MDJ 2010 Jan July

MDJ
Jan - June 2010 KDN PP 4069
MALAYSIAN DENTAL ASSOCIATION
Malaysian Dental Journal
Volume 31 Number 1
A Publication of the
Malaysian Dental Association
ISSN 0126-8023
MALAYSIAN DENTAL JOURNAL
Editor:

Associate Professor Dr. Seow Liang Lin

BDS (Mal), MSc. (London), FDSRCS (England), PhD (Mal), FICD
School of Dentistry
International Medical University
126, Jalan 19/155B, Bukit Jalil
57000, Kuala Lumpur, Malaysia
E-mail : llseow@gmail.com
Assistant Editor:
Secretary:
Treasurer:
Ex-Officio:
Dr. Shahida Mohd Said

Dr. Wey Mang Chek
Dr. Mohamad Muzafar Hamirudin

Dr. Lee Soon Boon
Editorial Advisory Board:

Professor Dr. Rosnah Mohd Zain

Professor Dr. Ong Siew Tin
Professor Dr. Phrabhakaran Nambiar
Associate Professor Dr. Roslan Saub
Dr. Elise Monerasinghe
Dr. Lam Jac Meng
Dr. Mohamad Muzafar Hamirudin
The Editor of the Malaysian Dental Association wishes to acknowledge the tireless efforts of the following referees to
ensure that the manuscripts submitted are of high standard.
Prof. Dr. Toh Chooi Gait
Prof. Dr. Ong Siew Tin
Dato Prof. Dr. Hashim b. Yaacob
Prof. Dr. Lui Joo Loon
Prof. Zubaidah Abdul Rahim
Prof. Dr. Phrabhakaran Nambiar
Dr. Zamros Yuzadi
Dr. Siti Mazlipah Ismail
Prof. Dr. Tara Bai Taiyeb Ali
Dr. Elise Monorasinghe
Prof. Dr. Siar Chong Huat
Prof. Dr. Rahimah Abdul Kadir
Dr. Lau Shin Hin
Assoc. Prof. Dr. Shanmuhasuntharam
Assoc. Prof. Dr. Datin Rashidah Esa
Dr. Loke Shuet Toh
Dr. Fathilah Abdul Razak
Assoc. Prof. Dr. Tuti Ningseh Mohd Dom
Dr. Shahida Said
Dr. Lam Jac Meng
Assoc. Prof. Dr. Roszalina Ramli
Dr. Zamri Radzi
Dr. Nor Himazian Mohamed
Assoc. Prof. Dr. Roslan Abdul Rahman
Dr. Siti Adibah Othman
Dr. Norliza Ibrahim
Dr. Dalia Abdullah
Dr. Zeti Adura Che Abd. Aziz
Dr. Wey Mang Chek
Dr. Wong Mei Ling

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

2010 The Malaysian Dental Association
Malaysian Dental Association Council 2009-2010

President
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President Elect
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Hon General Secretary
-
Asst Hon Gen Secretary
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Hon Financial Secretary
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Asst Hon Fin Secretary
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Hon Publication Secretary -
Elected Council Member
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-
Northern Zone Chairman
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Northern Zone Secretary
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Southern Zone Chairman
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Southern Zone Secretary
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Nominated Council member -

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-
Dr Lee Soon Boon

Dr How Kim Chuan
Dr Haja Badrudeen
Dr Neoh Gim Bok
Dr Mohamad Muzafar
Dr Marlynda Ahmad
Assoc. Prof. Dr Seow Liang Lin
Dr Muda Singh
Dr Chan Cheng Hoong
Dr Teh Tat Beng
Dr Koh Chou Huat
Dr Hong Yong Huat
Dr Leong Chee San
Datin Dr Nooral Zeila Junid
Dato Dr Prof Hashim Yaacob
Dr Jaspall Singh
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Cover page: Pictures courtesy of Dr. Daylene Jack-Min Leong and co-authors

Aim And Scope
The 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
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CONTENT
Editorial: Magnification in Dentistry
Seow LL
Clinical parameters of periodontal abscess: a case series of 14 abscesses

Y K Chan, W S Tien
Prosthodontic Management Of A Malpositioned Endosseous Implant In The Anterior Maxilla: A Clinical Report 8
Daylene Jack-Min Leong, Ansgar Chi-Chung Cheng, Elvin Woei-Jian Leong, Tee-Khin Neo, Helena Lee
Pattern Of Toothpaste Usage In Children Under Six Years Old
S.Nagarajan, Suhairah Jani, Noridawati Mohd Nor
14
What Dental Students Think About Fixed Prosthodontics e-Learning (FPeL)

Marlynda A, Natasya AT, Salleh MAM
20
Evaluation Of Orthodontic Treatment Outcome: A Self-Audit Using The Peer Assessment Rating (Par) Index
Loke Shuet Toh
25
Knowledge Of Prescribing Antimicrobial Among Dental Practitioners In Klang Valley Region

Huda Kh. AbdulKader, Salmiah Mohd Ali, Mohamed Ibrahim Abu Hassan, Mohamed Mansor Manan
35
Refining Occlusion With Muscle Balance To Enhance Long-Term Orthodontic Stability

Derek Mahony
44
Microleakage Of Class Il Cavities Restored Using Composite Resins

Normaliza Ab. Malik, Marhazlinda Binti Jamaludin, Seow Liang Lin
52
Instructions to contributors
58

EDITORIAL: Magnification in Dentistry

Human being had been described by the great philosopher Tielhard de Chardin as a
cerebro-manual creature. However, it is important to appreciate that the hands could
not treat what the eyes could not see. It is therefore recognised that the use of magnification in
dentistry not only improves the quality of care provided to patients, but also expands the range
of treatments that can be offered. Magnification in dentistry can be achieved with either surgical
loupes or dental microscopes. Surgical loupes were first used by restorative dentists in America
in the 1980s and the American specialist endodontists began integrating dental microscopes
into their practice in the mid 1980s. European restorative dentists were made aware of the use
of microscope in endodontics at the beginning of 1990s.
There are numerous benefits of incorporating magnification in the practice of dentistry, namely better posture and
improved comfort, magnified images, increased precision, better illumination, expansion of treatment options and
improved dental care. Ophthalmologists have suggested that while using magnification, the eye muscles become
accustomed to contracting to a given level, and they must relax again to regain normal function. To avoid or reduce
this challenge, it has been suggested that dental pratitioners wearing magnifying loupes should consider not
wearing them all of the time; instead, they should use loupes for some procedures that need precision eg. searching
for canal orifice, crown preparation, evaluating the fit of a long-span fixed prosthesis and unmagnified, normal vision
for other procedures eg. impression taking, extraction.
For the dental practitioners seeking to incorporate magnification into their practice, the choice of equipment
can be confusing as there are many choices available in the current market. The dental practitioners need to
decide the level of magnification they would like to have. Whilst dental operating microscopes can provide
staggering levels of magnification, many routine dental procedures can be performed well with high quality dental
loupes. Dental loupes are less expensive, more practical, portable and easier to use in comparison to the dental
microscopes; therefore it is an excellent alternative to a microscope for procedures that do not require high level
of magnification. It has been recognized that the higher the magnification, the greater detail that can be observed,
however viewing field became smaller.
A number of features must be well-thought-out when considering purchasing dental loupes. One of the most
critical features is the resolution of the loupes. Resolution is the ability to distinguish one small structure from
another. The quality and design of the lenses used in manufacturing the loupes will influence the resolution. The
dental practitioners need to understand that some lenses will provide good resolution across a portion but not
necessarily the entire viewing field. The resolution can only be determined with trying and comparing different
made of dental loupes. It is therefore important to request for a trial period whenever it is possible to determine the
performance of the instrument prior to purchasing.
One question that dental practitioners frequently asked is- What level of magnification is needed? The level of
magnification depends upon the type of procedure being undertaken and also the size of the person. The taller the
practitioner is, generally the higher the magnification should be, since the practitioners head is farther from the
operating site and the image is smaller. The most popular magnification level is about 2.5 X for an average-sized
person and general dental procedures eg. caries removal, crown preparation. For endodontic practice, higher
magnification eg. 4.5 X and 6 X may be desired. The use of a clinical microscope at magnification levels up to
20 times (20X) has been shown to improve treatment outcomes in the field of endodontics. However, learning to use
the microscope requires time and effort, and the cost of the devices is significant.
Using magnification in the field of dentistry is useful and can improve the quality of care render to patients.
Appropriately fitted dental loupes can improve posture during treatment of patients and hence help to reduce
occupational related muscle pain in the neck and shoulder. Dental practitioners should be encouraged to consider
incorporating magnification in their practice.
Associate Professor Dr. Seow Liang Lin
Editor

Clinical parameters of periodontal abscess: a case series of 14

abscesses
Y K Chan1 BDS, MSc, FDSRCS, FDSRCSE
W S Tien2 BDS
1
Consultant Periodontist, Unit Periodontik, Klink Pergigian, Jalan Mahmoodiah, 80100 Johor Bahru.
Dental Officer, Unit Periodontik, Klinik Pergigian, Jalan Mahmoodiah, 80100 Johor Bahru.
ABSTRACT
The prevalence of periodontal abscesses in emergency dental clinics was found to be between 8%-14%. The
purpose of this study was to study the clinical features of periodontal abscesses seen in a specialist periodontal
unit. There were 14 patients with equal distribution of gender. The mean age was 39.6 years. Twelve upper teeth
(86%) were found to be involved as compared to two lower teeth (14%). There were more posterior teeth involved,
a total of nine teeth (64%) as compared to five anterior teeth (36%). The mean pocket depth associated with the
abscesses was found to be 7.4mm. There were ten buccal sites (71%) as compared to four palatal sites (29%).
Average temperature of patients was 36.9 C. Only one patient was found to have cervical lympadenopathy (7%).
The teeth involved were found to be mostly mobile with mobility of grade I to III (71%).
Key Words: Periodontal abscess, pocket, periodontitis, clinical features
Introduction
METHODOLOGY

Periodontal abscess could be defined as a
localized purulent infection within the tissue adjacent to
the periodontal pocket that may lead to the destruction
of periodontal ligaments and alveolar bone.1 It is
classified as one of the three types of abscesses of the
periodontium (gingival, periodontal and pericoronal)
as described in the new classification of periodontal
diseases and conditions by the American Academy of
Periodontology.2

The periodontal abscess is the third most frequent
dental emergency, and it is prevalent among untreated
periodontal patients and periodontal patients during
maintenance.3 The prevalence of periodontal abscesses
in emergency dental clinics was found to be between
8%-14%.3 There is a paucity of scientific literature on
the clinical features of periodontal abscesses.

Herrera D et al.4 reported that 62% of abscesses
affected untreated periodontitis patients with 69%
associated with a molar tooth with bleeding and
suppuration. Mean pocket depth was found to be 7.28
mm with 79% presenting with some degree of mobility.
Cervical lymphadenopathy was noted in only 10% of
patients.

