1. Scientific Journal Published by University of Sulaimani
School of Dentistry
SULAIMANI DENTAL JOURNAL
ISSN: 2309-4656
SDJ
"ی""ن"لێما""س "كۆی""""نزا
Volume 1 Issue 2 December 2014
2. !
Scientific Publication of the University of Sulaimani
School of Dentistry
Sulaimani Dental Journal
All#informa+on#contained#in#this#journal#represents#the#opinions#of#the#authors#and#the#journal#do#not#
accept#any#responsibility#based#on#these#informa+on.#
All#rights#reserved#to#the#publisher.#
Papers#can#be#submi;ed#to#the#journal#office#or#to#the#journal#email.#
Publica+on#Office#
Iraq/!Kurdistan!Region/!Sulaymania!!
University!of!Sulaimani!
School!!of!Den<stry!
Tel!:!+(964)!533270913!!!K!!!+(964)!7701433728!
P.O.!Box!:!180!Sulaymania!–!IRAQ!
E?#mail#:#sulidentj@gmail.com##
Technical!contact:!den.journal@univsul.edu.iq!
Homepage:!hYp://univsul.edu.iq/JournalsAbout.aspx?Jimare=1&main=62
Upcoming Event;
Sulaimani Dental School Day III
Thursday
February 26, 2015
3. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Scientific Publication of the School of Dentistry / University of Sulaimani
Editor'(in('Chief(Emeritus(
Dr.!Falah!A.!Hawrami!
Editor('in('Chief(
Dr.!Ibrahim!S.!Gataa!
Associate(Editor(
Dr.!Abdulsalam!R.!Al7Zahawi!
Managing(Editor(
Dr.!Faraedon!M.!Zardawi!
Editorial)Board)
Professor'Sauza'A.'Faraj'
Professor'Salam'Al2Qaisi'
Professor'Balkees'T.'Garib'
Professor'Shanaz'M.'Gaffor'
Assist.'Professor'Saeed'A.'Lateef'
Assist.'Professor'Fadil'A.'Kareem'
Assist.'Professor'Aras'M.'Rauf'
''
Advisory)Editorial)Board))
Professor'Richard'van'Noort''''(UK)''''''''''''''''''''Assist.'Professor'Adil'Al2kayat'''(Iraq)'
Professor'Salem'Al2Samaray''''(Iraq)'''''''''''''''''''Assist.'Professor''Zeewar'Al2Qassab'''(Iraq)''
Professor'Ali'Al2Zubaidi'''''''''(Iraq)''''''''''''''''''''''Assist.'Professor'Qais'H.'Musa'''('Iraq)'
Professor'Anwar'Tappuni'''''(UK)'''''''''''''''''''''''''Assist.'Professor'Intesar'J.'Mohammed'(Iraq)'
Professor'Hussain'F.'Al2Huwaizi'''(Iraq)'''''''''''''Assist.'Professor'Lamia'H.'Al2Nakib''(Iraq)'
'''
Editorial)Of1ice))
Dr.'Mohammed'Abdalla'
Dr.'Tara'A.'Rasheed''
Dr.'Arass'J.'Noori'
Dr.'Dler'A.'Khursheed'
Dr.'Ranjdar'M.'Talabani'
Journal)Secretory))
Kaniaw'A.'Babala
SDJ
SULAIMANI DENTAL JOURNAL
4. Editorial!
In the second issue of Sulaimani Dental journal we have taken another step in
the march of issuing of the journal. The editorial board and editorial office of
the journal made every efforts to bring out the second issue on predicted time
on December 2014.
Readers may be noted that there are slight changes in the print style of the
journal. Actually, the editorial board felt that we should add more details to the
instructions of publishing in the journal within the approved regulations in
medical journals. This will reflected on the process of quality of the journal
academically while maintaining the privacy of Sulaimani Dental Journal.
On this occasion, we reiterate our welcome to any comments or notes from
the readers which will serve and contribute to the development of the work of
the journal. We would like also to inform the masters’ readers that they can
read and follow the electronic version of Sulaimani Dental Journal, after the
addition of the journal to the official website of the University of Sulaimani,
through the following links;
http://univsul.edu.iq/JournalsAbout.aspx?Jimare=1&main=62
or
http://goo.gl/FLAu3m
or
http://tinyurl.com/sulaimanidentaljournal
Finally, as we are in the end of this year we hope new happy year and wish
peace prevails for all people.
Editor in Chief
7. Table of Contents
Contents Page
I Molar-incisor hypomineralisation (MIH) among Kurdish children in Sulaimani
City, Iraq.
Arass Jalal Noori & Shokhan Ahmad Hussein
45
II Prevalence of cigarette smoking among Sulaimani University students.
Zhian Salah Ramzi
51
III Priority in selection of treatment methods used for lymphatic malformations
affecting maxillofacial region.
Qais H. Mussa
57
IV Prevalence of orofacial changes in patients with β-thalassemia major in Karbala
City, Iraq.
Muhanned Salah Abulsattar & Ali Mihsen Al-Yassiri
64
V Assessment of calcium ions diffusion and pH measurements of three intracanal
medicaments through dentinal tubules (in vitro comparative study).
Chrakhan A-Latif A-Qadir & Salam D. Al-Qaisi
68
VI Evaluation of some intracanal irrigants on push-out bond strength and mode of
failure of resin and non resin cements to root canal centin (in vitro comparative
study).
Rawa O. Ibrahim & Salam D. Al-Qaisi
74
VII Conservation of dentin thickness in the root canals orifice following two
preparation techniques.
Ranjdar Mahmood Talabani, Shawbo Muhamad Ahmad & Arass Jalal Noori
80
VIII The prevalence and etiology of maxillary midline diastema among orthodontic
patients attending Shorsh Dental Clinic in Sulaimani City.
Darwn Saeed Abdulateef, Azheen Jamil Ali & Nasih Fatih Othman
86
IX Angle’s classification of first molar occlusion among patients attending a private
orthodontic clinic in Sulaimani City.
Anwar Ahmad Amin, Awder Nuree Arf & Zhwan Jamal Rashid
91
X A retrospective panoramic study for alveolar bone loss among young adults in
Sulaimani City, Iraq.
Faraedon M. Zardawi, Alaa N. Aboud & Dler A. Khursheed
94
8. Sulaimani Dent. J. 2014; 1:45-50 Noori & Hussein
Introduction:
Over the past two decades, a congenital defect of
enamel mineralization commonly referred to as molar
incisor hypomineralisation (MIH) has been of
increasing concern to clinicians worldwide. The
defect involves hypomineralisation of one to four
permanent first molars and is associated frequently
with similarly affected permanent incisors(1).
Idiopathic enamel hypomineralisation was first noted
in Sweden in the late 1970s(2). In view of the
chronological distribution of enamel defects,
Weerheijm et al. in 2001 defined MIH as a hypomin-
eralisation of systemic origin of one to four first
permanent molars frequently associated with affected
incisors(3). This description emphasizes the fact that
permanent first molars are always involved in those
affected, and often there is a combination of molars
with demarcated opacities of the incisors(1,3,4). On the
other hand, opacities only on the permanent incisors
may indicate defects from other origin such as
traumatic injuries or periapical infection of the
primary incisors, and these lesions should not be
referred to as MIH(5).
Although the possibility of a genetic component in
the development of MIH has not been excluded, it’s
been postulated that MIH is a consequence of a
variety of environmental factors acting systemically,
which disturb the ameloblasts during their enamel
production phase(1). Clinically, the defect presents as
opaque lesions varying in color from white to yellow
or brown, with a sharp demarcation between the
affected and sound enamel. In severe cases, post-
eruptive enamel breakdown (PEB) can occur so
rapidly that it appears clinically as if the enamel has
been not formed at all. When PEB occurs because of
chewing forces, it is more conspicuous in the first
permanent molars than in the incisors(1).
Recent studies have emphasized that the presence
of MIH can produce a number of problems for the
patient including dental pain and hypersensitivity,
disfigurement, encouragement of rapid plaque
retention, and enhancement of caries development(6).
The need for orthodontic treatment intervention as a
consequence of tooth extraction caused by MIH has
also been reported(7). Moreover, substantial challenges
to dental care are caused by MIH, because of the lack
of appropriate restorative management and difficulties
with pain control(8).
A wide range of prevalence rate for MIH have
been reported around the world ranging from 2.9 to
38%(2,6,9-12). Only one research study concerning
prevalence and distribution of MIH is available in Iraq
which focused on 7 to 9 year school children in Mosul
City(13), mainly of Arabic ethnicity. This study aims to
investigate the prevalence and distribution of MIH
among Kurdish children in Sulaimani City, Iraq.
a Dep. of Pedodontics, Orthodontics, and Preventive Dentistry. School of Dentistry/ University of Sulaimani. (dr.arass@yahoo.com)
b Dep. of Oral Diagnosis. School of Dentistry/ University of Sulaimani.
Molar-incisor hypomineralisation (MIH) among
Kurdish children in Sulaimani City, Iraq
Sulaimani Dental Journal
SDJ
Arass Jalal Nooria
Shokhan Ahmad Husseinb
Abstract
Objectives: The aim of this study was to determine the prevalence and distribution of molar incisor hypomineralisation
among Kurdish children in Sulaimani City, Iraq.
Method: A cross-sectional survey was carried out on primary school students in Sulaimani City. A total of 2346 Kurdish
children aged 7 to 9 years old were examined; 1194 (50.9%) males and 1152 (49.1%) females, enrolled in 20 primary public
schools. The index teeth were evaluated using the European Academy of Paediatric Dentistry (EAPD) criteria for MIH.
Results: The prevalence of MIH was found to be 18.2% where no statistically significant association was found with age or
gender (P>0.05). Multiple teeth involvement (13.2%) was more common than a single molar involvement (5.1%). The mean
number of the affected index teeth with MIH per affected child was (3.1). Mild defects were present in 64.1% of the affected
teeth with demarcated creamy-white opacities were the most common finding (33.3%).
Conclusions: It’s been found that MIH is a prevalent pathology among Kurdish children in Sulaimani City which could result
in a large number of children continuously seeking professional dental treatment. Therefore, dental practitioners who deal
with child patients could encounter such cases and should be aware of the treatment choices and management protocols for
coping with this particular condition.
Keywords; Molar-incisor hypomineralisation, prevalence, index teeth, Kurdish children.
Received: August 2014, Accepted: October 2014.
9. Sulaimani Dent. J. 2014; 1:45-50 Noori & Hussein
Method:
The research approval was obtained from the ethical
committee for medical research in the Faculty of
Medical Sciences/ University of Sulaimani and proper
authorities and primary school administers at the city.
The city was divided in to 20 geographical sections
and a primary school was randomly selected from
each section, then at each school level a class was
selected randomly for the purpose of the study. A
cross-sectional survey was carried out on 2346
Kurdish primary school students (1194 males and
1152 females) aged 7-9 years from 2nd, 3rd and 4th
grade students.
The children were examined in their school sitting
upright in an ordinary school chair in daylight
classroom lighting conditions. Teeth were examined
wet, as suggested by the FDI Working Group (14),
using a mouth mirror and periodontal probe and
cotton rolls were used to remove food debris, as
necessary.
Examination of the twelve index teeth (Four first
permanent molars and eight incisors) were carried out
using an index developed by Sonmez et al.(15) in line
with European Academy of Pediatric Dentistry
(EAPD) criteria for MIH(4): Opacities (White-cream,
1; Yellow-brown, 2); Post-eruption structural loss
(Enamel defects, 3a; Atypical small cavities with
enamel and dentin loss, 3b; Atypical deep or large
cavities extending to the pulp and covering one or
more tubercle, 3c); Restored teeth, 4; Extracted teeth,
5. Lesion severity was recorded according to
Alaluusua et al.(16) as either mild, moderate, or severe
(Table 1).
