, biopsy, relative frequency

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INTRODUcTION

The management of oro-facial pathological lesions in Malaysia is traditionally provided through the Oral & Maxillofacial Surgery (OMFS) units based in each state within the country. The magnitude and array of oro-facial diseases seen and managed by individual OMFS units are likely to vary between state to state according to the relative frequency of disease occurrence. The state of Kelantan is situated in the northeastern region of Malaysia with an area encompassing 14,920 square kilometres.1 The estimated total population of Kelantan was 1.4 million, comprising of 49.7% males and 50.3% females. Kelantan consists of a multiethnic

population however the main population group is Malay (91.2%) with other population groups comprising of Chinese (4.3%), Indians (0.5%) and others (4.0%). (Data supplied by the Statistics Department of Malaysia for the 2000 mid-year population estimates based on the 1991 Population Census data). Two large main hospitals provide health services for the entire population of Kelantan and are namely, the University of Science Malaysia Hospital (HUSM) and the Kota Baru Hospital (HKB). Within these two hospitals are the two referral OMFS units for Kelantan i.e. the Head & Neck Clinic, Faculty of Medicine (HUSM) and the Oral Surgery clinic (HKB).

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Incident Oral & Maxillofacial Biopsy in Kelantan

A study into the range of pathology seen by these two units may provide valuable data regarding the overall pattern of oro-facial diseases in Kelantan. This is important not only from an epidemiological standpoint but also for future planning and provision of state health care services. While conducting a population-based survey may be the only other alternative of obtaining the necessary information, such an option would be costly. Hospital-based records are recognised as a reliable source for obtaining data on the occurrence and distribution of diseases within the population that it serves despite the unavoidable biases that are present in such records.2 Nevertheless, these records are a rich source of information and much can be harnessed when necessary steps are taken to limit potential biases. This survey was undertaken to determine the relative frequencies of various oral pathological entities encountered in Kelantan within the period of January 1994 to December 1998, and to compare the findings with other studies reported world-wide.

MATERIALS AND METHODS

Initial data were obtained from surgical biopsy records of the two OMFS referral centres in Kelantan between the period of 1 January 1994 to 31 December 1998. Two individual patient lists from each hospital were obtained and patients were matched for name, identification card number and hospital registration number to preclude the possibility of overlap. The home addresses were also verified to exclude patients who were not of Kelantan residential status at the time of biopsy. Only biopsies of new lesions were studied as repeat biopsies were excluded. When there were doubts regarding the diagnosis or when histological records were unavailable, these cases were ruled out of the study (Figure 1).

Figure 1: Flow chart of the screening process

HUSM surgicalbiopsy records

(n=124)

HKB surgical biopsyrecords (n=265)

List of combined biopsy cases(n=389)

Matched for name, IC number,hospital registration numbers

Confirm Kelantan residentialstatus at the time of biopsy

Obtain list of biopsy reports(n=398)

Histologically-confirmed reports(n=392)

Recognised pathologicalentities according to WHO

(n=367)

Reports of incident cases only(n=357)

Cytological reports only(n=6)

Normal / scar tissues(n=11)

Non-diagnostic / uncleardiagnosis (n=14)

Recurrent disease (n=1)

Additional reports ofsame incident case (n=9)

Excluded from study

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Ghazali / Zain / Samsudin / Abdul Raman / Othman

Corresponding histological reports were retrieved and reviewed by a single oral pathologist (RBZ). Non-malignant pathologies were subsequently re-classified according to the latest World Health Organization (WHO) International Classification of Diseases in Dentistry and Stomatology.3 Oro-facial malignancies were classified by site according to the WHO International Statistical Classification of Diseases, (ICD-9)4 and by histology based on the WHO Histological Typing of Oral and Oropharyngeal Tumours.5

RESULTS

During the 5-year period examined, 389 biopsies from the oro-facial region were carried out in Kelantan, where 124 cases were undertaken in HUSM (31.9%) and 265 cases in HKB (68.1%). Overall, a total of 398 biopsy reports were issued from the 389 biopsies done. These reports composed of three sub-types: cytological report only (n=6), histological report only (n=382 cases) and cytological-histological reports (n=10). Thirty-two biopsy reports were excluded from this study because of the following reasons: cytological biopsies without

corresponding histological reports (6 cases), normal/scar tissues (11 cases), non-diagnostic/unclear diagnosis (14 cases) and recurrent disease (1 case). There were 7 cases with additional reports on a same incident lesion amounting to 9 reports and these were also excluded from consideration. At the end of the screening process (Figure 1), a total of 357 reports of incident cases of pathological lesions were included for further analysis in the course of this study. When the combined number of biopsies from both hospitals (n=389) were analysed, the highest number of biopsies per year was 84 recorded in year 1997 (Figure 2) with a mean of 77.8 biopsies undertaken per year. Overall, females (n=212; 54.5%) had more frequent oro-facial lesions than did the male (n=177; 45.5%) counterpart. The age of patients in this cohort ranged between 1 to 92 years (Figure 3) and the most frequent age group was the 10-19 years (n=85; 23.8%). The vast majority of patients were from the Malay ethnic group, accounting for 90% (n=321) of all cases (Figure 4). The biopsies were mainly undertaken from intra-oral sites (n=326; 91.3%) while extra-oral sites included the neck, scalp, ear and various sites on the face (i.e. the eyelid, eyebrow, cheek, nose etc.).

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Figure 2: Number of biopsies per year Figure 3: Age distribution of patients biopsied

Figure 4: Distribution of biopsy according to ethnicity

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The histological diagnoses obtained from the biopsies were grouped into several main histological groupings (Table I) and the frequency distributions of these histological groupings are shown in Figure 5. The three most common histological-type groups are the connective tissue hyperplasia (n=90, 25.2%), epithelial dysplasia and neoplasia (n=68, 19%) and salivary gland cysts/mucocele (n=56, 15.7%) while the twenty most common histological diagnoses are listed in Table 2. Table I: Histological groupings of diagnoses of biopsies at HKB and USM

Mucosal inflammation• Inflammation• Non-specific ulcer

connective tissue (cT) hyperplasia• Pyogenic granuloma• Fibroepithelial hyperplasia• Epulides• Denture hyperplasia

connective tissue (cT) neoplasm• Lipoma• Haemangioma• Lymphangioma• Malignant fibrous histiocytoma• Lymphoma

Inflammatory bone lesion• Osteomyelitis• Osteoradionecrosis

Neoplasms and other lesions related to bone• Ossifying fibroma • Fibrous dysplasia• Central giant cell granuloma• Osteoma

Epithelial hyperkeratosis• Lichen planus• Seborrhic keratosis• Lichenoid reaction

Epithelial dysplasia and neoplasia• Naevus• Squamous cell papilloma• Epithelial dysplasia• Squamous cell carcinoma• Basal cell carcinoma• Undifferentiated carcinoma• Adeno-squamous cell carcinoma

Odontogenic tumours• Ameloblastoma• Adenomatoid odontogenic tumour• Odontoma• Calcifying odontogenic cyst

Odontogenic cysts• Odontogenic keratocyst• Dentigerous cyst• Nasopalatine cyst• Radicular cyst• Paradental cyst

Salivary gland cyst (Mucocele)• Mucous extravasation cyst • Mucous retention cyst

Salivary gland neoplasms• Pleomorphic adenoma• Mucoepidermoid carcinoma• Adenoid cystic carcinoma• Carcinoma ex pleomorphic Adenoma

Other benign lesions (Others)• Pemphigus• Choristoma• Infection

AbscessZygomycosisPeriapical granuloma

• Dermoid cyst• Epidermoid cyst• Proliferative fasciitis

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Table 2: Twenty most common diagnoses for biopsies at HKB and USM

Histological diagnosis Number of cases Percentage (N=357)

1. Mucocele 56 15.72. Squamous cell carcinoma 45 12.63. Epulides 31 8.74. Pyogenic granuloma 25 7.05. Fibroepithelial polyp 19 5.36. Mucosal inflammation 18 5.07. Denture hyperplasia 15 3.98. Radicular cyst 14 3.99. Epidermoid cyst 11 3.110. Naevus 10 2.811. Ameloblastoma 9 2.512. Non-specific ulcer 9 2.513. Dentigerous cyst 9 2.514. Lymphoma 8 2.215. Osteomyelitis 8 2.216. Basal cell carcinoma 7 2.017. Haemangioma 7 2.018. Fibrous dysplasia 5 1.419. Infection 5 1.420. Lichenoid reaction 4 1.1

Table 3: Distribution of Oro-facial malignancies

Diagnosis Number of Percentage Percentage cases (N=70) (N=357)

Epithelial Squamous cell carcinoma 45 64.29 12.61 Basal cell carcinoma 7 10.00 2.96 Adenosquamous carcinoma 1 1.43 0.28 Undifferentiated carcinoma 1 1.43 0.28

Salivary gland malignancy Mucoepidermoid carcinoma 4 5.71 1.12 Adenoid cystic carcinoma 1 1.43 0.28 Ca ex pleomorphic adenoma 1 1.43 0.28

Mesenchymal Malignant fibrous histiocytoma 1 1.43 0.8 Lymphoma 8 11.43 2.24

Metastatic 1 1.43 0.28

Total 70 100.01* 19.61

*Rounding error

Oro-facial malignancies (Table 3) made up almost one-fifth (n=70, 19.6%) of all diagnoses and squamous cell carcinoma was the most common sub-type (n=45, 64.3% of all orofacial malignancies). Lymphomas involving the oro-facial region (n=8, 11.4% of all orofacial malignancies) were more common than basal cell carcinoma (n=7,10% all orofacial malignancies) and salivary gland malignancies (n=6, 8.5% of all orofacial malignancies).

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Odontogenic cysts consisted of 8.7% (31 cases) of all diagnoses with the radicular cyst being the most common (14/31 cases, 45.2%) followed by the dentigerous cyst (9/31 cases, 29.0%). Odontogenic tumours accounted for 4.8% (n= 17) of all diagnoses and the most common type was ameloblastoma (9/17 cases, 52.9%). The distribution of the different types of odontogenic cysts and tumours are as in Table 4.

Table 4: Distribution of Benign Odontogenic Tumours and cysts

Diagnosis Number of Percentage Percentage cases (N=48) (N=357)

Odontogenic Tumours 17 100 4.76

Ameloblastoma 9 52.94 2.52Odontoma 4 23.53 1.12Adenomatoid odontogenic tumour 2 11.76 0.56Odontogenic fibroma 2 11.76 0.56 Odontogenic Cysts 31 100 8.68

Radicular cyst 14 45.16 3.92Dentigerous cyst 9 29.03 2.52Odontogenic keratocysts 2 6.45 0.56Nasopalatine cyst 1 3.22 0.28Other odontogenic cysts 5 16.13 1.40 Total Odontogenic Tumours and Cysts 48 100% 13.44

DIScUSSION

The findings obtained from this survey demonstrate the workload profiles of two OMFS units in Kelantan configured by the relative occurrence of oro-facial diseases there. Generally, OMFS services in Malaysia are primarily based in state government hospitals and clinics managed by the Ministry of Health. These units are staffed by a team of dentists headed by a consultant OMF surgeon and are usually supported by the Oral Pathology service provided by the Institute of Medical Research. Other establishments that provide OMFS care include various private OMFS practices and three OMFS departments based within the respective university teaching hospitals. Apart from the Federal Territory (Wilayah Persekutuan), Kelantan is the only other state in Malaysia with an additional OMFS unit attached to a higher learning institution (HUSM). The HUSM was established in 1994 and is equipped with a Pathology service with a wide range of facilities including cytology. On the other hand, HKB is the largest government hospital in Kelantan and the OMFS unit there has traditionally been the main referral centre for oral diseases in general. Since the setting up of HUSM, OMFS surgeons in HKB and HUSM have frequently collaborated in the management of complex OMFS cases e.g. clefts & craniofacial deformities and oral oncology.

The total number of completed biopsies of incident cases in HKB was more than twice the number undertaken in HUSM. This probably reflects the situation where HUSM is a relatively new health care centre and receives fewer numbers of patients and referrals per year compared with HKB. In addition, the number of cases excluded from this study was higher in the HUSM list (n=19) compared with the HKB (n=13). Cytological biopsies without a corresponding histological report accounted for 31.6% of those excluded in HUSM whereas HKB lacked any of such cases. Although these cases were excluded from this study for technical reasons, its presence underlies the importance of the cytological service provided by HUSM to the OMFS unit there. Cytological biopsies are excellent means of obtaining a quick diagnosis in certain pathological lesions. From the 6 cases of cytological biopsies done, there were two cases of salivary gland cysts and 1 case of Warthin’s tumour of the parotid gland. However, 3 cases were reported as being non-diagnostic. This observation echoes the fact that the reliability of cytological diagnosis largely depends on the skill of the operator and expertise of the pathologist reading the sample. A different profile of pathological lesions biopsied was noted in the respective hospitals. Hospital Kota Bharu had a higher proportion of biopsies done overall and certain pathological lesions, such as connective tissue hyperplasia,

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salivary gland cysts, odontogenic cysts and tumours were particularly more common in HKB in comparison to HUSM (Figure 5). Interestingly, the HUSM showed a higher number of salivary gland neoplasms in comparison to HKB (Figure 5) while both centres had similar number of epithelial dysplasia and neoplasm. The dissimilarity noted probably reflects the variations due to the different catchment areas serviced by each hospital, the range of hospital facilities available and expertise present in the individual units. Both the HKB and HUSM cater for the Kota Bharu population. However, HUSM, being a teaching hospital with better hospital facilities and more expertise also receives referral from the state of Trengganu and the northern states of the Peninsular Malaysia.

When evaluated as a whole, the main bulk of pathological lesions occurring in Kelantan during the investigated period consisted mainly of benign types where the underlying pathological processes were classified as mucosal inflammation and inflammatory bone lesions (n=26, 7.3%), connective tissue hyperplasia (n=90, 25,2), odontogenic cysts and tumours (n=48, 13.4%) and other benign lesions (n=23, 6.4%). This finding was also observed in other studies conducted as a survey of oral biopsies within an oral pathology service, such as, the studies in Cleveland, USA,6 Louisiana, USA7 and Singapore.8 Despite its non-life-threatening nature, these lesions may be a source of local pain or discomfort, cause local destruction of oro-facial tissues and interfere with oral functions. Furthermore, facial lesions are potentially disfiguring and may be a cause of worry and anxiety due to the real or imagined danger of malignant transformation.6 It is probably for these reasons that patients have sought for dental/medical attention in the first instance. The aforementioned studies have also reported that ‘neoplasia and premalignant lesions’ as the second most common type of pathological lesion, which was similarly observed in Kelantan. Although oro-facial malignancies do not predominate to the extent seen in Papua New Guinea (47%),9 squamous cell carcinoma (12.6%) came in second in the list of top twenty individual diagnoses overall. From this study, the profile of a typical patient with oral squamous cell carcinoma in Kelantan would be a Malay man in the 50-60 age group and it is most likely that the presenting site of complaint would be the cheek.

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Figure 5: Distribution of diagnoses according to histological groupings

When the incidence of oral cancer was calculated, the age-standardised incidence rate adjusted to world population (ASR) for oral cancer in Kelantan during the investigated period was estimated to be 1.1 ± 0.15 per 100,000.10 When this was adjusted for site and ethnicity, the Indian ethnic group had the highest ASR for mouth cancer (15 and 9 per 100,000 for males and females respectively). The Malays had the highest ASR for tongue (0.2 per 100,000 for both genders) and lip cancer (females, 0.2 per 100,000).10 When the ASR for mouth cancer among Kelantan Indians was compared with Indians of other parts of the world, Kelantan Indians were one of the highest figures noted world-wide.10

The underlying reason for this is unclear but it is well established that site-specific cancers are related to certain risk habits. Studies have shown that carcinomas of the gum/alveolus-sulci-cheek complex are related to betel quid chewing.11-14 While this habit may be disappearing among Malaysians in general,15 the prevalence of current smokers in Kelantan is known to be the highest in the country for those aged 18 and above.16 This is particularly significant from the perspective of oral cancer aetiology because tobacco usage is a well-established risk factor for the upper aero-digestive tract cancers. More recently, there is evidence to support the association between oral carcinogenesis and a reduction in the circulating levels of micronutrients among certain sections of the Kelantan population.17 It has been suggested that the reason behind this was due to unsatisfactory dietary intake i.e. low in fresh fruit and vegetables and/or high in fermented and preserved food.18

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A relatively high proportion of lymphomas (8/70, 11.7%) were observed amongst the orofacial malignancies diagnoses. Among the lymphomas recorded in this study 87.5% were non-Hodgkin types (n=7). Extranodal sites are more common in Non-Hodgkin's lymphoma and frequently involve the submucosal tissues of the gastrointestinal tract (including the oro-pharyngeal and Waldeyer's ring), bone marrow, liver and bronchial mucosa.19 These lesions share similar presenting complaint of other various non-malignant lesions. Previous reports in the literature have recorded non-Hodgkin's lymphoma to present with odontogenic pain, non-healing extraction sockets, non-vital tooth with periapical radiolucency, mental paraesthesia, facial swelling, gingival and periodontal problems.20-24 The current study was unable to record the signs and symptoms for lymphoma due to the retrospective nature of data collection where these information were unavailable in the biopsy reports and patient records. With a relatively high frequency of lymphoma in the Kelantan population, this disease should be considered as an important differential diagnosis by OMF surgeons as well as general dental practitioners in Kelantan when confronted with patients with those symptoms as reported in the literature. Odontogenic tumours accounted for 4.8% (17 cases) of all biopsies in Kelantan. This figure is comparable with those obtained in Singapore and Hong Kong, which range from 4.0 to 5.0%.9,25-26 Other biopsy studies in Canada,27 Mexico,28 Michigan, USA29 and Japan30 have reported figures of between 1.0 to 3.0%. However, the highest proportions of cases made up by odontogenic tumours have been reported from Africa, ranging from 8.6 to 30.8%.31,32 According to Tay,9 the relative frequency of the individual subtypes of odontogenic tumours reported in North America seemed slightly different to those reported in other parts of the world. Here, odontoma followed by ameloblastoma, were the top two most common diagnosis for odontogenic tumours while the opposite was observed in many parts of Asia,9,26,33 Africa32 and Turkey.34 In Kelantan, ameloblastoma (n=9, 2.5%) followed by odontoma (n=4, 1.1%) were the two most common types of odontogenic tumours. Odontogenic cysts are uncommon lesions that often grow to large sizes and may sometimes behave aggressively. Unfortunately, information on the relative frequencies of these cysts from different populations is not abundant. In several series, developmental cysts appear to be more common than inflammatory cysts35-36 while in others the direct opposite was observed.27 In this Kelantan series, the inflammatory types were found to be more common than developmental ones. Radicular cyst was the predominant type of inflammatory cyst accounting for 45.2% (14/31) of all cases of odontogenic cysts. This figure is lower than that found by other studies where 52.3 to 77.7%27,37,38 were reported. In view that radicular cysts arises from a non-vital tooth, it is possible that radicular cysts are under-reported since root canal therapies may have been done by private dental practitioners where radicular cysts may not be surgically removed.

This study was limited by two shortcomings. Firstly, lesions that may have been treated by practitioners working beyond the hospitals studied were inevitably omitted due to study methodology. This is particularly significant for small, benign type lesions that are readily treated by private dental practitioners. However, this may not be the case for larger benign and/or malignant lesions, which require hospital-based management. Secondly, individual diagnoses were not verified independently as histological slides were not available for reviewing. However, we have minimized this problem by excluding cases with inconclusive diagnoses and those that did not have histological reports. Nevertheless, we are reasonably satisfied that the findings obtained from the surgical and pathological database offers a valid contribution to our understanding of the relative frequencies of oro-facial lesions in Kelantan.

CONCLUSIONS

The range and relative frequencies of pathological lesions seen in the Kelantan series were not very different from others reported in the literature. The vast majority of incident biopsies done in the OMFS units in Kelantan originated from lesions occurring inside the mouth. These lesions were predominantly benign types. However, due to high frequencies of oro-facial malignancies in this population, OMF surgeons and dental practitioners should always consider this group of disease in reaching a definitive diagnosis. The reasons behind the relatively high occurrence of oral carcinoma in this population are probably due to tobacco abuse and a relatively non-protective diet against oral carcinogenesis. The reasons underlying other malignancies are not clear and should be investigated in the future.

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1. Department of Statistics. Malaysia Statistics Handbook. Percetakan Nasional Malaysia Berhad: Malaysia, 2000.

2. Young JL. Hospital based cancer registry. IARC Scientific Publication 1991;95:177-84.

3. World Health Organization. The Application of the International Statistical Classification of Diseases to Dentistry and Stomatology. Third edition, Chapter 11. 1995.

4. World Health Organisation. International Classification of Diseases, Ninth Revision. World Health Organisation: Geneva, 1978.

5. Wahi PN, Cohen B, Luthra UK, Torloni H. International Typing of Oral and Oropharyngeal Tumours. World Health Organisation: Geneva, 1971.

6. Rossi EP, Hirsch SA. A survey of 4,793 oral lesions with emphasis on neoplasia and premalignancy. J Am Dent Assoc. 1977;94:863-6.

7. Weir JC, Davenport WD, Skinner RL. A diagnostic and epidemiologic survey of 15, 783 oral lesions. J Am Dent Assoc. 1987;115:439-41

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8. Tay BG. A 5-year survey of oral biopsies in an oral surgical unit in Singapore: 1993-1997. Ann Acad Med Singapore. 1999;28:665-71.

9. Moody GH. Oral pathology in Papua New Guinea. Int J Oral Surg. 1982;11:240-5.

10. Ghazali N, Zain RB, Samsuddin AR, Rusdi AR. The Incidence of Mouth, Tongue and Lip Cancer in Kelantan, Malaysia. Oral Oncol. 2001;37:86.

11. Chen YK, Huang HC, Lin LM, Lin CC. Primary oral squamous cell carcinoma: an analysis of 703 cases in southern Taiwan. Oral Oncol. 1999;35:173-9.

12. van Wyk CW, Stander I, Padayachee A, Grobler-Rabie AF. The areca nut chewing habit and oral squamous carcinoma in South African Indians. A retrospective study. S Afr Med J. 1993;83:425-9.

13. Thomas SJ, MacLennan R. Slaked lime and betel nut cancer in Papua New Guinea. Lancet. 1992;340:577-8.

14. Ahmed F, Islam KM. Site predilection of oral cancer and its correlation with chewing and smoking habit- a study of 103 cases. Bangladesh Med Res Counc Bull. 1990;16:17-25.

15. Raman RA, Rahman ZAA, Zain RB, et al. Oral mucosal lesions in Malay quid and non-quid chewers in Kelantan. J Dent Res. 1999;78:1171 (abstract # 9).

16. Haniza MA, Maimunah AH, Rusilawati J, et al. National Health and Morbidity Survey 1996: Smoking among adults. Public Health Institute, Ministry of Health Malaysia, Kuala Lumpur 1999; vol 15: pg 23.

17. Zain RB, Rahman ZAA, Ikeda N, et al. Ethnic differences in the baseline serum micronutrients and the prevalence of oral precancer/cancer in quid chewers. Oral Oncol. 2001;37:34

18. Zain RB. Cultural and dietary risk factors of oral cancer and precancer – a brief overview. Oral Oncol. 2001;37:1-6.

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20. Parrington SJ, Punnia-Moorthy A. Primary non-Hodgkin's lymphoma of the mandible presenting following tooth extraction. Br Dent J. 1999;187:468-70.

21. Yamada T, Kitagawa Y, Ogasawara T, et al. Enlargement of mandibular canal without hypesthesia caused by extranodal non-Hodgkin's lymphoma: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89:388-92.

22. Duraccio R, Civai S, Carbone R, Mignogna MD. Non-Hodgkin lymphoma with primary location in the oral cavity, extranodal variety. Report of a case. Minerva Stomatol. 1997;46:603-7.

23. Bavitz JB, Patterson DW, Sorensen S. Non-Hodgkin's lymphoma disguised as odontogenic pain. J Am Dent Assoc. 1992;123:99-100.

24. Thomas DW, Gray W, Tate RJ. Non-Hodgkin's lymphoma presenting at the site of a recent dental extraction: a report of two cases. Br J Oral Maxillofac Surg. 1991;29:34-7.

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27. Daley TD, Wysocki GP, Pringle GA. Relative incidence of odontogenic tumours and oral and jaw cysts in a Canadian population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1994;77:276-80.

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30. Nakade O, Ohuchi T, Seki C et al. Survey of histopathological diagnostic services in the Department of Oral Pathology, School of Dentistry, Higashi-Nippon-Gakuen University, 1979-1989. Higashi Nippon Shigaku Zasshi 1989;8:39-46.