In 2005, Jaramillo A et al. 5 reported that
periodontal abscesses were also associated with
ongoing chronic periodontitis, bleeding on probing,
suppuration with affected teeth being lower anteriors,
upper anteriors and lower molars.
This is a descriptive study of patients with periodontal

abscesses that presented at the periodontal unit,
Mahmoodiah Government Dental Clinic, Johor Bahru,
Malaysia. The data was collected prospectively from
November 2006 to November 2007. The clinical
parameters recorded included sites, probing pocket
depth, mobility, Plaque Index (Silness & Le 1964),
Gingival Index (Le 1967), presence or absence of
cervical lymphadenopthy and temperature.

RESULTS
A total of 14 patients were involved in the study.
The mean age was 39.6 7.6 years. There was equal
distribution of gender with seven male and seven
female patients. Ethnic distribution comprises of two
ethnic races only, nine Malay patients (64%) and
five Chinese patients (36%). Twelve patients were
non-smokers (86%), one former smoker (7%) and
one current smoker (7%). Seven patients were on
supportive periodontal therapy, six were on active
periodontal treatment with only one new case.

There were twelve upper teeth and two lower
teeth with five anterior teeth (36%), five premolar
(36%) and four molars (28%). Probing pocket depth
associated with the abscesses was 7.41.6 mm. The
abscesses were associated with ten buccal sites (71%)
as compared to four palatal sites (29%). Most of the
teeth involved were mobile (71%) with seven teeth
with grade I mobility, two teeth with grade II mobility,
one tooth with grade III mobility. Most of the teeth
6
Chan / Tien
CONCLUSION
were vital with eleven teeth vital (79%) and only three
teeth was found to be non vital (21%).

The mean temperature recorded was 36.90.5
centigrade. There was hardly any involvement of the
cervical lymph nodes with only one patient examined
having cervical lymphadenopathy.

Overall oral hygiene was quite good with the
overall Plaque Index found to be 1.00.4. The overall
Gingiva Index was found to be 0.90.5.
Upper, posterior teeth and buccal sites were found

to be more likely affected by periodontal abscesses.
Periodontal abscesses were found to be associated with
deep pockets more than 6 mm. Systemic involvement
was minimal with most patients found to be afrebile
and without any cervical lymphadenopathy.
Further studies with a bigger sample sizes would be
needed to confirm this preliminary findings.
DISCUSSION
ACKNOWLEDGEMENTS
Periodontal abscess was found to occur more in the

middle age group (39.6 7.6) with equal distribution of
gender in this study. This is important clinically because
it is the significant group in terms of productivity with
a need to preserve the teeth for many more years to
come.

Posterior teeth were found to be more frequently
involved in agreement with a previous study 4 but with
molars and premolars having equal distribution. This
could be due to furcation involvement.

Only one current smoker and one former smoker
were among the fourteen patients. This was surprising
because smoking is an established risk factor for
periodontal disease. It could be due to the fact that half
of the patients were females who usually in Malaysia
do not smoke or due to the small sample size.

Probing pocket depth was found to be deep (7.4
mm) which was in agreement with Kaldahl et al. 6 and
Herrera D et al. (7.28 mm).4 A deeper pocket tends
to have a tortuous pathway contributing to bacterial
niche not easily accessible to debridement, hence
favoring the possible development of an abscess.

Most of the teeth involved had some degree
of mobility (71.4%), this was in agreement with a
previous study (79%).4 Mobility is most likely a clinical
manifestation of severe attachment and bone loss.
Most of the teeth involved were found to be vital
(79%). This is in agreement with the current view that
perio-endo lesion or combined lesion are relatively
uncommon, confirming that most of the severe
periodontally affected teeth were vital.7

The Plaque Index (1.0) and Gingiva Index
scores (0.9) in this study were relatively low. This was
surprising but could be due to the fact that the majority
of patients involved are in active or supportive phase
of periodontal treatments thus having improved oral
hygiene resulting in lower plaque accumulation and
inflammation.

There were hardly any systemic involvements
with only one patient having cervical lymphadenopathy
(7%) in agreement with a previous study 4 that found
only 10% having lymphadenopathy.

The majority of the patients were afrebile with
a mean temperature of 36.9 centigrade suggesting that
periodontal abscess rarely causes systemic signs and
symptoms.

The authors would like to extend their heartfelt
gratitude to the Johor State Deputy Director of Health
(Oral Health) for her help and encouragement. Special
thanks to Tan Sri Dato' Seri Dr. Hj. Mohd Ismail bin
Merican, Director General of Health, Malaysia for his
kind permission to publish this paper.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
American Academy of Periodontology. Parameters

on acute periodontal diseases. J. Periodontol
2000;71(5 Suppl):863-4.
Consensus Report: Abscessess of the periodontium.
Annals of Periodontology 1999; 4:83.
Ahl DR, Hilgeman JL, Snyder JD. Periodontal
emergencies. Dent Clin North Am. 1986
Jul;30(3):459-72.
Herrera D, Roldn S, Gonzlez I Sanz M. The
periodontal abscess (I). Clinical and microbiological
findings J Clin Periodontol. 2000 Jun;27(6):38794.
Jaramillo A, Arce RM, Herrera D, Betancourth M,
Botero JE, Contreras A. Clinical and microbiological
characterization of periodontal abscesses. J Clin
Periodontol. 2005 Dec;32(12):1213-8.
Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP,
Dyer JK. Long-term evaluation of periodontal
therapy: II. Incidence of sites breaking down. J
Periodontol. 1996 Feb;67(2):103-8
Bergenholtz G, Lindhe J. Effect of experimentally
induced marginal periodontitis and periodontal
scaling on the dental pulp. J Clin Periodontol.
1978 Feb;5(1):59-73.
Address for correspondence:

Y K Chan
Consultant Periodontist
Unit Periodontik, Klink Pergigian
Jalan Mahmoodiah, 80100 Johor Bahru
Tel: 07-2270470
Fax: 07-2277299
E-mail address: cykian99@hotmail.com
Prosthodontic Management Of A Malpositioned Endosseous

Implant In The Anterior Maxilla: A Clinical Report
Daylene Jack-Min Leong,1 Ansgar C Cheng,2 Elvin Woei-Jian Leong,3 Tee-Khin Neo,4 Helena Lee5
1
BDS, Graduate Periodontics Resident, Department of Periodontics and Oral Medicine, School of Dentistry,
University of Michigan, Ann Arbor, MI, USA
BDS, MS, FRCDC, FRACDS, FAMS. Adjunct Associate Professor, Graduate Prosthodontics, National University
of Singapore. Consultant Prosthodontist, Specialist Dental Group, Mount Elizabeth Medical Center, Singapore
BDS, MDS, MRDRCS, FRACDS, FAMS. Consultant Prosthodontist, Specialist Dental Group, Mount Elizabeth
Medical Center, Singapore'
BDS, MS, Diplomate, American Board of Prosthodontics, FRACDS, FAMS. Adjunct Senior Lecturer, Restorative
Dentistry, National University of Singapore. Consultant Prosthodontist, Specialist Dental Group, Mount
Elizabeth Medical Center, Singapore
BDS, MSc, FAMS. Consultant Periodontist, Specialist Dental Group, Mount Elizabeth Medical Center,
Singapore
ABSTRACT
Restoration of anterior teeth with implant-supported crowns is a technique-sensitive procedure. Despite careful
treatment planning, malpositioned implants is not uncommon. Several techniques have been described to
prosthodontically compensate for improperly inclined implants. The following clinical report describes and
illustrates an alternative technique for the prosthodontic management of a malpositioned endosseous implant in
the anterior maxilla.
Key Words: Malpositioned implants, anterior maxilla, prosthodontic management

maintaining an intact interdental papilla.10,11

Correct positioning of the implant in a
3-dimensional manner is another key factor that
contributes to the success of the restoration. Apical
positioning of the implant is required to mask the
metal of the implant and abutment. It is generally
accepted that the more apical the placement of the
implant, the better the emergence profile. 12 However,
placing the implant-abutment surface more apically
also means losing more crestal bone for establishing
the peri-implant biologic width. 13-15 The implant
shoulder should ideally be located approximately 2 mm
apical to the midfacial gingival margin of the planned
restoration 6. This allows for 3 mm of soft tissue
emergence on the direct labial surface of the implant. 6
It is generally recommended to position the implant
1.5 to 3 mm below the cementoenamel junction (CEJ)
of the adjacent teeth for optimal implant esthetics.16

Soft tissue factors also influence the ultimate
treatment outcome. One of which is the presence of
adequate keratinize gingiva. Although keratinized tissue
is not mandatory for implant placement, 17 it has been
shown to be preferable in the esthetic zone to ensure
tissue stability and to improve esthetics. 18-21 This taken
in consideration with the patients gingival biotype will
partly determine the risk for postsurgical recession
as the patients biotype would determine how the
Introduction

Restoration of anterior teeth with implantsupported crowns is a technique-sensitive procedure
and it is one of the challenges for the surgical-restorative
team.1-3 Factors that directly affect clinical outcomes
include the quantity and quality of available alveolar
residual ridge, correct positioning of the implant 3
dimensionally, the soft tissue biotype, the selection of
the implant abutment, the provisional restoration and
the fabrication of the definitive crown. 3

The amount of available bone is one of the
critical factors determining the ultimate success of the
implant. Sufficient facial bone thickness and height
is critical for long term stability of gingival margins
around implants and adjacent teeth, preventing buccal
recession and exposure of the implant. 4-6 Studies
have shown that 1.8 mm of buccal bone thickness7
or at least a width of 2 mm buccal wall8 is required
to maintain the alveolar bone level at the implant
platform and prevent bone loss in that area.

Besides buccal bone thickness, sufficient
interproximal bone height of the teeth adjacent to the
implant is also necessary as it influences the height
of the peri-implant papillae. 9 Studies have shown
that a distance of 4-5 mm from the alveolar crest to
the contact point would maximize esthetics through
Daylene Leong / Ansgar Cheng / Elvin Leong / Neo / Helena Lee
periodontium responds to implant placement, 22,23 thus

affecting the esthetic outcome.

It has been found that thick biotypes
characterized by dense fibrotic tissue, a thick band of
keratinized gingiva and a lack of scalloping between
the interdental papilla and buccal gingiva would pose
less of a challenge in attaining a desirable esthetic
response24. A thick gingival biotype is more resistant
to trauma from surgical or restorative procedures
and tends to respond to insult by pocket formation
instead of recession and keratinized gingiva is usually
abundant. A thin gingival biotype characterized by
thin, delicate soft tissue, minimal keratinized gingiva
and pronounced soft-tissue scalloping 25 would be
more prone to esthetic failure as the tissue would
respond to periodontal insult by recession. A gingival
thickness 1.5 mm and width of keratinized gingiva 2
mm has been reported as the soft tissue characteristics
for predictable esthetic implant placement.26

Incorrect implant placement may therefore
complicate the restorative treatment process and may
compromise the esthetic outcome. Recent technology
have allowed more predictable placement of
endosseous implants27-29 but malposition of endosseous
implants is still not uncommon.