Inclusion criteria for the study was children (aged
7-9 years old) of lifelong resident of Sulaimani City
with at least one first permanent molar erupted or
partially erupted (Any tooth with less than one third of
the crown erupted were regarded as unerupted) and
present on the day of examination, while, children
undergoing orthodontic treatment at the time of
examination or having amelogenesis imperfecta or
tetracycline staining and children with the crowns of
the first permanent molars completely worn-out or
lost and the cause cannot be assured to MIH were
excluded from the study.
Data analysis was performed using the SPSS
software program (Statistical Package for the Social
Sciences, version 16.0, SSPS Inc, Chicago, Ill, USA).
A descriptive analysis of the prevalence and
distribution of the clinical finding was performed and
the chi-square and Fisher’s Exact test was used for the
data analysis. Statistical significance (P-value) equal
or less than 0.05 was considered to be statistically
significant.
Results:
The total number of examined children reached 2347
child; 1194 (50.9%) males and 1152 (49.1%) females,
(Table 2).
The total number of children with enamel defects
(All kinds of enamel defects: hypocalcifications,
hypomineralizations, Turner’s teeth,…etc) were found
to be 592 child (25.3%), while the total number of
children with MIH only was 427 child (18.2%),
(Figure 1).
46
Table 1: Criteria for diagnosing the severity of MIH among the indedx teeth, Alaluusua et al
Severity Code Description
Mild 1 Demarcated creamy-white opacity
2 Demarcated yellow-brown opacity
Moderate 3a Enamel loss
Severe 3b Enamel and dentin loss
3c Atypical large cavities extending to pulp and covering one or more tubercle
4 Atypical restoration
5 Extracted tooth
Table 2: Distribution of the sample by age and sex
Age
Gender
Both
Male Female
No. % No. % No. %
7 years 405 51.07 388 48.93 793 33.8
8 years 396 51.3 376 48.7 772 32.91
9 years 393 50.32 388 49.68 781 33.29
Total 1194 50.9 1152 49.1 2346 100
(16)
10. Sulaimani Dent. J. 2014; 1:45-50 Noori & Hussein
Younger age groups and males were slightly more
affected by MIH. Although there was a small
difference in the ratio of the affected children with
MIH among different age groups and genders, these
differences did not reach any statistically significant
association, (Table 3) and (Table 4).
(Table 5) describes the distribution of the MIH
affected children by the number and types of teeth
affected. From the total 427 children affected, 119
(5.1%) child had only one molar affected and 163
(7%) child had more than one molar affected. The
remaining 145 (6.2%) children had molars and
incisors affected. The age and gender distribution of
the affected children shows minor differences
according to the type of teeth affected, and the
majority of teeth affected were molars and multiple
teeth involvement (13.2%) is more common than a
single molar (5.1%) involved by the defect.
47
Figure 1: Prevalence of children with developmental enamel defects and MIH
Table 3: Prevalence and distribution of MIH by age
Age
MIH No MIH
X2
No. % No. %
7 years 136 17.2 657 82.9
X2= 1.12
df=2
P=0.5712
8 years 141 18.3 631 81.7
9 years 150 19.2 631 80.8
Total 427 18.2 1919 81.8
Table4: Prevalence and distribution of MIH by gender
Gender
MIH No MIH
X2
No. % No. %
Male 222 18.6 972 81.4 X2= 0.2
df=1
P=0.6547Female 205 17.8 947 82.2
Both 427 18.2 1919 81.8
11. Sulaimani Dent. J. 2014; 1:45-50 Noori & Hussein
Among the 1345 teeth affected, 887 teeth (65.9%)
were molars and 458 teeth (34.1%) were incisors and
the mean number of the affected Index teeth with
MIH per affected child was (3.1). Mild defects were
present in 64.1% of the affected teeth with demarcated
creamy-white opacities were the most common
finding (33.3%). Severe defects were found in about
one-fifth (22.4%) of the total findings and moderate
defects were present in the remaining 115.9%. It’s
also worthy to note that more molar teeth were
affected by severer forms of the defect than incisors,
(Table 6).
Discussion:
Given the significant clinical consequences of MIH, it
is clearly important to assess the impact of this
condition when planning dental healthcare delivery,
and the first step in this process is to establish whether
MIH is a significant dental public health issue or not
in the community(17).
In this study, the overall prevalence of MIH in a
sample of primary school children in Sulaimani City
was found to be 18.2%. This prevalence figure was
comparable to those reported by another study
(18.6%) from Mosul City, Iraq(13) and with some
other studies(6,18,19), but differ from prevalence rates
reported from other studies(20-22). The differences in
reported rates of MIH throughout the world have been
attributed to differences in the age of study
participants, geographic locations, environmental
factors and evaluation criteria(15). Although the age for
examination had been recommended at over 7 to 8
years were most of the index teeth had erupted
(2,4,23-25), further standardization of the sampling
model, examination criteria and indices used are
needed to establish comparable results and to
48
Table 5: Prevalence and distribution of MIH in the permanent index teeth by age and gender
MIH affected teeth
Male Females 7 year 8 year 9 year Total
No. % No. % No. % No. % No. % No. %
Single molar 65 5.4 54 4.7 36 4.5 39 5.1 44 5.6 119 5.1
Two to four molars 81 6.8 82 7.1 52 6.6 54 7 57 7.3 163 7
Molars + Incisors 76 6.4 69 6 48 6.1 48 6.2 49 6.3 145 6.2
Total 222 18.6 205 17.8 136 17.2 141 18.3 150 19.2 427 18.2
Table 6: Severity distribution of MIH affected molars and incisors
Defects Molars Incisors
Total by severity
code
Total by severity
index
Severity Code No. % No. % No. % No. %
Mild 1 273 30.8 175 38.2 448 33.3
852 64.1
2 248 28.0 166 36.2 414 30.8
Moderate 3a 132 14.9 82 17.9 214 15.9 214 15.9
Severe 3b 123 13.9 12 2.6 135 10.0
269 20
3c 76 8.6 8 1.7 84 6.2
4 20 2.3 15 3.3 35 2.6
5 15 1.7 0 0 15 1.1
Total 887 65.9 458 34.1 1345 100 1345 100
12. Sulaimani Dent. J. 2014; 1:45-50 Noori & Hussein
determine exact epidemiological nature of the
condition.
No significant differences in the prevalence rates
were found among males and females, which is
comparable with the findings reported by other studies
(6,11,13,20,21) and this may indicate that the condition is
not a gender associated disease. As reported by some
other studies(13,26) no significantly different prevalence
figures were found among different age groups, but
the prevalence in our study was slightly increased
with age and this may be related to the dynamic
nature of the defects(13) where some minor defects
may be overlooked in younger teeth at younger ages
and these defects possibly will develop to severer
forms of the defect overtime, because of the inferior
quality of the enamel(27,28), and their identification
become easier when staining, enamel breakdown and/
or caries develops. It’s been found that multiple teeth
affected by MIH is more common than a single first
permanent molar involvement and this result is in
accordance with findings from other studies(12,13), and
again emphasizing the systemic nature of the disease.
These findings supports the theory that MIH is a
developmental defect that occurs once the threshold
level for the insult required to disturb enamel
formation at a critical stage is reached(29).
The mean number of the affected index teeth with
MIH per affected child was 3.1, of which about 2.1
were first permanent molars, which is near the figures
found in other studies(5,9,10,20). Although the index
teeth include only four molars with eight incisor teeth,
it’s been found that the number of molar teeth affected
by MIH is about twice the number of incisor teeth
indicating the concentration of the defect mainly on
the first permanent molars and incisor teeth are
involved when the condition become more severe
(12,13).
Mild defects were present in 64.1% of the affected
teeth with demarcated creamy-white opacities were
the most common finding (33.3%), and these are in
agreement with other studies that mild forms of the
defect are the most prevalent one(12,13,18). Sever
defects were found to be also prevalent, about one-
fifth of the affected cases and it was noted that molars
can be affected more severely than incisors which is
been found by other studies where more enamel
breakdown occurs in molars due to the absence of
masticatory forces on the incisors(10,13,15,18).
It should be noted that MIH defects, whether mild
or severe, could become more and more symptomatic
over time, which can influence the general health and
quality of life of the affected child and its treatment is
often challenging to both the patient and the
clinician(30).
Conclusions:
It’s been found that MIH is a prevalent pathology
among Kurdish children in Sulaimani City which
could result in a large number of children
continuously seeking professional dental treatment.
Therefore; dental practitioners who deal with child
patients could encounter such cases and should be
aware of the treatment choices and management
protocols for coping with this particular condition.
References:
1. Weerheijm KL. Molar incisor hypomineralization (MIH):
clinical presentation, aetiology and management. Dent
Update. 2004;3:9–12.
2. Koch G, Hallonsten AL, Ludvigsson N, Hansson BO,
Holst A, Ullbro C. Epidemiologic study of idiopathic
enamel hypomineralization in permanent teeth of
Swedish children. Community Dent Oral Epidemiol.
1987;15:279–85.
3. Weerheijm KL, Jälevik B, Alaluusua S. Molar-incisor
hypomineralisation. Caries Res. Karger Publishers;
200;35:390–1.
4. Weerheijm KL, Duggal M, Mejàre I, Papagiannoulis L,
Koch G, Martens LC, et al. Judgement criteria for molar
incisor hypomineralisation (MIH) in epidemiologic
studies: a summary of the European meeting on MIH
held in Athens, 2003. Eur J Paediatr Dent. 200;4:110–3.
5. Cho SY, Ki Y, Chu V. Molar incisor hypomineralization
in Hong Kong Chinese children. Int J Paediatr Dent.
2008;18:348–52.
6. Leppäniemi A, Lukinmaa PL, Alaluusua S. Nonfluoride
hypomineralizations in the permanent first molars and
their impact on the treatment need. Caries Res.
2001;35:36–40.
7. Ong DC-V, Bleakley JE. Compromised first permanent
molars: an orthodontic perspective. Aust Dent J.
2010;55:2–14.
8. Crombie FA, Manton DJ, Weerheijm KL, Kilpatrick NM,
Kilpatrick NM. Molar incisor hypomineralization: a
survey of members of the Australian and New Zealand
Society of Paediatric Dentistry. Aust Dent J. 2008;53:
160–6.
9. Calderara PC, Gerthoux PM, Mocarelli P, Lukinmaa PL,
Tramacere PL, Alaluusua S. The prevalence of molar
incisor hypomineralisation (MIH) in a group of Italian
school children. Eur J Paediatr Dent. 2005;6:79–83.
10. Jasulaityte L, Veerkamp JS, Weerheijm KL. Molar
incisor hypomineralization: review and prevalence data
from the study of primary school children in Kaunas/
Lithuania. Eur Arch Paediatr Dent. 2007;8:87–94.
11. Preusser SE, Ferring V, Wleklinski C, Wetzel W-E.
Prevalence and severity of molar incisor hypominer-
alization in a region of Germany -- a brief
communication. J Public Health Dent. 2007;67:148–50.
12. Wogelius P, Haubek D, Poulsen S. Prevalence and
distribution of demarcated opacities in permanent 1st
molars and incisors in 6 to 8-year-old Danish children.
Acta Odontol Scand. 2008;66:58–64.