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32. Arotiba JT, Ogunbiyi JO, Obiechina AE. Odontogenic tumours: a 15-year review from Ibadan, Nigeria. Br J Oral Maxillofac Surg 1997;35:363-7.

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Professor Dr Rosnah Binti ZainDirector, Oral Cancer Research and Co-ordinating Centre, University of Malaya (OCRCC, UQ), Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur, MALAYSIA.Tel : 603-79674896Fax : 603-79547301Email : [email protected]

Predominant Supragingival Plaque Microflora in a Malaysian PopulationFathilah AR. BSc(Hons), MSc. PhD. Lecturer, Oral Biology Department, Faculty of Dentistry, University of Malaya, Kuala Lumpur.

Rahim ZHA. BSc(Hons), PhD. Professor & Head, Oral Biology Department, Faculty of Dentistry, University of Malaya, Kuala Lumpur.

Othman Y. BSc(Hons), MSc. PhD. Professor, Institute of Biological Sciences, Faculty of Science, University of Malaya, Kuala Lumpur.

ABSTRACTThe tooth provides a non-shedding surface ideal for microbial and plaque accumulation. Despite being exposed to regular environmental perturbations, the microbial composition and proportions in the plaque often remains in homeostasis and is relatively stable over time. Supragingival plaque sampled from various sites on the tooth surface was pooled and conventionally analyzed for its microbial constituent. Classification of microbial isolates was made based on the characteristics exhibited by the growth colonies, Gram-stained cells, as well as biochemical reactions using the API Identification System kit. Observation was also made of the colony forming units on both non-selective and selective agar culture plates. A variety of bacteria, both of the facultative and anaerobic types, were isolated from the supragingival plaque of the Malaysian population. Among those found to predominate the supragingival plaque include the Gram positive and Gram negative cocci and rods from the genera Streptococcus, Staphylococcus, Actinomyces, Fusobacterium, Corynebacterium, Clostridium, Bacteroides, Veilonella and Lactobacillus. In addition, yeast within the genus Candida was also isolated from the plaque samples.

Key words plaque, oral cavity, microflora, bacteria, saliva

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InTrODuCTIOn

Dental plaque is made up of 80% water and20% organic material, 10% of which are bacterial inorigin.1,2Withrespect to itsmicrobialcomponents, ithasbeen generally accepted that the supragingival plaqueis dominated by the Gram positive facultative cocci androds, while the Gram negative anaerobes dominated thesubgingival plaque.3,4Although it has been reported thatthe oral community undergoes frequent changes in itsflora due to the many environmental factors within themouth,variations in the typeof flora fromonemouth toanother,isnotexpectedtobeofanydifferent.4,5However,informationastothedetailsonthemicrobialcharacteristicsare often not included in the references. The aim of thestudywastoisolateandidentifysomeofthepredominantmicroflorathatconstitutesthemicrobialpopulationofthedentalplaquefoundintheMalaysianmouth.Informationgathered from the study which includes characteristicsof the microbial cells and colonies, will help provide adatabase on the common types of microorganism, whichcanbereadilyisolatedfromtheMalaysianmouth.

MATErIALS AnD METHODS

Experimental concept and design

Thedentalplaquemicrofloracanvaryincompositionover relatively small distances on the tooth surface.4 Toavoid the possibility of sample collection being made atcertain restricted sites, pooledplaqueconsistingof smallsamplescollectedfromdifferentsitesofthesupragingivaltooth surface were made. Plaque samples were collectedfrom healthy males and females of various age groups,whosepermanentdentitionhasfullyerupted.Thesubjectswere not asked to follow any specific diet or brushingregimepriortothecollection.Undertheseconsiderations,the plaque samples obtained would best represent thesupragingivalplaquefloraoftheMalaysianmouth.

Plaque collection

Sampling of plaque specimen was carried outunderstrictaseptictechniquesusingtheexcavator.6Plaquesamples were collected from ninety eight patients who


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Fathilah / Rahim / Othman

visitedtheDentalFacultyPolyclinic,UniversityofMalaya,fororaltreatment.Smallsamplesofsupragingivalplaquewereobtained fromdifferentsitesof the toothsurface inthepatient’smouth.Thecollectedplaquewasthenpooledand placed in Bijou bottle containing 10 ml of reducedtransportfluid(RTF).7

Isolation and identification process

The plaque specimens were dispersed by half-immersing the Bijou bottles in a water bath sonicatorfor2minbefore theywereseriallydiluted to10-7usingRTF. A 100 μl of the plaque suspension was aliquoted out and spread on to both non-selective and selective bloodagar plates. Incubation for microbial growth on the non-selectivemedia(BHI;Oxoid,England)wascarriedoutat37ºC for24 to36hrs, both in the aerobic andanaerobicconditions. The anaerobic condition was obtained byinserting a gas generating sachet (GasPak system, BBL)

into the anaerobic jar. The jar was then placed in theincubator throughout the incubation period. Followingthe incubation period, the characteristics of the colonyformingunits(CFU)withrespectstocolour,edges,textureand haemolytic reaction under both growth conditionswere observed and compared.The appearance of a cleargrowth zone surrounding a growth colony indicated aβ-haemolysis while a greenish-yellow zone indicatedan α-haemolysis reactions. Colony with no haemolysedzonesurroundingitwascategorisedasγ-haemolytic.6ThenumberofCFUonthenon-selectiveplatesrepresentedthetotalviablecountsofmicrofloraintheplaquesamples.Toexamine the morphology of the microbial cells, colonieswith distinct characteristics were picked and spread onseparate glass slides for Gram staining procedure.8 Themorphology of the Gram stained cells were examinedunder oil immersion at 100x magnification using a lightmicroscope.Figure1wastheguidelineemployedtohelpintheidentificationofthepositiveplaquebacteria.

Reaction of the microbial isolates to catalase was carried out to differentiate between the Gram positiveStreptococcus and Staphylococcus, andbetween thenon-branchingaerobicandanaerobic rods.Thecatalase testwasperformedbyexposinganisolatedcolonyofthemicrobetoadropofhydrogenperoxide(3%v/v).6Thereleaseoffineairbubblesfollowingtheexposureindicatedapositivereactionwhiletheonewithoutshowedanegativereaction. In addition to the growth on non-selective media, 100 μl of the plaque suspension was also inoculated on mitis-salivarius(MS)(Difco,England)andSabouraud(SA)(Oxoid,England)selectivemediaplatestospecificallyisolatethestreptococciandyeast,respectively.StreptococcicoloniesformedontheMSplateswerefurthercharacterizedbytheirresponse tobiochemical reactionsusing theAPIStrep Identificationsystemkit (bioMerêux,France).Throughout thestudy,enumerationoftheCFUwascarriedoutbycountingthenumberofcoloniesthatformedoneachplatefollowingthespecifiedincubationperiod.

Catalasepositive

Catalasenegative

Catalasepositive

Catalasenegative

Gram positive plaque bacteria

COCCI RODS

Staphylococcus StreptococcusAnaerobic cocci

Non-branching Branching

Aerobic Anaerobic

Aerobic Anaerobic

Clostridium

Actinomyces

NocardiaStreptomycesActinomadura

Sporing Non-sporing

Bacillus ListeriaCorynebacterium

ErysipelothrixGardnerellaLactobacillus

Figure 1: A schematic flow chart of the guideline employed in the identification process of plaque bacteria.8

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Predominant Supragingival Plaque Microflora in a Malaysian Population

rESuLTS

Table1showsthemixedpopulationofmicroorganismsisolatedfromtheplaquesamples.Themaincharacteristicsoftheisolatedmicrobeswhichincludetheircolonyandcellcharacteristics,anaerobiosisandreactionstohaemolysin,catalaseandGramstainwereusedintheidentificationoftheisolates.Mostoftheplaquemicroorganismswereofthefacultative types as they grew equally well on plates incubated aerobic and anaerobically. Eighty seven percent outof232colonies isolatedwereof theGrampositive type,outofwhich73%werecocci,26%were rodsand1%wasyeasts.StreptococcicomparedtostaphylococciconstitutesmajorityoftheGrampositivecocci.TheGrampositiverodscomprisedofthebacilliandpleomorphicrodssuchastheactinomyces.OnlythirteenpercentoutofthetotalisolateswereGramnegativebacteria,andtheseincludetherodsBacteroides and Fusobacterium,andthecocciVeillonella.

Table 1: Colony and cell morphology of microorganisms isolated from the supragingival plaque samples. Cells were cultured on BHI blood agar, MS and Sabouraud agar plates and incubated both under the aerobic and anaerobic conditions. Cells morphology was examined from gram stained slides preparation. Identification of the isolates at the genus level was based on guideline in Figure 1. The API Strep Identification System kit was employed to help in the identification of isolates under the genus Streptococcus down to the species level.

Plates Descriptions of colony Descriptions of cells Anaero-biosis

Gram reaction

API & Conventional Identification

a Greycolonies,glistening,1-3mmdiameter,36-48hrsincubation, γ-hemolytic

Pleomorphicrods,stainspaleanduneven

Anaerobe Negative Bacteroides sp.

b Smooth,soft,stronglyadher-enttoagar,entire,convex,translucent,small(1mm),catalasenegative

Coccus (<1μm), individually orinchain

Facultativeanaerobe

Positive Streptococcus san-guinis

c Largecolonies,doublezonesof hemolysis, β-hemolytic

Largenon-branchingrods,ap-pearanceofsporeatoneend,irregularlystained

Facultativeanaerobe

Positive Clostridium sp.

d Smooth,soft,non-adherent,circular,entire,convex,trans-lucent,small(0.5-1.0mm),γ-hemolytic, colourlesstowhite,catalasepositive

Coccus (<1μm), individually orinchain

Facultativeanaerobe

Positive Streptococcus mitis

e Dark-grayraisedcolonies,<2mm diameter, α-hemolytic, catalasepositive

Pleomorphicshortrods,non-capsulated,singlyorinclusters,stainsunevenly

Aerobe Positive Corynebacterium sp.

f Smooth,soft,mucoid,circu-lar,white,opaque,1-2mmdiameter,non-hemolytic

Largeopaque,appearanceofbuds

Facultative Positive Candida sp.

g Brownish,convexwithuni-formedge,1-2mmdiameter,36-48hrsincubation,catalasenegative

Large,truerods,singlyorinchain

Anaerobe Positive Lactobacillus sp.

h Soft,mucoid,adherent,creamwhite,umbonate(witharaisedbumpinthecentreofthecolony),large(1-5mm),α-hemolytic, catalase positive

Rod,pleomorphicwhichattimeshowedbranching

Facultative Positive Actinomyces sp.

i Softwhite,opaquemucoid,<1mmdiameter,glistening,catalasenegative

Coccus,singlyorinchains Facultativeanaerobe

Positive Streptococcus mutans

j Soft,circular,translucent,smallcolonies,<1mmdiam-eter,non-hemolytic

Coccus,singly Anaerobe Negative Veilonella sp.

95

Fathilah / Rahim / Othman

k Greycolonies,glistening,1-3mmdiameter,36-48hrsincubation, γ-hemolytic

Shortrods,pleomorphic Anaerobe Negative Bacteroides sp.

l Soft,translucent,smallcolo-nies,<1mmdiameter,non-hemo-lytic

Longtaperingrodswithpoint-edends,singlyorinchains

Anaerobe Negative Fusobacterium sp.

m Yellowishwhite1-4mmcolo-nies,non-hemolytic,catalasepositive

Coccus,singlyorincluster Aerobe Positive Staphylococcus sp.

n Brownish-cream,1-2mmcolonies,catalasepositive

Longandshortrods,branch-ing,pleomorphic

Facultativeanaerobe

Positive Actinomyces sp.

Figure2showsthemicrographsofsomeoftheisolatedmicroflorafromthedentalplaquesamples.AmongsttheshortrodswasClostridiumsp.whichwasreadilyidentifiedbytheappearanceofsporebearingrods.TheclostridiumisalsoidentifiedbytheirirregularlyreactiontoGramstainingprocedure,somuchsothatthecellsmayappearredinthemicrograph(Figure2c).This irregularitywasalsomentionedbySummanenetal.9TheyeastCandidasp.reactedpositivelytoGramreactionandwasidentifiedeasilybythepresenceofitsvegetativecells(Figure2f).10Someofthevegetativecellswereobservedtobeinthebuddingstagetoproduceblastospores(arrowed).Figure 2 (a-n): Micrographs of supragingival plaque microorganisms isolated from patients receiving dental treatment at the dental clinic. Both Gram positive and Gram negative bacteria isolated from the plaque samples were; (a) Bacteroides sp., (b) Streptococcus sp., (c) Clostridium sp., (d) Streptococcus mitis, (e) Corynebacterium sp., (f) Candida sp., a yeast which also stained positive in Gram reaction, (g) Lactobacillus sp., (h) Actinomyces sp., (i) Streptococcus mutans, (j) Veillonella sp., (k) Bacteroides sp., (l) Fusobacterium sp., (m) Staphylococcus sp., and (n) Actinomyces sp. 1000x magnification under oil immersion.

e f

dc

a b

hg

i

k

j

m

l

n

AmongsttheGramnegativebacteriawhichwereeasilyidentifiedfollowingtheGramreactionweretheBacteroidessp.(Figure2a),Corynebacteriumsp.(Figure2e),andthelongfilamentousFusobacteriumsp.(Figure2l).

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Predominant Supragingival Plaque Microflora in a Malaysian Population

DISCuSSIOn

The biological properties of the oral tissues makethe mouth highly selective in terms of the types ofmicroorganismsthatareabletocolonizeitssurfaces.Thetooth surface for example is colonized first by the earlycolonizers which are reported to comprise mostly of theoral streptococci.11This pioneer community continues togrowandcolonizeuntileventuallythemicroenvironmentonthesurfacesofthetoothismodifiedbytheirmetabolicactivities to conditions suitable for colonization by asuccessionofotherpopulation.Eventuallyastablesituationtermedtheclimaxcommunitywithhighspeciesdiversityisreached.12

Inthestudy,examinationsofthemicrobialcomponentofthesupragingivalplaquesampleshaveshownthatapartfromsomeGramnegativebacteria,majorityof the typesthatresideinthedevelopedsupragingivalplaqueweretheGrampositivecocciandrods,whichisinaccordancewithearlier reports.4,13 Most of the microorganisms isolatedwere of the facultative types with high tolerance foroxygenandwereabletogrowwellunderbothaerobicandanaerobicconditions(Table1andFigure2).Thevarietyofbacteriageneraisolatedfromthepooledsupragingivalplaque samples reflects the many different sites on thetooth surface which may be suitable growth habitats foravarietyofmicroorganisms.Thefacultative typeswhichhave a specific demand for oxygen would occupy areasmore accessible by the saliva.2,4 The anaerobes on theotherhandoccupyareaswhere theaccessibilityofsalivaandoxygenismorerestrictedsuchasontheinterproximalsurfaceswhereplaqueaccumulateseasily.Fusobacteriumsp.,Corynebacteriumsp.,Veillonella sp.andBacteroidessp.(Table1)wouldprobablyhavecomefromsuchhabitats.Onthecontrary,Candidasp.whichisnotusuallyreportedas a common occupant of the dental plaque was alsoamong the microbes isolated. Earlier report have shownthattheoccurrenceofyeastinthemouthisquitecommonespecially after the consumption of foods like bread.14Although it is not possible to confirm in retrospect, itcouldbeinferredthatbreadwhichisoneofthestapledietin all Malaysian communities may have some influencein determining the predominant supragingival plaquemicrobial composition in the Malaysian mouth.Anotherbacterium which was isolated in the plaque samples andnotanormalresidentofthedentalplaquewasClostridiumsp. (5 %). One way in which it could have got into themouthwouldbethroughtheconsumptionofcontaminatedfoodordrinks.

COnCLuSIOn

A variety of microorganisms comprising mostlyof bacteria from the facultative and anaerobic types canbe isolated from the supragingival dental plaque in themouthoftheMalaysianpopulation.ThesemicroorganismsconsistedbothoftheGrampositiveandGramnegativecocciandrods fromthegeneraStreptococcus,Staphylococcus,

Actinomyces, Fusobacterium, Corynebacterium,Clostridium, Bacteroides, Veilonella and Lactobacillus.YeastwithinthegenusCandidawasalsoisolated.

ACKnOWLEDGEMEnT

ThisworkwassupportedbyVoteFresearchgrant(F0359/2002C)fromtheUniversityofMalaya,Malaysia.

rEFErEnCES

1. ColeAS,EastoeJE.BiochemistryandOralBiology2ndedn.Butterworth&Co.1988.

2. WilletNP,WhiteRR,RosenS.EssentialDentalMicrobiology.Appleton&Lange1991.

3. Nisengard RJ, Newman MG. Oral Microbiology andImmunology2ndedn.WBSaunders1994.

4. MarshMV,MartinP.OralMicrobiology4thedn.ChapmanandHall1999.

5. Marsh PD, Bradshaw DJ. Microbial community aspects ofdental plaque. In: Dental plaque revisited. Newman HN,Wilson M edt. University College London, BioLine 1999:237-253.

6. Smith JR,LaudicinaRJ,RufoRD.Learningguides for themedicalmicrobiologylaboratory.JohnWiley&sons1985.

7. Syed SA, Loesche WJ. Survival of dental plaque flora invarioustransportmedia.ApplMicrobial1972;24:638-644.

8. Gerhardt P, Murray RGE, Costilow RN, et al. Manual ofmethods for general bacteriology, American Society forMicrobiology1981:26-27.

9. SummanenP,BaronEJ,CitronDM,StrongCA,WexlerHM,Finegold SM. WadsworthAnaerobic Bacteriology Manual5thedn.StarPubCom1993.

10. Cheesebrough M. Medical Laboratory Manual forTropicalCountries, VolumeII: Microbiology, Butterworth & Co.(Pub.),UniversityPress,Cambridge1984.

11.Pearce C, Bowdes GH, Evans M, et al. Identification ofpioneer viridans streptococci in the oral cavity of humanneonates.JMedMicrobiol1998;42:67-72.

12.MarcotteH,LavoieMC.Oralmicrobialecologyandtheroleof salivary immunoglobulin A. Microbial Molec Biol Rev1998;62:71-109.

13.SlotsJ,TaubmanMA.Contemporaryoralmicrobiologyandimmunology.MosbyYearBook1992.

14.SamanarayakeLP,MacFarlaneTW.OralCandidosis.Wright1990.


Dr. Fathilah Abdul razak,BSc(Hons), MSc, PhDDepartment of Oral Biology, Faculty of Dentistry,University of Malaya, 50603 Kuala Lumpur,Malaysia. Tel: 03-75677416 / 4851Fax: 03-75674536E-mail: [email protected]

The Expert Says…… Oral Microbiology, Periodontal Disease and Cardiovascular DiseaseBy Dr. Nor Adinar Baharuddin. BDS (Adelaide), MDSc (Mal). Lecturer, Department of Oral Pathology, Oral Medicine and Periodontology, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.

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There are evidences that chronic oral infectionsare associated with cardiovascular disease (CVD).Periodontal disease is a common, mixed oral infectionaffecting the supporting structures around the teeth.It was reported that 75% of the adult population hasgingivitisand20%to30%exhibitstheseveredestructiveform of periodontitis.1Although more than 500 bacterialspecies inhabit the human oral cavity, only a fewGram negative bacteria such as Prevotella intermedia, Fusobacterium nucleatum, Porphyromonas gingivalis, Tannerella forsythensis, Treponema denticola and Actinobacillus actinomycetamcomitans causes gingivitisand periodontitis.2,3 These periodontal pathogen occupythesubgingivalspaceandorganizeasabacterialbiofilm.3The bacterial biofilm will be in direct contact with hosttissues along an ulcerated epithelial interface, calledperiodontal pocket.4 The break in the epithelial integritydirectlyexposesthehosttobacteriaandtheirproductseg.lipopolysaccharide(LPS)endotoxin. Meanwhile, CVD is the world’s leading cause ofdeath.5 Atherosclerosis is a major component of CVD,affects 1 in 4 persons and contributes to 38% of deathannually in the United States.6 Traditional CVD riskfactors such as smoking, poor diet, lack of exercise,hypercholesterolemia, hypertension and some geneticmarkers do not fully account for the development ofatherosclerosis. This is because many patients withatherosclerosis lack theseexposureorgenotypesentirely.Therefore, current attention has focused on potentiallinksbetweenCVDandperiodontaldisease.7Thisarticlewill put up the hypotheses to explain these associationsincluding common susceptibility, systemic inflammation,directinfectionofthebloodvesselsandcrossreactivity. The initialhypothesiswas theassociation ismadeby common susceptibility. Based on this hypothesis,periodontal diseases and cardiovascular diseases havecommon genetically determined phenotypes. If a patientshares the common susceptibility, then the patient willbe at a greater risk of both atherosclerosis as well asoral infection. What it means is that in the presence ofperiodontal pathogens, a susceptible person can developperiodontal disease. This same person would also be

susceptibletoatherosclerosis.However,accordingtothishypothesis, the periodontal disease does not cause theatherosclerosis. Thesecondhypothesiswas the involvementofaninflammatory component in the atherosclerotic lesions.Thiswaswellsupportedbyotherdisciplinessuchascellbiology, epidemiology, clinical trials and experimentalanimal research studies. Based on this hypothesis,inflammationleadstoanincreaseinthelevelsofcirculatingcytokines,whichinturndamagethevascularendotheliumand ultimately result in atherosclerosis. The circulatingcytokines of interest include C-reactive protein (CRP),Interleukin-1, Interleukin 1-6 (IL-6), tumour necrosisfactor alpha (TNF-α) and prostaglandin. The highestrelativeriskformyocardialinfarctionwasfoundtobethelevelsofCRPtogetherwiththeratiooftotalcholesteroltohighdensitylipid.8CRPisapowerfulmarkerofvascularriskandthereissomeevidenceforadirectroleinvasculardysfunctionandatherogenesis.ItisproducedbytheliverandisstimulatedbyTNF-αandIL-6,leadingtoadecreaseinnitricoxideavailabilityandanincreaseinangiotension1receptors.Itbindstolowdensitylipids,increasingtheiruptakebymacrophagesandhenceanincreaseinfoamcellformation.Forthesereasons,CRPhadbeenpostulatedasamajormechanismforatherosclerosis.Two recent analyses from theThirdNationalHealth andNutrition Evaluation Survey (NHANES III) confirm thatclinical periodontal disease is significantly associatedwith increased serum levels of the acute-phase markersC-reactive protein (CRP) and fibrinogen.9,10 Independentstudies also demonstrate that patients with elevatedserum CRP and fibrinogen exhibit an increased risk forcardiovasculardisease(CVD)events,suchasmyocardialinfarction(MI)orstroke.11 The third hypothesis is direct infection of theblood vessels by bacteria. Studies also have shown thatperiodontal bacteria can directly invade the endotheliumand thereby lead to inflammation in the blood vesselwall resulting in atherosclerosis. In this hypothesis,the bacterial pathogens get into the bloodstream andsubsequentlyinvadetheendotheliumleadingtoendothelialdysfunction, inflammation and atherosclerosis. Study by


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The Expert Says…… Oral Microbiology, Periodontal Disease and Cardiovascular Disease

Ford et al.12 using Polymerase Chain Reaction showedclearlythatP gingivaliswasfoundin100%ofthearteries.Fusobacterium necleatumwas foundapproximately80%ofthearteries,Tannerella forsythiawasfoundinjust50%andC pneumoniawasfoundinjustfewerthan30%.Theseresultsclearlyshowedthatoralorganismscananddoinvadebloodvesselwallsbutitisunclearastowhethertheycancauseatherosclerosisorsimplyinvadeanalreadydamagedartery. It is also found that local periodontal infectiontriggers systemic inflammatory response via transientbacteremia in affected patients. These bacteremias canoccurinperiodontallydiseasedpatientaftermasticationormanipulationoforaltissues,andbacterialloadappearstoincreasewithperiodontaldiseaseseverity. Thefourthhypothesis is thatofcross-reactivityormolecular mimicry.13 In this hypothesis, the periodontalbacteria induce a local immune response, whichsubsequently cross-reacts with self-antigens expressedonthevascularepithelium.This in turn leads tovascularinflammationandatherosclerosis.Recently,therehasbeenincreasingawarenessthatimmuneresponsesarecentraltoatherogenesis, and a mechanism by which infection mayinitiateandfacilitatetheprogressionofatherosclerosiscanbeexplainedintermsoftheimmuneresponsetobacterialheat shock genes and heat shock proteins (HSPs). AllcellsexpressHSPsonexposuretovariousformsofstress,including temperature, oxidative injury and infection.Duringinfection,bacterialHSPsconstitutemajorantigenicdeterminants, which have been studied extensively todetermine their role in the inductionofprotectiveornonprotectiveimmuneresponse.Theimmunesystemmaynotbe able to differentiate between self HSP and bacterial-HSP.CrossreactiveepitopesofTcellswithspecificityforself-HSPcanbeactivatedduringinfectionandantibodiesgenerated by the host directed at pathogenic HSP couldresultinanautoimmuneresponsetosimilarsequencesinthehost.Becauseof thehomologousnatureof theHSPsamong species, cross reactivity of antibodies to bacterialHSP (termed GroEL) with hHSP60 on endothelial cellsmaysubsequentlyresultinendothelialdysfunctionandthedevelopmentofatherosclerosis. Noneof thehypotheses ismutuallyexclusiveandit is clear that one or either of the proposed mechanismmay be more important. It is also clear that infectioncan contribute to atherosclerosis.This infection couldbeof respiratory, gastrointestinal or oral origin. Togetherthese all contribute to the total burden of infection oronly a minor contributor. These consistent relationshipsbetweenoralinflammationandsystemicdiseasessuggestan interdisciplinary model in managing patients who areatrisk.Patients,dentists,physiciansandotherhealthcareproviders should be aware of the emerging relationshipsbetween periodontal infection, oral inflammation, andsystemic disease. Clinicians and patients should alsoappreciate the value of preventive strategies that reduceoral inflammation, improve dental health and enhanceoverallwell-being.Neverthelessitistheresponsibilityofdental professional to ensure all oral infection is kept atbay.