Several techniques have been described to
prosthodontically compensate for improperly inclined
implants30-34. The following clinical report describes
an alternative technique for the prosthodontic
management of an unfavorable implant position.
Fig. 1: OPG during orthodontic treatment prior to

implant placement

Fig. 2: OPG of bonded composite resin pontic as

provisional after implant placement
Clinical report

At second stage surgery, the composite resin
pontic was removed and a soft tissue flap was raised to
expose the implant. Placement of the implant was found
to be excessively inclined towards the buccal direction
(Fig. 3). An implant level definitive impression was
made and the composite resin pontic was rebonded to
the adjacent maxillary central incisor.

A 30 year-old healthy Chinese female who is a
non-smoker presented with a missing left maxillary
central incisor. Pre-operative examination revealed a
crest width of more than 2 mm and sufficient ridge
height with no signs of facial bone atrophy. More than
2 mm of keratinized gingiva on the facial aspect of the
upper anterior teeth was also present and the patient
had a moderately thick gingiva biotype. Smile analysis
revealed a medium smile line.

Orthodontic treatment was carried out to
obtain the desired mesiodistal width, alignment and
incisor overlap for the replacement of the left central
incisor (Fig. 1). After initial insertion of the implant,
a composite resin pontic was bonded to the adjacent
maxillary incisor to serve as a provisional restoration
(Fig. 2).
Fig. 3: Implant placement excessively inclined towards

the buccal
Prosthodontic Management Of A Malpositioned Endosseous Implant In The Anterior Maxilla: A Clinical Report

An implant level burn out type abutment was
selected (UCLA abutment, Implant Innovation Corp.).
A full contour sculpture of the tooth was fabricated
using acrylic resin (Fig. 4) (Pattern Resin, GC America,
Chicago, Ill.). The pattern was cutback 1.5 mm for
the development of a full ceramic crown. The acrylic
resin pattern was subsequently casted in type III gold
alloy (Degulor C, Degussa, Hanau, Germany) (Fig.
5). A provisional restoration was made using a bisacrylic composite material (Luxatemp, DMG, Hamburg,
Germany).
Fig. 6: Abutment screw access hole was filled up with

gutta-percha and composite resin material
Fig. 4: Full contour sculpture of tooth fabricated using

acrylic resin
Fig. 7: Post-cementation of provisional crown
Fig. 5: Custom abutment casted in type III yellow gold

The custom abutment was autoclaved and it was
inserted on the implant after a flap was raised. The
abutment was torqued down to 35Ncm. The labially
positioned abutment screw access hole was filled up
with gutta-percha and composite resin material (Z100,
3M, St. Paul, MN) (Fig. 6). The provisional crown was
inserted using provisional cement (Tempbond NE, Kerr,
Romulus, MI) (Fig. 7). The implant site was allowed
to heal for 6 months before the fabrication of the
definitive restoration. 6 months later, the provisional
crown was replaced with a definitive full ceramic
crown (Fig. 8 - 11).
Fig. 8: Post-cementation of definitive all-ceramic crown
Fig. 9: Post-operative frontal view of patients smile
10

From the prosthetic aspect, duration of
provisionalization was stretched over 6 months. The
definitive abutment was torqued down and a provisional
crown placed for 6 months. This would allow for the
establishment of soft-tissue contour and optimize
gingival esthetics.35 The crown was also fabricated with
a long interproximal contact area to ensure a contactto-alveolar bone distance of not more than 5 mm,
which managed to support the interproximal papillae
during the issue visit.

Although the implant was excessively inclined
towards the buccal, the implant shoulder measures
approximately 4 mm below the CEJ of the adjacent
incisors, which contributed to a more favorable
emergence profile. To promote implant integration, a
fixed restoration bonded to the adjacent incisor teeth
was the provisional of choice after implant insertion,
to avoid placing any pressure on the implant healing
cap. Gold alloy was the material of choice for the
custom abutment because a cast metal abutment can
be easily shaped to the desired definitive contour, for
optimal retention and resistance form, and thickness
of the ceramic crown.35 The cast metal abutment can
also be easily contoured to replicate the emergence
profile established by the provisional restoration, 36
to enhance the overall esthetic outcome of the allceramic crown.

Working in our favor in this case was also the
patients soft tissue biotype. Having a moderately thick
gingiva biotype and adequate width of keratinized
gingiva of more than 2 mm lowers the patients risk
of gingival recession and a poorer esthetic outcome.
Furthermore, the patient has a medium smile line,
which is an advantage because patients with a high lip
line will show more tissue and reveal any unesthetic
aspects of the peri-implant tissue.

Despite the reasonably successful restoration
of the misangulated implant in this report, longterm follow-up appointments would be necessary to
monitor for potential peri-implant bone loss, soft tissue
recession and/or formation of periodontal pockets
especially at the labial aspect where composite resin
was placed at the screw access hole. It must also be
stressed to the patient the importance of a meticulous
oral hygiene maintenance regime, in order to increase
the long-term success of the implant restoration.
Fig. 10: OPG of implant with definitive PFM crown
Fig. 11: PA xray of implant with definitive PFM crown
Discussion

Improperly inclined implants can lead to more
technically demanding prosthodontic management.
To compensate for the potential esthetic complication
with the misangulated implant, several measures were
undertaken.

From the surgical aspect, the crestal incision
at stage II surgery to expose the implant was located
approximately 2 to 3 mm towards the palatal aspect
and extended through the sulcus of the adjacent
incisor teeth to the facial aspect of the alveolar crest.
Such incision design avoids the formation of scar tissue
in the midcrestal area and ensures sufficient vascularity
of the buccal flap in the area of the future papillae.
Bone augmentation was not carried out in this patient
as more than 2 mm of buccal bone thickness was
present at implant placement.
Summary

Despite
careful
treatment
planning,
malpositioned or unfavourable inclination of implants
is not uncommon. A relatively inexpensive and simple
clinical solution has been presented and illustrated.
11
Prosthodontic Management Of A Malpositioned Endosseous Implant In The Anterior Maxilla: A Clinical Report
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Daylene Jack-Min Leong, BDS
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Department of Periodontics and Oral Medicine
University of Michigan School of Dentistry
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E-mail address: daylene@umich.edu
13
Pattern of Toothpaste Usage in Children Under Six Years Old
S.Nagarajan M.P.Sockalingam
BDS (MALAYA), MDentSci (LEEDS) Faculty Of Dentistry, National University Of Malaysia
Suhairah Jani
DDS (UKM), Faculty Of Dentistry, National University Of Malaysia
Noridawati Mohd Nor
DDS (UKM), Ministry Of Health, Malaysia
ABSTRACT
Objectives: To assess pattern of toothpaste usage among young children under 6 years old.
Materials and methods: This was a cross-sectional descriptive study carried out at the Faculty of Dentistry, Universiti
Kebangsaan Malaysia. Parents of children below 6 years old were involved. 200 questionnaires were distributed and
136 (68%) were returned for analysis. The questionnaire covered the following parameters: type, frequency, and
quantity of toothpaste usage among children, level of parental knowledge of fluoride concentration in toothpaste
and selection criteria of suitable toothpaste for their children. Results: Majority of the respondents (83.1%) said
they used childrens toothpaste to brush their childs teeth and 62.5 % of them knew that the toothpaste used had
fluoride in it. Slightly more than half of the respondents (53.7%) said they started brushing their childs teeth one
year after eruption of the first tooth. Almost an equal proportion of the respondents reported using toothpaste
twice daily (50.7%) and only 44.1% of them supervised their childrens brushing. Respondents generally used more
than a pea-sized toothpaste quantity (53.6%). Taste, fluoride concentration and brand of the toothpaste appeared
to be the main criteria that influenced the selection of the toothpaste (55.9%). Income and educational levels of
the respondents did not influence the type of toothpaste used. Conclusion: These findings indicated that although
parents were brushing their childrens teeth with children toothpaste, they were still unaware of the proper usage
and importance of fluoridated toothpaste.
Key Words: Toothpaste, Fluoride, Pattern
Introduction
under six years old in an urban setting.

Toothbrushing is an aid for oral hygiene care.
Effective brushing with selected toothpaste helps to
remove dental plaque that contributes to dental caries.
There are many types of toothpaste available in the
market in Malaysia1. Generally the type, frequency
and quantity of toothpaste used by children are based
purely on parental preference.

Children below the age of six are often closely
scrutinised in many dental researches especially in
relation to usage of fluoridated toothpaste 2,3. Over the
years, overzealous usage of fluoride has been linked to
dental fluorosis4. Accidental ingestion of fluoridated
toothpaste is said to be one of the main contributing
factor of dental fluorosis5. Children between the ages
of 15 and 30 months are most at risk to develop dental
fluorosis especially to the anterior teeth 6,7,8. Numerous
guidelines have been published regarding the usage of
fluoridated toothpaste in dentistry 9,10. It is not clear
how fluoridated toothpaste is used among young
children in an urban population.

The aim of this study is to assess parental
pattern of toothpaste usage among young children
MATERIALs AND METHODS


This was a cross-sectional descriptive study
involving parents of children below 6 years old
attending for treatment at the Universiti Kebangsaan
Malaysia (UKM) Dental Faculty. The selection of the
participants for this study was based on the following
inclusion criteria:

Parents who have one or more children below 6
years of age.

Parents having children with one or more teeth.

Parents able to understand the purposes, risks
and benefits of this study.

Parents able to give a written consent if needed.

Parents with significant cognitive impairment
who were unable to give informed consent and who
were unable to read or write in either Bahasa Melayu
or English language were excluded from this study.

Verbal and written information of the study were
also given to the selected parents prior to the study.
The parents had to answer a questionnaire that was
14
S.Nagarajan / Suhairah / Noridawati
Table 1: Toothbrushing practices and knowledge of

toothpaste used
given to them. The questionnaire has two parts; Part A

and Part B. Part A was related to questions pertaining
to personal demographic details of the parents or
guardians, and Part B focused on information related
to patterns of toothbrushing and toothpaste usage
among children below 6 years old and the level of
parental knowledge on their childrens oral health
care.

The questionnaire was pretested to assess the
suitability of the questionnaire design on 10 selected
individuals. Some corrections to the main questionnaire
were made based on the evaluation of the baseline
information gathered.

This study was approved by the ethics committee
of the Faculty of Dentistry, Universiti Kebangsaan
Malaysia (UKM).

Data collected, was computed and statistically
analysed using SPSS Version 14 Statistical Software.
ITEM

RESPONSES PERCENTAGE
(n)
(%)
Commencing time of toothbrushing with

toothpaste after eruption of first primary tooth
Immediately
after eruption
29
21.3
Few months to a
year after eruption
34
25.0
More than one

year after eruption
73
53.7
113
22
1
83.1
16.2
0.7
Type of toothpaste used
RESULTS
Childrens toothpaste
Adult s toothpaste
Herbal or other toothpastes

A total of 200 questionnaires were distributed
to the parents through student clinicians. Of the 200
questionnaires, 152 were returned giving a response
rate of 76%. During the data analysis stage, a further
16 questionnaires were rejected because of incomplete
information. In all, only 136 questionnaires (68%) were
used in the statistical analysis. Of the 136 respondents,
94.7% (n=130) of them had undergone secondary or
tertiary level of education. When the income levels of
the parents were compared, 77.2% (n=105) of them
earned more than RM 1000 a month.