13. Ghanim A, Morgan M, Mariño R, Bailey D, Manton D.
Molar-incisor hypomineralisation: prevalence and defect
characteristics in Iraqi children. Int J Paediatr Dent.
2011;21:413–21.
49
13. Sulaimani Dent. J. 2014; 1:45-50 Noori & Hussein
14. A review of the developmental defects of enamel index
(DDE Index). Commission on Oral Health, Research &
Epidemiology. Report of an FDI Working Group. Int
Dent J. 1992;42:411–26.
15. Sönmez H. The prevalence and severity of molar incisor
hypomineralization in a group of children living in
Ankara Turkey. Clin Dent Res. 2013;37:35–41.
16. Alaluusua S, Lukinmaa PL, Koskimies M, Pirinen S,
Hölttä P, Kallio M, et al. Developmental dental defects
associated with long breast feeding. Eur J Oral Sci.
1996;104:493–7.
17. Balmer R, Toumba J, Godson J, Duggal M. The
prevalence of molar incisor hypomineralisation in
Northern England and its relationship to socioeconomic
status and water fluoridation. Int J Paediatr Dent.
2012;22:250–7.
18. DA COSTA-SILVA CM, JEREMIAS F, De SOUZA JF,
Cordeiro RDCL, Santos-Pinto L, Zuanon ACC, et al.
Molar incisor hypomineralization!: prevalence , severity
and clinical consequences in Brazilian children. Int J
Paediatr Dent. 2010;20:426–34.
19. Zawaideh FI, Al-Jundi SH, Al-Jaljoli MH. Molar incisor
hypomineralisation: prevalence in Jordanian children
and clinical characteristics. Eur Arch Paediatr Dent.
2011;12:31–6.
20. Ahmadi R, Ramazani N, Nourinasab R. Molar incisor
hypomineralization: a study of prevalence and etiology
in a group of Iranian children. Iran J Pediatr.
2012;22:245–51.
21. Fteita D, Ali A, Alaluusua S. Molar-incisor
hypomineralization (MIH) in a group of school-aged
children in Benghazi, Libya. Eur Arch Paediatr Dent.
2006;7:92–5.
22. Condò R, Perugia C, Maturo P, Docimo R, Cond o R.
MIH: epidemiologic clinic study in paediatric patient.
Oral Implantol (Rome). 2012;5:58–69.
23. Jälevik B. Prevalence and diagnosis of molar-incisor-
hypomineralisation (MIH): A systematic review. Eur
Arch Paediatr Dent. 2010;11:59–64.
24. Mahoney EK, Morrison DG. The prevalence of molar-
incisor hypomineralisation (MIH) in Wainuiomata
children. N Z Dent J. 2009;105:121–7.
25. Lygidakis NA, Wong F, Jälevik B, Vierrou AM, Alaluusua
S, Espelid I. Best clinical practice guidance for
clinicians dealing with children presenting with Molar-
Incisor-Hypomineralisation (MIH): An EAPD Policy
Document. Eur Arch Paediatr Dent. 2010;11:75-81.
26. Biondi AM, López Jordi MDC, Cortese SG, Alvarez L,
Salveraglio I, Ortolani AM. Prevalence of molar-incisor
hypomineralization (MIH) in children seeking dental
care at the Schools of Dentistry of the University of
Buenos Aires (Argentina) and University of la Republica
(Uruguay). Acta Odontol Latinoam. 2012;25:224–30.
27. Mahoney EK, Rohanizadeh R, Ismail FSM, Kilpatrick
NM, Swain M V. Mechanical properties and
microstructure of hypomineralised enamel of permanent
teeth. Biomaterials. 2004;25:5091–100.
28. Xie Z, Kilpatrick NM, Swain MV, Munroe PR, Hoffman
M. Transmission electron microscope characterisation of
molar-incisor-hypomineralisation. J Mater Sci Mater
Med. 2008;19:3187–92.
29. Whatling R, Fearne JM. Molar incisor hypomin-
eralization: a study of aetiological factors in a group of
UK children. Int J Paediatr Dent. 2008;18:155–62.
30. Jälevik B, Klingberg G. Treatment outcomes and dental
anxiety in 18-year-olds with MIH, comparisons with
healthy controls - a longitudinal study. Int J Paediatr
Dent. 2012;22:85–91.
50
14. Sulaimani Dent. J. 2014; 1:51-56 Ramzi
Introduction:
Cigarette smoking is one of the major public health
problems and its the leading preventable cause of
morbidity and mortality. Currently, five million and
four hundred thousand people die because of cigarette
smoking every year in the world, and this number will
rise to eight million per year by 2030(1). Moreover,
more than 80% of deaths, caused by smoking,
occurred mostly in developing countries(2). Half of the
people start smoking cigarette since their teenage years
and still goes on, will be died(3). Teenage smoking
prevalence is around 15% in developing countries and
around 26% in the United Kingdom and United
States(4). According to the WHO, in the world, there
are almost one billion smoking men and 250 million
smoking women. In the year 2000, world inhabitants
smoked about 5.5 trillion cigarettes(5). While cigarette
consumption has been declining in high-income
countries; it is rising in low-income and middle-
income countries. By 2030, approximately 70% of
deaths attributable to smoking worldwide are expected
to occur in developing countries(6). The negative health
consequences of smoking are considerable and have
been well-documented(7). Epidemiological studies
among different university student populations in Arab
and Eastern Mediterranean countries demonstrated a
marked variation in the prevalence of smoking(8-18).
Studies on smoking habits among university
students in Sulaimani are scarce, which focus on a
specific group of the university student population
(19-21). The prevalence of smoking reflects the
magnitude of the problem, and determining its
importance since it provides a basis for the planning of
public health actions. The present study was an
epidemiological survey to determine the prevalence of
smoking and its associated factors among Sulaimani
University students in 2007.
Subjects and Methods:
Sulaimani University comprises many colleges. The
total number of students at the academic year
2006-2007 was 15329 students distributed in 22
colleges. The researcher categorized colleges of the
university in three groups; medical colleges, non
medical scientific colleges, and non medical literary
colleges. Nine colleges were selected by simple
random sampling; three from each group, including
college of medicine, dentistry, nursing, engineering,
agriculture, fine arts, administration and economic,
law and politics, and physical education. The total
number of students among the selected nine colleges
was 4215.
* Lecturer at Department of Community Medicine, School of Medicine/University of Sulaimani. (zhiansalah2001@yahoo.com)
Prevalence of cigarette smoking among
Sulaimani University students
Sulaimani Dental Journal
SDJ
Zhian Salah Ramzi*
Abstract:
Background: Tobacco smoking is a global behavior and it is a growing public health problem in the developing countries.
Objectives: The study was carried out to determine the prevalence of cigarette smoking and find out the socio-demographic
correlates of smoking among Sulaimani University students.
Subjects and Methods: A cross-sectional study was conducted from October to November 2007 on 2750 students in
Sulaimani University. A systematic stratified sampling technique was used. A self-administered questionnaire was used for
data collection on age and gender of students, college, years of study, and age of starting smoking.
Results: Out of 2722 respondents, 302 students were smokers giving a prevalence rate of 11.1%. The prevalence of smokers
was significantly (P< 0.001) higher in males than females (19% and 1% respectively). The highest rate of smokers was among
the age group 23-26 years in both sexes. About 10% of students started smoking at age less than 12 years, 8.2% at age 12-17
year, 50% at 18-22, and 31.7% at 23-26 years.
Conclusions: The prevalence of smoking was moderate. More than half of students started smoking during their study years
in the university. Males and students in third and fourth academic years were more likely to smoke. The results provide
baseline data to develop an anti-smoking program to limit smoking in the university.
Keywords: Prevalence, smoking, Sulaimani university, students
Received: May 2014, Accepted: August 2014
15. Sulaimani Dent. J. 2014; 1:51-56 Ramzi
This cross-sectional survey was conducted from
October to November 2007 in Sulaimani University.
All students enrolled in the above 9 colleges (4215),
were the population of this study. A self-administered
questionnaire was designed by the researcher and
pretested by a pilot study. The questions were grouped
into categories related to socio-demographics,
prevalence of smoking, reasons for smoking, not
smoking and quitting attempts. Questionnaires were
distributed during the classes by a well trained
personnel. The students were informed that the results
would be used for the stated research purposes only
and their participation was voluntary. No identification
was required and confidentiality was assured verbally.
Filled questionnaires were collected and checked
for completeness before being entered into a personal
computer and analyzed using SPSS version 17.
Descriptive statistics and X2 test were used for
studying association of smoking and categorical
variables. A statistical level of ≤0.05 was considered
significant. The outcome variable was smoking status,
classified into three categories: current smokers, ex-
smokers and non-smokers. Current smokers were
defined as those who had smoked cigarettes on one or
more days during the previous 30 days. Those who had
been smokers before, but had stopped smoking at time
of survey, were defined as ex-smokers. Those who had
never smoked in his/her lifetime were defined as non-
smokers.
Financial level was classified by the average
annual income for single Iraqi subject according to the
Ministry of Planning and Development, defined as low
(<729$ ), moderate (729-4000$), good (4000-8000$),
and very good (>8000$)(22).
Results:
A total of 2722 undergraduate students participated in
the study, giving a response rate of 64.6%. The age of
the respondents ranged from 17 to 28 years old with a
mean ± SD of 21.2 ± 2.7 years. Males constituted
55.8% and females 44.2%.
A total of 302 students out of 2722 reported being
current smokers, thus the prevalence of current
smokers in this study was 11.1%. The prevalence of
current smokers in males, 19.1% was significantly
higher than prevalence among females, 1% (p<0.001).
The ex-smoking rate was 4.5%. These rates, however,
varied significantly between colleges. The male to
female ratio among all respondents was 1.3:1; this
ratio became 24.2:1 among current smokers. A
significantly higher prevalence of current and ex-
smoker was found among males (P=0.008) as shown
in Table 1. The prevalence of smoking was higher
among the age group 24-28 (17.4%) in all colleges in
both males and females, followed by age group 21-23
(11.1%) and least prevalence was recorded among age
group 18-20 (7.1%) with a statistical significant
!52
Table 1: Smoking status among male, female and total population
Category
Males Females Total
Male: female ratio
No. (%) No. (%) No. (%)
Current smokers 290 96.02 12 3.97 302 11.1 24.2:1
Ex-smokers 109 89.34 13 0.5 12 4.5 8.4:2
Non- smokers 1120 48.74 1178 51.3 2298 84.4 0.9:1
Total 1519 55.80 1203 44.2 2722 1.3:1
Chi, P value X2= 6.99, P= 0.008
Table 2: Age and gender distribution of smokers
Age group
(years)
Males Females Total
No. of
participants
Smokers No. of
participants
Smokers No. of
participants
Smokers
No. % No. % No. %
18-20 550 70 12.7 471 2 0.4 1021 72 7.1
21-23 643 138 21.5 557 5 0.9 1200 143 11.1
24-28 326 82 25.2 175 5 2.9 501 87 17.4
Total 1519 290 19.1 1203 12 1.0 2722 302 11.1
16. Sulaimani Dent. J. 2014; 1:51-56 Ramzi
variation in the prevalence among different age groups
(Tables 2 and 3).