REFERENCES

1. AlbandarJ,BrunelleJA,KingmanA.Destructiveperiodontaldisease in adults 30 years of age and older in the UnitedStates,1988-1994.JPeriodontol.1999;70:13-29.

2. PasterBJ,BochesSK,GalvinJL,etal.Bacterialdiversityinhumansubgingivalplaque.JBacteriol.2001;183:3770-83.

3. SocranskySS,HaffajeeAD.Periodontalmicrobialecology.Periodontol2000.2005;38:135-87.

4. PageRC.Thepathobiologyofperiodontaldiseasemayaffectsystemic disease: inversion of a paradigm.AnnPeriodontal.1998;3:108-20.

5. WorldHealthOrganization.The World Health Report 2002.Geneva:WorldHealthOrganization:2002.

6. American Heart Association. Heart Disease and Stroke Statistics – 2005 Update. Dallas, Tex: American HeartAssociation;2004.

7. Beck JD, Offenbacher S, Williams RC et al. Periodontitis:a risk factor for coronary heart disease? Ann Periodontol.1998:3:152-60.

8. Ridker PM. Evaluating novel cardiovascular risk factors:can we better predict heart attacks? Ann Intern Med1999;130:933-7.

9. Slade GD, Offenbacher S, Beck JD et al. Acute-phaseinflammatory response to periodontal disease in the USpopulation.JDentRes.2000;79:49-57.

10.Wu T, Trevisan M, Genco RJ et al. An examination ofthe relation between periodontal health status andcardiovascularriskfactors:serumtotalandHDLcholesterol,C-reactiveprotein,andplasmafibrinogen.AnnJEpidemiol.2000;85:180-9.

11.Ridker PM, Morrow DA. C-reactive protein, inflammationandcoronaryrisk.CardiolClin.2003;21:315-25.

12.FordPJ,GemmellE,HamletSM,et al.Cross reactivityofGroEL antibodies with human heat shock protein 60 andquantificationofpathogensinatherosclerosis.OralMicrobiolImmunol.2005;20:296-302.

13.Seymour GJ, Ford PJ, Gemmell E, Yamakazi K. InfectionorInflammation:ThelinkbetweenPeriodontalDiseaseandSystemic Disease. Inside Dentistry vol 2 (Special Issue 1)InternationalConsensusStatement.


Dr. Nor Adinar Baharuddin, BDS (Adelaide), MDSc (Mal). Lecturer, Department of Oral Pathology, Oral Medicine and Periodontology, Faculty of Dentistry, Univesity of Malaya, Kuala Lumpur, Malaysia.Tel: 603-79674883E-mail: [email protected]

Management of an Unerupted, Dilacerated Maxillary Permanent Central Incisor by a Combined Surgical – Orthodontic Approach: A Case Report.Sockalingam G. BDS (Mal), MSc Paeds (Lond), FDSRCS (Eng), Paediatric Dental Surgeon, Paediatric Dental Specialist Clinic, Hospital Sultanah Aminah, 80100 Johor Bahru, Malaysia.

Ngah I. BDS (Otago), D.Orth, RCS (Eng), DDO, RCPS (Glasgow) Consultant Orthodontist, Specialist Orthodontic Clinic, Abdul Samad Clinic, 80100 Johor Bahru, Malaysia.

ABSTRACTThis case report presents a combined surgical – orthodontic approach to the management of an unerupted maxillary right permanent central incisor in a 13 year-old Chinese male. Radiographic investigations revealed that the tooth was severely dilacerated, most likely as a result of trauma sustained to the upper maxillary right deciduous central incisor at the age of 3 years. After securing adequate space for the unerupted tooth by fixed appliance therapy, surgical exposure of the crown was carried out under local anaesthesia and oral sedation. A gold chain was bonded to the exposed crown of the tooth. Traction was then carried out and the tooth was successfully brought to its final and correct position in the arch after 36 months of active orthodontic treatment.

Key words orthodontic, surgery, dilacerated tooth, treatment.

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INTRODUCTION

Failure of eruption of permanent maxillary anterior teeth may be a distressing event for children and their parents. The maxillary incisors play a pivotal role in the aesthetics of the dentition. Failure of eruption of the permanent central incisor may result in adjacent teeth tilting towards the site of the missing tooth. This leads to loss of space and shifting of the midline.1 The possible causes of failure of eruption of these teeth are:2

• obstruction in the path of eruption due to the presence of supernumerary teeth, odontomes or pathology such as cysts, tumors or clefts.

• inadequate space in the arch due to crowding of the developing tooth follicles.

• soft tissue impaction whereby the erupting tooth is unable to penetrate through the overlying soft tissue.

• tooth malformations such as fused tooth, macrodont tooth or dilacerated tooth.

Dilaceration refers to an angulation, sharp bend or curve in the root or crown of a developed tooth.3 This occurs due to a disturbance of the relationship between the uncalcified and already calcified portions of the developing tooth.4 The most widely cited cause of dilaceration is early trauma to the primary predecessor. This may be explained by the intimate proximity of the apex of the traumatized primary tooth and the developing permanent tooth bud.5,6 It has also been suggested that in some cases dilacerated maxillary incisors are developmental in origin. The root during its formation was molded to match the palatal curve or deflected by an obstruction such as a supernumerary tooth or an odontome. This phenomenon is called ectopic development of the tooth germ.4 Dilacerations have been reported to occur in both primary and permanent dentitions. No sex predilection has been reported.3 Dilacerations are usually diagnosed on radiographic assessment. Treatment modalities for dilacerated incisors that have been described in the literature consist of either removal of the dilacerated tooth


100

Management of an Unerupted, Dilacerated Maxillary Permanent Central Incisor by a Combined Surgical – Orthodontic Approach

or attempting to reposition the tooth in its correct position by surgical-orthodontic means. Surgical-orthodontic techniques that have been described in the literature are:

• surgical exposure followed by orthodontic traction7,8

• surgical repositioning followed by orthodontic alignment9

• surgical re-implantation followed by orthodontic traction10

The surgical-orthodontic option is usually considered when the patient is cooperative and is willing to undergo the lengthy treatment involved and the position and shape of the involved tooth is favorable for repositioning. The final outcome of surgical-orthodontic repositioning will depend on the skill and ability of the orthodontist, the surgical technique used for the exposure, the shape of the crown of the involved tooth, the quality of enamel and dentine of the crown of the involved tooth, the length and final position of the root, the quality and quantity of the supporting bone and the gingival appearance of the treated tooth. A successfully managed unerupted, dilacerated maxillary incisor will avoid the necessity for prosthetic replacement of the unerupted tooth. Having a natural dentition will have a more positive psychological impact than having a prosthetic tooth replacement.11

CASE REPORT

A 9 year-old Chinese boy presented at the late mixed dentition stage with a missing upper right permanent central incisor (11). He was of normal height and weight and did not give any medical history of significance. He however claimed to have sustained injury to his baby teeth as a result of a fall at the age of 3 whereby he had lost the upper right deciduous incisor (61). Intraoral examination revealed missing 11. Space between 12 and 21 was only 5mm. The lateral incisor (12) was in cross bite (Figure 1). Teeth present were as charted.

6 E 4 - 2 - 1 2 C 4 E 6

6 E D C 2 1 1 2 C D E 6

Radiographic assessment revealed 11 to be dilacerated (Figure 2). The crown of the tooth was palatal and the root was buccal. The lateral cephalometric radiograph revealed the bend at the crown root junction to be about 120 degrees and the root directed palatally (Figure 3). As the patient was still in the mixed dentition stage it was decided to correct the cross bite of 12 with an upper removable appliance with a z spring and to maintain the space between 12 and 21 with an upper partial denture. The patient was then put on regular follow up to await establishment of his complete permanent dentition.

At the age of 12 it was decided to extract 14 to make space for 13 to erupt. At the age of 14 the patient was again assessed at the combined orthodontic-paediatric joint clinic. His permanent dentition had been established. He had a skeletal Class 1 pattern with competent lips. Intraorally the upper arch was fairly well aligned except for the missing 11 and spacing of about 5mm (Figure 4). The overbite and overjet was within normal

Figure 1

Figure 2

Figure 3

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Sockalingam / Ngah

limits. The lower arch was mildly crowded. At this time the patient and parents were given the option of surgically exposing the buried tooth and attempting to reposition it with fixed appliance therapy. They accepted the treatment offered. They however were not keen on fixed appliance therapy for the lower arch.

Fixed appliance therapy using .022 x .028 preadjusted appliance system was commenced in the upper arch only as the patient was not keen on lower arch treatment. Space was regained for the unerupted 11 using nitinol push coils and it was hoped that the tooth would erupt spontaneously as the space regained was more than adequate. However this failed to occur. After 13 months of orthodontic treatment without signs of 11 erupting spontaneously, the patient was again seen in a joint clinic session. It was decided to surgically expose the crown of the tooth and attach a gold chain to assist in its eruption. Surgical exposure was carried out under local anaesthesia with oral sedation (diazepam). The crown of the tooth was exposed via a palatal window and a gold chain was bonded to exposed crown. Traction was subsequently applied using a .014 nitinol wire tied piggyback to a .018 stainless steel base archwire. Traction was activated regularly at an 8 weekly intervals. After 8 months of active traction the tooth was successfully repositioned into the arch (Figure 5). This was followed by further orthodontic detailing and space closure which took another 15 months

to complete. Upon debonding an upper removable retainer was fitted to be worn fulltime for six months and then another six months during bedtime.

DISCUSSION

Generally unerupted, dilacerated maxillary incisors have a poor prognosis. However when radiographic assessment reveals that the crown of the buried tooth appears to be of normal size and shape and is accessable for surgical exposure for the attachment of the eruption device and when the location and direction of the bend in the root is such that it will not impede with the final repositioning of the tooth in the arch, then it may be worthwhile to attempt surgical-orthodontic repositioning. Several studies have shown that there are several areas of decreased periodontal health and poor clinical appearance of previously unerupted teeth in comparison to adjacent unaffected teeth. Some of the findings were greater risk of gingival recession and uneven gingival margins. Other complications that have been reported are:12,13,14

• deterioration of post treatment and post alignment stability.

• pulp obliteration resulting in opacity of clinical crown.

• pulp necrosis. In the aesthetic point of view uneven gingival margins and a longer clinical crown as compared to the adjacent unaffected tooth may be extremely unsatisfactory for a patient with increased gingival display at the incisor region. The surgical-orthodontic option was considered in this case as radiographic assessment revealed that the root was directed palatally and as such would not be in danger of perforating the buccal plate. Furthermore the crown of the tooth was accessible surgically in this case via a palatal flap. The patient was willing to undergo the treatment as he wished to avoid a prosthetic replacement. However he was not keen on comprehensive orthodontic treatment which would have involved treating the lower arch with fixed appliance. Treatment time from surgical exposure to debonding took a total of 23 months. The final result was satisfactory although the outcome would have been better if the patient had agreed to lower arch treatment as well. A periapical radiograph of 11 (Figure 6) showed widening of periodontal ligament space. However, vitality test revealed that the tooth remained vital without any symptoms. However there was gingival recession exposing the crown root junction (Figure 7). In this case however this was not apparent to the patient as there was no gingival display due to his long upper lip (Figure 8). Overall the patient and his parents were happy with the result achieved.

Figure 4

Figure 5

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Management of an Unerupted, Dilacerated Maxillary Permanent Central Incisor by a Combined Surgical – Orthodontic Approach

Although surgical-orthodontic repositioning is an option in the management of dilacerated teeth, negative aesthetic and periodontal effects on the treated tooth should be anticipated. Patients should therefore be informed of the possible complications and the need for additional periodontal procedures if necessary at the end of orthodontic alignment. Long term monitoring of these teeth should also be carried out to check for pulpal changes and stability of the final position of these teeth. Proper selection of cases is therefore the key for a successful outcome.

CONCLUSION

This article reports a successful attempt to align a dilacerated tooth. Proper planning and detailed discussion is essential to ensure the objective is achieved.

ACKNOWLEDGEMENTS

The authors wish to thank the Director General of Health Malaysia and the Director of Oral Health services Malaysia for permission to publish this case report.

REFERENCES

1. Danial E. Management of impacted anterior teeth utilizing basic orthodontic principles. J Dent Child 1989;56:353-7.

2. Brin I, ZilbermanY, Azaz B. The unerupted maxillary incisor: review of its etiology and treatment. J Dent Child 1982;49:352-6.

3. Prabhu SR, Wilson DF, Daftary DK, Johnson NW. Oral Diseases in the Tropics Oxford University Press, 1993:544.

4. Smith DMH, Winter GB. Root dilacerations of maxillary incisors. Br Dent J. 1981;150:125-7.

5. Lowe PL. Dilaceration caused by direct penetrating injury. Br Dent J. 1985;159:373-4.

6. Andreasen JO, Sundstrom B, Ravn JJ. The effect of traumatic injuries to primary teeth on their permanent successors. Scand J Dent Res. 1971;79:219-83.

7. McNamara T, Woolfe SN, Mcnamara CM. Orthodontic management of a dilacerated maxillary central incisor with an unusual sequela. J Clin Orthod 1998;32:293-7.

8. Lin YT. Treatment of an impacted dilacerated maxillary central incisor.Am J Orthod Dentofacial Orthop.1999;115:406-9.

9. Tsai TP. Surgical repositioning of an impacted dilacerated incisor in mixed dentition. J Am Dent Assoc 2002;133:61-6.

10. Agrait EM, Levy D, Gil M, Singh GD. Repositioning an inverted maxillary central incisor using a combination of replantation and orthodontic movement; a clinical case report. Pediatr Dent. 2003;25:157-60.

11. Klages U, Bruckner A, Zentner A. Dental aesthetics, self awareness and oral health related quality of life in young adults. Eur J Orthod 2004;26:507-514

12. Becker A, Brin I, Ben-Bassat Y, Zilberman Y,Chaushu S. Periodontal status following surgical-orthodontic alignment of impacted maxillary incisors by a closed-eruption technique. Am J Orthod Dentofacial Orthop. 2002;122:9-14.

13. Chaushu S, Brin I, Ben-Bassat Y,Zilberman Y,Becker A. Periodontal status following surgical-orthodontic alignment of impacted central incisors with an open-eruption technique. Eur J Orthod. 2003;25:579-84.

14. Mostafa YA, Iskander KG, El-Mangoury NH. Iatrogenic pulpal reactions to orthodontic extrusion. Am J Orthod Dentofacial Orthop. 1991;99:33-3.


Dr. Ganasalingam SockalingamBDS (Mal), MSc Paeds (Lond), FDSRCS (Eng), AM (Mal)Paediatric Dental SurgeonPaediatric Dental Specialist ClinicHospital Sultanah Aminah80100 Johor Bahru, Malaysia.E-mail: [email protected]

Figure 6

Figure 7

Figure 8

Cyclosporine-induced Gingival Overgrowth in a Patient with Hepatitis C Virus Infection - A Case ReportSubramaniam U. BDS (Malaya) FDSRCS (England) MDSc (Perio) Periodontal Specialist, Klinik Pakar Periodontik, Klinik Pergigian Jalan Zaaba, 70100 Seremban, Negeri Sembilan Darul Khusus, Malaysia.

ABSTRACTGingival overgrowth is a well-recognized unwanted effect associated with three major drugs / drug groups - phenytoin, cyclosporine and the calcium channel blockers. Cyclosporine is the first-choice immunosuppressant for preventing allograft rejection in patients who have received organ or bone marrow transplants. This report aims to highlight a case in which the patient on cyclosporine therapy had also contracted Hepatitis C virus infection.

Key words gingival overgrowth, drugs, treatment, infection, virus.

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Periodontal tissues can exhibit manifestations of adverse effects due to systemic drug therapy. Drug-induced gingival overgrowth is a side effect associated with three types of drugs namely anticonvulsants (phenytoin), immunosuppressive agents (cyclosporine A) and various calcium channel blockers such as nifedipine for cardiovascular diseases.1 Cyclosporine is a hydrophobic, cyclic endecaptide derived from the metabolic products of two fungal species, Trichoderma polysporum and Cylindrocarpon lucidium. Approximately 30% of patients medicated with cyclosporine experience significant gingival changes.2

Hepatitis C virus (HCV) is a single-stranded Ribonucleic acid (RNA) virus of the Flaviviridae family, with 6 known genotypes. Prevalence of HCV infection in the world is almost 3%.3 In patients undergoing haemodialysis, prevalence of HCV positivity is reported to be from 1%-54% depending on the methods used for detection.4 HCV is transmitted parenterally and poses a potential occupational hazard to health care workers, including dental personnel. No vaccine is currently available. Although the acute disease is milder than that caused by the Hepatitis B virus (HBV), infection with HCV more frequently results in persistent infection. Approximately 50% of individuals with acute HCV infection will develop chronic active hepatitis, of whom 20% will eventually develop cirrhosis.5 Saliva is a potential source of infection for dental health care workers, HCV RNA has been found in the saliva of infected patients.6

CASE REPORT

A 46 year old medium-built gentleman was referred to the Periodontal Specialist Clinic, Seremban by a dental surgeon in an urban hospital. He had a history of renal transplant followed by cyclosporine therapy. The referring dental surgeon enlightened the fact that the patient was infected with the HCV. The patient had been diagnosed with renal failure and underwent haemodialysis and blood transfusion in Singapore. Renal transplant was carried out in Hospital Kuala Lumpur, the donor was his sibling, tissue matching was 100%. Patient was started on azathioprine, an anti-rejection drug. He was discovered to have contracted HCV infection and this was suspected to have occurred during haemodialysis. His physician later replaced azathioprine with cyclosporine due to the effects of azathioprine on the bone marrow. At the time the patient presented at the Periodontal Clinic, he had difficulty speaking since he was unable to achieve lip seal due to the bulk of hyperplastic tissue at the lower anterior labial aspect. In fact patient’s main complaint was that he was unable to speak or masticate properly, in addition to the undesirable aesthetics. On intraoral examination, the overgrowth tissue was extensive and markedly so in the interproximal papillae, especially in the lower anterior labial segment (Fig. 1), gross hyperplasia was also present in the anterior lingual region (Fig. 2). The architecture of the gingival contour was completely distorted, the tissues appeared to be hyperaemic, more so on the labial aspect. The lower

MALAYSIAn dEnTAL JOURnAL

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Cyclosporine-induced Gingival Overgrowth in a Patient with Hepatitis C Virus Infection - A Case Report

incisors, especially 31, 32 and 42 were splayed out of alignment and there was noticeable interference with occlusion.

Prior to starting any treatment, the patient’s physician was consulted firstly to enquire about the possibility of alternative drugs due to the adverse effect of cyclosporine on the gingival tissues, secondly to rule out possibilities of bleeding tendencies and stepping up the corticosteroid therapy in the event of undertaking surgical gingivectomy and thirdly about the status of the patient’s infection. In this patient’s case according to the physician, the cyclosporine could not be replaced. Therefore, the patient was advised that recurrence of growth was a high possibility due to the cyclosporine being a long-term therapy. Universal precaution was strictly observed during each appointment.Initially scaling was impossible to perform due to the overwhelming presence of overgrown tissue. Incisional biopsy was done and histopathological examination reported mucosal mass composed of fibrous connective tissue with a focal moderate infiltration of lymphocytes and plasma cells and having a surface covering of acanthotic parakeratinised stratified squamous epithelium. Histopathological interpretation was consistent with drug-induced gingival hyperplasia (Fig. 3).

Surgical gingivectomy was carried out over a few visits in combination with CO2 laser (Fig. 4). The aim was to reduce the overgrowth so that he could masticate properly in addition to performing proper oral hygiene procedures. Scalpel gingivectomy was performed under local anaesthesia (2% xylocaine with 1:100,000 epinephrine), the excess tissue was released by means of a long bevel incision which allows the removal of soft tissue walls of the pseudopockets, particularly in the interdental region. This exposed the crowns of the teeth and elimination of calculus deposits was facilitated. The CO2 laser was used intermittently for re-contouring the gingiva. In addition it helped with haemostasis. Patient was reviewed periodically to monitor the gingival condition (Fig. 5).

Figure 2. Lingual aspect of gingival overgrowth

Figure 1. Overwhelming growth of gingival tissue

Figure 3. H&E image showing mucosal mass of fibrous connective tissue with a surface of acanthotic parakeratinised stratified squamous epithelium (Original magnification: 10x)

Figure 4. Clincial appearance after a session of laser therapy

Figure 5. Bulk of gingival tissues reduced from the initial presentation

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dISCUSSIOn

Cyclosporine A was initially produced as an antimicrobial agent, but early investigations showed that it had an inhibitory effect on lymphocyte proliferation. The drug has been found to act selectively on the T-lymphocyte response with little or no action on B-lymphocytes.7 Since the discovery of its immunosuppressant properties, cyclosporine has been mainly used to prevent graft rejection in organ transplantation. The drug is also used in the treatment of a variety of autoimmune disorders such as Type I diabetes, rheumatoid arthritis, psoriasis and other skin disorders.8 Renal transplantation is the most common organ-grafting procedure and hence one where cyclosporine is widely used. To maintain immunosuppression, an oral therapeutic dose of between 10 to 20 mg/kg body weight/ day is required.9 Cyclosporine-induced gingival overgrowth commences as a papillary swelling that is more pronounced on the labial aspects of the gingiva than on the palatal or lingual. The swelling enlarges and adjacent papillae appear to coalesce. This gives the gingiva a lobulated appearance. Overgrowth is restricted to the width of the attached gingival but can extend coronally and interfere with occlusion, mastication and speech.10

Gingival changes usually manifest within three months of cyclosporine dosage. Surgical excision, prevention and maintenance constitute several categories of management of drug-induced gingival overgrowth. Excessive gingival tissue needs to be removed to restore contour and the knife-edge gingiva. This in turn will facilitate mechanical plaque control. This procedure is usually done under local anaesthesia and if the whole mouth is affected, one quadrant is treated at a time. The organ transplant patient might also be taking prednisolone. Thus, before surgery they may require corticosteroid cover (100mg hydrocortisone hemisuccinate, intramuscularly, half-an hour before surgery) and antibiotic cover.9 Hepatitis C is a blood-borne virus which is transmitted when infected blood enters the bloodstream of another person. The main modes of transmission are reusing or sharing syringes, needles, receipt of blood or blood products prior to 1990, exposure through unsterile tattooing or body piercing, exposure via a penetrating injury (needle stick).11 Transmission of the virus by saliva is a possibility if it is contaminated with blood.12 Effective infection control for all communicable diseases lies in the application of Universal Precautions when caring for all patients regardless of perceived risk.13 These procedures include aseptic technique, hand washing, use of appropriate personal protective equipment (which incorporates gloves, gowns, plastic aprons, masks/face shields and eye protection), as well as appropriate handling of instruments and equipment.14

COnCLUSIOn

Severe gingival overgrowth is often disfiguring and can interfere with both speech and mastication.15 Effective oral hygiene maintenance is also compromised. For organ transplant patients there is little or no scope for the withdrawal of cyclosporine and repeated gingival surgery remains their main treatment option. However, newer immunosuppressants such as tacrolimus,16 sirolimus17 or mycophenolate mofetil18 seem to have less potential to cause drug-induced gingival overgrowth. In suitable cases, converting a patient from cyclosporin to tacrolimus can assist in the management of severe gingival overgrowth.19 Change in medication is an option, but there may be medical or financial reasons why this cannot be expedited.20 Cooperation with the patient’s physician is imperative in order to render best treatment options.