To the question as to when they started using
toothpaste to brush their childs teeth, slightly more
than half of the respondents reported it to be few
months to a year after eruption of the first tooth
(54.4 %). Almost a quarter of the overall respondents
(24.3%) also said they only started using toothpaste to
brush their childs teeth with toothpaste more than a
year after the eruption of the first tooth (Table 1).

The majority of the respondents (83.1%) said
they used children toothpaste to brush their childrens
teeth. Usage of herbal toothpaste for brushing in this
surveyed group is negligible (0.7%). However, there
were still a small proportion of respondents (16.2%) in
our survey who were still using adult toothpaste (Table
1).
Aware of fluoride presence in the toothpaste used

Aware
Not aware
Not sure
85
15
36
62.5
11.0
26.5
No of times toothpaste used for toothbrushing

per day
once
Twice
More than twice
49
69
18
36.0
50.7
13.2
Quantity of toothpaste placed on toothbrush

brittles during toothbrushing
Pea-sized
Half-length
Entire length
63
49
24
46.3
36.0
17.6
76
60
55.9
44.1
Supervised toothbrushing
Not supervised
Supervised
Immediate post toothbrushing behaviour

Rinse with plenty of
water and spit out
106
78.0
Spit out without rinsing
15
11.0
Swallow toothpaste
15
11.0
15
the respondents (11%) said their children swallow

toothpaste during brushing (Table 1).

When the respondents were asked to select two
main factors that they would take into consideration
when buying toothpaste for their children, majority of
them have selected taste (39.7%), fluoride concentration
(20.6%) and brand (16.9%) of the toothpaste as their
primary reasons (Table 2).

When the respondents educational and income
levels were analysed with reference to the type of
toothpaste used, the results showed there were
no obvious differences (Table 3 and 4). Majority
of respondents used children toothpaste regardless
of either their educational background or earning
capacity.

Almost two thirds of the respondents (62.5 %)
said they knew that the toothpaste used to brush their
children teeth contain fluoride in it. There was still a
significant percentage of parents (37.5%) who were
still not sure or do not know of the presence fluoride
in the toothpaste used (Table 2).
Table 2: Main criteria for selection of toothpaste for
children by parents
CRITERIA

RESPONSES PERCENTAGE
(n)
(%)
Price
Brand
Taste
Colourful Packaging
Fluoride concentration
Recommended by others
Based on believes
Total responses
26
44
108
14
22
16
8
9.6
16.2
39.7
5.2
20.6
5.9
2.9
272
Table 4: Type of toothpaste used with various income

levels

TYPE OF
TOOTHPASTE

100.00
*Two selection criteria were recorded for each respondent
Adult
Children
Herbal / others
E DUCATION
LEVEL
10(14.5%)
58(84.1%)
1(1.4%)
12(19.7%)
49(80.3%)
0(0%)

Regarding quantity of toothpaste used for
brushing, 46.3% respondents said they placed only
a pea-sized toothpaste quantity. Slightly more than
half of the respondents (53.6%) said the quantity of
toothpaste used was of half length or entire length of
the toothbrush bristles (Table 1).

Only 32.4% of the respondents surveyed said
they supervised their childrens toothbrushing. Slightly
more than half of respondents (55.9%) said their
children brushed their teeth without any supervision
(Table 1).

More than two thirds of the respondents (77.9%)
said their children rinsed mouth with plenty of water
and spit it out after brushing. A small proportion of
4(9.5%)
37(88.1%)
1(2.4%)

Questionnaires are commonly used as an
important tool to evaluate and determine patients
knowledge, attitudes and practises, although they
may have their limitations. In this study sample,
the response rate to the questionnaires that were
distributed to the respondents was 76%. Demographic
analysis on the income and educational levels of the
respondents showed that two thirds (77.2%) of them
were earning a minimum wage of above RM 1000
and 95.6% of them had obtained education beyond
the secondary level respectively. This sample may
be reflective of an urban population such as in Kuala
Lumpur in terms of income and educational heights.

Based on this study, more than half of the
respondents (53.7%) said they only started brushing
their childrens teeth with toothpaste between few
months and a year after eruption of the first tooth.
This shows that most respondents were unaware about
the exact timing to start using toothpaste to brush
their childrens teeth. The available recommendations
indicate that plaque removal should be carried with
either washcloth or a soft, small headed toothbrush
in a combination with smear layer of childrens
fluoridated toothpaste as the childs first tooth erupts
9,10,11
. However, one has to bear in mind that not
all children are able to tolerate the presence of
PRIMARY SECONDARY TERTIARY

EDUCATION EDUCATION EDUCATION
(n=6)
(n=69)
(n=61)
0(0%)
6 (100%)
0(0%)
16(25.4)
47(74.6%)
0(0%)
DISCUSSIONS
Table 3: Type of toothpaste used with various

educational levels
TYPE OF
TOOTHPASTE

INCOME LEVEL

>RM1000 RM1000-3000 >RM3000
(n=31)
(n=63)
(n=42)
Adult
2(6.5%)
Children
29 (93.5%)
Herbal / others
0(0%)

All the respondents claimed that their children
carried toothbrushing with toothpaste daily. Nearly
two thirds of the respondents (63.9%) reported using
toothpaste twice or more daily when brushing their
childrens teeth (Table 3).
16
level, much is still needed to be done to increase the

awareness of fluoride role in caries prevention. Besides
emphasis on fluoride anti-caries action, one should
also focus on educating the public on what are the
ill-effects of fluoride if taken excessively. This is very
important to ensure preventive and remedial steps can
be instituted to prevent untoward incidents of fluoride
overdose that may be detrimental to health17.

The present study also showed that herbalbased toothpastes were not very popular among
respondents (0.7%). This is probably due to the taste
of the toothpaste which may not be to the liking of
small children. Religious sentiment or belief also does
not seem to be a major determinant when it comes to
selection of children toothpaste.

All the respondents in the present study said
they used toothpaste to brush their childrens teeth.
About half of the respondents (50.7%) said they used
toothpaste twice daily to brush their childrens teeth.
This is in line with the finding by Tay and Jaafar (2008)18
where 47.2% of children in their study sample were
brushing their teeth twice daily. A small proportion
of respondents (13.2%) in the present study said they
used toothpaste to brush their childrens teeth more
than twice daily. The frequency of brushing often
varies from one person to another. Most people brush
their teeth at least once daily as a norm. However,
toothbrushing twice daily with fluoridated toothpaste is
a common practice often recommended as a routine. It
is not very clear whether increasing the toothbrushing
more than twice daily will result in lower dental caries
experience. However, multiple toothbrushing episodes
each day probably can result in ingestion of excess
fluoride especially in children19. When focusing on
toothbrushing, one should not ignore the fact that
effectiveness of toothbrushing is much more important
than frequency of toothbrushing.

Children below the age of six have poorly
coordinated swallowing reflex and also unable to
expectorate oral content effectively20,21. This may lead
to high probability of accidental swallowing of large
quantities of toothpaste per day if the amount used is
not monitored, more so if they are using fluoridated
toothpaste. When the respondents in this study were
asked on the amount of toothpaste used to brush their
childrens teeth, 53.6% of the parents said they use
more than half the length of the toothbrush bristles.
Only 46.3% of the respondents said they used a peasized toothpaste quantity for brushing. This is similar to
an earlier study conducted by Amdah & Jaafar 22 who
reported only 40% of children used the recommended
pea-sized shape toothpaste volume. The quantity of
toothpaste placed onto the bristles of the toothbrush
is very essential to prevent the excessive intake of the
fluoride by the children.

Young children below the age of six were also
reported to swallow a mean of 0.3 g of toothpaste per
brushing and this can inadvertently swallow as much
toothbrush or toothpaste in their mouth. This may

be a reason why respondents (78.7%) in the present
study did not commence early toothbrushing besides
of the unawareness of the actual timing to commence
toothbrushing in children. We believe that oral hygiene
care should begin as early as 3 months into infancy well
before the first primary tooth erupt where the gums
of the teeth bearing areas should be wiped gently
using water with gauze or cotton. Thereafter, early
introduction to toothbrushing activity such as using
soft finger tip toothbrushing aid either dipped in warm
water or with smear layer of fluoridated childrens
toothpaste if the child can tolerate should commence
as soon as the first tooth starts to erupt. This process
which begins in early infancy may be a useful aid in
providing a learning curve for a child to accustom to
toothbrushing with toothbrush and toothpaste as it
grows older.

When questioned about the type of toothpaste
used to brush their childrens teeth, most of the
respondents (83.1%) said they used childrens
toothpaste. This is in line with the European Academy
of Paediatric Dentistry (EAPD)9 and American Academy
of Pediatric Dentistry (AAPD)10 recommendations,
which suggested that children below the age of six
should used children toothpastes with low fluoride
concentration (less than 500 ppm). However, one has
to be cautious when selecting an appropriate childrens
toothpaste as not all children toothpastes marketed
has fluoride in them. Some even may have a higher
than the recommended concentration of fluoride.
Of late there is also a growing dilemma against early
use of fluoride toothpaste in infants below the age of
two. There are two schools of thought on this issue;
one argues that children below the age of two are
at higher risk for enamel fluorosis than children who
begin to use fluoride toothpaste later or not at all 12-15.
Therefore, it recommends use of gauze and water or
non fluoride toothpaste for cleaning of infants teeth.
Another school claims use of smear layer childrens
fluoride toothpaste may be beneficial in preventing
caries. One cannot deny the role of fluoride in caries
prevention and this has been proven clinically through
various studies16. Therefore, recommendations by
EAPD9 and AAPD10 on fluoride toothpaste usage in
children below 6 years old should be used as a guide
until its proven otherwise.

Although majority of respondents (83.1%) have
indicated they were using childrens toothpaste, only
62.5% of them knew that fluoride was present in the
toothpastes that they were using. These findings indicate
that some of the respondents were using childrens
toothpaste even without realising it has fluoride in it
or not. It is likely that many of the respondents were
using fluoridated toothpaste for their children without
knowing of its clinical importance in relation to dental
health. Although majority of respondents (95.5%)
in this study were educated above the secondary
17
as 0.8 g in a day23,24. This is why children below the

age of six were advised to use low fluoride toothpaste
and controlled quantity of toothpaste in order to gain
maximum benefit anti-caries activity and to prevent
accidental ingestion of fluoride 25. The findings of
this study showed lack of knowledge of respondents
on quantity of toothpaste that should be used. It is
prudent to suggest that children between 6 months to
2 years of age should use small smear of low fluoride
toothpaste to clean the teeth. While children between
2 and 6 years old should use a pea sized quantity of less
than 500 ppm of fluoride containing toothpaste, unless
it is recommended otherwise by their dentists as
outlined in the EAPD9 and AAPD10 recommendations.
More than half of the children (55.9%) in this study were
brushing their own teeth without any supervision. This
is similar to the studies conducted by Amdah & Jaafar
(2000)22, and Tay & Jaafar (2008)18, where most of the
parents or guardians did not supervise their childrens
brushing regularly. Young children usually lack the
fine manual dexterity to carry out brushing effectively
and also inability to expectorate, parents must ensure
that they supervise their childrens tooth-brushing or
brush their toddlers teeth, especially by standing or
kneeling behind the child in front of the sink or mirror.
This is important to in order to avoid over ingestion of
toothpaste and to make sure that their childrens teeth
are effectively cleansed11.