Table 3 shows the prevalence of current smoking
by some socio-demographic and academic charact-
eristics. Students of medical colleges recorded
significant higher prevalence of 12%, compared to
10.1% in non-medical scientific colleges and 9.5% in
non-medical and non medical literary colleges
(P<0.001). The lowest prevalence was among students
of first year and the prevalence increased in second
and third year with highest prevalence of 16.4%
among fourth, fifth and sixth year students collectively
(P<0.001). Married students showed a significantly
lower prevalence of current smoking than single
students (P<0.0001). No significant association was
found between prevalence of smoking and family
income.
!53
Table 3: Prevalence of current smoking among Sulaimani University students, by
demographic and academic characteristics
Variable Total No.
Smoking
P-value
No. %
Sex
Male 1519 290 19.1
0.0001*
Female 1203 12 1.0
Age (years)
18-20 1021 72 7.1
0.000121-23 1200 143 11.1
24-28 501 87 17.4
Colleges (Faculty)
Medical colleges 1000 120 12
0.001Non-medical scientific colleges 1122 113 10.1
Non-medical non scientific 600 57 9.5
Years of study
1st 700 60 8.6
0.0001
2nd 673 65 9.7
3rd 850 95 11.2
4th ** 499 82 16.4
Family income (ID/year)
< 958,000 549 61 20.2
0.997
958,000- 4,839,000 983 109 36.1
4,840,000- 9,679,000 714 79 26.2
≥9,680,000 476 53 17.5
Marital status
Single 2403 243 80.5
0.0001
Married 319 59 19.5
Total 2722 302
*X2 test;** 4th + 5th year dentistry and 6th year medical college
17. Sulaimani Dent. J. 2014; 1:51-56 Ramzi
!54
Table 4: Some characteristics of smokers
Variable
Current smokers
No. %
Starting age of smoking(years)
9- 13 47 17.2
14-18 71 25.9
19-22 141 51.5
23-27 15 5.5
Total 274 100
When smoking?
During stress 166 55
After meal 64 21
At any time 42 14
With alcohol 15 5
Other causes 12 4
No response 3 1
Reason for starting smoking
Smoking of other member of family 73 24
Having a smoking friend 60 20
For pleasure 55 18
Social problems 33 11
Advertising 33 11
Other causes 48 16
Smoking status(cig/day)
Light ( 1-10) 52 17.5
Moderate (11-20) 147 48.5
Heavy (> 20) 103 34
Preference of place of smoking
Public 88 29
Smoking rooms 214 71
Intention to quit smoking
Yes 184 60.9
No 118 39.1
Total 302 100
18. Sulaimani Dent. J. 2014; 1:51-56 Ramzi
The age of initiation of smoking ranged from 9 to
24 years with mean of 16.3± 3.3 years and was
significantly higher in males than in females (16.3±2.8
compared to 14.0±4.4). More than half of current
smokers smoked during stress, 21% after meals, 5%
with alcohol and 14% liked to smoke at any time.
Regarding reasons for starting smoking, 24% reported
having another family smoker, 20% reported having a
smoking friend and 18% for pleasure. Approximately
half of smokers smoked 11-20 cig/day and 34% were
heavy smokers. Eighty-eight of smokers preferred to
smoke in public places (29%) compared to 214 (71%)
in smoking rooms. Regarding quitting smoking, 60.6%
had intention to quit smoking (Table 4).
Discussion:
The aim of this study was to evaluate the Sulaimani
University students' smoking habits and the associated
socio-demographic factors. The main finding of this
study was that 11.1% of Sulaimani University students
were current smokers.
Prevalence of smoking: This prevalence is lower
than that reported previously in Sulaimani University
13.6% in 2005(19), and among students of Hawler
Medical University in Erbil in 2007, 12.3%(20). A much
lower prevalence of 9.3% was reported among
students of Salahaadin University in Erbil in 2002(21).
The prevalence of smoking in this study is also lower
than that reported among participants of the Kurdistan-
Iraq Global Youth Tobacco Survey in 2006, 15.3%(23).
A much higher prevalence was reported in Duhok
(24.5%) in a house hold survey among those aged
25-65 years in 2004(24).
In 2005 Mousawi reported a slightly lower
prevalence among Karbala University Students
(10.5%)(25), While another study in Karbala university
reported a higher rate (19%) in 2009(27). Iraq Family
Health Survey in 2006 reported a prevalence of
15.5%(26).
The smoking prevalence rate found in this study is
consistent with those reported by other studies in Syria
and Jordan(28-30). However, other studies in Jordan
(30,13), Syria(32), Iran(33), and Saudi Arabia(34) reported
higher rates. While other studies reported lower rates
than this rate in Iran(35), Saudi Arabia(36), and Syria(37).
Variations in smoking prevalence in Iraq might be
a real difference or may be related to a difference in
the methodology, including the characteristics of the
population surveyed, sampling, and methods of data
collection. The large sample of this study might
provide more confident outcomes or that the
educational programs about smoking in Sulaimani
might be more efficient.
Variations in the prevalence of smoking in
neighboring countries may be related to differences in
use of different criteria for defining smoking, different
age groups studied and different methodologies
adopted.
Age of starting smoking: The finding that the most
common age for starting smoking was between 19-22
years is consistent with the findings of other studies
(11,13).
Years of university education: This study indicates
that the prevalence of smoking increased significantly
with higher number of years of university education.
This may be due to longer exposure to other smokers
(friends, teachers) within university environment who
may influence their attitude and behavior. These
findings are consistent with those of other studies
(11,13).
Prevalence by gender: The finding of a significant
difference in the prevalence of smoking by gender is in
agreement with many studies conducted in Kurdistan,
Iraq and Arab countries that reported much higher
prevalence among males(19-21). However, the low
prevalence among females might be under estimated
due to reporting bias.
Causes of starting smoking: Friends, a smoking
member of the family were considered the major
causes for starting smoking, followed by stress and
pleasure. Other studies had revealed similar results
(20,25,31). This may be due to youth behavior of dealing
with stress and the bad influence of friends and family
members.
About 60% of smokers expressed a desire to quit
smoking in the near future; a finding which is similar
to other studies(19,20,32). This indicates that smokers
may respond well to cessation programs.
Weakness and limitations of study include the
general weakness of self-administered questionnaires
with the possible underreporting among females and
the low response rate. Also, as smoking behavior
among students was self-reported there could have
been a reporting bias. Verification of self-reported
smoking behavior could not be verified biochemically.
Conclusions:
The prevalence of smoking among Sulaimani
University students was moderate. More than half of
students started smoking during their study years in
the university. Males and students in advanced years of
study were more likely to smoke. The results provide
baseline data to develop an anti-smoking program to
limit smoking in the university.
Acknowledgment:
I would like to extend my acknowledgment and
gratitude to Dr. Ruzhgar Abid-Alla Saleem for her
effort and precious help in distributing the
questionnaires for different classes and colleges and
recollecting them.
!55
19. Sulaimani Dent. J. 2014; 1:51-56 Ramzi
References:
1. Ezzati M, Lopez AD, Rodgers A, Vander HS, Murray
CJ. Selected major risk factors and global and regional
burden of disease. Lancet. 2002; 360: 1347-60.
2. World Health Organisation. WHO report on global
tobacco epidemic 2008: the M Power package?
Geneva: WHO; 2010.
3. Marshall L, Schooley M, Ryan H, Cox P, Easton A,
Healton C, et al. Youth tobacco surveillance, United States
2001-2002. MMWR Surveill Summ. 2006; 55: 1-56.
4. Steptoe A, Wardle J, Cui W, Baban A, Glass K, Pelzer
K, et al. An international comparison of tobacco
smoking, beliefs and risk awareness in university
students from 23 countries. Addiction. 2002; 97:1561–
71.
5. MackayJ, Eriksen M.The tobacco atlas. Geneva: WHO;
2002.
6. Anthonisen NR, Skeans MA, Wise RA, Manfreda J,
Kanner RE, Connett JE, et al. The effect of smoking
cessation intervention on 14.5-year mortality: a
randomized clinical trial. Ann Intern Med. 2005;
142:233-9.
7. Peto R, Darby S, Deo H, Silcocks P, Whitly E, Doll R.
Smoking, smoking cessation, and lung cancer in the UK
since 1950: combination of national statistics with two
case-control studies. BMJ. 2000;321:323–9.
8. Alansari B. Prevalence of cigarette smoking among
male Kuwait University undergraduate students.
Psychol Rep. 2005; 96:1009–10.
9. Metintas S, Sariboyaci MA, Nuhoglu S, Metintas M,
Kalyoncu C, Etiz S, et al. Smoking patterns of university
students in Eskisehir, Turkey. Public Health.
1998;112:261-4.
10. Kofahi MM, Haddad LG. Perceptions of lung cancer
and smoking among college students in Jordan. J
Transcul Nurs. 2005, 16:245–54.
11. Haddad LG, Malak MZ. Smoking habits and attitudes
towards smoking among university students in Jordan.
Int J Nurs Stud. 2002; 39:793-802.
12. Almas K, Al-Hawish A, Al-Khamis W. Oral hygiene
practices, smoking habit, and self-perceived oral
malodor among dental students. J Contemp Dent Pract.
2003; 4:77–90.
13. Tamim H, Terro A, Kassem H, Ghazi A, Abou Khamis T,
Abdul Hay MM, et al. Tobacco use by university
students, Lebanon, 2001. Addiction. 2003;98:933–9.
14. Saatci E, Inan S, Bozdemir N, Akpinar E, Ergun G.
Predictors of smoking behavior of first year university
students: questionnaire survey. CMAJ. 2004;45:76–9.
15. Ahmadi J, Khalili H, Jooybar R, Namazi N, Aghaei PM.
Cigarette smoking among Iranian medical students,
resident physicians and attending physicians. Eur J
Med Res. 2001; 6:406–8.
16. Hasim TJ. Smoking habits of students in college of
applied medical science, Saudi Arabia. Saudi Med J.
2000; 21:76–80.
17. Maziak W, Mzayek F. The dynamics of tobacco smoking
among male educated youths in Aleppo, Syria. Eur J
Epidemiol. 2000; 16:769–72.
18. Maziak W, Hammal F, Rastam S, Asfar T, Eissenberg T,
bachir ME, et al. Characteristics of cigarette smoking
and quitting among university students in Syria. Prev
Med. 2004; 39:330–6.
19. Mohammed AO. Survey of cigarette smoking among
Sulaimani University students, Kurdistan- Iraq. Zanco
J Med Sci. 2008;12:137-42.
20. Mahmood S, Saleh AM, Belal KH. Prevalence of
Cigarette Smoking among Hawler Medical University
Students 2009. Zanco J Med Sci. 2009; 13: 2-6.
21. Jambaz SJ. Epidemiological survey of smoking habits
among Salahaddin University students. MSc thesis.
Salahaddin University (College of Medicine). Iraq;
2002.
22. Ministry of Planning and Development Cooperation.
Central Organization for Statistics and Information
Technology. Annual Per capita Income in Iraq; 2010.
23. Siziya S, Muula AS, Rudatsikira E. Correlates of current
smoking among in-school adolescents in the Kurdistan
Region of Iraq. Conflict and Health. 2007; 1:13.
24. Abdulrahman M. Risk factors survey for non-
communicable diseases in Duhok City. Duhok Med J.
2010;4:69-83.
25. Mousawi A. The prevalence of smoking among
Karbala/Iraq University students in Iraq in 2005.
Tobacco Use Insight. 2014; 7:9-14
26. MoH, MoP, WHO. Iraq Family Health Survey 2006/7.
Ministry of Health / Iraq, Ministry of Health/Kurdistan,
Kurdistan Regional Statistics Office, WHO/Iraq Office;
2007.