The first step in providing effective dental care to people with infectious diseases is an understanding of the infection and the potential health problems associated with it. It is important that procedures to observe infection control are strictly practiced in order to prevent disease transmission for the safety of patients and healthcare workers.

ACknOwLEdGEMEnT

The author wishes to thank the Director of Dental Health Services, Ministry of Health, Malaysia for all the encouragement. A special thanks to the Director-General of Health, Malaysia for his kind permission to publish this article.

REFEREnCES

1. Kataoka M, Kido J, Shinohara Y, Nagata T. Drug-induced gingival overgrowth- a review. Biol Pharm Bull. 2005;28:1817-21.

2. Seymour RA, Smith DG, Rogers SR. The comparative effects of azathioprine and cyclosporine on some gingival health parameters of renal transplant patients. J Clin Periodontol. 1987;14:610-3.

3. Rodes J, Tapias SJM. Hepatitis C. Nephrol Dial Transplant. 2000;15 (supl 8);2-11.

4. Broumand B, Shamshirsaz AA, Kamgar M et al. Prevalence of Hepatitis C infection and its risk factors in haemodialysis patients in Teheran: Preliminary report from “The effects of dialysis unit isolation on incidence of Hepatitis C in dialysis patients” project. Saudi J Kidney Trans. 2002;13:467-72.

5. Dienstag JL, Alter HJ. Non-A, Non-B Hepatitis evolving epidemiologic and clinical perspective. Semin Liv Dis. 1986;6;67-81.

6. Wang JT, Want TH, Lin JT, Sheu JC, Lin SY, Chen DS. Hepatitis C virus RNA in saliva of patients with post transfusion hepatitis C infection. Lancet. 1991;48;337.

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Cyclosporine-induced Gingival Overgrowth in a Patient with Hepatitis C Virus Infection - A Case Report

7. Butler RT, Kalkwarf KL, Kaldahl WB. Drug-induced gingival hyperplasia: phenytoin, cyclosporine and nifedipine. J Am Dent Assoc. 1987;114:56-60.

8. Khoori AH, Einollahi B, Ansari G, Moozeh MB. J Can Dent Assoc 2003;69:236-41.

9. Seymour R, Heasman P, Macgregor I. Drugs, Diseases and the Periodontium 2nd edn. Oxford University Press 1992: 80.

10. Tyldesly WR, Rotter E. Gingival hyperplasia induced by cyclosporine A. Br Dent J. 1984;157:305-9.

11. National Health and Medical Research Council. A Strategy for the detection and management of Hepatitis C in Australia. Australian Printing Service 1997:61.

12. Coates EA, Walsh L, Logan R. The increasing problem of Hepatitis C virus infection. Aust Dent J. 2001:46:13-7.

13. Standard Guidelines, Occupational Health Unit, Ministry of Health Malaysia; 2nd edition 2005:1.

14. Commonwealth Department of Health and Aged Care, Draft Infection Control Guidelines, Canberra, November 2001:11-5.

15. Mayrogiannis M, Ellis JS, Thomason JM, Seymour RA. The management of drug-induced gingival overgrowth. J Clin Periodontol. 2006;33:434-9.

16. Almawi WY, Melemedjian OK. Clinical and mechanistic differences between FK506 (tacrolimus) and cyclosporin A. Nephrol Dial Transplant. 2000;15:1916-8.

17. Ingle GR, Sievers TM, Holt CD. Sirolimus:continuing the evolution of transplant immunosuppression. Ann Pharmacother. 2000;34:1044–55.

18. Meier-Kriesche HU, Ojo AO, Leichtmann AB et al. Effect of mycophenolate mofetil on longterm outcomes in african american renal transplant recipients. J Am Soc Nephrol. 2000;11:2366-70.

19. Hernandez G, Arriba L, Lucas M, de Andres A. Reduction of severe gingival overgrowth in a kidney transplant patient by replacing cyclosporin A with tacrolimus. J Periodontol. 2000;71:1630-36.


dr. Uma SubramaniamBDS (Malaya) FDSRCS (England) MDSc (Perio)Periodontal SpecialistKlinik Pakar Periodontik, Klinik Pergigian Jalan Zaaba, 70100 Seremban, Negeri Sembilan Darul KhususTel : 06-7623071/ 06-7631306/ 013-3904662Fax : 06-7620229E-mail : [email protected]

The Expert Says…….. Current Concept in Gingival OvergrowthDr Ahmad Sharifuddin Mohd Asari. BDS, MSc (Lon), FDSRCPS (Glasgow), Consultant Periodontist, Klinik Pergigian, Tingkat 2, Bangunan Cahaya Suria, Kuala Lumpur, Malaysia.

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Gingival overgrowth (gingival hyperplasia, gingival fibromatosis) can be caused by underlying factors such as taking certain medications or genetic in origin. The extent of the enlargement varies in different individuals and also within the same individuals. Aesthetics and effective plaque control is compromised and part of the objectives of treatment is to help in these aspects.

Current concept on gingival overgrowth, especially aetiology

The term gingival hyperplasia or hypertrophy was used to describe the enlargement of the gingivae. These terms can be a misnomer. Hyperplasia means increase in number of cell components of the gingivae while hypertrophy means increase in size of the cell components without the increase in numbers. The word overgrowth is now preferred as it can described both, or even the combination of both. Gingival overgrowth occurs in circumstances such as:

a) Gingival Fibromatosis (GF)This can be hereditary or idiopathic. There is a localised variant of GF called symmetrical fibromatosis of the tuberosity, where it is localised to the posterior aspects of the arch. Clinically, GF presents as a generalized, irregular enlargement of the attached and marginal gingival; painless, slowly progressive and dependent to a great extent on the oral hygiene of the individual. The enlarged tissue is usually firm, but inflammation and edema may make it spongy, redness and bleeds easily. It is not unusual for the fibromatosis to completely cover the teeth.

Recent studies have relate the changes in a specific gene, called son of sevenless 1 (SOS1) gene, which encodes a protein that is known to activate the ras pathway, one of the key growth signals in our cells.1

b) Complication of medicationsPhenytoin, calcium channel Blockers and cyclosporin A are medications that can results in gingival overgrowth.2,3,4,5 If they are given in combination, such as cyclosporine A and nifidipine, then the combined effects may result in greater enlargement.5 Phenytoin is an epileptic drug, calcium channel blockers used for hypertension, migraine and Rheumatoid arthritis. Cyclosporin A has been the mainstay of graft rejection therapy in transplant patients. As early as 1978, it has been noted that cyclosporin A resulted in gingival overgrowth.4

However, bacterial plaque appears to be important in determining the severity of the enlargement.2

Histological picture

Histologically, the picture is the same for the fibromatosis and drug-induced overgrowth, comprised of dense or moderately dense, rather avascular, bland collagenic connective tissue with scattered chronic inflammatory cells (predominant type of infiltrating inflammatory cells is the plasma cell), especially beneath the surface epithelium. The attached gingival epithelium may have extreme elongation of rete processes.7 The crevicular epithelium facing the tooth surfaces usually shows considerable degeneration, subepithelial edema, and more extensive inflammatory cell infiltration because of the gingivitis or periodontitis so often present.


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Treatment

The most important thing in treatment for medication-induced gingival overgrowth is early intervention or even consultation before the prescription of the medication. As we know that the effects of the medication on the gingivae probably modify the response of the gingivae towards the presence of plaque.

Once established, the treatment for gingival overgrowth includes:1. Good oral hygiene practice. This will reduce the

inflammation and facilitates further treatment procedures. It is important that the patient maintain good plaque control. This can be done by showing the patient the effective and efficient brushing techniques and other adjunct measures needed such as flossing, mouthwash and interdental brush. It is important to remember that the more the gingival enlargement, the more difficult it is to remove the plaque. This give the patient in a disadvantages position as the more the plaque, the faster is the enlargement.

2. Scaling (gross and fine in few visits): This will further help in plaque control efficiency and reduce inflammation.

3. Gingivectomy: for aesthetic reasons, helps in plaque control and prevent periodontal breakdown.

. Periodontal flap surgery: in cases where the enlargement is superimposed with pre-existing chronic periodontitis.

5. Changing of medication: There are now few alternatives to cyclosporine A to prevent graft reduction. These new medication, have less tendency to produce gingival overgrowth. Tacrolimus is an alternative which is less likely to cause hypertrophy.8,9,10 Other medications include sirolimus and mizoribin.

6. Miscellaneous / othersa. Extraction of poor prognosis teethb. Removal of plaque retentive factors (overhanging

margins of restorations) 7. Maintenance: Once the periodontal health is achieved,

maintaining the health status is important to prolong the interval between the surgeries. Recurrence is more

likely in patient with inadequate plaque control. The duration between visits will depend on the patient’s ability to achieve effective and efficient plaque control. It can be between 2 to 6 months.

Outcome:

Outcome will very much depends on few factors:1. The time the patient presented to the dental

practitioner:a. Age of patientsb. Presentation before transplant and start of

medications

2. The ability to maintain good oral hygiene practicea. Manual dexterity problemsb. Personal attitude

In general, the outcome will be good if the patients is young, with no periodontal diseases and highly motivated. Below are 2 cases which gives very good outcome, an evidence that early consultation in young patients with no periodontal diseases gives the best outcome.

CASE 1:

A 16-year old girl was referred to the Periodontic Unit for management of severe gingival overgrowth in November 2002. History revealed she had undergone kidney transplant in 1999. She was on Cyclosporin A 50mg bd, Prednisolone 12.5mg daily, MMR 750mg in the morning and 500mg at night and Atenolol 50mg at night. Examination showed generalised gingival hyperplasia (Figure 1a, b, c, d), most severe at lower anterior and posterior buccal areas. Patient was informed that the overgrowth is part of the side-effects of cyscloporin A. Initial therapy consisting of Oral Hygiene Instruction (OHI) and scaling was done in 4 visits. Her physician decided to change the cyclopsporin A to FK506 (Tacrolimus) 2mg at night alternating with 3mg dosage. The gingival condition improved 5 months after her starting the treatment (Figure 2a, b, c, d). The patient is now on six-monthly maintenance and the gingival condition is good.

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Mohd Asari

Before Treatment After Treatment: (4 visits and 5 months later)

Figure 1a

Figure 1b

Figure 1c

Figure 1d

Figure 2a

Figure 2b

Figure 2c

Figure 2d

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The Expert Says…….. Current Concept in Gingival Overgrowth

CASE 2:

A 23 year old lady referred for her gingival overgrowth in August 1999. She had kidney transplant in 1997 and on Cyclosporin A 75mg daily, Prednisolone 10mg bd, Azathioprine 50mg daily and Nifedipine 20 mg tds, Prazosin 0.5mg bd. Intraorally, generalised gingival overgrowth, with the upper and buccal aspects worse than the lower and lingual aspects (Figure 3a, b, c). Treatment done consisting of OHI, scaling and gingivectomy of all the quadrants, some requires 2 to 3 gingivectomy sessions. At present, patient is on maintenance with some minor gingivectomy to a very localised interdental papillae (Figure 4a, b, c).

After Treatment:

Figure 3a

Figure 3b

Figure 3c

Figure 4a

Figure 4b

Figure 4c

Before Treatment:

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Mohd Asari

COnCLuSIOn

Medication-induced gingival overgrowth can be managed successfully if the patients is seen as early as possible, either before the commencement of the medication or immediatley after it. Effective plaque control measures is important both in medication-induced and hereditary gingival overgrowth to reduce the severity of the enlargement or the necessity for repeated surgeries. Once periodotal health is attained, maintenance on regular basis is a must for this group of patients.

rEFErEnCES

1. Hart TC, Zhang Y, Gorry MC, Hart PS, Cooper M, Marazita ML, Marks JM, Cortelli JR, Pallos D. A Mutation in the SOS1 Gene Causes Hereditary Gingival Fibromatosis Type 1. Am J Hum Genet. 2002;70:943-54.

2. Majola MP, McFadyen ML, Connolly C, Nair YP, Govender M, Laher MH. Factors influencing phenytoin-induced gingival enlargement. J Clin Periodontol. 2000;27:506-12.

3. Miranda J, Brunet L, Roset P, Berini L, Farre M, Mendieta C. Prevalence and risk of gingival enlargement in patients treated with nifedipine. J Periodontol. 2001;72:605-11.

4. Calne RY, White DJ, Thiru S, Evans DB, McMaster P, Dunn DC, Craddock GN, Pentlow BD, Rolles K. Cyclosporine A in patients receiving renal allograft from cadaver donors. Lancet. 1978;2:1323-7.

5. Borel JF, Feurer C, Gubler HU, Stähelin H. Biological effects of cyclosporin A: a new antilymphocytic agent. Agents Actions. 1976;6:468-75.

6. Santi E, Brai M. Effect of treatment on cyclosporine and nifiedipine-induced gingival enlargement: clinical and histologic results. Int J of Periodontics and Restorative Dentistry. 1998;18:80-5.calura

7. Mariani G, Calastrini C, Carinici F, Marzola R, Calura G. Ultrastructural features of CsA-induced gingival hyperplasia. J Periodontol. 1993;64:1092-7.

8. James JA, Boomer S, Maxwell AP, Hull PS, Short CD, Campbell BA, Johnson R, Irwin CR, Marley JJ, Spratee H, Linden GJ. Reduction in gingival overgrowth associated with conversion from cyclosporin A to tacrolimus. J Clin Periodontol. 2000;27:144-8.

9. James JA, Jamal S, Hull PS, Macfarlane TV, Campbell BA, Johnson RW, Short CD. Tacrolimus is not associated with gingival overgrowth in renal transplant patients. J Clin Periodontol, 2001;28;848-52.

10. Hernandez G, Arriba L, Lucam M, de Andres A. Reduction of severe gingival overgrowth in a kidney transplant patient by replacing cyclosporin A with tacrolimus. J Periodontol. 2000;71:1630-6.


Dr Ahmad Sharifuddin Mohd Asari (BDS, MSc (Lon), FDSRCPS (Glasgow)Consultant Periodontist,Klinik Pergigian, Tingkat 2, Bangunan Cahaya Suria,Jalan Tun Perak, 50050 Kuala LumpurTel: 603-20267741 Fax: 603-20323157E-mail address: [email protected]

Current Philosophies and Practices of General Dental Practitioners pertaining to Direct Restorations, Bleaching and Endodontics Lim TW. BDS (Malaya), Klinik Pergigian Kulim, Jalan Hospital Lama, 09000, Kulim, Kedah.

Goh AC. BDS (Malaya), Klinik Pergigian Bahagian Bintulu, Lebuhraya Abang Galau, Peti Surat 2751, 97012, Bintulu, Sarawak

Seow L L. BDS (Malaya), MSc (London), FDSRCS (England), PhD (Malaya), Department of Conservative Dentistry, Faculty of Dentistry, Universiti Malaya, 50603, Kuala Lumpur

ABSTRACTThe aim of the present study was to assess the current approaches and philosophies pertaining to direct restorations, bleaching and root canal treatment amongst general dental practitioners (GDPs) in the Klang Valley, Malaysia. A questionnaire, together with a stamped addressed envelope and an explanatory letter, was sent to 200 GDPs in the Klang Valley in April-July 2005. The GDPs were selected at random. A total of 153 (76.5%) of the GDPs responded to the survey. 46.4% of the respondents stated that the use of amalgam was decreasing whereas 79.7% stated an increase in the use of composite resins. Clinical indication (85.6%) and patients’ demand for aesthetics (73.9%) appeared to be the main factors influencing the choice of restorative materials. Fractured restorations was the main reason for the replacement of amalgam restorations (77.1%) whilst secondary caries was the main reason for the replacement of composite resin restorations (73.9%). Almost two thirds of the GDPs surveyed provided chair side bleaching while 75.8% of the GDPs would supervise home bleaching. Sodium hypochlorite was the most common endodontic irrigant used amongst the GDPs surveyed and cold lateral compaction was the most commonly used obturation technique.

Key words General dental practitioners, direct restorations, bleaching, endodontics

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InTRoDuCTIon

Differences in the usage of direct restorative materials such as amalgam, composite resins, compomer, conventional and resin-modified glass-ionomer cements amongst various countries have become apparent in recent years. Dental amalgam was considered as the most commonly used direct restorative material in the Saudi Arabia1, however in Sweden and Finland, the usage of amalgam has decreased2,3. In surveys carried out by Burke and colleagues, the GDPs reported 50% and 59% decrease in the use of dental amalgam over the previous 5 years in the United Kingdom (UK) and Australia respectively4,5. The reasons for the decline in amalgam usage include potential health side effects, environmental concern of mercury pollution and proposed banning by politicians2,3. On the other hand, the use of alternative materials such as composite resins, glass-ionomer cements and variants seems to be increasing. The introduction of minimal preparation techniques and patients demand for

tooth-coloured restorations have contributed to this trend5,6. Burke et al.4,5 have reported an increase of 62% and 72% respectively in the usage of composite resin materials in United Kingdom and Australia. The advantages of adhesion and fluoride release have also made glass-ionomer cement gaining its momentum in dentistry. With increasing awareness amongst patients for pleasing and aesthetic appearance, cosmetic dentistry e.g. bleaching is gaining popularity. Bleaching is considered conservative to dental tissue and may defer the need for more invasive treatments like veneers and crowns7. Studies have indicated that carbamide peroxide bleaching materials are safe and effective when administered under dentists’ supervision8. The main side effect reported was transient dentinal sensitivity. The stability of the shade change can last for six to 12 months or longer for some patients9. Infection control is very crucial to ensure the success of endodontic treatment10. Rubber dam is used to isolate the pulp space from contamunation by saliva and bacteria. It also prevents aspiration and accidental swallowing


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of endodontic instruments and irrigants. The root canal system is not cleaned and shaped by instrumentation alone but together with chemical adjuncts that help in debridement. Irrigants are needed to flush out the debris and toxic materials which are removed and loosened within canals during mechanical cleaning and shaping. There are many types of irrigant solutions being used, such as distilled water, normal saline, sodium hypochlorite, local anaesthetic solution and chlorhexidine. At present, aqueous sodium hypochlorite (0.5-5.25%) is advocated as the standard irrigant solution. It is a good antimicrobial agent and has profound soft tissue solvent activity to dissolve organic debris in the canal11. It is considered timely and appropriate to gain information with regards to the general dental practitioners’ (GDPs) practices and philosophies in the use of direct restorative materials, bleaching treatment and endodontics in Malaysia as GDPs are the key figures treating the common dental diseases amongst the general public. The information gained from such an assessment will be important in the planning of future dental services and continuing professional education programmes. To the best knowledge of the authors, no such investigation had ever been undertaken in Malaysia at the time of conducting the present study. The objectives of the present study, therefore, were to determine the current approaches and philosophies pertaining to direct restorative materials, bleaching and root canal treatment amongst the GDP in the Klang Valley in Malaysia.


Burke et al.4,5 has modified the original questionnaire used by Widstrom and Forse3 in Finland to assess the trend of direct restorations and the practices of GDPs in the United Kingdom and Australia. The current study used a questionnaire modified from these studies to assess the current practices and philosophies of GDPs pertaining to direct restorative materials, bleaching and endodontic treatment in the Klang Valley, Malaysia. It comprises 12 multiple-choice questions which had been prepared according to the objectives of this study. The list of GDPs practicing in the Klang Valley in year 2005 was obtained from the Malaysian Dental Council. From the registry, 200 GDPs were randomly selected and sent the questionnaires in April-July 2005. The selection was carried out by simple random sampling. A stamped addressed envelope for returning of the questionnaire and an explanatory letter were enclosed together with the questionnaire. The GDPs were given one month’s time to complete the questionnaire and sent it back to the authors. Telephone calls were made to the identified non-respondents after 1 month and some of the clinics were also visited to aid in increasing the response rate.The returned questionnaires were coded and the data analyzed using SPSS statistics package (version 12 for Windows). Data analysis involved descriptive statistics

and cross-tabulations. Potential associations were tested using Chi-square tests to determine any statistical significant differences (P<0.05). The questions that were left unanswered were treated as missing data. RESuLTS

Out of the 200 questionnaires sent, 153 completed questionnaires were received, achieving a response rate of 76.5%. The first three questions in the questionnaire aim to obtain social and demographic data of the GDPs. Nearly two thirds (60.1%) of the respondents were male. With regards to the year of graduation, majority (50%) of the respondents had graduated from 1990 onwards. Two thirds (62%) of the respondents graduated from local universities namely Universiti Malaya and Universiti Kebangsaan Malaya. Majority of the foreign degrees were obtained from Singapore and India. The other countries included Australia, United Kingdom, Taiwan, Indonesia and Pakistan. The subsequent findings of the survey will be presented coupled with the questions in the questionnaire:

Direct restorative materials and techniques

Question 4: Treatment need for restorations in your practice for the last five years (including redo and initial placement):

Almost half of the GDPs stated that the treatment need for restorations amongst their patients has increased in the last five years (Fig 1). One third of the respondents perceived that the treatment need has remained stable (Fig. 1).

Figure 1: Treament need for the last five years

Percentage

72.8

12.7

7.8 6.7Malay

Indian

Chinese

Others

Increased R em ained stab le D ecreased U ncerta in

Fig. 1 Treatment need for restorations in the last five years

0

10

20

30

40

50

Per

cen

tag

e o

f re

spo

nse

s %

124

Current Philosophies and Practices of General Dental Practitioners pertaining to Direct Restorations, Bleaching and Endodontics

Question 6: Factors influencing choice of restorative materials in your dental practice:

Clinical indications (85.6%), the patients’ demand for aesthetic restorations (73.9%) and the patients’ choices (32%) appear to be the main factors influencing the choice of restorative materials in the GDPs’ practice (Figs. 4-6). Lecturer’s suggestions seem to have very little influence on the choice of restorative materials (Fig. 7).

Question 5: use of direct restorative materials in the last five years:

Almost half of the respondents stated that the use of amalgam had decreased in the last five years (Fig. 2). On the other hand, majority (79.7%) of the respondents stated an increased use in composite resin (Fig. 3). The use of GIC and derivatives has also increased.

9.8%

32.7%

46.4%

11.1%

0

10

20

30

40

50

Increased Remained stable Decreased Do Not use at all

Fig. 2 Use of dental amalgam in the last five years

80

60

40

20

0

Increased Remained stable Decreased

79.9%

18.3%

2.0%

Fig. 3 Use of composite resins in the last five years

85.6%

100

80

60

40

20

0Very much Somewhat Only slightly Missing Data

11.1%

2.0% 1.3%

Fig. 4 Clinical indications

80

60

40

20

0

17.0%

73.9%

7.8%

0.7% 0.7%

Very much Somewhat Only slightly Missing DataDo not know

Fig. 5 Patient’s aesthetic demand

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Lim / Goh / Seow

Verymuch

Somewhat Onlyslightly

MissingData

Do notknow

Not at all

32.0%

41.8%

21.6%

1.3%2.6%

0.7%

40

50

30

20

10

0

Fig. 6 Patient’s wish for a certain materials

Verymuch


MissingData

Do notknow

Not at all

4.6%

13.1%

29.4%

20.3%

27.5%

5.2%5

10

15

20

25

30

Fig. 7 Lecturer’s suggestions

Question 7: Reasons for replacement of amalgam and composite resin restorations:

Fractured restorations were the most frequently reported reason (77.1%) for replacement of amalgam restorations. It was followed by secondary caries, lost fillings and fracture of tooth structure. According to 73.9% of the

respondents, secondary caries was the most common reason for replacement of composite resin restorations. Other major contributory reasons for replacement of composite resin include fracture of tooth structure, fractured and lost fillings and patient’s wish (Fig. 8).

77.10%

66.70%71.90%

66.70%62.10%

57.50%

67.30%

46.40%

39.90%42.50%

30.10%

69.90%

59.50%

68%73.90%

69.30%

0%

30%

60%

90%

Fra

ctu

red

rest

ora

tio

n

Fra

ctu

re o

fto

oth

str

uct

ure

Sec

on

dar

yca

ries

Lo

st f

illin

g

Sen

siti

vity

Wea

r

Pu

lpal

sym

pto

ms/

pai

n

Pat

ien

t's w

ish

Amalgam

Compositeresin

Fig. 8 Reasons for replacement of amalgam and composite resin restorations

126


(ii) Calcium hydroxide alone as lining

(iii) Glass-ionomer cement alone as lining

(iv) Flowable composite lining

Question 8: use of composite resins and techniques employed:

(a) How often do you place extensive, occlusion-bearing composite resin restorations in Posterior regions?

Fig. 9 Use of composite resins in extensive, occlusion-bearing posterior regions

The frequency of placement of extensive, occlusion-bearing composite restorations in molar teeth is shown in Fig. 9. Only a quarter of the GDPs surveyed would always place composite resin in load-bearing areas. Half of the GDPs would place it occasionally.