In this study only a small proportion of the
respondents (11%) said that their children swallowed
toothpaste during brushing. This is indeed a good
practice as it minimises the amount of toothpaste
swallowed. However, one has to interpret this finding
with caution because about half of the respondents
(55.9%) said that they did not supervise their childrens
toothbrushing. In order to reap the beneficial effect
of fluoride in caries prevention, one has to ensure
continues presence of fluoride orally for considerable
period for it to assert its effect on the teeth 26,27.
Majority of respondents (78%) in this study said their
children rinsed with a lot of water and spit out after
toothbrushing and this may not be a good practice as
it tends to wash away the fluoride needed for caries
prevention activity28,29. Therefore, childrens below
the age of six should be encouraged to either rinse
briefly with a small amount of water or spit out the oral
content without rinsing in order to retain more fluoride
in the mouth.

Taste, fluoride and brand of the toothpaste
appeared to be the three main determinants for
parents to select the toothpaste of their choice. These
findings suggested that fluoride concentration is not
the primary determinant for selection of toothpaste,
although majority of the respondents (83.1%) in this
survey said they were using childrens toothpaste which
generally contains less than 500 ppm fluoride. One has
to be careful about using taste as the primary criteria
for toothpaste selection, as in one hand it encourages
children to brush their teeth and in another it increases

the risk of fluoride ingestion. One reassuring aspect
of the present study is that the respondents also
considered fluoride concentration in the toothpaste as
one of the criteria for toothpaste selection.

When income and educational levels of the
respondents were compared with the type of toothpaste
used, the majority of them use children toothpaste for
brushing and there are no obvious disparities between
the groups. This shows that education and income
levels do play a role for good oral hygiene care in our
society.

Based on the findings of this study, it appears
that the general public is still much unaware of the
proper guideline on the selection and usage of the
toothpastes in children. There is much needed to be
done to improve the knowledge, attitude and practices
of oral health our general public. In relation to oral
hygiene of care of young children, greater emphasis
should be directed towards educating the ante-natal
mothers, in order to prepare them psychologically to
face the challenges of oral healthcare that they may
encounter later on their children.
CONCLUSION

Although most respondents in this study
were using children toothpaste for toothbrushing, a
significant proportion of them were not practicing the
recommended steps on toothpaste usage. However,
these findings need to be substantiated with a larger
representative sample especially comparing the
knowledge, attitude and practices between urban and
rural populations.
ACKNOWLEDGEMENT

The authors would like to record their sincere
appreciation to the members of the research committee
of the Faculty of Dentistry, Universiti Kebangsaan
Malaysia for their assistance in the research project
and our heartfelt thanks to Brigadier General Dato Dr.
Arichandra Nadarajah and Dr Alida Mahyuddin for their
advice and comments.
REFERENCES
1.
2.
3.
18
S Musa et al. Toothpaste available in the Malaysian

market. Annals Dent University Malaya 1998; 5:
45-48,
Lynch RJM, Navada R & Walia R. Low-levels of
fluoride in plaque and saliva and their effect
on the demineralisation and remineralisation of
enamel; role of fluoride toothpastes. Int Dent J
2004; 54: 304-309.
Featherstone JDB, Prevention and reversal
of dental caries; Role of low level fluoride,
Community Dent Oral Epidemiol 1999; 27: 31-40
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Mascarehas AK. Risk factors for dental fluorosis:

A review of recent literatures. American Academy
of Pediatric Dentistry 2000; 22(4): 269-277
Tanbari E.D et al. Dental fluorosis in permanent
incisor teeth in relation to water fluoridation,
social deprivation and toothpaste usage in infancy,
British Dent J 2000; 189(4): 216-220
Milsom K & Mitropoulos CM. Enamel defects in
8-year-old in fluoridated and non-fluoridated
parts of Cheshire. Caries Res 1990;24:286-289
Pendrys DG, Katz RV & Morse DE. Risk factors for
enamel fluorosis in a non-fluoridated population.
Am J Epidemiol 1996;143:808-815
Osuji OO et al; Risk Factors for dental fluorosis
in a fluoridated community, J Dent Res 1988; 67:
1488-1492,
Oulis C J et al; Guidelines on the use of fluoride
in children; a EAPD policy document; European
Journal of Paediatric Dentistry 2000; 1(1): 7-12,
American Academy of Pediatric Dentistry. Policy
on early childhood caries (ECC): Classifications,
consequences, and preventive strategies. Peadiatr
Dent 2008;30(suppl):40-42
Richard Welbury et al. Textbook of Paediatric
Dentistry. 3rd ed; Oxford University Press; 2005
p.139.
Lalumandier JA & Rozier RG. The prevalence
and risk factors of fluorosis among patients
in paediatric dental practice. Pediatr Dent
1995;17:19-25
Skotowski MC, Hunt RJ, Levy SM. Risk factors for
dental fluorosis in paediatric dental patients. J
Public Health Dent 1995;55:154-159
Mellberg JR. Fluoride dentifrices: current status
and prospects. Int Dent J 1991;41:9-16
Mascarenhas AK & Burt BA. Fluorosis risk from
early exposure to fluoride toothpaste. Community
Dent Oral Epidemiol 1998; 26(4): 241-248
Clarkson JE, Ellwood RP & Chandler RE. A
comprehensive summary of fluoride dentifrice
caries clinical trials. Am J Dent;6 (special issue):59106
Li Y. Fluoride: safety issues. J Indiana Dent Assoc
1993;72(3):22-26
Tay HL and Jaafar N. Mothers knowledge of
fluoride toothpaste usage by their preschool
children
Levy SM. Review of fluoride intake from fluoride
dentifrice. J Dent Child 1993;61:115-124
Nacacche H, Simard PL, Trahan L, et al. Factors
affecting the ingestion of fluoride dentifrice by
children. J Public Health Dent;52:222-226
Simard PL, Nacacche H, Lachapelle D & Brodeur
JM. Ingestion of fluoride from dentifrices by
children aged 12 to 14 months. Clin Pediatr
1991;30:614-617
22. Amdah M and Jaafar N. Fluoride toothpaste

utilization behaviour among pre-school in Banting
Selangor. Paper presented at the First Scientific
Meeting (Malaysian Section) of the IADR (SEADiv.),
University Malaya, 16 Sept. 2000
23. Levy SM. Review of fluoride exposures and
ingestion. Community Dent Oral Epidemiol
1994;22:173-180
24. Levy SM. An update on fluoride and fluorosis. J
Can Dent Assoc 2003;69(3):286-291
25. Pang DT, Vann WF Jr. The use of Fluoride containing
toothpastes in young children: The scientific
evidence for recommending a small amount.
Pediatr Dent 1992;14(6):384-387
26. Duckworth RM and Morgan SN. Oral fluoride
retention after use of fluoride dentifrices. Caries
Res 1991;25:123-129
27. Reintsema H, Schuthof J & Arends J. An in
vivo investigation of fluoride uptake in partially
demineralised human enamel from several
different dentifrices. J Dent Res 1985;64:19-23
28. Duckworth RM, Knoop DTM, Stephen KW. Effect
of mouthrinsing after toothbrushing with a
fluoride dentifrice on human salivary fluoride
levels. Caries Res 1991;25:337-342
29. Chesnutt IG, Schafer F, Jacobson APM, Stephen
KW. The influence of toothbrushing frequency
and post-brushing rinsing on caries experience
in a caries clinical trial. Community Dent Oral
Epidemiol 1998;26:406-411
Lt Col (Rtd) Dr S.Nagarajan M.P.Sockalingam
Department Of Operative Dentistry
Universiti Kebangsaan Malaysia
Jalan Raja Muda Abdul Aziz
50300. Kuala Lumpur
E-MAIL: drnaga67@gmail.com
FAX: 03-92897798
TELEPHONE: 03-92897859 / 019-2185493
19
What Dental Students Think About Fixed Prosthodontics

e-Learning (FPeL)
Marlynda A
Senior lecturer, Department of Prosthodontics, Faculty of Dentistry, National University of Malaysia
Natasya AT
Senior lecturer, Department of Prosthodontics, Faculty of Dentistry, National University of Malaysia
Salleh MAM
Lecturer, School of Media and Communication Studies, Faculty of Social Sciences and Humanities, National
University of Malaysia
ABSTRACT
Introduction: Nowadays, there is a worldwide trend for universities to utilize the benefits of e-learning as a
mechanism to facilitate improvements in teaching and learning. Purpose: The aim of this study is to evaluate the
effectiveness of using e-learning in the teaching of fixed prosthodontic course i.e. FPeL. Materials and Methods: This
was a retrospective analysis of questionnaire data, collected from fourth and fifth year dental undergraduates at the
Faculty of Dentistry, National University of Malaysia (Universiti Kebangsaan Malaysia, UKM). For fixed prosthodontics
(FP), all students had received a series of traditional classroom lectures, seminars, video demonstration, preclinical
and Fixed Prosthodontics e-Learning or FPeL in semester 1 and 2 during their 4th year. The questionnaire of 4
sections was administered after the students completed fixed prosthodontics course. Results: Questionnaires were
returned by 136 students (80.9% response rate). Unfortunately, the response rate dropped 12.4% when only 115
students accessed and used the FPeL (68.5%). Majority of FPeL users felt PFeL was beneficial to their learning in
the fixed prosthodontic course. PFeL users recommended printable version with detailed explanations, illustrated
with more photos and with addition of references. Conclusions: PFeL assisted users in the learning process of fixed
prosthodontics.
Key Words: Fixed prosthodontics, e-learning, online, satisfaction level, internet
Introduction
Computer Assisted Assessment (CAA), Computer

modelling & visualization, Specialist software, Video
conferencing and many more. 1

The increased use of internet-based or online
technologies as supplementary or sole modes of
teaching is beginning to spread extensively. This
challenged the conventional way of learning strategies
such as lecture based, live video demonstration, group
discussion and many more. Learners today have come
to expect more from their classroom experience,
preferring an active role, as compared with the passive
style of learning by lecture.2 Pintauro stated that
Web-Based Learning (WBI) environments can broaden
the educational opportunities offered to learners by
providing them with an independent, self-paced, and
flexible learning experience. 3 This group reported
that WBI is as effective as lecture-based method for
teaching a college-level course on Food Safety and
Regulation and that the combination of lecture and
WBI is significantly more effective than lecture-based
or WBI alone.3 This study was supported by a few
earlier studies. 4-10

Today, internet resource of dental information
can be as good as traditional library. Most universities,
associations, companies and some private practices

Nowadays, revolution in information technology
utilizing internet as a medium of communication
has been an important changes in our daily life.
Further more, internet is a medium of communication
via discussion forums, audio or video conference
and realtime chatting. Many learning institutions
and organizations have implemented online courses.
Dentistry is also experiencing the increasing demand
for online courses. This technology is becoming more
popular due to several advantages. However, there are
still pros and cons of usage of e-learning as a learning
medium.