27. Alghabban SI. Prevalence of current smoking among
students in University of Karbala. Karbala Journal of
Medicine. 2009;2:645–62.
28. Al-Kubaisy W, Abdulla NN, Al-Nuaimy H, Halawany G,
Kurdy S. Epidemiological studies on tobacco smoking
among university students in damascus, Syrian Arab
Repuplic. 2012;18: 723-7.
29. Alomarri Q, Barrieshi-Nusair K, Said K. Smoking
prevalence and its effect on dental health attitudes and
behaviour among dental students. Med Princ Pract.
2006;15:195-9.
30. Khabour OF, Alzoubi KH, Eissenberg T, Mehrota P,
Azab M, Carroll M, et al. Waterpipe tobacco and
cigarette smoking among university students in Jordan.
Int J Tuberc Lung Dis. 2012;16:986-92.
31. Khader YS, Alsadi AA. Smoking habits among
university students in Jordan: prevalence and
associated factors. East Mediterr Health J. 2008;
14:897-904.
32. Maziak W, Hammal F, Rastam S, Asfar T, Eissenberg T,
bachir ME, et al. Characteristics of cigarette smoking
and quitting among university students in Syria. Prev
Med. 2004;39:330-6.
33. Haghdoost AA, Moosazadeh M. The prevalence of
cigarette smoking among students of Iran's universities:
A systematic review and meta-analysis. J Res Med Sci.
2013;18:717-25
34. Mahfouz MS, Alsanosy RM, Gaffar AM, Makeen A.
Tobacco use among University students of Jazan
Region: Gender differences and associated factors.
Biomed Res Int. 2014, Article ID 27923: 7 pages.
35. Nasirian M, Ziaaddini H, Assadollahi S. Smoking
intensity and its relation to general health of the
students of Kerman unoiversity of medical sciences,
Iran. Addict Health. 2013;5:102-7.
36. Almutairi KM. Prevalence of tobacco use and exposure
to environmental tobacco smoke among Saudi medical
students in Riyadh, Saudi Arabia. J Community Health.
2014; 6 [Epub ahead of print].
37. Almerie MO, Matar HE, Salam M, Morad A, Abdulaal
M, Koudsi A et al. Cigarettes and waterpipe smoking
among medical students in Syria: a cross-sectional
study. Int J Tuberc Lung Dis. 2008;12:1085-91.
!56
Type to enter text
20. Sulaimani Dent. J. 2014; 1:57-63 Mussa
Introduction:
The lymphatic system develops during the 6th week of
embryonic life (1). Lymphatic malformation (LM)
characterized by the size of the malformed channels
which are microcystic, macrocystic, or combined. It's
usually noted at birth or within the first 2 years of life.
On occasion, LM first becomes evident in later
childhood, adolescence, or even adulthood (2).
The Hamburg classification is currently the most
accepted classification system. It is subject to
continual improvement by the International Society for
the Study of Vascular Anomalies (ISSVA)(3,4). LM is
most commonly located on the head and neck; other
common sites are the axilla, chest, and perineum. LM
typically causes deformity and psychosocial issues,
especially when it involves the head and neck.
The two most common complications associated
with LM are bleeding and infection. Intralesional
bleeding occurs in up to 35% of lesions causing
ecchymotic discoloration, pain, or swelling (5). Oral
lesions may lead to macroglossia, poor oral hygiene,
and caries. Swelling due to bleeding, localized
infection, or systemic illness may obstruct vital
structures. Two-thirds of infants with cervicofacial LM
require tracheostomy (6). Bony overgrowth is another
complication; the mandible is most commonly
involved resulting in an open bite and prognathism (7).
These lesions are diagnosed by history and physical
examination. Small, superficial or asymptomatic
lesions do not require further evaluation and
intervention as they are benign lesions.
Large or deep LMs are assessed by MRI to: (1)
confirm the diagnosis; (2) define the extent of the
malformation; (3) plan the treatment. LM appears as
either a macrocystic, microcystic or combined lesion
with septations of variable thickness (8,9). Histological
confirmation of LM is rarely necessary (10). An infected
LM often cannot be controlled with oral antibiotics
and needs intravenous antimicrobial therapy with
hospital admission. Intervention for LM is reserved for
symptomatic lesions that cause pain, significant
deformity, or threaten vital structures (5).
Sclerotherapy is first-line management for large or
problematic macrocystic/combined LM and its
preferred due to lower complications rate than
attempted resection (11). Several sclerosing agents are
used to shrink LM likes doxycycline, sodium-
tetradecyl sulfate (STS), ethanol, bleomycin, and
OK-432 (9,12).
Excision of LM can cause significant morbidity:
major blood loss, iatrogenic injury, and deformity (5,6).
Usually excision is usually subtotal because LM
involves multiple tissue planes and important
structures so recurrence is common (35–64%) (13). In
small, well-localized LM (microcystic or macrocystic)
complete excision is recommended with preservation
of the anatomy of the affected area. Subtotal excision
* Department of Oral & Maxillofacial Surgery/ College of Dentistry-University of Kerbala, Iraq. (drqais@live.com)
Priority in selection of treatment methods used
for lymphatic malformations affecting
maxillofacial region
Sulaimani Dental Journal
SDJ
Qais H. Mussa*
Abstract:
Objectives: The purpose of this paper was to discuss and evaluate the treatment plan selection and the outcomes of 82 cases
of lymphatic malformation in oral & maxillofacial region.
Materials & methods: The analysis included of 82 cases of lymphatic malformation in oral & maxillofacial region during the
period between January 2004 to November 2013 at maxillofacial department in Al-Hilla General Teaching Hospital. The
treatment plans selection depend on details patient history, clinical examination & imaging investigations. Different
techniques were used depended on age, extension, site & types of lymphatic malformation. The treatment methods were
conservative treatment, surgery, use of sclerosing agents or combinations of them.
Results: Total number of the patients were 82 complains from different types lymphatic malformation, 30 were males
constituting 36.5% while 52 were females constituting 63.5% . The youngest patient was 5 days, while the oldest one was 45
years. Forty case treated by sclerotherapy and surgery (48.7%) . Surgery alone as primary treatment done for 27 patients
(32.9%) other 10 cases treated by sclerotherapy alone ( 12.1%) & 5 cases ( 6% ) only needs observation .
Conclusions: Careful treatment plan selection depends on age, extension, type of lesion & experience of surgeon associated
with good prognosis. Conservative resection was the most effective method in treatment of lymphatic malformation.
Keywords: Vascular malformation, lymphangioma, sclerosing agent.
Received: April 2014, Accepted: September, 2014
21. Sulaimani Dent. J. 2014; 1:57-63 Mussa
of problematic areas, such as bleeding vesicles or a
hyper-trophied lip should be carried out rather than an
attempting “complete” resection that might result in a
worse deformity than the malformation itself.
Macroglossia may require reduction to return the
tongue to the oral cavity or to correct an open-bite
deformity (14). In order to assess different modalities of
treatment of lymphatic malformations affecting the
maxillofacial area this study was done.
Materials and Methods:
Eighty-two patient treated by the same surgeon during
the period between January 2004 to November 2013 at
maxillofacial department in Al-Hilla General Teaching
Hospital.
Patient records, treatment modality used, response
to treatment, the period of treatment & its complicati-
ons were reviewed. The diagnosis depends on physical
examination, ultrasound, computed tomography &
magnetic resonance imaging (MRI) study. According
to MRI examination, the patients grouped into
macrocystic (45 cases), microcystic (22 cases) &
unicystic (15 cases). The treatment plan divided the
patients in 4 groups (Table 1) depend on the types, site
of the lesion &age of the patients as follows:-
1- Patients underwent surgery as primary treatment.
Indicated in all unicystic & localized macrocystic
or microcystic cases
2- Patients underwent pre-surgical treatment by
percutaneous sclerosing agent injection (Ethanol or
bleomycin). Indicated in diffuse Microcystic &
macrocystic lymphangioma that’s located in
different tissues planes.
3- Patients underwent percutaneous sclerosing agent
injection (Ethanol or bleomycin) alone. Indicated
in cases of macrocystic & microcystic lymphan-
giomas. Its safety as compared to surgery that’s
may be at risk to damage important structures.
4- Patients need observation & follow-up without
treatment. Indicated in small lesion that’s not
affected the esthetic or function & without
complication.
Ethanol (95%) 1mL/kg was used in pre-surgery &
as primary sclerosing agent in the period from January
2004 till the end of 2009 while bleomycin was used
between at the end of 2009 till November 2013.
The bleomycin diluted 1mg/1ml normal saline/kg
after the fluid aspirated from the lesion the material
injected into the lesion under deep sedation or general
anesthesia. The procedure repeated each three weeks
and in some cases the injection of sclerosing agent
performed with ultrasonography guidance under deep
sedation or GA.
Indications for treatment have based on tissue
destruction or disfigurement (Fig.1) & obstruction of
vital functions (Fig.6). The surgery in most of these
cases represents the main modality of treatment as the
first choice or follows different sclerosing agents
treatment (Fig.5).
58
Figure 1: Clinical view of neck lymphangioma extend
to floor of mouth & raise the tongue due to infection
Figure 2: A : Clinical view of unicystic lymphangioma B: Post surgical excision (surgery primary treatment)
A B
22. Sulaimani Dent. J. 2014; 1:57-63 Mussa
Results:
Patients recorded in this study were 82 complains
from different types lymphatic malformation 30
patients were males constituting 36.5% and 52 were
females constituting 63.5% .
The youngest patient was 5 days while the oldest
one was 45 years. Forty cases treated by sclerotherapy,
followed by surgery (22 Ethanol & 18 bleomycin)
represented (48.7%). Primary surgical excision used
for 27 cases (15 unicystic, 7 macrocystic & 5
microcystic) represented (32.9%), while 10 cases
treated by sclerotherapy alone (7 Ethanol & 3
bleomycin) represented (12.1%) & 5 case only needs
observation (6% ) as summarized by (Table 1).
Primary surgical excision was effective in 25 of 27
patients, most of them were unicystic and macrocystic.
Ethanol pre-surgery was effective in 10 case, were
59
A B
C D
Figure 3: A- Clinical view of macrocystic lymphangioma, B- Surgical excision through submandibular
approach, C- Multiple cystic appearance of the specimen, D- Immediate post surgical with reduction of
macroglossia
Table 1: Number of patient's distribution according treatment plan selection
Type
Lymphangioma
No . of
patients
Surgery
Ethanol pre-
surgery
Bleomycin
pre-surgery
Ethanol only
as a
sclerosing
agent
Bleomycin
only as a
sclerosing
agent
Observati-
on only
Unicystic 15 15
Macrocystic 45 7 10 11 5 2
Microcystic 22 5 12 7 2 1
Total 82 27 22 18 7 3 5
23. Sulaimani Dent. J. 2014; 1:57-63 Mussa
60
Figure 4: A- Clinical view of macrocystic lymphangioma, B- Surgical view of multicystic specimen,
C- Post surgical view
B
C
24. Sulaimani Dent. J. 2014; 1:57-63 Mussa
61
Figure 5: Clinical view of huge macrocystic lymphangioma treated by bleomycin pre-surgical excision
Figure 6: A- Clinical view of macrocystic lymphangioma,
B- Sclerosing agent used pre-surgical excision of the lesion
A
B
25. Sulaimani Dent. J. 2014; 1:57-63 Mussa
completely cure other 7 case showed permanent
shrinkage > 70% of their size & 5 cases had permanent
shrinkage 50 - 70%.