(b) Do you commonly use techniques below for placement of composite resin restorations?

(i) Total etch/dentine bonding

Majority (83%) of the GDPs surveyed employed the total etch technique/dentine bonding during placement of composite resins. The minority resort to self etching type materials. Slightly over a quarter of the GDPs surveyed would use calcium hydroxide alone as lining (Fig. 10), while half of them stated they would use calcium hydroxide with another lining material. A high number of respondents would also use GIC or flowable composite as lining when indicated (Fig. 11 and Fig. 12). Almost half of the respondents (45.8%) never used rubber dam isolation in composite resin restorations.

Not at all(5.2%)

Missing Data(0.7%)

Always(25.5%)

Use of composite resin in extensive, occlusal-bearing areas

Sometimes (49.7%)

Seldom(19.0%)

40

30

20

10

0

28.1%

37.3%

19.6%

15.0%

Always Sometimes Seldom Not at all

Fig.10 Calcium hydroxide alone as lining in composite resin restorations

60

50

40

30

20

10

0

12.4%

57.5%

17.6%

10.5%

2.0%

Always Sometimes Seldom Not at all Missing Date

Fig.11 Glass-ionomer cement alone as lining in composite resin restorations

50

40

30

20

10

0

16.3%

41.8%

20.3%19.0%

2.6%


Fig.12 Flowable composite as lining in composite resin restorations

127

Lim / Goh / Seow

24.80%26.80%

24.80%

71.90%

63.40%

5.90%

46.40%

38.60%41.80%

21.60%

5.20%3.30%

16.30%

9.20%

52.90% 52.90%

4.60% 4.60%4.60%

19%23.50%

17%17.60%

19%

15%15%11.80%

16.30%

11.10% 5.20%

0.70%2.60%3.30%2.60%

0.70%

0%

20%

40%

60%

80%

Sec

on

dar

yca

ries

Ro

ot

filli

ng

s

Lo

st f

illin

gs

Pat

ien

t's

sati

sfac

tio

n

Tec

hn

ical

chal

len

ges

Sta

ffal

lerg

icp

rob

lem

s

Pat

ien

tal

lerg

icp

rob

lem

s

Increased

RemainedstableDecreased

Do not know

Missing data

Question 9: In your opinion, what will be the changes following a decreased use of amalgam?

Majority (71.9%) of the GDPs surveyed reckoned that patients will be more satisfied with dental treatments following the phasing out of amalgam restorations; however it will be more technically challenging to provide the more aesthetic substitute restorations (Fig. 13).

Bleaching

Question 10: Are these treatment options available in your clinic?

Table 1 Availability of home and chair-side bleaching in clinics

75.8% of the respondents supervised home bleaching while 62.7% provided chair-side bleaching (Table 1).

Yes No Missing data

(i) Home bleaching

75.8% 22.9% 1.3%

(ii) Chair-side bleaching

62.7% 35.9% 1.3%

Always Sometimes Seldom Not at all MissingData

0

5

10

15

20

25

30

26.8%

21.6% 22.2%

26.8%

2.6%

Fig.14 Use of rubber dam isolation in endodontic treatment

Fig.13 Changes following a decreased use of amalgam

Endodontic Treatment

Question 11: Do you commonly use these techniques for endodontic treatment?

(a) Rubber dam isolation

Slightly over a quarter of the GDPs always use rubber dam isolation during endodontic treatment with similar number of GDPs does not employ rubber dam isolation at all. The other half of the respondents use it occasionally when indicated (Fig. 14).

128


(b) use of radiograph in root canal treatment

Two thirds of the respondents took intra-operative radiograph during root canal treatment (Fig. 15).

(c) use of obturation techniques in root canal treatment

Cold lateral compaction appeared to be the obturation technique frequently employed by GDPs while half of the GDPs surveyed did not use thermoplasticized gutta percha at all (Fig. 16).

58.2%

44.4%

68%

34.6%

19%

34%

2.6% 5.2%

13.7%

2%5.2%

5.2%2.6%

2.6% 2.6%

0%

20%

40%

60%

Pre

-o

per

ativ

era

dio

gra

ph

Intr

a-o

per

ativ

era

dio

gra

ph

Po

st-

op

erat

ive

rad

iog

rap

h

Always

Sometimes

Seldom

Not at all

Missing data

Fig. 15 Use of radiograph in root canal treatment

43.1%

22.2%24.2%24.8%

23.5%

15%

28.1%24.2%

11.8%

17%

9.8%13.1%18.3%

47.7%

34.6%

30.7%

2.6% 2.6% 3.3% 3.3%

0%

20%

40%

60%

War

m la

tera

lco

mp

acti

on

Co

ld la

tera

lco

mp

acti

on

War

m v

erti

cal

com

pac

tio

n

Th

erm

op

last

iciz

edg

utt

a p

erch

a

Always

Sometimes

Seldom

Not at all

Missing data

Fig. 16 Use of obturation techniques in root canal treatment

129

Lim / Goh / Seow

Question 12: What is the irrigant solution normally used in root canal treatment?

Sodium hypochlorite was the most common root canal irrigant solution used by the respondents (71.9%), followed by normal saline (39.9%) (Table 2).

Table 2 Irrigant solutions in root canal treatment

DISCuSSIon

Sending questionnaires by mail is an efficient method to determine dentists’ attitudes, philosophies and practices especially for a large sample size. However, the possibilities of non-response bias, low response rates and inability to check the validity of the respondents’ replies are the common limitations for this method5. According to Dillman12 in Total Design Method, there are several ways to increase the response rate, namely inclusion of stamped addressed envelope, a short and simple questionnaire, covering letter, personalization of correspondence and follow-ups by mail and/or telephone calls. A considerably high response rate (76.5%) was achieved for this study. It is higher than the mean response rate (64 %) reported by Tan and Burke for mailed questionnaires to dentists13. We must recognize the limitation of the present study as the result might not be truly representing all the GDPs in the Klang Valley, however it does provide some useful information and insight about the contemporary trend of direct restorative materials, bleaching and endodontic treatment in this area. Nearly half of respondents indicated that the need for restorations had increased over the past 5 years with another one third stated that the need had remained stable (Fig. 4). Klang Valley is an urban area and the residents are more concern with regards to their oral health status. Besides, GDPs may practice in a more conservative way and attempt to salvage teeth rather than extract it. Reasons above may have contributed to the increase of treatment need for restorations. Nevertheless, increase of treatment need in the UK and Australia was only 4% and 10% respectively4,5. The findings in Malaysia showed a marked difference in comparison to the findings in those parts of the world. There is a significant decrease in the usage of dental amalgam and an increase in the usage of composite resins over the past 5 years. Similar findings have been reported in Finland, UK, and Australia3,4,5. These data appear to support a strong adoption of adhesive techniques by

Yes No Missing data

(i) Sodium hypochlorite 71.9% 25.5% 2.6%(ii) Normal saline 39.9% 57.5% 2.6%(iii) Local anaesthetic

solution13.1% 84.3% 2.6%

(iv) Chlorhexidine 10.5% 86.9% 2.6%(v) Other irigant

solution2.6%

dentists nowadays14. Adhesives in dentistry has provided the advantages of a less destructive preparation, the potential sealing of dentine by using dentine bonding agents and ability to attain aesthetically pleasing restorations15. Moreover, the possible mercury toxicity and detrimental effects on general health with regards to dental amalgam may also have an impact to this downward trend16. The use of resin modified glass-ionomer and glass-ionomer cement has also increased. It may be due to the inherent desirable properties of these materials such as fluoride release and adhesion to tooth structure. Related surveys carried out in the UK and Australia reported the same results by the GDPs in the respective countries4,5. Surprisingly, one third of the respondents in the present study do not use compomer at all. Majority (85.6%) of the GDPs surveyed stated that clinical indication is a predominant factor that influences the selection of restorative materials (Fig. 4). In the UK and Australia, similar figures were reported4,5. However, there is a marked difference between Klang Valley, UK and Australia with regards to other influencing factors on the selection of restorative materials namely the patient’s aesthetic demand (Fig. 5). In the present study, the patient’s aesthetic demand was the second most important factor (73.9%) influencing the selection of restorative materials whilst the corresponding figures in UK and Australia were only 39% and 55% respectively4,5. This may suggest that patients’ awareness towards aesthetic restorations in the Klang Valley has increased. Keen competition amongst the dental clinics in the Klang Valley may also contribute to the dentists trying to fulfill the patients’ demand for aesthetic restorations. The result of this study showed that a lecturer’s suggestion have very little influence on the selection of restorative materials in private dental practices, implying that procedures or techniques taught in the dental schools may not always diffuse well into practices17. The most common reason for replacement of amalgam restorations was fracture of restorations followed by secondary caries (Fig. 8). More tooth structure will have to be removed to provide bulk for the amalgam restorations. Extensive cavity preparation for amalgam restoration may weaken the remaining tooth structure and predispose the tooth to fracture. With regards to composite resin restorations, secondary caries was the most common reason for replacement (Fig. 8). In Finland and Saudi Arabia, secondary caries was the most common reason for replacement for both amalgam and composite resin restorations1,18. Polymerization shrinkage of composite resin will lead to formation of marginal gap and in turn allows the ingress of cariogenic bacteria which was closely related to formation of secondary caries. Discolouration of composite resin restorations in anterior teeth may affect the aesthetics and require replacement. Only one quarter of GDPs would always use composite resin to restore extensive cavities in the load-bearing posterior region. This showed that composite resin was not the preferred choice of restorative materials in this condition and the GDPs have reservation to rely on this material when strength and good wear resistance is call forth. According to Wilson et al.19, there are a few factors that limit the use of composite resin in the UK, for instance,

130


general dental services fees and regulations, the limitations of composite resin material and a lack of confidence and expertise in placing composite resin in extensive and load-bearing cavities at posterior region19. In the UK, guidance is issued by the General Dental Services of the Department of Health, which does not allow provision of composite resin restorations in load-bearing surfaces of posterior teeth. On the other hand, a large proportion (41%) of Australian dentists used composite resin to restore extensive and load-bearing cavities in molar teeth5. With regards to the techniques used during placement of composite resin restorations, 83% of the respondents would always use the total etch/dentine bonding technique i.e. GDPs have adopted the technique advocated by Fusayama20 which has proven to work clinically. Conversely, in Australia only two thirds of the GDPs would always and often employed total etch/dentine bonding during placement of composite resin restorations5. Using flowable composite resin as a lining material is gaining popularity now (Fig. 12). The use of flowable composite resin as lining has been advocated to minimize marginal microleakage and voids in composie resin restoration21. However, some studies have revealed that using flowable composite to reduce microleakage at dentine margins might be questionable22. The use of dental amalgam is decreasing over the years. Respondents were asked about their opinions towards this situation. Over 70% of respondents replied that patient’s satisfaction would increase and two thirds believed that technical demand would become more challenging in future. Similar findings were reported in the UK and Australia4,5. The most commonly used alternative material to dental amalgam is composite resin. The availability of various shades, tints and opaque in composite resin systems enable the GDPs to place highly aesthetic restorations which can fulfill the patient’s satisfaction. However, meticulous operative procedures are required during placement of composite resin restorations, for instance, stringent moisture control and increase the chair-side time compared to dental amalgam restorations23. Patients’ demand for aesthetics has increased the provision of bleaching treatment in private dental clinics. It is not surprising that three quarters of GDPs would supervise home bleaching while two thirds of respondents provided chair-side bleaching (Table 1). The results indicated an increase in the provision of these treatment in comparison with a previous study, which was conducted in Klang Valley in 2000/0124. In that study only 58% of respondents would supervise home bleaching and 53% provided chair-side bleaching24. In contrast, provision of bleaching treatment was relatively low in the UK; the main reason may be due to the great controversy with regards to the side effects of bleaching and bleaching products namely soft tissue inflammation, tooth sensitivity and systemic effects19. In the UK, majority (61%) of respondents never used rubber dam for endodontics19. Surprisingly, only about 27% did not use rubber dam at all in the present study (Fig.14). It is a consolation to learn that GDPs in the

Klang Valley adhered to the protocol of infection control and they understood the rationale of applying rubber dam in endodontics. Majority (68%) of the respondents always took intra-operative radiograph in root canal treatment (Fig. 15). It is important for working length determination and trial gutta percha to ensure success for endodontic treatment25. Cold lateral compaction was still the most popular and acceptable obturation technique amongst the GDPs in the Klang Valley (43.1%). It is the most advocated technique and widely taught in various dental schools including University of Malaya. A higher figure (75%) was reported in a study conducted in the UK19. The difference could be due to the increasing popularity of other obturation techniques such as warm lateral compaction, warm vertical compaction, heated gutta percha carriers and injectable gutta percha in the present study. Furthermore, cold lateral compaction is more time consuming in which time is equivalent to money in private practices. Therefore, GDPs would rather choose simpler and faster technique. Respondents were asked about the irrigant solutions they normally used for root canal cleansing. Most of them replied that they used more than one irrigant solutions. Sodium hypochorite was the most widely used irrigant (72%), followed by normal saline, local anaesthetic and chlorhexidine (Table 2). A small proportion chose hydrogen peroxide, EDTA and distilled water as alternatives. Most dental schools teach the use of sodium hypochorite as irrigant solution, suggesting that undergraduate education have profound impact on future practicing behaviour in this particular aspect. In contrast, local anaesthetic was the most favourite irrigant solution in UK based on the study conducted by Whitworth et al.17. The reason was some of the GDPs especially the younger graduates were less confident in their local anaesthetic technique during endodontic treatment17. Irrigation of local anaesthetic into the canal may help to anaesthetize further residual vital pulp tissue.

ConCLuSIonS

It has been perceived by the GDPs in the Klang valley that the treatment need is on the rise and the use of amalgam has decreased over the past few years. Composite resins is gaining popularity, however, GDPs still have reservation using it at the load-bearing posterior region. Demand for bleaching treatment has also increased. Overall the GDPs surveyed have fair understanding of treatment principles pertaining to direct restorations and endodontics.

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Seow Liang Lin BDS (Malaya), MSc (London), FDSRCS (England), PhD (Malaya)Department of Conservative DentistryFaculty of DentistryUniversiti Malaya, 50603Kuala Lumpur

Current Philosophies and Practices of General Dental Practitioners pertaining to Direct Restorations, Bleaching and Endodontics Lim TW. BDS (Malaya), Klinik Pergigian Kulim, Jalan Hospital Lama, 09000, Kulim, Kedah.

Goh AC. BDS (Malaya), Klinik Pergigian Bahagian Bintulu, Lebuhraya Abang Galau, Peti Surat 2751, 97012, Bintulu, Sarawak

Seow L L. BDS (Malaya), MSc (London), FDSRCS (England), PhD (Malaya), Department of Conservative Dentistry, Faculty of Dentistry, Universiti Malaya, 50603, Kuala Lumpur

ABSTRACTThe aim of the present study was to assess the current approaches and philosophies pertaining to direct restorations, bleaching and root canal treatment amongst general dental practitioners (GDPs) in the Klang Valley, Malaysia. A questionnaire, together with a stamped addressed envelope and an explanatory letter, was sent to 200 GDPs in the Klang Valley in April-July 2005. The GDPs were selected at random. A total of 153 (76.5%) of the GDPs responded to the survey. 46.4% of the respondents stated that the use of amalgam was decreasing whereas 79.7% stated an increase in the use of composite resins. Clinical indication (85.6%) and patients’ demand for aesthetics (73.9%) appeared to be the main factors influencing the choice of restorative materials. Fractured restorations was the main reason for the replacement of amalgam restorations (77.1%) whilst secondary caries was the main reason for the replacement of composite resin restorations (73.9%). Almost two thirds of the GDPs surveyed provided chair side bleaching while 75.8% of the GDPs would supervise home bleaching. Sodium hypochlorite was the most common endodontic irrigant used amongst the GDPs surveyed and cold lateral compaction was the most commonly used obturation technique.

Key words General dental practitioners, direct restorations, bleaching, endodontics

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InTRoDuCTIon

Differences in the usage of direct restorative materials such as amalgam, composite resins, compomer, conventional and resin-modified glass-ionomer cements amongst various countries have become apparent in recent years. Dental amalgam was considered as the most commonly used direct restorative material in the Saudi Arabia1, however in Sweden and Finland, the usage of amalgam has decreased2,3. In surveys carried out by Burke and colleagues, the GDPs reported 50% and 59% decrease in the use of dental amalgam over the previous 5 years in the United Kingdom (UK) and Australia respectively4,5. The reasons for the decline in amalgam usage include potential health side effects, environmental concern of mercury pollution and proposed banning by politicians2,3. On the other hand, the use of alternative materials such as composite resins, glass-ionomer cements and variants seems to be increasing. The introduction of minimal preparation techniques and patients demand for

tooth-coloured restorations have contributed to this trend5,6. Burke et al.4,5 have reported an increase of 62% and 72% respectively in the usage of composite resin materials in United Kingdom and Australia. The advantages of adhesion and fluoride release have also made glass-ionomer cement gaining its momentum in dentistry. With increasing awareness amongst patients for pleasing and aesthetic appearance, cosmetic dentistry e.g. bleaching is gaining popularity. Bleaching is considered conservative to dental tissue and may defer the need for more invasive treatments like veneers and crowns7. Studies have indicated that carbamide peroxide bleaching materials are safe and effective when administered under dentists’ supervision8. The main side effect reported was transient dentinal sensitivity. The stability of the shade change can last for six to 12 months or longer for some patients9. Infection control is very crucial to ensure the success of endodontic treatment10. Rubber dam is used to isolate the pulp space from contamunation by saliva and bacteria. It also prevents aspiration and accidental swallowing


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of endodontic instruments and irrigants. The root canal system is not cleaned and shaped by instrumentation alone but together with chemical adjuncts that help in debridement. Irrigants are needed to flush out the debris and toxic materials which are removed and loosened within canals during mechanical cleaning and shaping. There are many types of irrigant solutions being used, such as distilled water, normal saline, sodium hypochlorite, local anaesthetic solution and chlorhexidine. At present, aqueous sodium hypochlorite (0.5-5.25%) is advocated as the standard irrigant solution. It is a good antimicrobial agent and has profound soft tissue solvent activity to dissolve organic debris in the canal11. It is considered timely and appropriate to gain information with regards to the general dental practitioners’ (GDPs) practices and philosophies in the use of direct restorative materials, bleaching treatment and endodontics in Malaysia as GDPs are the key figures treating the common dental diseases amongst the general public. The information gained from such an assessment will be important in the planning of future dental services and continuing professional education programmes. To the best knowledge of the authors, no such investigation had ever been undertaken in Malaysia at the time of conducting the present study. The objectives of the present study, therefore, were to determine the current approaches and philosophies pertaining to direct restorative materials, bleaching and root canal treatment amongst the GDP in the Klang Valley in Malaysia.


Burke et al.4,5 has modified the original questionnaire used by Widstrom and Forse3 in Finland to assess the trend of direct restorations and the practices of GDPs in the United Kingdom and Australia. The current study used a questionnaire modified from these studies to assess the current practices and philosophies of GDPs pertaining to direct restorative materials, bleaching and endodontic treatment in the Klang Valley, Malaysia. It comprises 12 multiple-choice questions which had been prepared according to the objectives of this study. The list of GDPs practicing in the Klang Valley in year 2005 was obtained from the Malaysian Dental Council. From the registry, 200 GDPs were randomly selected and sent the questionnaires in April-July 2005. The selection was carried out by simple random sampling. A stamped addressed envelope for returning of the questionnaire and an explanatory letter were enclosed together with the questionnaire. The GDPs were given one month’s time to complete the questionnaire and sent it back to the authors. Telephone calls were made to the identified non-respondents after 1 month and some of the clinics were also visited to aid in increasing the response rate.The returned questionnaires were coded and the data analyzed using SPSS statistics package (version 12 for Windows). Data analysis involved descriptive statistics

and cross-tabulations. Potential associations were tested using Chi-square tests to determine any statistical significant differences (P<0.05). The questions that were left unanswered were treated as missing data. RESuLTS

Out of the 200 questionnaires sent, 153 completed questionnaires were received, achieving a response rate of 76.5%. The first three questions in the questionnaire aim to obtain social and demographic data of the GDPs. Nearly two thirds (60.1%) of the respondents were male. With regards to the year of graduation, majority (50%) of the respondents had graduated from 1990 onwards. Two thirds (62%) of the respondents graduated from local universities namely Universiti Malaya and Universiti Kebangsaan Malaya. Majority of the foreign degrees were obtained from Singapore and India. The other countries included Australia, United Kingdom, Taiwan, Indonesia and Pakistan. The subsequent findings of the survey will be presented coupled with the questions in the questionnaire:

Direct restorative materials and techniques

Question 4: Treatment need for restorations in your practice for the last five years (including redo and initial placement):

Almost half of the GDPs stated that the treatment need for restorations amongst their patients has increased in the last five years (Fig 1). One third of the respondents perceived that the treatment need has remained stable (Fig. 1).

Figure 1: Treament need for the last five years

Percentage

72.8

12.7

7.8 6.7Malay

Indian

Chinese

Others

Increased R em ained stab le D ecreased U ncerta in

Fig. 1 Treatment need for restorations in the last five years

0

10

20

30

40

50

Per

cen

tag

e o

f re

spo

nse

s %

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Question 6: Factors influencing choice of restorative materials in your dental practice:

Clinical indications (85.6%), the patients’ demand for aesthetic restorations (73.9%) and the patients’ choices (32%) appear to be the main factors influencing the choice of restorative materials in the GDPs’ practice (Figs. 4-6). Lecturer’s suggestions seem to have very little influence on the choice of restorative materials (Fig. 7).

Question 5: use of direct restorative materials in the last five years:

Almost half of the respondents stated that the use of amalgam had decreased in the last five years (Fig. 2). On the other hand, majority (79.7%) of the respondents stated an increased use in composite resin (Fig. 3). The use of GIC and derivatives has also increased.

9.8%

32.7%

46.4%

11.1%

0

10

20

30

40

50

Increased Remained stable Decreased Do Not use at all

Fig. 2 Use of dental amalgam in the last five years

80

60

40

20

0

Increased Remained stable Decreased

79.9%

18.3%

2.0%

Fig. 3 Use of composite resins in the last five years

85.6%

100

80

60

40

20

0Very much Somewhat Only slightly Missing Data

11.1%

2.0% 1.3%

Fig. 4 Clinical indications

80

60

40

20

0

17.0%

73.9%

7.8%

0.7% 0.7%

Very much Somewhat Only slightly Missing DataDo not know

Fig. 5 Patient’s aesthetic demand

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Verymuch


MissingData

Do notknow

Not at all

32.0%

41.8%

21.6%

1.3%2.6%

0.7%

40

50

30

20

10

0

Fig. 6 Patient’s wish for a certain materials

Verymuch


MissingData

Do notknow

Not at all

4.6%

13.1%

29.4%

20.3%

27.5%

5.2%5

10

15

20

25

30

Fig. 7 Lecturer’s suggestions

Question 7: Reasons for replacement of amalgam and composite resin restorations:

Fractured restorations were the most frequently reported reason (77.1%) for replacement of amalgam restorations. It was followed by secondary caries, lost fillings and fracture of tooth structure. According to 73.9% of the

respondents, secondary caries was the most common reason for replacement of composite resin restorations. Other major contributory reasons for replacement of composite resin include fracture of tooth structure, fractured and lost fillings and patient’s wish (Fig. 8).

77.10%

66.70%71.90%

66.70%62.10%

57.50%

67.30%

46.40%

39.90%42.50%

30.10%

69.90%

59.50%

68%73.90%

69.30%

0%

30%

60%

90%

Fra

ctu

red

rest

ora

tio

n

Fra

ctu

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oth

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ure

Sec

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dar

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g

Sen

siti

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Wea

r

Pu

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sym

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ms/

pai

n

Pat

ien

t's w

ish

Amalgam

Compositeresin

Fig. 8 Reasons for replacement of amalgam and composite resin restorations

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(ii) Calcium hydroxide alone as lining

(iii) Glass-ionomer cement alone as lining

(iv) Flowable composite lining

Question 8: use of composite resins and techniques employed:

(a) How often do you place extensive, occlusion-bearing composite resin restorations in Posterior regions?

Fig. 9 Use of composite resins in extensive, occlusion-bearing posterior regions

The frequency of placement of extensive, occlusion-bearing composite restorations in molar teeth is shown in Fig. 9. Only a quarter of the GDPs surveyed would always place composite resin in load-bearing areas. Half of the GDPs would place it occasionally.

(b) Do you commonly use techniques below for placement of composite resin restorations?