Learning is the act or process of developing
skill or knowledge. However, e-Learning is defined
by Joint Information Systems Committee (JISC) as
learning facilitated and supported through the use
of information and communications technology (ICT).
1
E-learning includes delivery of courses; on-line
assessment; student to student and student to teacher
communications; use of internet resources; and other
learning activities involving ICT and the Internet.
E-learning can be in the form of Virtual Learning
Environments, Websites, Communications, WebCT,
20
Marlynda / Natasya / Salleh
email, chat room, audio and video are not available.

FPeL is supported by Power Point Presentation and
Macromedia Flash document. The two-dimensional
representation enabled graphic visualisation of each
procedure. The images were shot using Nikon Digital
Camera and manipulated using Adobe Photoshop
7.0 (Adobe System Inc). The completed FPeL can be
accessed on Prosthodontic Department web server
at the Faculty of Dentistry, Universiti Kebangsaan
Malaysia. No password is required; thus it is accessible
by public as well.

FPeL Courseware provides student with an online
web course materials. Lecturers will use this avenue to
publish the course contents and materials. Lecturers
will publish the contents of courseware on the web and
student can access the web courseware anywhere and
anytime.
now have their own website. The website/homepage

usually consists of information on their company and
its related detail as well as items of educational values
such as online scientific journals, personal / private
opinions, lecture notes, quizzes and assessments and
at a more advanced level, it includes usually video
demonstration or simulation. Most of the internet
resources are available free but some requires
registration to obtain username and password for
security purpose.

Downes in 2007 classified these dental internet
resources into ten categories. 11
1. Main dental disciplines.
2. Dental and medical organisations.
3. Dental universities.
4. Dental and medical journals.
5. Dental companies.
6. Dental care professions.
7. Dental study/research.
8. Dental link sites.
9. Discussion fora.
10. Patient resources.
Questionnaire
The questionnaire (structured multiple choice and
open-ended questions) of 4 sections was administered
after the students completed their fixed prosthodontic
course. The 1st section consists of demographic data
such as academic year and gender that will allow us to
look for systematic differences among students based
on demographic factors. The 2nd section contains
questions on internet access. Here, information on the
different types of processor, modems speed, surfing
time as well as availability of computer for students
who used campuss computer was gathered. The 2nd
section is also sought for the information on students
computer skills. The Likert Scale was used for extracting
information regarding the didactic contents was part of
3rd section. Section 4 is on students evaluation and
satisfaction on FPeL. The questionnaire ended with
open-ended questions for comments and suggestions.
Data Analysis
The data were processed and analyzed by means of the
Statistical Package for the Social Sciences (SPSS version
12.0).

Educational researches have acknowledged
a number of changes to the learning experience
since e-learning was introduced into the curriculum.
In UKM, Prosthodontics Department had utilized
Fixed Prosthodontics E-Learning or FPeL for its fixed
prosthodontics course since 2006. Fixed prosthodontics
was introduced to the 4th year dental undergraduates
at the beginning of the 1st semester. The objective of
this study was to evaluate the relative effectiveness of
FPeL. The outcome measures are to
1.
2.
3.
4.
determine the number of students who had used

FPeL
determine the effectiveness and helpfulness of
features included in FPeL
determine the students problems while using
FPeL
gather valuable information for future changes
and improvements.
RESULTS AND DISCUSSION
MATERIALS AND METHODS
A. Users Background

An overall response rate of 80.9 % (136 out of
168) was obtained. The response rate for Year 5 was
75.9 % (n=79, 79 out of 104) while for Year 4 was 89.1
% (n=57, 57 out of 64). From 136 respondents, only
22 (16.2%) were males and majority 114 (83.8%) of
the respondents were females, reflecting the gender
distribution of students in the faculty. Approximately
half of the respondents (47.1%) categorized themselves
as internet surfers. Out of 136 respondents, 84.6% of
them accessed and used the FPeL. Therefore, only 115
respondents can proceed with the rest of questionnaire
resulting in 68.5% response rate.
Respondents
The 4th and 5th year dental undergraduates of Faculty
of Dentistry UKM were asked to participate in this
study. All students had received a series of traditional
classroom lectures, seminars, video demonstration,
preclinical and Fixed Prosthodontics e-Learning
courseware or FPeL in semester 1 and 2 during 4th
year.
Fixed Prosthodontics e-Learning (FPeL) Courseware
FPeL courseware is a simple e-learning course material
for fixed prosthodontics. It encompasses only didactic
materials. Quizzes, grades, glossary, hyperlink,
21
should be a mandatory supplement. 3-10 However,

Padalino showed evidence of an equal acquisition of
knowledge in both groups; confirming the efficacy of
both methods. While in 2002, Spickard concluded that
students who participated in an online lectures on
screening saved time and achieved knowledge scores
to those students who participated in traditional
classroom lecture.6

Freedom in learning specifically in term of time,
pace and place were seen as the obvious benefit to the
users. Sixty two users reported FPeL is very beneficial
and 51 reported it is somewhat beneficial. These
groups of users must have utilised the benefit of FPeL.
However, using the same material in both lectures
and e-learning may promote absenteeism among the
students. Only 2 users described it was not beneficial
to them.
B. Access and skill

Of 115 respondents, majority of them (75.7%)
accessed the internet from computers on campus
while 28 (24.3%) primarily accessed the internet from
outside the campus such as cyber cafe. Fifty seven
(49.6%) respondents accessed the internet during
daytime, 47 (40.9%) used the internet only in the
evening and 11 (9.6%) accessed at late night or early
in the morning. Majority (80.9%) of the respondents
reported that they had adequate computer skills to
access and use the FPeL while 22 (19.1%) of them
claimed that they do not have computer skill at all.
However, in order to use FPeL, no specific skills were
required.
C. Materials

Majority of FPeL users rated it to be either
helpful (47%) or very helpful (28.7%). In relation to
classroom lecture style, most (52.2%) of the users
responded that the FPeL should be used as optional
supplement, 35 (25.7%) responded that the online
materials should be a mandatory supplement, while
18% responded that the online format is useful in place
of some traditional lectures. Majority of FPeL users felt
these virtual lectures are beneficial to their learning
process of FP. FPeL assisted them in many ways
especially as a preparation before traditional lecture
and examination. During the lecture, note taking is not
necessary since all the informations are available on
FPeL and the students can confirm on information that
they were not clear while reviewing FPeL earlier. Even
though it is beneficial, only half of the users felt that
FPeL should be used as optional supplement to the
traditional lecture. In contrast, Pilcher in 2001 reported
that majority of the students felt that online lecture
D. Students evaluation

The FPeL were divided into 6 main topics
according to prosthodontics syllabus. Each main topic
was again divided into many subtopics. Users are
able to choose the desired topic or module to review
directly without having to go through earlier topics
or modules. The content includes notes illustrated
with clinical and laboratory photos (Table 1). On
their evaluation regarding individual characteristics
included in the FPeL, majority of users were agreeable
or strongly agreeable to the syllabus, topics, contents,
photos and illustrations as well as its helpfulness to the
users. However, some users reported that the FPeL was
moderately user friendly, not really easy to browse,
difficult to access, slightly confusing and the subtopics
were moderately helpful. Figures 1 and 2 showed
pages displaying the main topics and subtopics.
Table 1: Users rated on online lecture topics

Topics

Not very
helpful
Not
helpful
Somewhat
helpful
Introduction to FP
20
Examination & Tx Planning
Occlusion

helpful
Very
helpful
18
26
73/63.4%
70/60.8%
28
57/49.5%
22
18
17
Facebow & Articulators
33
60/52.1%
Esthetics
18
75/65.2%
18
29
66/57.3%
10
14
78/67.8%
22
25
Diagnostic Wax-Up
Post & Core
Tooth Preparation
80/69.5%
Impression
15
73/63.4%
23
23
68/59.1%
22
23
69/60%
19
Provisional
Dental Materials
22
Marlynda / Natasya / Salleh
Figure 1: Main topics
Figure 3: Users feedback on FPeLs strength

As shown in Figure 4, problem with internet
server was the most common. The performace of the
server was the most common problem voiced by the
students in term of their internet connection. Since
the introduction of wireless connection in campus
and hostel, the server became slower as a result of
overloading and heavy on-line traffic for users. 10
respondents said they do not have easy internet
access. Other weakness related to FPeL was that it was
not printable or copyright exception, time consuming
probably due to slow server or old version computer
and too confusing due to too much materials or slides.
In the future, only simple frameworks of lecture will
be available in FPeL while the full version will be given
during classroom lectures. Therefore, FPeL will become
less confusing to the users.

Figure 2: Subtopics
Figure 4: Users feedback on FPeL weakness

E.
Comment and recommendation

Open-ended questions were utilized in the final
part. The users were asked to comment on strength
and weakness as well as their recommendation for
future improvement of FPeL. Forty one respondents
commented on the strengths FPeL. According to Figure
3, 17 users mentioned that FPeL is useful as it functioned
as a guide before classroom lecture while 12 of
them gave optimistic responses related to the quality
of photos and illustrations as well as its attractive
layout. Simple explanation counted as the third most
common comments on strength. Unfortunately, only
4 respondents commented on its easy access where
users can view FPeL anytime and anywhere.
Only 34 respondents gave recommendations toward

future improvement of PFeL. PFeL users recommended
and preferred a version with more explanations,
illustrated with more photos and addition of references
(Figures 5 and 6). The users suggested that the
background colour should be changed and handout
should be made available for them to print. Refer to
Table 2 for users recommendations.
23
Table 2: Users recommendations

Feedback - Recommendations
discussion and question-answer dialogue to improve

the quality of the teaching and learning process.
Users
More explanation
More photos and illustrations
Printable version
10
To add references
To change FPeLs background
To provide handouts
Total
34
REFERENCES
1.
E-Learning pedagogy programme. http://www.