The use of bleomycin pre-surgery was effective in
9 cases which were completely cure, other 5 cases had
permanent shrinkage > 70% of their size & 4 cases
showed permanent shrinkage 50 - 70% from their size.
Ethanol as a primary sclerosing agent was effective
in 5 cases causing permanent shrinkage > 70% & 2
cases had permanent shrinkage 50 - 70% of the size
of lesions.
Bleomycin as primary sclerosing agent was
effective in 2 cases which had permanent shrinkage >
70% & 1 case show permanent shrinkage 50 - 70% of
the size of lesion (Table 2).
Complication after primary surgical excision
included lymphorrhea (3 cases), infection (2 cases)
and unacceptable tissue scar (2 cases). The complic-
ation after ethanol pre-surgical excision included
lymphorrhea (8 cases), infection (4 cases), palsy of
mandibular & cervical branches of facial nerve (2
cases), and tissue scar (4 cases). The complication
after bleomycin pre-surgical excision included
lymphorrhea (5 cases), infection (2 cases). The
complication after ethanol as a primary treatment
alone included infection (3 cases), palsy of mandibular
branch of facial nerve (1 case) and tissue scar (2
cases). The complication after bleomycin as a primary
treatment alone included skin scar in one case (Table
3). The ethanol has a greater incidence of adverse side-
effects than bleomycin. The major side-effect is skin
necrosis & Severe pain that does not occur following
the injection of bleomycin and there are fewer adverse
reactions.
Discussion:
Based on the size of the lymphatic lumen, LMs
(previously termed lymphangiomas) can be divided
into microcystic lesions (previously termed lymphang-
ioma circumscriptum), macrocystic lesions (previously
termed cystic hygromas) (fig.4) and a combined form.
Hence the term cystic hygroma has now been replaced
by the term macrocystic. The most important
diagnostic tool in lymphatic malformations is clinical
examination and information from magnetic resonance
scanning (MRI), which demonstrates the extent of the
lesion and helps to differentiate between it and other
vascular lesions.
Doppler ultrasound can confirm the flow of the
lesion (15) and in this study the diagnosis depended on
history , physical examination and MRI in majority of
cases, but its cost and some time limited availability
make the CT scan & ultrasonic used in diagnosis the
lesions & classify them into macrocystic , microcystic
& unicystic lesions.
Indications for treatment depend on the size,
location and symptoms of the lesion. Cosmetic
disability, presence of recurrent infection, oozing,
crusting, ulceration and pain are the most frequent
62
Table 3: Complications according to type of treatment plan
Type of complication
Primary
surgery
27 case
Ethanol pre-
surgery
22 case
Bleomycin
pre-surgery
18 case
Ethanol
7 case
Bleomycin
3 case
Total
82 case
Lymphorrhea 3 8 5 0 0 16
Airway obstruction 0 0 0 0 0 0
Infection 2 4 2 3 0 11
Tissue scar or ulceration 2 4 0 2 1 9
Facial nerve or any branch palsy 0 2 0 1 0 3
Total 7 18 7 6 1 39
Table 2: The effectiveness of primary treatment according to the treatment plan modalities
The cure or
permanent
shrinkage
percentage
Primary surgery
27 case
Ethanol pre-
surgery
22 case
Bleomycin pre-
surgery
18 case
Ethanol
7 case
Bleomycin
3 case
100% cure 25 10 9 0 0
> 70% 2 7 5 5 2
50-70% 0 5 4 2 1
<50% 0 0 0 0 0
26. Sulaimani Dent. J. 2014; 1:57-63 Mussa
indications for treatment. This indications supported
by surgical excision is recommended for resectable
lesions, there is a high recurrence rate (11).
Raveh et al reported a recurrence rate of 22% in 74
children treated with primary surgical excision, but in
our study Cure rates were superior in the group having
primary surgical excision in type with low compli-
cation rates (16). The effectiveness of treatment were
superior in the group having surgery with
sclerotherapy (ethanol & bleomycin) similar result
were observed by Kim et al. (17) & approximately
similar result in ethanol & bleomycin pre-surgery but
the complication with ethanol more than bleomycin
were used presurgery.
Sclerotherapy is the first-line management for large
or problematic macrocystic/combined LM (11). In this
study the sclerotherapy (ethanol & bleomycin) used as
a first line of treatment only in macrocystic 7 cases &
3 microcystic cases with similar acceptable outcome
but the complication with ethanol is more than
bleomycin. Five cases did not need treatment, just
observation alone without any intervention; this fact
supported by Dasgupta et al. that patients with
asymptomatic macrocystic LMs of the head and neck,
who underwent interventional procedures had a higher
complication and recurrence rate compared to patients
who were managed by observation alone (18). Priority
should be placed on preservation of normal function
and restoration of a normal appearance. Microcystic
lymphangioma are diffuse, located in different tissues
planes, and it is difficult to distinguish involved tissue
from normal tissue. Macrocystic lesions on the other
hand are more localized and are more easily excised
this result supported by other study & surgical
management in some cases associated with correction
of macroglossia (14) .
Conclusions:
Careful treatment plan selection depends on age,
extension, type of lesion and experience of surgeon
associated with good prognosis. Conservative
resection was the most effective method in treatment
of lymphatic malformation and the macrocystic lesions
are most easily excised. Diffuse microcystic lesions
are more difficult and may require multiple operations.
Care should be taken to identify and preserve
important structures, because tissue planes are often
damaged.
References:
1. Mulliken JB, Young A. Vascular birthmarks:
hemangiomas and malformations. Philadelphia: WB
Saunders; 1988.
2. Marler JJ, Fishman SJ, Upton J, Burrows PE, Paltiel
HJ, Jennings RW, et al. Prenatal diagnosis of vascular
anomalies. J Pediatr Surg. 2002; 37:318–26.
3. Lee BB, Laredo J, Lee TS, Huh S, Neville R.
Terminology and classification of congenital vascular
malformations. Phlebology. 2007; 22: 249-52.
4. Mattassi R, Loose DA, Vaghi M. Hemangiomas and
Vascular Malformations, An Atlas of Diagnosis and
Treatment. Springer Verlag. 2009.
5. Padwa BL, Hayward PG, Ferraro NF. Cervicofacial
lymphatic malformation: clinical course, surgical
intervention, and pathogenesis of skeletal hypertrophy.
Plast Reconstr Surg. 1995;95:951–60.
6. Edwards PD, Rahbar R, Ferraro NF, et al. Lymphatic
malformation of the lingual base and oral floor. Plast
Reconstr Surg. 2005;115:1906–15.
7. Greene AK, Burrows PE, Smith L. Periorbital
lymphatic malformation: clinical course and
management in 42 patients. Plast Reconstr Surg.
2005;115:22–30.
8. Finn MC, Glowacki J, Mulliken JB. Congenital
vascular lesions: clinical application of a new
classification. J Pediatr Surg. 1983;18:894–900.
9. Choi DJ, Alomari AI, Chaudry G. Neurointerventional
management of low-flow vascular malformations of the
head and neck. Neuroimag Clin N Am. 2009;19:199–
218.
10. Florez-Vargas A, Vargas SO, Debelenko LV.
Comparative analysis of D2–40 and LYVE-1
immunostaining in lymphatic malformations.
Lymphology. 2008;41:103–10.
11. Smith MC, Zimmerman B, Burke DK. Efficacy and
safety of OK-432 immunotherapy of lymphatic
malformations. Laryngoscope. 2009;119:107–15.
12. Burrows PE, Mitri RK, Alomari A. Percutaneous
sclerotherapy of lymphatic malformations with
doxycycline. Lymphat Res Biol. 2008;6:209–16.
13. Alqahtani A, Nguyen LT, Flageole H. 25 years’
experience with lymphangiomas in children. J Pediatr
Surg. 1999;34:1164–8.
14. Grimmer JF, Mulliken JB, Burrows PE, Rahbar R.
Radiofrequency ablation of microcystic lymphatic
malformation in the oral cavity. Arch Otolaryngol Head
Neck Surg. 2006;132:1251-6.
15. Marler JJ, Mulliken JB. Current management of
hemangiomas and vascular malformations. Clin Plast
Surg. 2005;32:99–116.
16. Raveh E, de Jong AL, Taylor GP, Forte V. Prognostic
factors in the treatment of lymphatic malformations.
Arch Otolaryngol Head Neck Surg. 1997;123:1061–5.
17. Kim KH, Sung MW, Roh JL, Han MH. Sclerotherapy for
congenital lesions in the head and neck. Otolaryngol
Head Neck Surg. 2004;131:307–16.
18. Dasgupta R, Adams D, Elluru R, Wentzel MS, Azizkhan
RG. Non interventional treatment of selected head and
neck lymphatic malformations. J Pediatr Surg.
2008;43:869–73.
63
27. Sulaimani Dent. J. 2014; 1:64-67 Abulsattar &Al-Yassiri
Introduction:
The thalassemias are a group of congenital disorders
characterized by a deficient synthesis of either the α or
β chains of globin in the hemoglobin molecule. As a
result, the red blood cells are microcytic and
hypochromic with an aberrant morphology. The
homozygous type that is known as β- thalassemia
major or Cooley's anemia is the most common
monogenic disorder in the Mediterranean basin, the
Middle East, Asia and the South Pacific(1-3).
β-thalassemia major is the most severe congenital
hemolytic anemia. At 4 to 6 months of life, with the
change from fetal xx chain to adult xx chain
hemoglobin production, the first clinical manifes-
tations appear. The hematocrit decreases to less than
20, the degree of anemia can reach a hemoglobin level
of 2 to 3 g/dl, and the hemolysis is extensive, as in the
iron overload(1,4). Growth and development in children
is slow. In adolescence, secondary sex characteristics
are delayed. The skin color becomes ashen-gray due to
the combination of pallor, jaundice, and hemosid-
erosis. Patients also present cardiomegaly, hepatome-
galy, and splenomegaly(5) .
Bimaxillary protrusion and other occlusal abnorm-
alities are frequent in thalassemia major cases. Dental
and facial abnormalities include spacing of teeth, open
bite, prominent malor bones, and protrusion of maxilla
and saddle nose. In addition, the pneumatization of the
maxillary sinuses is delayed. Because of these skeletal
changes, the upper lip is retracted, giving the person a"
chipmunk" or "rodent face" (6).
In β-thalassemia major, there is no correlation
between the chronologic, skeletal and dental age. The
skeletal retardation increases with age due to hypoxia
from severe anemia, endocrine hypodysfunction
secondary to iron deposition, or the toxic action of iron
enzyme systems leading to tissue injury.
The oral mucosa is pale or lemon yellow color due
to anemia and deposition of billirubin pigment, then
decrease lysis of red blood cells cause less deposition
of billirubin(1,5).
Radiographic changes resulting from expansion
of the marrow spaces in long bones include cortical
a Oral and Maxillofacial Surgery Department, College Of Dentistry, Karbala University. Iraq. Email: muhaned80@yahoo.com
b Oral Medicine, Oral and Maxillofacial Surgery Department, College Of Dentistry, Babylon University, Iraq. Email: ali_mihsen@yahoo.com
Prevalence of orofacial changes in patients with
β-thalassemia major in Karbala City, Iraq
Sulaimani Dental Journal
SDJ
Muhanned Salah Abulsattara
Ali Mihsen Al-Yassirib
Abstract:
Background: The thalassemias are a group of hemoglobinnopathies characterized by a reduced rate of production of one or
more of these globin chains. The imbalance is due to disturbances in the control mechanisms of protein synthesis and results
in altered function of the hemoglobin molecule and aberrant erythrocyte morphology. β- thalassemia major is the most severe
congenital hemolytic anemia. The oral complications or manifestations are most common present in major thalassemic
patients. The aim of this study was to investigate findings of oral abnormalities or changes in these patients, and compare it to
healthy control subjects.