(i) Total etch/dentine bonding

Majority (83%) of the GDPs surveyed employed the total etch technique/dentine bonding during placement of composite resins. The minority resort to self etching type materials. Slightly over a quarter of the GDPs surveyed would use calcium hydroxide alone as lining (Fig. 10), while half of them stated they would use calcium hydroxide with another lining material. A high number of respondents would also use GIC or flowable composite as lining when indicated (Fig. 11 and Fig. 12). Almost half of the respondents (45.8%) never used rubber dam isolation in composite resin restorations.

Not at all(5.2%)

Missing Data(0.7%)

Always(25.5%)

Use of composite resin in extensive, occlusal-bearing areas

Sometimes (49.7%)

Seldom(19.0%)

40

30

20

10

0

28.1%

37.3%

19.6%

15.0%

Always Sometimes Seldom Not at all

Fig.10 Calcium hydroxide alone as lining in composite resin restorations

60

50

40

30

20

10

0

12.4%

57.5%

17.6%

10.5%

2.0%


Fig.11 Glass-ionomer cement alone as lining in composite resin restorations

50

40

30

20

10

0

16.3%

41.8%

20.3%19.0%

2.6%


Fig.12 Flowable composite as lining in composite resin restorations

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Lim / Goh / Seow

24.80%26.80%

24.80%

71.90%

63.40%

5.90%

46.40%

38.60%41.80%

21.60%

5.20%3.30%

16.30%

9.20%

52.90% 52.90%

4.60% 4.60%4.60%

19%23.50%

17%17.60%

19%

15%15%11.80%

16.30%

11.10% 5.20%

0.70%2.60%3.30%2.60%

0.70%

0%

20%

40%

60%

80%

Sec

on

dar

yca

ries

Ro

ot

filli

ng

s

Lo

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Tec

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ical

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Sta

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rob

lem

s

Pat

ien

tal

lerg

icp

rob

lem

s

Increased

RemainedstableDecreased

Do not know

Missing data

Question 9: In your opinion, what will be the changes following a decreased use of amalgam?

Majority (71.9%) of the GDPs surveyed reckoned that patients will be more satisfied with dental treatments following the phasing out of amalgam restorations; however it will be more technically challenging to provide the more aesthetic substitute restorations (Fig. 13).

Bleaching

Question 10: Are these treatment options available in your clinic?

Table 1 Availability of home and chair-side bleaching in clinics

75.8% of the respondents supervised home bleaching while 62.7% provided chair-side bleaching (Table 1).

Yes No Missing data

(i) Home bleaching

75.8% 22.9% 1.3%

(ii) Chair-side bleaching

62.7% 35.9% 1.3%

Always Sometimes Seldom Not at all MissingData

0

5

10

15

20

25

30

26.8%

21.6% 22.2%

26.8%

2.6%

Fig.14 Use of rubber dam isolation in endodontic treatment

Fig.13 Changes following a decreased use of amalgam

Endodontic Treatment

Question 11: Do you commonly use these techniques for endodontic treatment?

(a) Rubber dam isolation

Slightly over a quarter of the GDPs always use rubber dam isolation during endodontic treatment with similar number of GDPs does not employ rubber dam isolation at all. The other half of the respondents use it occasionally when indicated (Fig. 14).

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(b) use of radiograph in root canal treatment

Two thirds of the respondents took intra-operative radiograph during root canal treatment (Fig. 15).

(c) use of obturation techniques in root canal treatment

Cold lateral compaction appeared to be the obturation technique frequently employed by GDPs while half of the GDPs surveyed did not use thermoplasticized gutta percha at all (Fig. 16).

58.2%

44.4%

68%

34.6%

19%

34%

2.6% 5.2%

13.7%

2%5.2%

5.2%2.6%

2.6% 2.6%

0%

20%

40%

60%

Pre

-o

per

ativ

era

dio

gra

ph

Intr

a-o

per

ativ

era

dio

gra

ph

Po

st-

op

erat

ive

rad

iog

rap

h

Always

Sometimes

Seldom

Not at all

Missing data

Fig. 15 Use of radiograph in root canal treatment

43.1%

22.2%24.2%24.8%

23.5%

15%

28.1%24.2%

11.8%

17%

9.8%13.1%18.3%

47.7%

34.6%

30.7%

2.6% 2.6% 3.3% 3.3%

0%

20%

40%

60%

War

m la

tera

lco

mp

acti

on

Co

ld la

tera

lco

mp

acti

on

War

m v

erti

cal

com

pac

tio

n

Th

erm

op

last

iciz

edg

utt

a p

erch

a

Always

Sometimes

Seldom

Not at all

Missing data

Fig. 16 Use of obturation techniques in root canal treatment

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Lim / Goh / Seow

Question 12: What is the irrigant solution normally used in root canal treatment?

Sodium hypochlorite was the most common root canal irrigant solution used by the respondents (71.9%), followed by normal saline (39.9%) (Table 2).

Table 2 Irrigant solutions in root canal treatment

DISCuSSIon

Sending questionnaires by mail is an efficient method to determine dentists’ attitudes, philosophies and practices especially for a large sample size. However, the possibilities of non-response bias, low response rates and inability to check the validity of the respondents’ replies are the common limitations for this method5. According to Dillman12 in Total Design Method, there are several ways to increase the response rate, namely inclusion of stamped addressed envelope, a short and simple questionnaire, covering letter, personalization of correspondence and follow-ups by mail and/or telephone calls. A considerably high response rate (76.5%) was achieved for this study. It is higher than the mean response rate (64 %) reported by Tan and Burke for mailed questionnaires to dentists13. We must recognize the limitation of the present study as the result might not be truly representing all the GDPs in the Klang Valley, however it does provide some useful information and insight about the contemporary trend of direct restorative materials, bleaching and endodontic treatment in this area. Nearly half of respondents indicated that the need for restorations had increased over the past 5 years with another one third stated that the need had remained stable (Fig. 4). Klang Valley is an urban area and the residents are more concern with regards to their oral health status. Besides, GDPs may practice in a more conservative way and attempt to salvage teeth rather than extract it. Reasons above may have contributed to the increase of treatment need for restorations. Nevertheless, increase of treatment need in the UK and Australia was only 4% and 10% respectively4,5. The findings in Malaysia showed a marked difference in comparison to the findings in those parts of the world. There is a significant decrease in the usage of dental amalgam and an increase in the usage of composite resins over the past 5 years. Similar findings have been reported in Finland, UK, and Australia3,4,5. These data appear to support a strong adoption of adhesive techniques by

Yes No Missing data

(i) Sodium hypochlorite 71.9% 25.5% 2.6%(ii) Normal saline 39.9% 57.5% 2.6%(iii) Local anaesthetic

solution13.1% 84.3% 2.6%

(iv) Chlorhexidine 10.5% 86.9% 2.6%(v) Other irigant

solution2.6%

dentists nowadays14. Adhesives in dentistry has provided the advantages of a less destructive preparation, the potential sealing of dentine by using dentine bonding agents and ability to attain aesthetically pleasing restorations15. Moreover, the possible mercury toxicity and detrimental effects on general health with regards to dental amalgam may also have an impact to this downward trend16. The use of resin modified glass-ionomer and glass-ionomer cement has also increased. It may be due to the inherent desirable properties of these materials such as fluoride release and adhesion to tooth structure. Related surveys carried out in the UK and Australia reported the same results by the GDPs in the respective countries4,5. Surprisingly, one third of the respondents in the present study do not use compomer at all. Majority (85.6%) of the GDPs surveyed stated that clinical indication is a predominant factor that influences the selection of restorative materials (Fig. 4). In the UK and Australia, similar figures were reported4,5. However, there is a marked difference between Klang Valley, UK and Australia with regards to other influencing factors on the selection of restorative materials namely the patient’s aesthetic demand (Fig. 5). In the present study, the patient’s aesthetic demand was the second most important factor (73.9%) influencing the selection of restorative materials whilst the corresponding figures in UK and Australia were only 39% and 55% respectively4,5. This may suggest that patients’ awareness towards aesthetic restorations in the Klang Valley has increased. Keen competition amongst the dental clinics in the Klang Valley may also contribute to the dentists trying to fulfill the patients’ demand for aesthetic restorations. The result of this study showed that a lecturer’s suggestion have very little influence on the selection of restorative materials in private dental practices, implying that procedures or techniques taught in the dental schools may not always diffuse well into practices17. The most common reason for replacement of amalgam restorations was fracture of restorations followed by secondary caries (Fig. 8). More tooth structure will have to be removed to provide bulk for the amalgam restorations. Extensive cavity preparation for amalgam restoration may weaken the remaining tooth structure and predispose the tooth to fracture. With regards to composite resin restorations, secondary caries was the most common reason for replacement (Fig. 8). In Finland and Saudi Arabia, secondary caries was the most common reason for replacement for both amalgam and composite resin restorations1,18. Polymerization shrinkage of composite resin will lead to formation of marginal gap and in turn allows the ingress of cariogenic bacteria which was closely related to formation of secondary caries. Discolouration of composite resin restorations in anterior teeth may affect the aesthetics and require replacement. Only one quarter of GDPs would always use composite resin to restore extensive cavities in the load-bearing posterior region. This showed that composite resin was not the preferred choice of restorative materials in this condition and the GDPs have reservation to rely on this material when strength and good wear resistance is call forth. According to Wilson et al.19, there are a few factors that limit the use of composite resin in the UK, for instance,

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general dental services fees and regulations, the limitations of composite resin material and a lack of confidence and expertise in placing composite resin in extensive and load-bearing cavities at posterior region19. In the UK, guidance is issued by the General Dental Services of the Department of Health, which does not allow provision of composite resin restorations in load-bearing surfaces of posterior teeth. On the other hand, a large proportion (41%) of Australian dentists used composite resin to restore extensive and load-bearing cavities in molar teeth5. With regards to the techniques used during placement of composite resin restorations, 83% of the respondents would always use the total etch/dentine bonding technique i.e. GDPs have adopted the technique advocated by Fusayama20 which has proven to work clinically. Conversely, in Australia only two thirds of the GDPs would always and often employed total etch/dentine bonding during placement of composite resin restorations5. Using flowable composite resin as a lining material is gaining popularity now (Fig. 12). The use of flowable composite resin as lining has been advocated to minimize marginal microleakage and voids in composie resin restoration21. However, some studies have revealed that using flowable composite to reduce microleakage at dentine margins might be questionable22. The use of dental amalgam is decreasing over the years. Respondents were asked about their opinions towards this situation. Over 70% of respondents replied that patient’s satisfaction would increase and two thirds believed that technical demand would become more challenging in future. Similar findings were reported in the UK and Australia4,5. The most commonly used alternative material to dental amalgam is composite resin. The availability of various shades, tints and opaque in composite resin systems enable the GDPs to place highly aesthetic restorations which can fulfill the patient’s satisfaction. However, meticulous operative procedures are required during placement of composite resin restorations, for instance, stringent moisture control and increase the chair-side time compared to dental amalgam restorations23. Patients’ demand for aesthetics has increased the provision of bleaching treatment in private dental clinics. It is not surprising that three quarters of GDPs would supervise home bleaching while two thirds of respondents provided chair-side bleaching (Table 1). The results indicated an increase in the provision of these treatment in comparison with a previous study, which was conducted in Klang Valley in 2000/0124. In that study only 58% of respondents would supervise home bleaching and 53% provided chair-side bleaching24. In contrast, provision of bleaching treatment was relatively low in the UK; the main reason may be due to the great controversy with regards to the side effects of bleaching and bleaching products namely soft tissue inflammation, tooth sensitivity and systemic effects19. In the UK, majority (61%) of respondents never used rubber dam for endodontics19. Surprisingly, only about 27% did not use rubber dam at all in the present study (Fig.14). It is a consolation to learn that GDPs in the

Klang Valley adhered to the protocol of infection control and they understood the rationale of applying rubber dam in endodontics. Majority (68%) of the respondents always took intra-operative radiograph in root canal treatment (Fig. 15). It is important for working length determination and trial gutta percha to ensure success for endodontic treatment25. Cold lateral compaction was still the most popular and acceptable obturation technique amongst the GDPs in the Klang Valley (43.1%). It is the most advocated technique and widely taught in various dental schools including University of Malaya. A higher figure (75%) was reported in a study conducted in the UK19. The difference could be due to the increasing popularity of other obturation techniques such as warm lateral compaction, warm vertical compaction, heated gutta percha carriers and injectable gutta percha in the present study. Furthermore, cold lateral compaction is more time consuming in which time is equivalent to money in private practices. Therefore, GDPs would rather choose simpler and faster technique. Respondents were asked about the irrigant solutions they normally used for root canal cleansing. Most of them replied that they used more than one irrigant solutions. Sodium hypochorite was the most widely used irrigant (72%), followed by normal saline, local anaesthetic and chlorhexidine (Table 2). A small proportion chose hydrogen peroxide, EDTA and distilled water as alternatives. Most dental schools teach the use of sodium hypochorite as irrigant solution, suggesting that undergraduate education have profound impact on future practicing behaviour in this particular aspect. In contrast, local anaesthetic was the most favourite irrigant solution in UK based on the study conducted by Whitworth et al.17. The reason was some of the GDPs especially the younger graduates were less confident in their local anaesthetic technique during endodontic treatment17. Irrigation of local anaesthetic into the canal may help to anaesthetize further residual vital pulp tissue.

ConCLuSIonS

It has been perceived by the GDPs in the Klang valley that the treatment need is on the rise and the use of amalgam has decreased over the past few years. Composite resins is gaining popularity, however, GDPs still have reservation using it at the load-bearing posterior region. Demand for bleaching treatment has also increased. Overall the GDPs surveyed have fair understanding of treatment principles pertaining to direct restorations and endodontics.

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24. Muk YP, Seow LL. Aspects of treatment for discoloured dentition in Klang Valley: a survey. Asian J Aesthet Dent 2003; 11: 3-6.

25. Seow LL, Toh CG, Wilson NHF. The restoration of

endodontically treated teeth: a survey of contemporary approaches amongst general dental practitioners in the Klang Valley. Malaysian Dental Journal 2004; 25: 60-71.


Seow Liang Lin BDS (Malaya), MSc (London), FDSRCS (England), PhD (Malaya)Department of Conservative DentistryFaculty of DentistryUniversiti Malaya, 50603Kuala Lumpur



CDE SELF-ASSESSMENT IN CLINICAL DENTISTRY

PART XIX SECTION II

DR WONG FOOT MEOWBDS (Mal), FDSRCPS (Glasg), FICD, AM (Mal), FICOIHonorary Associate Clinical Professor, ICE, Warwick Medical School, UK

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PreambleThis self-assessment series Parts I to Part XIX Sect I was previously published in the Malaysian Dental Association Newsletter. Part I first appeared in the August / September 1995 MDA News issue during the Presidency of Dato’ Dr A Ratnanesan. Part XIX Sect 1 was published in June 2007. Altogether including this instalment 27 segments have been published during the last 12 years in the MDA newsletter.However on the persuasion of our formidable Publication Secretary we have now moved to the loftier heights of the Malaysian Dental Journal starting in the December 2007 issue. An informal question-and-answer format in a non-examination atmosphere has proven in many circumstances to be an excellent vehicle and medium to improve the knowledge of all levels of practising dental professionals in the field of clinical dentistry. Problem solving from astute clinical observations and deductions is an important and fundamental skill for dentists in all specialities. The answers are informative (based on the author’s experience) and it is hoped, goes further than just providing the response to the questions. It is hoped that my little contribution will allow my fellow colleagues to reorganize and apply knowledge in a practical way which when supplemented with their own clinical experience then becomes highly effective. By this means of presenting illustrative clinical problems, the conscientious dental practitioner is provided with an aid to CDE learning. You may be pleased to know that attempting this CDE Quiz entitles you to 3 Credit points. Singapore has implemented compulsory acquiring of 30 credit points annually and MDC is to follow suit in the not so distant future.

The questions and answers are provided by the author and the main emphasis will inevitably be on oral surgery with some overlap covering other disciplines in an attempt to present diverse subject material in an integrated manner. Accordingly, the responsibilities of the correctness of the answers and management plan are that of the author alone but general principles of mainstream dentistry are

strictly adhered to. It is hoped that colleagues will pursue additional references and readings in areas they find stimulating and give input on our efforts so that we can improve this series further.

QUESTION 3: THREE INTERESTING WHITE LESIONS OF THE ORAL MUCOSA

3. White lesions are due to the appearance of keratinised epithelium at sites in which the epithelium is not normally keratinised, or of excessive keratinisation in areas normally keratinised. Consider the following 3 cases :a. This 65year old Caucasian male executive

was seen a few years ago with stomatitis nicotina and was recommended symptomatic treatment and systematic review. Recently he became afflicted with malignant lymphoma (Hodgkin’s Lymphoma), has Pel- Ebstein fever and showed up requesting extraction of tooth 16. The oral cavity presented like this clinically (Fig 3a) with a mirror image view in Fig 3b.

Fig 3a

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b. This 49 year old Chinese businessman entertains quite a bit at nightspots necessitating plenty of drinking and smoking and presented with this white lesion in the buccal mucosa ( Fig 3c). However upon retracting the cheek further a more sinister sight unfolded ( Fig 3d). There were no palpable lymph nodes.

c. This 53 year old Caucasian entrepreneur was referred by his dentist who was concerned about the increasing white patches in his client’s palate. He smokes and drinks quite a bit . Oral cavity is otherwise normal (Fig. 3e)

(i) What is a Leukoplakia ? Which of the 3 cases above has a better prognosis and why?

(ii) What would you consider are the important white patches in the mouth? On what aetiological basis do they come about?

(iii) List 6 features in a white lesion which are likely to increase the likelihood of malignant transformation over time?

(iv) Should a biopsy be performed for all 3 cases? Under what circumstances should a biopsy not be done in general dental practice?

(v) Name 10 features in a white lesion that will give indications on its future behaviour and possible parameters of malignant transformation?

(vi) Fig 3d revealed mixed red and white patches. What are the causes of mixed red and white patches in the mouth?

(vii) Patient 3a has lymph cancer. What are the 2 categories of cancer of the lymphatic system ? What is malignant lymphoma? What is Pel- Epstein fever? By what mechanism has the malignant lymphoma altered the clinical picture of stomatitis nicotina ( Fig 3b)? Why would the mere extraction of tooth 16 be hazardous in this scenario? What do you know about Burkitt’s lymphoma (related to Dentistry )?

(vii) What types of treatment are possible for case 3b and 3c, and what is the prognosis ?

Fig 3b

Fig 3c

Fig 3d

Fig 3e

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CDE SELF-ASSESSMENT IN CLINICAL DENTISTRY • PART XIX SECTION II

e. What are the important structures to consider when doing surgery in this general area? Name at least 7 important structures that can clearly be seen in Fig. 4c and 4d ? When operating in this general area one should be very well versed with the surgical anatomy. Can you glean the salient features and discuss anatomical features of note from Figs 4e, 4f and 4g ?

QUESTION 4 : SWELLING IN THE FLOOR OF THE MOUTH

This 40 year old Chinese Photographic Shop owner complained of this recurring “bubble ” in his mouth which ruptured on trauma only to increase in size after each rupturing episode. He is worried that it may be cancerous. a. What descriptive terms are used for this swelling in the

floor of the mouth (Fig 4a)? How are mucoceles related to this swelling ?

b. How did this swelling develop (pathophysiological aspects)? What other problems may the patient complain about?

c. Should the patient be warned about possible complications before surgery?

d. What surgical approach is utilised in Fig 4b? Name the various surgical methods and approach used in the treatment of this lesion? What do you know about the recurrence rates of the various techniques ?

Fig 4a

Fig 4b

Fig 4c

Fig 4d

Fig 4e

ADAPTED FROM ANATOMY, REGIONAL AND APPLIED, RJ LAST

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f. Fig 4h is the post operative appearance after 6 days.What has been achieved here ?

g. What is the long term prognosis of this particular case ?

Fig 4h

Fig 4f

Fig 4g



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ANSWERS FOR DENTAL QUIZ PART XIX SECTION II

CDE SELF ASSESSMENT IN CLINICAL DENTISTRY SERIES

DR WONG FOOT MEOWBDS(Mal), FDSRCPS (Glasg), FICD, AM(Mal), FICOIHonorary Associate Clinical Professor, ICE, Warwick Medical School, UK

QUESTION 3: THREE WHITE LESIONS

The colour of white lesions of the oral mucosa is produced by the scattering of light through an altered epithelial surface and this altered epithelial surface is caused by either excessive keratinisation in areas normally keratinised or appearance of keratinisation in a non keratinised area. 3 (i) Leukoplakia is a clinical term. It is a precancerous

lesion, defined as a white patch or plaque of the oral mucosa that cannot be detached and cannot be identified as a lesion belonging to any specific disease entity. The main predisposing factors are smoking, alcohol, human papillomavirus, Candida Albicans, and chronic trauma. There are 3 main forms of oral leukoplakia ie.a. Homogenous ( low risk of malignant transformation

2-4 % )b. Speckled ( high risk of malignant transformation

20-30 % )c. Proliferative verrucous (very high risk of malignant

transformation 30-40 %) On the above basis it would appear that Case 1c in

Fig 3e has the better long term prognosis. He has leukoplakia of recent origin on the low-risk palate which does not look sinister clinically. However only a biopsy and histopathologic examination will define the nature and relative risk of the leukoplakia. Molecular biological and immuno-histochemical techniques will identify leukoplakia with high risk for malignant transformation.

(ii) The more important white patches in the oral cavity will include the following :a. Traumatic lesions including frictional keratosis,

chemical burns, cheek and tongue bitingb. Inherited epithelial disorders eg white sponge

naevus and pachyonychia congenitac. Normal mucosal entities eg Leukoderma and

Fordyce spots

d. Infections eg Thrush, Chronic hyperplastic candidosis, chronic mucocutaneous candidosis ,hairy leukoplakia and syphilitic leukoplakia

e. Lichen planus and allied conditions eg lichen planus, lichenoid reactions and lupus erythemathosus

f. Unknown including idiopathic keratosis (homogenous leukoplakia, verrucous leukoplakia,sublingual keratosis,speckled leukoplakia.)

g. Smoking related eg smoker’s keratosis and stomatitis nicotina

h. Neoplastic ie squamous cell carcinoma

(iii) 6 features which may cause future complications by malignant transformation include the following:a. Associated red areas eg in Fig 3db. Speckled areasc. Ulceration, especially if persistently chronicd. Induratione. Enlarged lymph nodes draining the sitef. Lesions in a high risk area eg floor of the mouth

(iv) Yes, all 3 lesions should be subjected to a formal biopsy. Biopsies are mandatory for a definitive diagnosis. As a matter of proper procedure any odd looking white patch of more than 4 weeks duration should be subjected to a histopathological examination for establishing a baseline to work upon in subsequent reviews for comparison purposes. As a rule of thumb, biopsy of the following mucosal lesions is NOT encouraged in general dental practise:a. Any lesion with clinical features suggesting

malignancy. (refer to answer v below )b. Lesions that require hospital care or treatment once

the diagnosis is confirmedc. Haemangiomas and vascular malformationsd. Growths in the posterior soft palate or faucese. Inaccessible areas

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f. Swellings of salivary gland origin which are not mucoceles as 50 % of such growths tend to be malignant

(v) The following features in a white patch give indications on it’s future behaviour, mitotic abnormality or the potential for malignant transformation : a. Dysplasia - The degree of dysplasia is the best and

most important predictor but it may change, either progressing or regressing, with time.

b. Site - White lesions localised in the floor of mouth, posterior and lateral tongue and retromolar area carry the highest risk. Those on the hard palate and dorsum of the tongue give negligible risk.

c. Colour - Development of red areas carries a high risk and is usually associated with severe dysplasia .

d. Tobacco use - Smoking indicates increased risk. However, smoking also causes other white patches with no dysplasia. Paradoxically white patches in non-smokers carry an even higher risk.

e. Age - The risk of malignant transformation rises with age. However carcinoma in the elderly tend to be well differentiated .

f. Size. - Larger lesions especially those larger than 1 cm, carries a higher risk of malignant transformation.

g. Duration - Patches present for a longer time have a higher risk of malignant transformation.

h. Family history of carcinoma in upper digestive tract indicates increased risk.

i. Candidal infection in presence of dysplasia indicates a small increase in risk.

j. Change in clinical appearance - Changes apart from colour, such as size, nodularity or development of a verrucous surface, confers a higher risk.

k. Underlying conditions - Conditions which predispose to oral carcinoma, such a submucous fibrosis, raise the relative risk of malignant transformation.