jisc.ac.uk/whatwedo/programmes/elearning_
pedagogy.aspx. Accessed October 25, 2007.
2. Litchfield R, Oakland M, Anderson J. Improving
dietetics education with interactive communication
technology. J Am Diet Assoc 2000; 100(10):1191
4.
3. Pintauro SJ, Krahl AG, Buzzell PR, and Chamberlain
VM. Food Safety and Regulation: Evaluation of
an Online Multimedia Course. J Food Sci Educ
2005;4: 6-69
4. Carew L, Elvin D, Yon B, Alster F. A college-level,
computer-assisted course in nutrition. J Nutr Educ
1984; 16:4650.
5. Buzzell P, Chamberlain V, Pintauro S. The
effectiveness of Web based multimedia tutorials
for teaching methods of human body composition
analysis. Adv Physiol Educ 2002; 26(1):219.
6. Spickard A, Alrajeh N, Cordray D, Gigante J.
Learning About Screening Using an Online or Live
Lecture. Does It Matter? J Gen Intern Med. 2002
Jul; 17(7):540-5.
7. Culbertson JD, Smith DM. On-line compared with
face-to-face introductory food sciences courses:
An assessment. J Food Sci Educ 2003; 2(1):136.
8. Javenkoski JS, Schmidt SJ. Complementing
traditional instruction with asynchronous learning
networks. Food Technol 2000; 54(5):4858.
9. Tuckman B. Evaluating ADAPT: a hybrid
instructional model combining Web-based and
classroom components. Comput Educ 2002;
39(3):2619.
10. Riffell S, Sibley D. Using web-based instruction
to improve large undergraduate biology courses:
An evaluation of a hybrid course format. Comput
Educ 2005; 44(3):21735.
11. Downes PK. Dental resources on the Internet. Br
Dent J 2007; 202(12):719-730.
Figure 5: Didactic materials
Figure 6: Techniques

Dr. Marlynda Ahmad
Department of Prosthodontics,
Faculty of Dentistry, National University of
Malaysia
Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur.
Phone: 603-92895748 Fax: 603-92895798
Email: drmarlynda@yahoo.co.uk
CONCLUSIONS

PFeL assisted users in the learning process of
fixed prosthodontics (FP). Valuable informations are
useful to upgrade the FPeL. e-learning tool provide
more a empowered teaching and learning environment
for students. Lecturers will teach the course in two
methods, a face-to-face mode and on-line mode using
communication technologies via internet environment.
During the class, students and lecturers will lead the
24
Evaluation Of Orthodontic Treatment Outcome: A Self-Audit

Using The Peer Assessment Rating (PAR) Index
Loke Shuet Toh

BDS(Mal), MSc.Ortho (Lond), M.Orth.RCS(Edinburgh), M.Orth.RCS(England), Head of Orthodontic Specialist Unit,
Teluk Wanjah Dental Clinic, Alor Star, Kedah
ABSTRACT
Introduction: The peer assessment rating (PAR) index was used to self-audit 4 years of completed pre-adjusted
edgewise appliance cases treated by a single orthodontist in a government clinic. The objectives of this study were
to evaluate orthodontic treatment standards and factors which may influence treatment outcomes and treatment
time. Methodology: Pre and post-treatment study models were scored using the PAR index by the author. 17
models were re-examined for intra-examiner reliability using intra-class correlation coefficient (ICC). ICC was
excellent for pretreatment (0.96), post-treatment (0.98) and reduction in PAR (0.96) scores. Results: There were
173 cases (51 males; 122 females) with mean age 17.6 (SD 5.75) years. Mean treatment time was 18.6 (SD 6.47)
months with range between 5-40 months. There was no statistically significant difference between one-arch and
two-arch cases and between routine and compromised cases. Treatment time in extraction cases (mean 19.5, SD
6.17) was significantly different (p=0.000) compared with non-extraction cases (mean 11.6, SD 4.10) although this
accounted for 15% of the variation only (r=0.388). 76.3% cases were greatly improved, 22.0% improved and 1.7%
worst/ no different. Mean pretreatment, post-treatment and reduction in PAR score was 34.1(SD 9.68), 6.4 (SD
6.84) and 27.9 (SD 9.69) respectively. Mean percentage PAR score reduction was 82.0% (SD 1.96). Pretreatment
(p=0.000), post-treatment (p=0.000) and reduction (p=0.489) in PAR scores was significantly different between
routine and compromised cases. There was significant difference (p=0.000) between category of improvement and
pretreatment scores but not with treatment time. Conclusion: Severe malocclusions had larger reduction in PAR
scores and required longer treatment time. Extraction cases took longer to complete and routine cases had better
outcomes than compromised cases with severe skeletal discrepancy.
Key Words: PAR index, pre-adjusted edgewise appliance, self-audit
Introduction
greatly improved, improved, worst /no different

by interpretation from the PAR nomogram. Besides
its usefulness in rating performance and treatment
outcomes, the PAR can also be used to indicate
treatment severity, need and difficulty 11,12,13,14,15.
Since the PAR is only assessed on study models and
not on patients, one of the criticisms of the index
is that the improvement in the dentition may not
always be correlated with overall facial improvement.
However, self-auditing is a useful exercise to evaluate
personal performance, compare treatment techniques,
elucidate factors influencing treatment options plus
impart more accurate information to identify specific
problems in individual patients 7,8,16,17,18,19,20 .

The Clinical Effectiveness Committee of the
British Orthodontic Society has developed a benchmark
for the standard of treatment expected from consultant
orthodontists in the United Kingdom following an audit
on the treatment outcome of fixed appliance treatment
by hospital-based orthodontists in 2003 7 . Similarly, the
PAR index has been adopted by the Ministry of Health
Malaysia in recent years as a quality assurance and
key performance indicator for orthodontic treatment
carried out by government orthodontists22. A general
evaluation of the overall performance of government

An orthodontic index is used to describe a rating
or a categorizing system that assigns a numeric score or
an alphanumeric label to a persons occlusion 1. Several
international indices like the Peer Assessment Rating
(PAR) and Index of Treatment Complexity, Outcome
and Need (ICON) which were developed in the United
Kingdom and the American Board of Orthodontics
Objective Grading System (OGS) have been developed
and used to assess orthodontic treatment outcomes
and standard 2,3,4,5,6,7,8,9 . These indices compared pre
and post-treatment study models to determine the
quality of the results qualitatively or quantitatively.

The PAR is a quantitative objective method
designed to ensure uniform interpretation and
application of criteria in measuring a malocclusion.
It has been validated in many countries and in
different ethnic groups 10,11. This index provides a
single summary score for assessment of many of
the occlusal anomalies present in the dentition.
The overall weighted score indicates how much a
malocclusion deviates from normal occlusion. The
degree of improvement is expressed quantitatively
as percentage improvement or qualitatively as
25

Evaluation Of Orthodontic Treatment Outcome: A Self-Audit Using The Peer Assessment Rating (PAR) Index
orthodontists was reported at annual meetings.

Unfortunately not all orthodontists submitted their
PAR assessment results and no inferential analyses
were done at the Ministry level.

Thus, the two main objectives of this study were
to determine treatment outcomes and treatment time
of cases completed by a single operator. Other patient
variables which may influence treatment outcome
and treatment time such as malocclusion severity,
different treatment modalities and options were also
evaluated.
MATERIALS AND METHODS

Sample selection

This is a cross-sectional of consecutively
completed orthodontic cases over a 4-year period (mid2003 to mid-2007), treated from start to finish with
fixed appliances ( removable/ functional appliances)
by a single orthodontist in a government orthodontic
clinic in Kedah, Malaysia. All fixed appliance cases
were treated with pre-adjusted edgewise brackets and
straight-wire technique. McGuiness and McDonald23
found highly significant (p<0.001) difference in
treatment times when there were operator changes
during treatment. The average treatment time for
patients treated by one operator was 17.67 months (SD
4.15) compared with 26.1 months (SD 6.78) in one or
more operators. Treatment with removable appliances
per se has been reported to have poor treatment
outcomes13,18. Thus for homogeneity, exclusion criteria
included cases that had operator changes, transfer
cases, removable or functional appliance therapy only,
orthognathic surgery, cleft and craniofacial syndrome
patients13,23,24.

Fig. 1: Scoring on pretreatment and post-treatment study

models in 3 planes
PAR Index measurements

This index looks at 5 components of the occlusion,
namely; the upper and lower anterior, segments,
left and right buccal occlusion, overjet, overbite and
centerline (Fig.1). The individual scores for each
component are multiplied by the assigned weightings
and then summed to establish the overall total score.
Weightings derived for the 5 components are (x1) for
upper and lower anterior segment alignment, (x1) for
right and left buccal occlusion, (x6) for overjet, (x2) for
overbite and (x4) for centerline. The total weighted PAR
score is recorded for the pre- and post-treatment study
models respectively. A total score of zero would indicate
perfect alignment and higher scores indicate increased
levels of irregularity or deviation from the ideal. The
percentage change between pre- and post-treatment
PAR scores indicates the degree of improvement.
Fig. 2: PAR ruler
Fig. 2: Measuring tooth displacement with PAR ruler
26
Loke
Statistical Analysis

All but one of the consecutively completed 174
cases was treated with fixed appliances. Thus, for
homogeneity the only case treated with removable
appliances was excluded from the study. Parametric
tests were used to analyse treatment time, pretreatment
scores and reduction in PAR scores since there was
normal distribution and homogeneity of variances in
the sample. One-way analysis of variance (ANOVA) was
used to test differences in treatment time between
extraction versus non-extraction patients, one-arch
versus two-arch treatment, routine versus compromised
treatment and one-arch versus two-arch extractions.
Bonferronis Post Hoc Multiple Comparisons were run
to compare means in more than three groups. Where
test assumptions were not met, the Wilcoxon signed
ranks test was used to test for significance. Pearsons
correlation coefficient or Spearmans rank correlation
were applied where assumptions were met to test
for association between the variables. Patients were
regrouped into different treatment modalities for
statistical analyses.
Measurements were made easier and quicker with

the specifically designed PAR ruler2. All models were
scored with the PAR ruler by the author (Figs. 2 and 3).
The PAR nomogram was used to categorize treatment
outcome as greatly improved, improved or worst/ no
different by reading the pre- and post-treatment scores
from the respective axes (Fig.4). Worse/no different
scores reflect a reduction in weighted PAR score of less
than 30%, improved indicates an improvement equal
to or greater than 30% and greatly improved indicates
an improvement of 22 or more PAR points2,25.

The degree of improvement (% reduction in
PAR score) was also expressed as a percentage. The
degree of improvement as expressed by the nomogram
is not directly correlated with percent improvement
because the nomogram takes into account the size of
the pretreatment score. The larger the pretreatment
score means the more severe the malocclusion.
This means that a 100% improvement in a mild
malocclusion is only categorized as improved by the
nomogram. Conversely, a 70% improvement in a severe
malocclusion may be categorized as greatly improved
due to the larger pretreatment score.
Definition of grouping of cases:
Routine extractions
: Extractions involving a combination of premolars or anterior teeth
(1-4 teeth)
Non-routine extractions : Extractions involving more than 4 teeth or inclusive of molar teeth
Routine cases
: Cases without severe skeletal discrepancy that can be corrected with routine fixed appliance
treatment.
Compromised cases
: Cases with severe skeletal discrepancy requiring orthognathic surgery as the ideal treatment,
but was treated with limited goals in fixed appliances only
Statistical significance was set at p<0.05. SPSS for Windows (version 11.0) was used.
RESULTS
Error study

In order to determine intra-examiner reliability,
17 cases (10%) were randomly selected and
re-measured by the same investigator about 8 weeks
apart. Differences in measurements for pretreatment,
post-treatment and reduction in PAR scores were
estimated by calculating the intra-class correlation
coefficient of reliability (ICC). ICC values of 0 represent
agreement equivalent to that expected by chance, and
1 represents perfect agreement 26. In accordance with
Landis and Koch 27, the following ICC interpretation
scale was used: poor to fair (<0.4), moderate (0.410.60), excellent (0.61-0.80), and almost perfect (0.811.00). The kappa statistic () was used to test for
agreement in category of improvement.