Materials and Methods: Patients were selected from Thalassemia Center of Pediatric of Al Hussaini Teaching Hospital in
Holy-Karbala during the period from March to September 2013. Forty (40) subjects were incorporated in this study. All these
patients with age range (4-15) years, (22 males, and 18 females). All these patients were without any other systemic diseases.
Results: The prevalence of orofacial complications in β-thalassemia major patients was: prominent maxilla (85%), bad oder
(80%), oral ulcers (50%), angular stomatitis (40%), candidal infection (35%), changes in oral mucosa (30%), xerostomia
(15%), and the last one was enlargements of salivary glands (zero).
Discussion: Thalassemia is among the most widely distributed genetic disorders to cause a major public health problem. Β-
thalassemia major is a life-threatening condition characterized by severe anemia, hepatoseplenomegaly, growth retardation,
skeletal changes due to hypertrophy and expansion of erythroid marrow , susceptibility to infection, endocrine dysfunction
and cardiac failure following iron deposition in the myocardium.
Conclusions: Knowing the prevalence of complication can help the dentists to do properly for these patients to solve their
problems and improve knowledge of the parents about their children's dental health.
Keywords: Orofacial changes , major β-thalassemia, prominent maxilla.
Received: January 2014, Accepted: June 2014
28. Sulaimani Dent. J. 2014; 1:64-67 Abulsattar &Al-Yassiri
erosions, subcortica lucencies, rarefaction, enlarged
nutrients foramina, and "raindrop" spaces within the
cortex(7,8). In the jaws, there is generalized rarefaction
of alveolar bone, thinning of cortical bone, and a
"chicken-wire" appearance of enlarged marrow spaces
and coarse trabeculation. In some cases, the lamina
dura may be thin, the roots of teeth short, and the
premaxilla prominent(9). In the skull, proliferation of
the marrow may completely erode the cortex, leaving
only periosteum, and produce a hair-on-end Holy-
Karbala radiographic appearance(6). In addition,
pneumatization of the paranasal sinuses may be
delayed, and the nasal cavity or the middle ear may be
encroached upon to the point of occluding the
anatomic spaces(7).
The common orofacial features among patients
with severe β-thalassemia include: frontal bossing,
skeletal changes, characteristic chipmunk facies, upper
lip retraction(10-12), and various malocclusion stages
due to bi-maxillary, alveolar bone expansion, skeletal
and dental retardation. Marginal gingivitis which was
mainly located at the level of lower frontal teeth due to
malocclusion and poor oral hygiene(12,13 ), poor oral
hygiene and high caries risk were reported in many
studies(13) . Iron deposition (hemosiderosis) all over the
body has been reported; face (ashen-gray color)(10),
oral mucosa (bluish-black discoloration)(14), teeth
(yellowish-brown)(10) and in parotid glands cause
swelling and pain(15), iron overload from blood
transfusion and increased iron absorption will lead to
fatal complications(16).
There is higher tendency of glossitis (Depapillation)
and candidiasis of the tongue due to chronic anemia,
poor oral hygiene and other causes(17,18). There is
susceptibility to recurrent infections, overwhelming
and severe infections especially in splenectomized
patients(18).
Materials and Methods:
Patients were selected from Thalassemia Center of
Pediatric of Al-Hussaini Teaching Hospital in Holy-
Karbala during the period from March to September,
2013. Forty (40) subjects were incorporated in this
study, Informed consent and ethical approval was
obtained. For each individual a questionnaire case
sheet was filled out. All these patients with age range
(4-15) years, (22 males, and 18 females). All these
patients were without any other systemic diseases.
All these Thalassemic patients were previously
diagnosed by hematologist specialists, and were
selected according to: clinical features, hematological
examination (Hb<9.5 g/dl, RBC morphology), and
Hemoglobin electrophoresis. Intra and extra-oral
examination for these patients to record all the
orofacial manifestations or findings (oral ulcerations,
gingivitis, bad odor (halitosis), dry mouth or
xerostomia, candidacies infections, prominent maxilla,
enlargement of salivary glands, angular stomatitis, and
changes in oral mucosa).
Results:
The total numbers of patients with β-thalassemia major
were (40). The percentages of orofacial abnormalities
in patients with β- thalassemia major was as fallow
(Figure 1):
1. Prominent maxilla (85%), 34 out of 40 cases.
2. Oral ulcers (50%), 20 out of 40 cases.
3. Changes in oral mucosa (30%), 12 out of 40 cases.
4. Candidal infection (35%), 14 out of 40 cases.
5. Xerostomia (15%) 6 out of 40 cases.
6. Halitosis (80%), 32 out of 40 cases.
65
Figure 1: Distribution of orofacial abnormalities in patients with β- thalassemia major in the oral cavity
29. Sulaimani Dent. J. 2014; 1:64-67 Abulsattar &Al-Yassiri
7. Angular stomatitis (40%), 16 out of 40 cases.
8. Enlargements of salivary glands (zero).
Discussion:
Thalassemia is among the most widely distributed
genetic disorders to cause a major public health
problem. β-thalassemia major is a life-threatening
condition characterized by severe anemia, hepatosepl-
enomegaly, growth retardation, skeletal changes due to
hypertrophy and expansion of erythroid marrow,
susceptibility to infection, endocrine dysfunction, and
cardiac failure following iron deposition in the
myocardium(19,20) . The clinical features of the disease
are well documented(14,15,21-23).
Forty thalassemic patients were studied, (22)
males and (18) females, the age range (4-15) years.
The incidence of thalassemia were more in males than
females, these results were matched with [Mattia et al.,
1996 and Al- Kaysi, 2002].
In this study, the most common oral findings or
manifestations among thalassemics maxillary promi-
nence 85%, oral ulcers 50%, bad odors 80%, angular
stomatitis 40%, change in oral mucosa 30%, candidial
infection 35%, bad odors 10% and finally enlargement
of salivary glands zero %.
Facial deformities such as maxillary prominence or
expansion and protrusion of upper anterior teeth were
observed 85% of the cases, as studies of [Caffey, 1957
and Baker, 1964]; we observe a close correlation
between frequency and severity of bone changes and
the severity of anemia. Patients with the mean low Hb.
concentration have significantly higher and severe
frontal bossing and facial deformities than those whose
high or normal Hb concentration.
In our study, this was highly significant increase in
maxillary prominence among beta-thalassemic major
patients.
In this study, most of the patients with β-
thalassemia major were in the first or second decodes
of life, which indicates a lack of life expectancy.
Alveolar expansion that causes maxillary promi-
nence were observed in this study, significantly
increasing with age and duration of the illness, due to
gradual bulging of alveolar buccal bone overlying the
upper central incisors with increasing age, these results
were matched with findings of [Johnson and Kragman,
1964].
The incidence of oral ulcers, changes of oral
mucosa, and angular stomatitis among thalassemics
were significantly higher than controls, the presence of
these manifestations were multifactorial including:
nutritional deficiency, folate, Vitamin-B complex
deficiencies. Rarely diabetes or staphylococcus, β.
Hemolytic streptococcus. The majority of angular
stomatitis cases were associated with candida albicans
in thalassemics (27-29).
The incidence of candidial infection was
significant among thalassemic patients compared to
controls, because they were prone to infection
particularly opportunistic candidiasis , other factors as
iron overloaded, these findings were matched with
[Abbott and Galloway, 1986].
The severity of oral findings or abnormalities
among thalassemics of rural areas was higher than
urban areas. This was because of: lower socioeco-
monic status, difficult transplantation and difficulty of
proper management in the rural areas unfortunately.
Dry mouth (Xerostomia) in thalassemics found to
increase with age and severity of oral findings , due to
iron deposition , pain and swelling in the parotid
glands of patients with thalassemia major have been
reported, possibly as a result of iron deposits in the
serous cells, these findings were matched with [Hattab
et al., 2001 and Goldfarb et al., 1983]. The presence
of bad odors is due to bad oral hygiene.
Conclusions:
Thalassemia hemglobinopathies produce a wide variety
of signs, symptoms, and complications in those patients
who inherit the diseases. The orofacial changes and
bone deformities were common finding among severe
β-thalassemic patients.
Successful management of a patient with thalass-
emia depends on a proper diagnosis and treatment plan
that considers both the systemic and oral conditions.
Regular and repeated blood-infusion preserving the
hemoglobin amount in an appropriate level (at least
10g/dl), along with iron removal can prevent face and
skull deformities. Therefore; skull and face deformities
can be closely related to the patient's age, the intensity
of anemia and the beginning time of treatment.
Patients receiving inadequate blood transfusion in
childhood will face more bone changes (expansion and
deformity) in adolescence are cause of hyper activity
of bone marrow to compensate anemia. Then early
diagnosis and blood infusion cause less prevalence of
complications.
References:
1. Braun wald, Antony S fuci, Kasper, Hauser, Longo,
Jameson: Harrison's principle of internal medicine. 15th
ed. New York, Mc-Grow Hill. pp, 2001;666-74.
2. Malcolm A, Martin S Greenberg: Burket's oral medicine.
9th ed. Philadeiphia, Lippincott. pp. 1994:534-9.
66
30. Sulaimani Dent. J. 2014; 1:64-67 Abulsattar &Al-Yassiri
3. Farhud D, Sadighi H. Investigation of prevalence of beta
thalassemia in Iranian provinces. Iranian J Pub Health.
1997: 26:3-6.
4. Miller. Blood disease in infancy childhood. 3rd ed .
London, Mosby. pp. 1989:280-340.
5. Gerrnberg M S. Burket's oral medicine. 10th ed.
Philadelphia, Lippincott, pp. 2003: 430-6.
6. Margot L, Van Dis. Thalassemia. oral manifestations and
complications. Oral Med, Oral Path, Oral Surg.1986;
62:229-33.
7. Modell B, Berdoukas V. The clinical approach to
thalassemia. New York, Grune and Stratton,pp, 1984;
53-75.
8. Lawson JP, Ablow RC, Pearson HA. The ribs in
thalassemia. I, The relasioship to therapy. Radiology.
1981; 140:663-77.
9. Poynton HG. Oral radiology, Baltimore, Williams and
Wilkins, pp, 1982; 230-2.
10. Martin S. Greenberg, Adi Garfukel. Hematologic
Disease, Thalassemias, Diagnosis and Treatment,
Burket's Oral Medicine 9th ed, 1994; 536-7.
11. Ernest Butler. Hemoglobinopathies, thalassemia
syndromes, Harrison's Principles of Internal Medicine.
McGraw-Hill. 15th ed, 2001; 106:668-74.
12. De Mattia D, Pettini PL, Sabato V, Rubini G, Laforgia A,
Schettini F. Oromaxillofacial changes in thalassemia
major. Minerva Pediatr. 1996;48:11-20.
13. Al-Kaysi GH. Dental and oral changes in a group of
Iraqi thalassemia patients, the first scientific congress on
thalassemia and hemoglobin pathies. Baghdad, 2002.
14. Duggal MS, Bedi R, Kinsey SE, Williams SA. The dental
management of children with sickle cell disease and
beta-thalassaemia: a review. Int J Paediatr Dent.
1996;6:227-34.
15. Goldfarb A, Nitzan DW, Marmary Y. Changes in the
parotid salivary gland of beta-thalassemia patients due
to hemosiderin deposits. Int J Oral Surg. 1983;12:115-9.