(vi) There are 5 main categories causing mixed white and red patches in the oral cavity:a. Trauma from chemical burns and cheek bitingb. Infections eg Thrush and candidal leukoplakiac. Lichen planus , lichenoid reactions and lupus

erythematosusd. Idiopathic keratosis including sublingual keratosis

and speckled leukoplakiae. Neoplasia ie squamous cell carcinoma

(vii) The patient in Case 1a. has malignant lymphoma superimposed on to a gross smoker’s palate. Cancer of the lymphatic system or Lymphoma is divided into 2 categories based on the appearance of the tumour cells viz :a. Hodgkin’s lymphoma ( HL ) –Minimal oral

manifestations. Pel –Ebstein fever is a low grade fever that exhibits a periodic pattern.

b. Non- Hodgkin’s lymphoma ( NHL ). A complex group of lymphoid tissue malignancies, 90% from B- lymphocyte series and 10 % from T-lymphocyte series. Of the lesions in the oral cavity, 80 % arises in Waldeyer’s ring and palate.

The progressive proliferation of lymphocytes involves the bone marrow and replaces normal haematopoiesis. This results in anaemia and suppression of normal immunity mechanisms. This plus consequent chemotherapy has allowed superimposed candidiasis to take hold on top of the stomatitis nicotina giving the mixed picture in Fig 3a and 3b.

Dental extractions especially molars , may cause prolonged bleeding from the thrombocytopenia. If extractions are absolutely necessary make sure that the platelet levels is at least more than 100,00 per cu. mm. of blood. Antibiotics are important to prevent serious infections as the oral flora has been changed by chemotherapy.

Burkitt’s lymphoma : This is a lymphosarcoma occurring extensively in certain humid regions of Central and West Africa. It mainly affects children up to the age of 15 years and presents as jaw enlargement usually in the maxilla. There is evidence that the Epstein –Barr virus (which also causes glandular fever )is the major aetiological agent.

Treatment is highly dependant on early diagnosis. Accordingly treatment may be by radiotherapy (implant or external beam), by surgery or both in combination. The final decision will depend on the results of investigations to stage the carcinoma (to determine its size and extent of metastases to lymph nodes and distant sites). In the absence of metastasis, treatment is likely to be surgery alone and a 5 year survival rate of 85% or better can be achieved. If the lesion were larger, implant radiotherapy might well be suggested. If the patient in case 1b survives 10 years he is likely to be cured. However, 10% of oral carcinoma patients develop a second primary lesion in the mouth or upper digestive tract as the mucosa is already primed. The chances of developing a second lesion are assumed to be reduced by stopping smoking and the patient should be encouraged to do so. Smoking and associated cardiovascular disease, if severe, may also compromise treatment.

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ANSWERS FOR DENTAL QUIZ PART XIX SECTION II • CDE SELF ASSESSMENT IN CLINICAL DENTISTRY SERIES

QUESTION 4 : SUBMUCOSAL CYSTIC DILATATION OF FLOOR OF MOUTH

Ranula is the name given to a form of mucocele which occurs in the floor of the mouth and is associated with the ducts of the submandibular and the sublingual salivary glands. They are usually unilateral swellings, 2-3 cm in diameter, and are soft and fluctuant with a bluish violet colour. Although generally painless, ranula sometimes interfere with speech , mastication and swallowing. ( Fig. 4a and 4b.)

a. Large retention cysts in the floor of the mouth are termed ranula ( small frog ) because of their peculiar appearance which resembles the belly of a frog. ( Pindborg 1992 ) . These appear on the floor of the mouth as spherical ,balloon-like, irritating but painless distensions usually bluish-violet in colour . Collectively, the mucocele, and ranula are clinical terms for a pseudocyst that is associated with mucus extravasation into the surrounding soft tissues. These lesions occur as the result of trauma to the salivary gland excretory duct, although obstruction of salivary flow is implicated in some instances.

Ranulas, which involve the major salivary glands, are

divided into 2 types: oral ranulas and cervical ranulas. Oral ranulas are secondary to mucus extravasation that pools superior to the mylohyoid muscle, whereas cervical ranulas are associated with mucus extravasation along the fascial planes of the neck.

Histologically, mucoceles may be a mucus-extravasation cyst or a mucus retention cyst. The former is caused by minor trauma of minor excretory ducts resulting in mucus spillage into the connective tissue stroma with a lining of granulation tissue. The latter results from a partial obstruction to the flow of saliva with duct dilatation causing formation of cystic lesion lined with simple columnar or pseudostratified squamous epithelium.

b. The development of mucoceles and ranulas depend on the disruption of the flow of saliva from the secretory apparatus of the salivary glands. The lesions are most often associated with mucus extravasation into the adjacent soft tissues caused by a traumatic ductal insult; the injuries may either be a crush-type injury or severance of the excretory duct of the minor salivary gland. There are 3 possible mechanisms of formation i. The disruption of the excretory duct results in

extravasation of mucus from the gland into the surrounding soft tissue.

ii. The rupture of an acinar structure caused by hypertension from the ductal obstruction is another possible mechanism for the development of such lesions.

iii. Trauma that results in damage to the glandular parenchymal cells in the salivary gland lobules is the third mechanism.

c. Surgical excision of the ranula along with the adjacent associated sublingual salivary glands is recommended. The risk for recurrence is minimal when appropriate surgical excision has been performed. Aspiration of the ranula contents often results in recurrence. Large plunging lesions may be marsupialized to prevent significant loss of tissue or to decrease the risk for significantly traumatizing the labial branch of the mental nerve. If the fibrous wall is thick, moderate-sized lesions may be treated by dissection. If this surgical approach is used, the adjacent minor salivary glands must be removed. The patient must be warned of the possibility of profuse bleeding post operatively even necessitating a tracheostomy. Paraesthesia of the lingual nerve and problems with mastication occur if branches of the 12th cranial( Hypoglossal ) nerve is damaged. A normal submandibular gland may become symptomatic if the submandibular duct is compromised.

d. An excision biopsy is done with enucleation of the ranula and concomitant excision of the (L) sublingual gland in Fig 4c to 4f. Some clinicians use a tiered approach to the management of huge oral ranulas. The first attempt at management may be marsupialization of the ranula with packing of the entire pseudocyst with gauze for 7-10 days. The entire ranula is unroofed, and the packing material is firmly placed into the entire cavity of the pseudocyst. This technique allows for re-epithelialization of the pseudocyst cavity; seals the mucinous leak; and provokes a foreign body inflammatory reaction, leading to fibrosis and atrophy of the involved acini. The procedure may be effective with the sublingual gland because it has multiple draining excretory ducts. If this does not eliminate the ranula, additional surgical therapy is initiated with removal of the ranula and the offending salivary gland.

The recurrence rates of an oral ranula with various surgical treatment methods are as follows: • Incision and drainage, 71-100% • Ranula excision only, 0-25% • Marsupialization only, 61-89% • Marsupialization with packing, 0-12% (limited

studies)• Complete excision of the ranula with the sublingual

gland, 0-2%

e. Anatomically, the sublingual gland lies, in front of the anterior border of hyoglossus, between the mylohyoid muscle and the side of the tongue (genioglossus). It makes a smooth depression in the mandible at the general midline and lies below the termination of the

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submandibular duct. It is a mucous gland (Fig 4c), twice the size of an almond kernel. Of its 15 or so ducts half open directly into the submandibular duct and the rest separately on the sublingual papilla.

It is supplied by the lingual artery and by branches of the submental artery. The venous return is by corresponding veins. It is innervated from the submandibular ganglion.

In Fig 4c, the mucosal flaps are developed carefully by a combination of blunt and sharp scissor dissection from the fibrous attachments of the cyst wall with the mylohyoid muscle at the base of the sublingual gland. 7 important structures are seen in Fig 4d, notice the lingual vein and artery sitting on the hyoglossus muscle. The lingual nerve is seen coursing medially beneath the duct. Compare Fig 4d with Fig 4g. In Fig 4e the sublingual gland is carefully delivered leaving the submandibular duct, lingual nerve, submandibular ganglion and lingual vessels unscathed. See Fig 4h and fig 4i. The intimate relationship of these structures emphasizes the enfolding by the sublingual gland of the separate submandibular duct, passing from the mylohyoid extension of the submandibular gland to its mucosal orifice in the floor of the mouth at the sublingual papilla , at the lingual aspect of the anterior mandible.. Important Note : If the submandibular duct is damaged or sectioned electively , the excretory end should be divided cleanly and sharply and placed at the edge of the wound to encourage fistulization. If not there will be secondary complications with the submandibular salivary gland.

f. The most immediate postoperative problem is likely to be uncontrolled haemorrhage from a sublingual vessel. Notice the size of the lingual vein and artery in Fig 4d. Notice that the (L) floor of the mouth is now near to normal. The inflammation has subsided and saliva is flowing freely from the sublingual papilla with no post-op salivary backflow and no sign of infection. The tongue is freely mobile with the patient confirming that the lingual nerve is functioning perfectly.

g. The long term prognosis in this case is excellent as the pseudocyst was cleanly enucleated together with the sublingual gland without any residual damage to vital anatomical structures. (Fig 4f ). Mucoceles and ranulas tend to be relatively painless or asymptomatic lesions with little or no associated morbidity or mortality. Oral and plunging ranulas, if large, may affect swallowing, speech, mastication, or respiratory function. In this particular case there is no paraesthesia of the lingual nerve with no weakness of the tongue (Hypoglossal Nerve intact). Accordingly no long term problems are expected.

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ABSTRACTS OF SCIENTIFIC PAPERS PRESENTED AT SCIENTIFIC CONFERENCE OF THE MDA/FDI SCIENTIFIC CONVENTION & 64TH MDA AGM, 15-17TH JUNE 2007

Furcation Entrance Dimensions in Malaysian Permanent Molars and its Periodontal Implication.Al-Bayaty FH, Baharuddin NA, Hussain SF.Department of Oral Medicine and Periodontology, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.

The objectives of this study: To measure the Furcation Entrance Dimensions of first and second extracted permanent molars in Malaysian samples and to compare the Furcation Entrance Dimensions with the blade widths of periodontal instruments used for root surface instrumentation.

Materials and Methods: A total of 199 permanent extracted teeth were measured, which comprised of 51 mandibular first molars, 51 mandibular second molars, 45 maxillary first molars and 52 maxillary second molars.

Results: Demonstrated that 51.1 % of all the Furcation Entrance Dimensions of these teeth were less than the blade width of new Gracey curettes.

Conclusions: New periodontal curettes may not be the best choice of instrumentation and that ultrasonic debridement using a narrow tip may be a more appropriate choice.

Using a Restorative Glass Ionomer Cement as a Fissure Sealant in A School-Based Fissure Sealant Programme in the District of Pontian, Johor: A Five-Year ReviewHabibah Y, Klinik Pergigian Pontian, JohorMazlan A, Pusat Pengajian Sains Perubatan, USM Rashid I, Mohd Ayub S, Pusat Pengajian Sains Pergigian, USM Loh KH, Pejabat Timbalan Pengarah Kesihatan Negeri (Pergigian), Johor, Malaysia.

Introduction: Community oral health care focuses mainly on preventive measures such as water fluoridation, oral health promotion, oral cancer screening and the school-based fissure sealant programme. The aim of this study is to evaluate the effectiveness of a restorative glass ionomer cement as a fissure sealant after 5 years application.

Objectives of investigation: The objectives of the study were to determine the retention rate of a restorative glass ionomer cement (GIC) as a fissure sealant after five years and also to determine and compare the status of occlusal surface of lower left first permanent molars (FPM) in sealed and unsealed group after a 5-year-interval.

Material and Method: This was a retrospective cohort study comparing a group of high caries-risk school children receiving fissure sealants with a control group of high caries-risk school children receiving only yearly dental check-up and dental health education. Subjects (n=322) were selected by random sampling and given a questionnaire for socio-demographic status. Sealants, occlusal caries status and past deciduous caries experience (dft) were reviewed from their dental treatment records.

Results: The retention rate of fissure sealants was 19.4% while the total loss of sealants was 80.6%. The proportion of sound occlusal lower left FPM in the sealed group was 88.4% as compared to 76.8% in the unsealed group. About 11.6% of the sealed teeth and 23.3% unsealed teeth developed caries after a 5-year interval. Significant association was found between the proportion of sound occlusal lower left FPM in sealed and unsealed group with associated



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factors being controlled at both univariable (crude OR=1.78; 95% CI 1.02, 3.07) and multivariable analyses (OR=1.91; 95% CI 1.05, 3.49).

Conclusion: The five-year retention rate of GIC fissure sealants in this study is low at 19.4%. However, the occlusal caries status of lower left FPM in the sealed and unsealed groups tends to suggest that the use of the restorative GIC as a fissure sealant has afforded a significant degree of caries prevention, with unsealed teeth having higher chance of developing caries.

This study was supported by Universiti Sains Malaysia Short Term Grant no: (304/PPSP/6131387)

Occupational Exposures Occurring Among Dental Students in Universiti Kebangsaan Malaysia (UKM) and University of Malaya (UM)Ahmad NS, Yeng SW, Shung YS, Faculty of Dentistry, University Kebangsaan Malaysia Ismail SM, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Malaya HM Hussaini, Department of Oral Medicine and Oral Pathology, University Kebangsaan Malaysia.

Background: Students have a high risk of occupational exposure due to their lack of skills and experience. This study is done to assess the prevalence of occupational exposures and to evaluate the association of various factors with occupational exposure in third, fourth and final year dental students at University Kebangsaan Malaysia (UKM) and University of Malaya.

Material and Methods: 496 students in the third, fourth and final years of UKM and UM were asked to complete a self-administered, anonymous questionnaire. The questionnaires were divided into four areas of enquiry: personal details, Vaccination status regarding Hepatitis B (HBV), factors associated with occupational exposures, Reporting and follow-up.

Results: Of the total 396 respondents, 54.7% reported experiencing occupational exposures with a total of 345 exposures. There was statistically significant association between gender/year of dental course and reported numbers of exposures. Aerosol/splatter was the most common nature of exposure (68.8%). Most exposures occurred during hygiene procedures (78.2%). Time constrain was the major contributor (52.5%) and more experience may help in reducing occupational exposure (69.3%). Only 66.7% of students who had experienced parenteral exposures reported to supervisor. Only 70.2% of students completed HBV vaccination series and 32.2% had undergone post-screened for seroconversion.

Conclusion: More than half of the student has experienced occupational exposure. Most exposures are accidental and can be avoided by using safe work practices and following infection control guidelines. However, because some exposures are not preventable, immunization and appropriate post exposures management become the key defense.

Relationship between patients’ perceptions and clinical indications for dental extraction in Mukah Division, SarawakLing XF, Chen CJA, Division of Oral Health, Ministry of Health Malaysia, Sarawak, Malaysia.

Objective of investigation: The objective of our study was to compare between the patient’s perception and clinical indications for dental extraction in Mukah Division.

Methods used: The survey was done using self administered, structured questionnaires to collect information. The survey was done on all the patients 15 years old and above who requested for permanent tooth extraction. The dental officers were asked to record the tooth type extracted, whether the tooth was restorable and clinical indication for dental extraction.

Results: 89% of the patients refused restorative treatment. 61% of the responses refused restorative treatment because they had a misconception that extraction will solve all their dental problems.

Conclusion: From the patient’s perspective, the main reasons of tooth extraction were toothache and the presence of cavity. Clinically, caries (73%) was still the main clinical indication for tooth extraction. By comparing both the patients’ view and dental officers’ diagnosis, we found that 29% of restorable teeth were extracted.

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Clinical Practice Guidelines (CPG) Usage by Dental Officers in Malaysia.Loke ST, Ang LC, Orthodontic Unit, Teluk Wanjah Dental Clinic, Alor Star, Kedah

Objectives: To assess the dissemination and implementation of orthodontic CPGs by all government dental officers and orthodontists in Ministry of Health, Malaysia

Materials and Methods: Two different sets of self-administered questionnaires for the 2 target groups were sent to all states. Armed forces and teaching institutes excluded.

Results: 394(30%) questionnaires were returned from an estimated 1,327. There was poor response from some states and no participation from 3 states. Officer group: 89% have heard of CPGs , 61% have read orthodontic CPG and 77.4% have read other CPGs, 73% found CPGs useful and 72% regularly use them. Although 14% felt that CPGs were not encouraged and 4% had difficulty assessing CPGs. Overall, senior officers were more aware of CPGs than first-year officers. Generally, orthodontists were positive although only 64% introduced CPGs to their officers.

Conclusion: Dissemination of CPGs is reasonably good but implementation is below expectations.

Susuk: Any Cause for Concern? Nambiar P, Ibrahim N, Muslim Tandjung YR, Shanmuhasuntharam P., Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.

Objectives of investigation: A study was done to determine the number of susuks, their distribution in the craniofacial region, gender, racial affiliation and age of the wearers. Furthermore, we wanted to find out if there was any potential hazard imposed by the presence of susuk in patients requiring magnetic resonance imaging.

Methods used: Susuks are almost always an incidental finding in radiographs. The most favorite areas in the craniofacial region where they are inserted were investigated. A susuk was suspended inside a MRI machine (magnetic field of 1.5 Tesla) to see if it is attracted by the magnet.

Results: The susuks were detectable on dental panoramic tomographs, lateral skull radiographs, posterior-anterior view and occipitomental views. The sites of the presence of the susuks were at any area in the maxillofacial region (except the temporomandibular region) and also the forehead. The susuk did not show any ferromagnetic characteristics.

Conclusion: It is perceived that susuk is made from gold due to its biocompatibility to human tissue and not causing any problems to the wearers. Gold and other minor metal constituents do not to have any ferromagnetic characteristics as demonstrated in this study.

Effects of Refiring on the Flexural Strength of Low Fusing PorcelainSharif RM, Ministry of Health, Malacca, Malaysia.Ahmad R, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.

The strength and durability of porcelain improve with the degree of heat or firing treatment up to a point beyond which further treatment impairs these properties.

Objective: The objective of this study was to investigate the effect of refiring on the flexural strength and colour changes of low fusing porcelain.

Methods: Four groups of ten porcelain bars each were prepared from enamel powder of low fusing Finesse Porcelain. The specimens were fired under vacuum and ground to a final dimension of 4.0 x 1.5 x 25.0 mm using abrasive wheel, coated with 30-µm grit diamond particles on a Buehler, Metasserv Grinder. Group A served as a control group with no refiring treatment. Group B, C and D were subjected to one, two and three refiring cycles respectively. The flexural strength was determined using a three point bend test, on a universal testing machine (Instron) at a crosshead speed of 0.5mm/min. A spectrophotometer (Dataflash 100) was then used to measure the colour changes of refired specimens.

Results: Statistical analysis using ANOVA and Tukey’s post hoc test revealed that the mean flexural strength significantly increased after three refiring cycles at p<0.05. There was a 7% significant increase in flexural strength observed between Group A (80.01 ± 3.93 MPa) which received no refiring treatment and Group D (85.58 ± 3.61

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MPa) which was refired 3 times (p<0.05). There was no decrease in strength observed after refiring procedure. However, the specimens became significantly lighter (p<0.001) in groups, which were refired twice (C) and three times (D). The mean ∆E values for groups of specimens which were refired once, twice and three times were 2.37 ± 1.54, 7.26 ± 2.00 and 8.97 ± 1.47 respectively

Conclusions: Clinically, when there is a need for refiring of low fusing porcelain restorations, such procedure of refiring up to three cycles is regarded not detrimental to strength as long as the manufacturer’s firing recommendations is strictly followed.This study was supported by Vot F 0105 / 2002B (University of Malaya).

Detection of Periodontal Conditions among the Dental Practitioners in Kuala LumpurZenn YH, Johari N, Mohd Ayob MH, Mohd Said S, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Community Periodontal Index for Treatment Needs (CPITN), Basic Periodontal Examination (BPE) and Periodontal Screening Index (PSI) are some of the procedures used to facilitate detection of periodontal conditions or diseases during the first encounter of patient with dental clinicians. These indices do not only recognise signs of periodontal changes but also assist clinicians to identify patients with risk of developing and periodontal conditions/diseases as well as outline the management including treatment aims, regime, intervals and/or referrals. Despite recommendation and implementation of BPE as an essential part of parameter of care of patient management, many periodontal cases are still being diagnosed late and seen as not been managed accordingly.

Aims: A simple survey was carried out to investigate the understanding, perceptions and barriers on usage of the BPEs among the dental practitioners around Kuala Lumpur.

Methods: Self-administered questionnaires were posted to dental practitioners in Kuala Lumpur.

Results: Only twenty percent (n= 87) of the recipients responded to the survey. Our survey indicates that although most of the dental practitioners claimed that they have good understanding of BPE, they do not use BPE routinely in their practice. Time and unavailability of proper probes were identified as limitations for using the procedure.

Conclusion: Sufficient understanding of the rationale and procedures are essential to ensure efficiency and benefit of usage of the BPE in general dental practice. This paper also highlights the features and advantages of these indices as well as the practicality of usage in the dental practice.

The Prevalence of Dental Trauma in Department of Paediatric Dentistry, Hospital Alor Star (2000-2005)Soon HI, Mohd Ali A, Paediatric departmentJamal Din SK, Najar Din MY, Oral Surgery Department, Hospital Alor Star, Kedah, Malaysia.

Objective: The purpose of this study was to evaluate the prevalence and type of dental trauma referred in Department of Paediatric Dentistry, Hospital Alor Star, from the year of 2000 to 2005.

Materials and Methods: A retrospective review was conducted of 610 dental records of children registered in the dental paediatric clinic under category of trauma case (labelled in green). During the period of January 2000-July 2005, a total of 204 patients presented with dental trauma. The data regarding patient age, race group, gender, cause of injuries and number of tooth affected were analyzed. Type of dental trauma was documented according to Andreasen’s classification.

Results: The study revealed that a total of 204 patients with 442 traumatized teeth presented during 5 years interval. Of the 204 patients, 133 were boys (65.2%) and 71 were girls (34.8%). The incidence of dental trauma peaked in the age of 8 and 11 years. Malay patient was the prevalent race group of dental injuries patients, followed by Chinese, Indian and Siamese. The maxillary arch was involved in a higher percentage of trauma cases in primary dentition (93%). In the permanent dentition injuries, 261 (83.1%) tooth affected were in maxillary arch and 53 (16.9%) were in mandibular arch. The maxillary central incisors (64%) were found to be the most affected tooth in both primary and permanent dentition. The most frequent aetiology factors were falls (41.2%) and motor-vehicle accidents (40.6%), other causes including cycling (14.2%), sport injuries (1.5%) and miscellaneous (2.5%). The most common injuries type was avulsion (29.4%) and subluxation (28.5%).

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The Therapeutic Usage of Botulinum Toxin Type A in Orofacial Conditions – An Overview Andrew CKH. Private Practice, Selangor, Malaysia. Botulinum toxin Type A (BotoxTM; Allergan) injection remains that most commonly performed cosmetic procedure in the world especially in the USA. Botox was first approved by the US Food and Drug Administration (FDA) in 1989 to treat two eye disorders ie. Uncontrollable blinking (blepharospasm) and misaligned eyes (strabismus). By April 2002, the neurotoxin was granted approval to be used to smoothen out wrinkles on the face and other serious neurological movement disorders. Recently, Botox has also been administered for the treatment of hyperfunctional muscles related to the field of dentistry. This presentation will highlight the therapeutic effect of Botox for some of the commonly encountered disorders familiar to dental clinicians.

A Customer Satisfaction Survey of the Johor Oral Health Service Year 2006

Loh KH, Principal Assistant Director (Oral Health) Johor Department of Health, Tan EH, Dental Public Health Officer Muar District, Johor, Malaysia.

A coordinated customer satisfaction survey was conducted by Johor Oral Health Service (JOHS) in 2006.

Objectives: The objectives were to evaluate the customer’s perception, to measure the difference between the customer’s expectation and perception using the modified SERVQUAL instrument and to make recommendations for corrective action or continual improvement, if necessary.

Methodology: The Johor State Deputy Director of Health (Oral Health) office {DDH (OH) office} and dental clinics in the 8 districts which are in the scope of MS ISO 9001:2000 were involved in the survey. The survey instrument was adopted from a similar format used by Oral Health Division, Ministry of Health, Malaysia in a national survey on patient satisfaction in government dental clinics in 2005 and customised for the other categories of customers within JOHS. For outpatients, samples were selected by systematic sampling, while internal clients involved all dental personnel of JOHS. Other categories of clients were selected conveniently from population surveyed during the study period.

Results: Based on perception alone, satisfaction levels were high; i.e. 100% of external clients DDH (OH) office, 99.7% school health teachers, 99.1% outpatients, 96.8% school children and 96.7% internal clients. However, based on SERVQUAL, satisfaction levels were low; i.e. 34.5% for external clients at DDH (OH) office, 43.3% school health teachers, 47.9% outpatients, 44.1% school children and 42.3% internal clients. Outpatients and school health teachers were least satisfied with the dimension of Tangibles, while internal clients and external clients of DDH (OH) office were least satisfied with the dimension of Reliability. School children were least satisfied with the dimension of Assurance.