16. Olivieri NF. The beta-thalassemias. N Engl J Med.
1999 ;341:99-109.
17. Sonis, Fazio, Fang, Pigmented lesions. Hemochr-
omatosis, Principles and Practice of Oral Medicine, 2nd
ed, 1984;38;385.
18. Margot L. Van Dis, and Robert P. Langlais. The
thalassemia: Oral manifestations and complications.
Oral Surg. Oral Med, Oral Pathol. 1996;62:229-33.
19. Weatherall JD, Clegg JB. The thalassemia syndromes
(3rd edn). Oxford: Blackwell, pp, 1981; 132-74.
20. Modell B. Management of thalassemia major. Br Med
Bull. 1976; 32: 270-6.
21. Weel F, Jackson IT, Crookendale WA, McMichan J. A
case of thalassemia major with gross dental and jaw
deformities. Br J Oral Maxillofac Surg. 1987;25:348-52.
22. Kaplan RI, Werther R, Castano FA. Dental and oral
findings in Cooley's anemia: a study of fifty cases. Ann
NY Acad Sci. 1964; 119:664-6.
23. Van Dis ML, Langlais RP. The thalassemias: oral
manifestations and complications. Oral Surg Oral
Pathol. 1986; 62:229-33.
24. Caffey J. Cooley's anemia: a review of the rontgen-
ographic finding in the skeleton. Am J Roentgenol
Radium Ther Nucl Med. 1957; 78:381-91.
25. Baker D. H. Roentgen manifestations of Colley's anemia,
Ann.N. Y. Acad of Sci. 1964;119:641-61.
26. Jonston FE, Kogman WM. Patterns of growth in children
with thalassemia major. Ann N Y Acad Sci.
1964;119:667-79
27. Lynch M.A: Hematologic diseases, Diagnosis and
treatment of Hematologic diseases, Burket's Oral
Medicine, 7th ed, 1973; 203-409.
28. Sreebny LM, Valdini A. Xerostomia. Part I: Relationship
to other oral symptoms and salivary gland hypofunction.
Oral Surg Oral Med Oral Pathol. 1988;66:451-8.
29. Hattab FN, Hazza'a AM, Yassin OM, al-Rimawi HS.
Caries risk in-patients with thalassemia major. Int Dent
J. 2001; 51: 35-8.
30. Abbott M, Galloway A, Cunningham JL. Haemochr-
omatosis presenting with a double Yersinia infection. J
Infect. 1986;13:143-5
67
31. Sulaimani Dent. J. 2014; 1:68-73 A-Qadir & Al-Qaisi
Introduction:
Cleaning and shaping of the root canal system are
among the important phases in endodontic therapy.
Nevertheless, it is recognized that chemo-mechanical
instrumentation alone is unable to completely
disinfect root canal systems. The remaining bacteria in
the root canal after instrumentation have been shown
to proliferate between appointments. Intra canal
medicament is also well-established method for
inhibition of external root resorption and stimulation
of periapical healing in traumatized teeth(1).
Microorganisms are not only in the main root
canal, but also disseminated throughout the root canal
system therefore, the use of an intracanal dressing to
eliminate the microorganisms is indicated(2).
The selection of intracanal medicament depends
on the root canal microbiota and on the mechanism of
action of the medication. Calcium hydroxide is the
most used intracanal dressing due to its antimicrobial
effect within root canal, its indirect and direct actions
in the dentinal tubules(3).
Calcium hydroxide dissociate to hydroxyl ions and
calcium ions & create an alkaline environment inside
dentinal tubules, and as a result it shows antibacterial
properties and stimulates hard tissue barrier formation
in aqueous solution. Various biological properties
have been attributed to this substance, such as
inhibition of tooth resorption and induction of repair
by hard tissue formation(4,5).
The new intracanal medicaments has been
introduced like mineral trioxide aggregate (MTA) first
introduced as a root end filling material and for repair
of lateral root perforations since then it has been used
for many clinical applications like pulp capping,
pulpotomy & for treatment of root resorption & root
filling material; similar to calcium hydroxide it has
high alkaline pH & the same mechanism(6).
Recently calcium – silicate based material
(Biodentine) has been introduced with the same
clinical application as MTA but with a different
chemical composition. It exhibits high alkaline pH and
a M.Sc. Department of Conservative Dentistry, School of Dentistry, Faculty of Medical Sciences, University of Sulaimani.
b Professor. Department of Conservative Dentistry, School of Dentistry, Faculty of Medical Sciences, University of Sulaimani.
Assessment of calcium ions diffusion and pH measurements
of three intracanal medicaments through dentinal tubules
(in vitro comparative study)
Sulaimani Dental Journal
SDJ
Chrakhan A-Latif A-Qadira
Salam D. Al-Qaisib
Abstract
Objectives: The purpose of this study was to evaluate the release of Calcium ions from three intracanal medicaments
[Ca(OH)2 , White Proroot MTA , Biodentine], and to measure the PH of these three materials.
Materials and Methods: Forty-two single rooted permanent teeth were prepared using crown down technique with Protaper
rotary files to a master apical file size 40. The canals were irrigated by using 2 ml 5.25% NaOCl for 60 seconds after each
instrument change, final irrigation of canals using 5 ml of 17% EDTA for 3 minutes and 5 ml of 5.25% NaOCl for 60 seconds
and finally 10 ml of saline solution. The canals were dried and the intracanal medicaments were applied according to
manufacturer instruction after setting of materials, both apical and coronal openings were sealed by Cavit and a layer of
Epoxy resin on it. Each root was immersed in 30 ml of deionized water. The digital pH meter was used for measuring the pH
values for each root 10 times per each studied period (1, 2, 7, 15, 30, 45, 60) days; The Calcium ions release measurements
were taken for each studied periods using Atomic Absorption Spectrophotometer device. The results were analyzed
statistically using ANOVA (F test), a p-value < 0.05 was considered as a significant.
Results: The pH values for Ca (OH)2 and PMTA groups were gradually increased and need more time for increasing than the
Biodentine. The pH values for Biodentine were the highest at the first day then decreased in the 2nd and 7th days, then
increased over time until sixty days. The calcium ions release values were gradually increase for three medicament and its
values were highest for Biodentine followed by Ca(OH)2 and finally PMTA. The differences between groups were statistically
highly significant.
Conclusions: Biodentine exhibited highest mean values in the calcium ions release and pH measurements than other groups
and PMTA showed lowest mean values in the calcium ion release and pH measurement.
Keywords: Calcium hydroxide, Proroot MTA, Biodentine, deionized water
Received: March 2014, Accepted: October 2014.
32. Sulaimani Dent. J. 2014; 1:68-73 A-Qadir & Al-Qaisi
release of calcium ions & also has good antimicrobial
properties(7).
The pH measurement and calcium ions release
measurement are determined by using digital pH
meter and Atomic Absorption Spectrophotometer
device respectively.
Materials and Methods:
Forty-two extracted permanent maxillary central and
maxillary second premolar human teeth with single
and straight root were selected for present study. The
soft tissues and hard deposits were removed using the
ultrasonic scalar, the teeth were stored in 10%
Formalin at room temperature for two weeks before
instrumentation for sterilization, and then teeth were
rinsed with distilled water to remove formalin and
stored in normal saline until the time of instrum-
entation.
The length of teeth was measured by a vernier,
then the teeth were decoronated transversally with a
water-cooled diamond disc with straight handpiece at
the level of (12 mm) from the apex perpendicular to
the long axis of the root to obtain a relatively standard
root length. The pulp tissues removed by barbed
broach, the root canals were measured by insertion of
a K file #10 with a rubber stop. The root canals were
prepared with a rubber dam in place; using a crown-
down technique with Protaper rotary files to a master
apical file size of 40. The canals were irrigated by
using 2 ml of 5.25% sodium hypochlorite for 60 sec
after each instrument changed, After finishing the
instrumentation process, the canal was irrigated with 5
ml of (17% EDTA) for 3 minutes, followed by 5 ml of
5.25% NaOCl for 60 sec to remove smear layer,
Finally, the canal was irrigated with 10 ml saline
solution Then the canal dried with paper point size 40.
Sample grouping:
The prepared (42) roots were divided randomly in to
three main groups of fourteen roots, which were
calcium hydroxide, PMTA, and Biodentine as shown
in figure1.
The powder of materials was mixed with distilled
water according to manufacturer instruction. The
calcium Hydroxide (Bio Dinamica Hydroyde
Decalcium, France) and PMTA (Dentsply, Tulsa
Dental, USA) were applied by lentulo spiral filler size
40 to 1 mm shorter than full working length using
slow speed handpiece. While Biodentine (Septodent)
was applied to the canal by amalgam carrier. Then
materials condensed using finger plugger and
endodontic condenser until 2 mm remain coronaly for
sealing materials. Complete filling of the root canals
for all three groups were checked by the over flow of
material through the root canal opening and
radiographic documentation through taking periapical
radiograph for each root in buccolingual and
mesiodistal aspects.
When the filling material set, both opening of
roots were sealed by Cavit and when become hard, a
layer of epoxy resin used on it for better sealing. After
self drying of the epoxy resin, each root immersed in a
separated plastic tubes containing 30 ml of Deionized
water and transferred to an incubator at 37°C with
humidify environment. The digital pH meter (pH
meter 765 Calimatic, Knick, Germany) was used for
measuring the pH values for each root 10 times per
each studied period ( 1, 2, 7, 15, 30, 45, 60) days; The
calcium ions release measurements were taken for
each studied periods using Atomic Absorption
Spectrophotometer device (PYE uniCAM Spg;
Philips, England), figure 2. The results were analyzed
statistically using ANOVA (F test), a P-value < 0.05
was considered as a significant.
Results:
The changes in pH and calcium ion release within the
immersion medium are presented in table 1 and figure
3, table 2 and figure 4 respectively.
The pH values of the immersion media for three
groups were approximately between 6.166 and 8.634.
Group1 which is Ca (OH)2 and Group2 (Pro root
MTA) show positive increase of pH over time while
Group3 (Biodentine) shows very high pH values in
the first day then decreases in the 2nd and 7th days
69
Figure 1: Sample grouping
33. Sulaimani Dent. J. 2014; 1:68-73 A-Qadir & Al-Qaisi
70
Table 1: The Comparison between Mean and Standard Deviation of PH Measurement of Three Intra Canal
Medicament at Different Studied Periods
Period of
measurements
(Days)
Number
of teeth
Group 1
calcium hydroxide
Ca(OH)2
Mean±S.D
Group 2
Mineral Trioxide
Aggregate (PMTA)
Mean±S.D
Group 3
Biodentine
Mean±S.D
P- value
Significant
degree
1st day 14 7.423±0.520 6.166±0.289 8.634±0.877 < 0.001 S
2nd day 14 8.190±0.513 7.097±0.256 8.461±0.513 < 0.001 S
7th day 14 8.163±0.500 7.432±0.195 8.134±0.458 < 0.001 S
15th day 14 8.314±0.172 7.718±0.221 8.274±0.212 < 0.001 S
30th day 14 8.334±0.208 7.960±0.196 8.248±0.153 < 0.001 S
45th day 14 8.464±0.231 8.034±0.213 8.418±0.207 < 0.001 S
60th day 14 8.482±0.180 8.054±0.177 8.400±0.176 < 0.001 S
Figure 3: The Comparison between Mean pH at Different Period of Measurements
among Three Studied Groups
Figure 2: Atomic Absorption Spectrophotometer