Conclusion: This survey found that satisfaction level was high (96.7% to 100%) if based on perception alone. However, if based on SERVQUAL, JOHS was unable to meet 52.1% to 65.5% of its customers’ expectation. Recommendations for improvement in service were made based on findings in this survey. Corrective actions and continual improvement need to be planned and their implementation monitored for them to be effectively carried out.

Conclusion: There is a need for the parents to aware of the importance of immediate treatment for dental injuries in children. The teaching of injury epidemiology and trauma prevention to the public and guidelines for the health care workers should be improved and a multidisciplinary approach would be the mostly effective way to prevent dental trauma.

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Psychological Well Being Status and the Influencing Factors among Repaired Cleft Lip and Palate Patients in Wilayah Persekutuan and Selangor Marhazlinda J, Fakulti Pergigian, Universiti Malaya, Kuala Lumpur, Malaysia.Nizam A, Naing L, Pusat Pengajian Sains Pergigian, Universiti Sains Malaysia, Kelantan.

Objective: This study was to determine the health related quality of life (HRQL) and its influencing factors in relation to psychological well being dimension among repaired cleft lip and palate (CLP) patients. Health related quality of life and its influencing factors are now a topic of growing interest and are receiving increased clinical and research attention. HRQL encompasses many dimensions and in this study, psychological well being dimension was referred to the individuals' emotional well being as impacted by cleft condition. Measurement of it in the evaluation of treatment will give us broader insights into the patient’s well being while discovering the influencing factors can provide the focus of future intervention strategies.

Material and Method: An exploratory cross sectional study was conducted from Jun to October 2004 among 120 repaired CLP patients aged 12 to 30 years old, recruited from six main government orthodontic clinics in Wilayah Persekutuan and Selangor. After having piloted on 32 subjects, an assisted administered multidimensional HRQL questionnaire developed has shown good reliability and validity. Actual data collection was done either at the clinic or at home for subjects who had completed or defaulted treatments. Data was entered and analyzed using SPSS Version 11.5.

Results: The mean score of psychological well being dimension was 37.2 points (95% CI: 35.95, 38.48). The score was then categorized into good, moderate and poor where few items such as self confidence, nervousness, peacefulness, occurrence of being teased and work accomplishment were found to be affected by the CLP and its treatments. Having an isolated CL compare to other types of cleft, being a Buddhist compare to other religion except Islam and being more satisfied with the treatment outcome and the information delivered by health personnel appeared to be significantly associated with better psychological well being status.

Conclusion: Repaired CLP patients have moderate HRQL in term of psychological wellbeing status. Satisfaction with the treatment outcome and the information delivered by health personnel, types of clefts and religion had emerged as the significant influencing factors. Perhaps intervention such as expanding and emphasizing on the role of counselor, psychologist, and sociologist or support groups may help in promoting adaptation and acceptance of cleft consequences. A protocol to measure patient satisfaction with the treatment outcome may also help in indicating high risk group of developing psychological wellbeing problems.

This study was supported by Pusat Pengajian Sains Pergigian Universiti Sains Malaysia.

Readership of the Malaysian Dental Journal

Ngeow WC, Mohd Noor NS, Mohd Tahir NN, Malaysian Dental Association, Bukit Damansara, Kuala Lumpur, Malaysia.

Objective of Investigation: To get Malaysian dentists’ view on the content and quality of the Malaysian Dental Journal (MDJ).

Materials and Methods: 225 questionnaires were sent out to Malaysian dentists attending various conferences throughout Peninsular Malaysia from February 2006 to July 2006.

Results: 156 questionnaires were returned. Almost two-third (n=103; 66%) read more than one professional journal. The number of MDJ readers was 101 with only 24.75% reading all issues published. The editorial section was rated as “useful” by 70.3% of readers, while 79.2%, 87.1%, 87.1% and 80.2% readers rated the research article section, the review article section, the case reports section and book recommendation section similarly respectively. Feedback from readers indicated that they wanted more case reports, review articles on “how to do it” and on medical problems

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in dentistry. For the non-readers, the most common reasons cited for not reading was not being able to access to the MDJ, followed by not having time to read.

Conclusion: Malaysian dentists preferred to read article that can improve their clinical knowledge and skill.

An Analysis of the Root Canal Treatment Cases Treated at the Faculty of Dentistry, Universiti Kebangsaan MalaysiaSafura B, Sarmilia S, Rosdayana I, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.

Objectives: The objectives of this study are to determine the reasons for root canal treatment, type of teeth most commonly treated and the demographic distribution of the patients who attended the dental clinic at the Faculty of Dentistry UKM.

Materials and Methods: Patient’s folders from registration number A00001 until A30000 were retrieved from the registration department and analyzed. Teeth that has had received root canal treatment at least until the obturation stage were included in this study.

Results: A total of 407 teeth were included in this study. Caries was the most common cause for root canal treatment followed by traumatic injury to the anterior teeth. Both the upper central incisors were the most commonly treated teeth and patients in the age range between 20 to 29 years old were the highest number of patients that need root canal treatment.

Conclusion: In conclusion, carious lesion involving the anterior teeth in the younger adult patients was the most common reasons for root canal treatment at the Faculty of Dentistry UKM.

Indications for Impacted Mandibular Third Molar RemovalFadzira M, Hazlin I, Kanagaratnam SS, Department of Oral Surgery, Hospital Ampang, Kuala Lumpur, Malaysia.

Objective of Investigation: To determine the presenting complaints and referring general dental practitioners’ indications for impacted mandibular third molar removal, the average waiting time from referral date to management and the treatment outcomes with an emphasis on the complications encountered.

Methods used: This is retrospective study of all patients undergoing impacted mandibular third molar surgery at the Oral Surgery Department at Hospital Ampang from January to April 2007. The required information was obtained by going through the patients’ records.

Results: A total of 85 referrals were received, 74 patients treated under Local Anaesthesia and 11 under General Anaesthesia. The prevalent presenting complaints were pain and food impaction and the prevalent referral indications for surgery were soft tissue infection, caries of the impacted tooth or distal caries on the adjacent tooth. There was only one referral for prophylactic removal as requested by the patient. There was a concordance of diagnosis of 98% between the referring general dental practitioner and the attending oral surgeon. Waiting time for surgery was approximately 1 ½ - 2 months and the main complications were either dry socket or some residual pain and discomfort at one week review.

Conclusions: The General Dental Practitioners in our catchment area have clinically sound indications for impacted third molar surgery but their referral practice could be further refined by providing definite guidelines so as to reduce waiting time, avoid complications, litigation and reduce costs

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Preclinical Simulation and Foundation Skills in Teaching Fixed Prosthodontics: Porcelain Fused to Metal Crown

Natasya A.T, Marlynda A, Atika A. Department of Prosthodontics, Faculty of Dentistry, UKM, Kuala Lumpur, Malaysia.

Introduction: The effectiveness of teaching methods reflects the quality of the work. One has to evaluate the final work to determine whether the instructions that were given beforehand are clear and easy to understand. In teaching fixed prosthodontics, a number of evaluation methods are available to address student competence.

Purpose: It is the purpose of this study to evaluate porcelain fused to metal crown preparations that were made by dental undergraduate students during the preclinical session.

Materials and Methods: 84 plastic teeth that have been prepared by 4th year dental undergraduates during the preclinical session for PFM crown were examined by 2 examiners. The teeth were placed on the frasaco arches and were mounted in the frasaco head. The preparations were checked for the tapering, presence of undercuts, occlusal reduction and preparation of shoulder and chamfer margins. Preparations were examined using hand instruments and visual.

Results: Majority of the preparations were acceptable with regards to the overall axial and occlusal reductions. However about 34.5% of the preparations were left with sharp edges. Small number of them have undercut present. 59% of the margins appear not smooth with any continuity. 11% of the lingual margin is shoulder, while 17% of the buccal margin is chamfer.

Conclusions: It can be concluded that the crown preparations were good, considering this is the first time the students exposed in preparing crowns. Margins are very critical in the preparation, and it will take a lot of practice to make it perfect.

Preclinical Simulation and Foundation Skills in Teaching Fixed Prosthodontics: Post and CoreNatasya A.T, Marlynda A, Atika A. Lecturer, Department of Prosthodontics, Faculty of Dentistry, UKM, Kuala Lumpur, Malaysia.

Introduction: Dental undergraduates are required to develop the knowledge, skills and attitudes necessary to prepare them to be an independent and competent clinician at the point of graduation. The first step towards this goal is the preclinical session. Assessment of their work done in preclinical session would give the impression of their understanding before they make any preparation.

Purpose: It is the aim of this study to determine the quality of duralay burn-out post and core done by dental undergraduates in their preclinical session.

Materials and Methods: 90 duralay build up for burn-out post and core that have been prepared by 4th year dental undergraduates during the preclinical session were examined by 2 examiners. They were evaluated for the retention and resistance form of the build-up, coronal preparation for ferrule effect and preliminary crown preparation. Margin of the crown preparation was examined as well, together with the surface of the duralay.

Results: 61% of the duralay build-up surface was perfect with no voids. Majority of the build-up, 72% adapt very well to the tooth surface. On the other hand, ferrule effect only present in 52 teeth. Moreover, only 20 teeth out of 90 were prepared with preliminary crown preparation with 4 of the duralay build-up were shaped according to crown preparation.

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Conclusion: Students have the ability to build up duralay for the fabrication of post and core. However, most of them did not know the importance of the ferrule effect and preliminary crown preparation. These may due to lack of understanding from lectures and video demonstration given, as well as they do not have any experience in doing so.

Student Perception, Self Evaluation and Satisfactory Level in Preclinical Fixed Prosthodontics: Porcelain Fused to Metal CrownMarlynda A, Natasya A.T, Atika A. Department of Prosthodontics, Faculty of Dentistry, UKM, Kuala Lumpur, Malaysia.

Introduction: Hand skill is one of the most important factors in becoming a dentist. One has to know to control his/her hands to drill into patient’s mouth. Preclinical session is one way of training dental undergraduates to prepare teeth for restorations. It has been hoped that the transition from preclinical to clinical setting is eased and students would be well prepared and confident in treating patients.

Purpose: It is the aim of this study to evaluate student’s perception, self evaluation and satisfactory level in preparing plastic tooth for porcelain fused to metal crown in preclinical fixed prosthodontics sessions after lectures and video demonstrations.

Materials and Methods: The participants comprised of 104 fourth year dental undergraduate students in Faculty of Dentistry Universiti Kebangsaan Malaysia. Students were taught on preparing porcelain fused to metal (PFM) crown on tooth 24. Lecture on PFM crown was one-hour length. It consisted of diagrams of step-by-step procedure in preparing the crown. Video demonstration was conducted before students were asked to prepare the tooth. After they have satisfied with the preparation, they were asked to answer a series of multiple choice questions on their performance.

Results: Only 92 students completed the questionnaire. Majority of the students taught that their occlusal and axial reductions were about right. As for the margin, 50 students claimed that the margin located on gingival margin while 88 students said that they prepared shoulder margin buccally and 4 students created chamfer margin buccally. 74 out of 92 students slightly satisfied with their crown preparation. 25 students said that they were very competent and confident in doing crown preparation to patients and most of them satisfied with the teaching methods.

Conclusions: Majority of forth year dental students can perform porcelain-fused-to-metal crown preparation. Most of them felt competence and confidence in treating patients with crown. Our teaching methods and aids were proven to help them in preparing these tasks.

Student Perception, Self Evaluation and Satisfactory Level in Preclinical Fixed Prosthodontics: Post and CoreAhmad M, Tarib N, Marlynda A, Natasya A.T, Atika A, Department of Prosthodontics, Faculty of Dentistry, UKM, Kuala Lumpur, Malaysia.

Introduction: Preclinical teaching using simulation is very beneficial in training dental graduates. Dentistry has been investigating the extended use of simulation for its undergraduate training during the preclinical years.

Purpose: The aim of this study is to evaluate student’s perception, self evaluation and satisfactory level in preparing duralay burn-out post in preclinical fixed prosthodontics sessions following lectures and video demonstrations.

Materials and Methods: The participants comprised of 104 fourth year dental undergraduate students in Faculty of Dentistry Universiti Kebangsaan Malaysia. One hundred and four freshly extracted, single-rooted, maxillary and mandibular premolar as well as incisors were examined and mounted. Students were then asked to do root canal treatment on these teeth. The gutta percha were then removed and the canals were prepared. They then proceed

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with the preparation of duralay build-up/pattern based on the lecture, video demonstration and manual given. Once completed and satisfied with their work, students were asked to answer the questionnaires in the simulation manual.

Results: Student response rate was 88.46% (92/104). Majority of the students satisfy with their canal preparation, with about 5mm gutta percha left apically, nicely shaped canal with sufficient retention and resistance form. They also thought that the surface of the duralay was perfect with no voids. With regards to the coronal preparation, majority of them incorporated ferrule effect and prepared preliminary crown preparation. More than half of the students claimed the level of difficulty of this procedure was moderate and they felt ‘so-so’ in treating patient with post and core with means of duralay build-up. Furthermore, majority of them said that the lecture, the video demonstration and the manual were really good and helpful together with the help from the supervisors.

Conclusions: From this study, majority of fourth year dental students can perform good canal preparation as well as duralay pattern post and core. Unfortunately, two-third of the students did not feel competent and confident in doing canal preparation and duralay pattern post and core. Our teaching methods and aids were proven to help them in preparing these tasks.

Periodontal Awareness among Outpatients in an Urban Dental ClinicUma S, Normisra AZ, Klinik Pergigian Jalan Zaaba, Seremban, Negeri Sembilan, Malaysia.

Objective: This prospective study was undertaken to ascertain the awareness about periodontal disease among a group of adult patients attending an outpatient dental clinic in Seremban.

Methods: Patients were randomly selected to answer a questionnaire containing several questions pertaining to periodontal disease. Prior to this an explanation was given about the study. This study was conducted over duration of six weeks.

Results: A total of 409 subjects participated in this study. It was found that (i) 64.55% of subjects knew what was plaque (ii) 76.28% were aware of the diseases caused by plaque (iii) 36.67% realized that they experienced bleeding gums while brushing(iv) 29.1% thought they had halithosis (v) 27.38% stated they had mobile teeth (vi) 58.19% thought brushing was the most effective method to prevent periodontal disease and(vii) 16.63% felt that they had periodontal disease

Conclusion: The majority of participants realized that plaque causes periodontal disease

Acid-Etched Bridge as an Immediate Replacement of Function and Aesthetic for Periodontally-Involved TeethMohd Said S, Hamiruddin MM, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.

One of the most challenging difficulties in periodontal management is choosing a suitable replacement for missing teeth in a dentition with reduced periodontal support and an altered occlusion. Teeth alignment, occlusal load, remaining support, aesthetics as well as maintaining periodontal health are some of the important factors that one should considers when planning for teeth replacement.

Aim: This paper will discuss some of these considerations and advantages offered by acid-etched bridges for such situation.

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Method and Results: Seven sets of bridges were issued immediately on extraction of teeth on patients and are still functioning optimally for the previous four to eleven months.

Conclusion: With appropriate planning and good supportive periodontal therapy, patient with periodontally-involved missing teeth can benefit longer on function and aesthetic with acid-etched bridge.

Microleakage of Class II Composite Restorations Lined With Flowable Resin or Glass Ionomer CementN. AB. Malik, L.L. Seow, Faculty of Dentistry, University of Malaya, Kuala Lumpur

Objective of Investigation: The objectives of the study were to evaluate the marginal microleakage in class II cavities restored with various types of composites resins and lining materials

Materials and Method: Class II cavities were prepared in the proximal surfaces of 40 intact premolars. A standard class II cavities were made: 2mm occlusal extension, 4mm bucco-lingual and the gingival margins for the cavities were prepared 1mm below the CEJ. Four types of composite resins (Esthet-X, Filtek Z350, Beautifil and Solare P) were used to restore the mesial cavities (acting as control) while the distal cavities were lined with various lining materials namely; the Fuji IXGP (GC), the Beautifil flow(Shofu), the Filtex Z350 flow(3M) and the Esthet-X flow(Denstply) prior to restoration with respective composite resins. All the specimen were thermocycled in 50˚C and 550˚C water for 500 cycles and then immersed in 0.5% basic fuschin dye for 24 hours. All the specimen were then rinsed with distilled water and dried. Two layers of varnish were applied 1mm away from the cavity margin. The specimens were then sectioned in mesio-distal direction. Two sections were made for each tooth and the extent of microleakage was examined using the image analyzer. The microleakage was scored using the ISO microleakage scoring system. Data was analyzed using Kruskal-Wallis test and Mann-Whitney U test.

Results: There was a significant difference between the microleakage of class II composite resin restorations at the occlusal margin and the cervical margin (p=0.000). Filtek Z350 flow showed significantly reduced the microleakage (p=0.030) than Esthet-X flow and Beautifil flow. Similar finding was observed for Solare P group, having FujiIXGP as a lining at cervical margin has reduced microleakage compared to the control group (p=0.017).

Conclusions: Different types of composite resin showed different extent of microleakage in class II cavities. The cavities lined with glass ionomer cements showed less extent of microleakage than the cavities lined with flowable composite resin at the cervical margin.

This study was supported by Vot F, no: F0104/2005C

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Continuing Professional Development Quiz (CPD Points = 2)

Dear Colleagues,

In this issue of the MDJ, we continue with column of Continuing Professional Development Quiz whereby you will get two (2) CPD points by just trying out the quizzes. This is a self-administered test and is designed to help colleagues accumulate CPD points. Your feedback is greatly appreciated. The answers to these quizzes are available in the various articles contributed by Professor Phrabhakaran Nambiar, Professor Rosnah Zain, Asst. Professor Dr. Roszalina Ramli, Dr. Ganasalingam Sockalingam, Dr. Liana Ma Abdullah, Dr. Uma Subramaniam and Dr. Fathilah Abdul Razak. They were also the contributors of the quizzes.

Thank you.

Assoc. Professor Dr. Ngeow Wei Cheong,Editor, Malaysian Dental Journal.

1. What is the commonest malignancies in oral cavity?

A. Metastatic tumorB. Malignant salivary tumorC. Squamous cell carcinoma D. Osteosarcoma

2. Which statement is true?

A. All squamous cell carcinoma are preceded by premalignant lesion.

B. Only a small percentage of premalignant lesion in the oral cavity progress to squamous cell carcinoma.

C. Squamous cell carcinoma has a single risk factorD. Squamous cell carcinoma starts in the connective

tissue

3. What is the normal function of p53?

A. Regulate cell growth and replicationB. Sense gene mutationC. Cause apoptosisD. Cause metastasis

4. What was the most common cause of permanent tooth extraction in Universiti Kebangsaan Malaysia?

A. caries and its sequelaeB. prosthetic reasonsC. orthodontic reasonsD. trauma

5. What was the most common permanent tooth removed

in Universiti Kebangsaan Malaysia?

A. PremolarB. IncisorC. MolarD. Canine

6. Which of the following age group were associated with the most frequent dental extraction in Universiti Kebangsaan Malaysia?

A. 0-15 years oldB. 16-30 years oldC. 31-45 years oldD. 46-60 years old

7. The term tooth dilaceration refers to:

A. Hypoplasia of the crown of the toothB. A brownish discoloration of the crown of the toothC. A sharp bend or curve in the crown or root of a

developed tooth.D. Failure of eruption of the tooth

8. The following may cause failure of eruption of permanent incisor teeth EXCEPT

A. Obstructions due to the presence of supernumerary teeth, odontomes or pathology

B. Dilaceration of the root of the toothC. Soft tissue impaction due to ectopic eruption

pathway D. Genetic disturbances such as amelogenesis

imperfecta

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9. Among the drugs listed below, which does NOT have the side-effect of gingival overgrowth?

A. Dilantin sodiumB. Mefenemic acidC. NifedipineD. Cyclosporine

10. In treating a patient with a history of renal transplantation, the dental practitioner should have precaution of all the conditions listed below EXCEPT:

A. Increased bleedingB. Possibility of infectionC. RegurgitationD. Increased need for corticosteroids

11. What is the most common benign lesion seen at the 2 major hospitals in Kelantan within the period of 1994 – 1998 (Oral Surgery Department, Hospital Kota Bharu & Oral Maxillofacial Surgery Department, Universiti Sains Malaysia)?

A. Pyogenic granulomaB. AmeloblastomaC. Mucocoele D. Fibroepithelial Polyp

12. Among the oral malignancies diagnosed in Kelantan from 1994 to 1998, the most common type of oral malignancy is:

A. Squamous cell carcionoma B. Mucoepidermoid carcinomaC. LymphomaD. Fibrosarcoma

13. Name the most prevalent risk habit/s practiced by the Kelantan population.

A. Betel quid chewingB. Chewing tobacco and betel quidC. SmokingD. Drinking alcohol and smoking

14. The mandibular canals in the Malay samples were most commonly located in the:

A. Upper levelB. Intermediate level.C. Low levelD. Everwhere

15. One of the following statements regarding the supragingival plaque is FALSE:

A. It is found on the tooth surface above the gingival margin.

B. 87% of its microbial components are of the Gram positive type.

C. Staphylococci contributes majority of the Gram positive cocci.

D. The predominant habitant of the plaque include genera of the Streptococcus, Actinomyces, Staphylococcus, Bacteroides and Lactobacillus.

16. Facultative oral bacteria:

A. Are Gram negatives. B. Have high tolerance for oxygen.C. Bacteroides and Fusobacterium are examples of the

bacteria.D. Are found only in the subgingival plaque.

1. C 2. B 3. A 4. A 5. C 6. D 7. C 8. D

9. B 10. C 11. C 12. A 13. C 14. B 15. C 16. B

ANSWERS:

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Full papersPapers should be set out as follows with each beginning in a separate sheet: title page, summary, text, acknowledgements, references, tables, caption to illustrations. Title page. The title page should give the following information: 1) title of the article; 2) initials, name and address of each author, with higher academic qualifications and positions held; 3) name, address, telephone, fax and e-mail address. Text. Normally only two categories of heading should be used: major ones should be typed in capital in the centre of the page and underlined; minor ones should be typed in lower case (with an initial capital letter) at the left hand margin and underlined.Do not use he or she if the sex of the person is unknown; e.g. 'the patient'. References. The accuracy of the references is the responsibility of the author. References should be entered consecutively by Arabic numerals in superscript in the text. The reference list should be in numerical order on a separate sheet in double spacing. Reference to journals should include the author's name and initials (list all authors when six or fewer; when seven or more list only the first three and add ‘et al.’), the title of paper, Journal name abbreviated, using index medicus abbreviations, year of publication, volume number, first and last page numbers (ie. Vancouver style). For example:

Ellis A, Moos K, El-Attar. An analysis of 2067 cases of zygomatico-orbital fractures. J Oral Maxillofac Surg 1985;43:413-417.

Reference to books should be sent out as follows: Scully C, Cawson RA, Medical Problems in Dentistry 3rd edn. Wright 1993:175.

Tables. These should be double spaced on separate sheets and contain only horizontal rules. Do not submit tables as photographs. A short descriptive title should appear above each table and any footnotes, suitably identified below. Care must be taken to ensure that all units are included. Ensure that each table is cited in the text.

IllustrationsLine illustration. All line illustrations should present a crisp black image on an even white background (127 mm x 173 mm or 5 x 7 inches) or no larger than 203 mm x 254 mm or 8 x l0 inches.Photographic illustrations and radiographs. These should be submitted as clear lightly contrasted black and white prints (unmounted) sizes as above. Photomicrographs should have the magnification and details of the staining technique shown. Radiographs should be submitted as photographic prints carefully made to bring out the details to be illustrated, with an overlay indicating the area of importance.All illustration should be carefully marked (by label pasted on the back or by a soft crayon) with figure number and authors name and the top of the figure should be indicated by an arrow. Never use ink of any kind. Do not use paper clips as these can scratch or mark illustrations. Caption should be typed, double spaced on separate sheets from the manuscript.Patient confidentiality. Where illustrations must include recognizable individuals living or dead and of whatever age, great care must be taken to ensure that consent for publication has been given. Otherwise, the patient’s eyes or any indentifiable anatomy should be covered.Permission to reproduce, borrowed illustration or table or identifiable clinical photographs. Written permission to reproduce, borrowed material (illustrations and tables) must be obtained form the original publisher and authors and submitted with the typescript. Borrowed material should be acknowledged in the caption in this style. 'Reproduced by the kind permission of...... (publishers) from /....(reference)'.

Page ProofsPage proofs are sent to the author for checking. The proofs with any minor corrections must be returned by fax or post to the editor within 48 hours of receipt.

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