There was excellent intra-examiner reliability
with ICC of 0.96, 0.98, 0.96 and 0.97 for pretreatment,
post-treatment scores, reduction in scores and percent
improvement respectively. Agreement was excellent
in categorization of improvement with mean kappa
statistic of 0.68. There were a total of 173 cases
comprising 51 males (29.5%) and 122 (70.5%) females,
with ethnic distribution of 73 (42.2%) Malays, 93(53.8%)
Chinese, 6 (3.5%) Indians and 1 (0.6%) others with
mean age 17.6 (SD 5.75) years. 128 (74.0%) cases were
treated with two-arch fixed appliances compared with
33 (19.1%) one-arch fixed, 10 (5.8%) cases with fullfixed + active removable plates and 2 (1.2%) cases with
full-fixed + functional appliances. Treatment time was
normally distributed with a mean of 18.6 (SD 6.47)
months and range 5-40 months.
27
(SD 6.17) and 18.9 (SD 6.27) months respectively.

ANOVA and Post hoc tests showed there was
statistically significant difference in treatment times
between non-extraction and these two groups
of extraction cases (p=0.000) but not within the
extraction cases.
i. Treatment time with different variables (Tables 1

and 2)
Extraction v non-extraction
There were 20 non-extraction and 153 (48
one-arch, 105 two-arch) extraction cases. The most
common extraction pattern was a combination
of two upper and two lower premolars (40.8%)
followed by two upper premolars only (19.5%)
and non-routine extraction combination (12.6%).
Extraction cases took longer to complete with
mean treatment time of 19.5 (SD 6.17) months
compared with 11.6 (SD 4.10) months in nonextraction cases. Mean treatment time for onearch and two-arch extraction cases was 18.3 (SD
6.03) and 20.1 (SD 6.16) months respectively (Table
1). There was statistically significant difference
between non-extraction (p=0.000) and extraction
cases, but no significant difference between onearch and two-arch extraction cases. Although there
was positive association between treatment time
and extraction/non-extraction modality, this factor
only accounted for about 15.1% of the variation
(r=0.388).
When the extraction cases were regrouped
into routine extractions (n=130) and non-routine
extractions (n=22), mean treatment time was 19.6
Fixed one-arch v two-arch

Mean treatment time for one-arch and twoarch cases was 17.5 (SD 6.75) and 18.9 (SD 6.36)
months respectively. Two-arch treatment which
required additional active removable plates or
functional appliances had a mean treatment time
of 17.9 (SD 6.64) months. There was no statistically
significant difference in treatment times between
these three groups.
Routine v compromised cases
There was no statistically significant difference
in mean treatment time for routine (18.7 months,
SD 6.51) and compromised cases (18.4 months, SD
6.29).
Pretreatment, post-treatment and reduction
in PAR scores (Table 2)
There was positive correlation and
statistical significance between treatment time
and pretreatment PAR score (p=0.001) and with
reduction in PAR score (p=0.001).
Table 1: Descriptive statistics and ANOVA tests for treatment time with different variables
Variable groups N(%)

Treatment time
Mean S.D.
P value
1. Non-Extraction
Extraction 1 arch
Extraction 2 arch
20(11.6)
48(27.7)
105(60.7)
11.6
18.3
20.1
4.10
5.98
6.16
.000*
2. Fixed 1 arch
Fixed 2 arch
37(21.4)
136(79.6)
17.5
18.9
6.75
6.36
.235
3. Routine cases
Compromised cases
143(82.7)
30(17.3)
18.7
18.4
6.51
6.29
.847
Table 2: Descriptive statistics and significance test for treatment time and PAR scores in the total sample
N

Treatment
time
PAR scores
Pretreatment
Post-treatment
Reduction
% improvement
Mean SD
Mean SD
Mean SD
Mean SD
Mean SD
173
18.6
34.1
6.4
27.9
82.0
6.47
9.68
P=.001
P=
Significance set at p<.05

Ns= not significan
6.84
28
9.96
P=.001
ns
1.96
Loke
Category of improvement
There was statistically significant difference (p=0.029) in mean treatment time between the categories
of improvement with longer treatment time in greatly improved cases compared with improved and
worse/no different cases (Table 3).
ii. Treatment outcomes with different variables (Tables 2-5)
Since there was no statistically significant difference in pre- and post-treatment, reduction in PAR and
percent reduction in PAR scores between males and females, the sample was anaylsed as a whole.
Percentage improvement
Mean pretreatment, post-treatment and reduction in PAR scores in the sample was 34.1 (SD9.68), 6.4
(SD 6.84) and 27.9 (SD 9.69) respectively (Table 2). The mean PAR score reduction was 82.0% (SD 1.96).
Pretreatment scores were positively correlated with post-treatment scores (p=0.01).
PAR scores and different variables (Table 3)
There was no statistically significant difference in mean pretreatment and post-treatment scores in
extraction and non-extraction cases. However, there was statistical significant difference in the reduction
of PAR scores between extraction and non-extraction cases. There was statistical significant difference in
pretreatment (p=0.019) and reduction in PAR scores (p=0.000) between one-arch and two-arch treatment.
Mean pretreatment scores for routine cases was lower (32.7) compared with compromised cases (40.8) and
it was statistically significant (p=0.000). Mean post-treatment scores in routine and compromised cases was
5.2 (SD 5.68) and 11.8 (SD 9.06) respectively. The Wilcoxon Signed ranks test was used to test for statistical
significance in the post-treatment and reduction in PAR scores in these two groups as assumptions were
not met for ANOVA test. There was statistically significant difference (p=0.000) in both post-treatment and
reduction in PAR scores.
Table 3: Descriptive statistics and significance tests for PAR scores for variable groups

PAR scores
pretreatment
post-treatment
reduction
Variable
groups N
Mean SD
Mean SD
Mean SD
20
.030*
7.17
.062
7.3
7.01
.872
23.1
7.42
.030*
48
33.0
9.71
6.6
7.68
27.1
11.6
105 35.3
9.95
6.1
6.45
29.1
8.84
37
8.95
8.3
8.96
22.5
9.59
9.73
5.9
6.08
29.3
9.22
9.1
5.2
5.7
27.7
8.9
11.8
9.1
29.0
12.9
1. Non Extraction

Extraction
1 arch

Extraction
2 arch
2. Fixed 1 arch

Fixed 2 arch
30.8
136 35.0
3. Routine cases 143 32.7

Compromised 30 40.8
case
.021*
.000*
9.9
.167
.000*
.000*
.383
Mann-Whitney U test for fixed 1 arch/two arch and routine/compromised cases.

Kruskal-Wallis rank sum test for non-extraction/extraction groups
29
Category of improvement (Tables 4 and 5)

There were 132 (76.3%) greatly improved, 38 (22.0%) improved and 3 (1.7%) worse/ no different
cases. There was statistical significant difference between mean pretreatment (p=.000), post-treatment
(p=.000) and reduction in PAR scores (p=.000) and treatment time (p=.029) with the different categories of
improvement (Table 4). More cases were greatly improved in two-arch extraction cases; two-arch treatment
and routine cases (Table 5).
Table 4: Descriptive statistics and ANOVA tests for Mean PAR scores and treatment time for category of

improvement
Category of improvement

Worse/
no Improved Greatly

different
improved
N=3 N=38 N=132
Variable
Mean SD
Mean SD
Mean SD

P
value
Pretreatment PAR score

Post-treatment PAR score
Reduction in PAR score
Percent reduction in PAR score
38.3
26.0
12.3
16.9%
17.21
12.00
23.60
54.6%
23.6
7.2
16.4
72.6%
6.73
7.01
4.78
23.1%
37.0
5.7
31.5
86.2%
8.07
5.99
7.17
19.6%
.000*
.000*
.000*
.000*
Treatment time
15.0
6.93
16.4
6.48
19.3
6.32
.029*
Table 5: Descriptive statistics of category of improvement for different variables

Variable groups Category of improvement

Worse/
Improved Greatly improved

no different
N (%)
n(%)
n(%)
n(%)
1. Non-Extraction
Extraction 1 arch
Extraction 2 arch
20(11.6)
48(27.7)
105(60.7)
0 (0)
1 (2.1)
2 (1.9)
7 (35.0)
12 (25.0)
19 (18.1)
13 (65.0)
35 (72.9)
84 (80.0)
2. Fixed 1 arch
Fixed 2 arch
37(21.4)
136(79.6)
2 (5.4)
1 (0.7)
12 (32.4)
26 (19.1)
23 (62.2)
109 (80.1)
3. Routine cases
Compromised cases
143(82.7)
30(17.3)
0
3(10.0)
33 (23.1)
5 (16.7)
110 (76.9)
22 (73.3)
iii. Factors associated with PAR score change (Table 6)

Multiple linear regression analysis of PAR score change with pretreatment and post-treatment PAR
scores showed high association with these two variables (r=0.969). This was predicted and excluded
when running analysis with other possible factors. Other possible predictors included were one/two-arch
treatment, extraction/non-extraction, routine/compromised cases and treatment time. Multiple linear
regression analysis showed that variability in arch treatment (p=.029), routine/compromised cases (p=.000)
and treatment time (p=.000) were associated with PAR score change although this contributed to about 17%
of possible factors (r=0.435).
30
Loke
Table 6: Multiple linear regression of Reduction in PAR score with extraction/non-extraction, one-arch/two-

arch treatment, routine/compromised treatment and treatment time
Variable
Unstandardized Standardized
t
sig
R
Coefficients Coefficients

(Constant)
Extraction/ non-extraction
Routine/ compromised
Treatment time
One-arch/ two-arch
B Std. Error
4.732
-.715
.826
.457
7.921
Adjusted
R squa
Beta
3.853
1.151
-.051
.375
.162
.113
.304
1.901
.336
1.228
-.622
2.201
4.032
4.166
.221
.535
.029*
.000*
.000*
.438a
.172
a. Predictors: (Constant), extraction, case type, treatment time, arch treatment

b. Dependent variable: Reduction in PAR score
DISCUSSION
to PAR score change in contrast to other studies that

reported high percentage variability of PAR change due
to initial PAR score 13,23,28. The present study similarly
found statistically significant association (p=0.01)
between pretreatment and post-treatment PAR score,
and between pretreatment and reduction in PAR score.
This is obvious since PAR score change is the difference
in pre- and post-treatment PAR score. Multiple linear
regression analysis showed that variables such as onearch/two-arch treatment, routine/compromised cases
and treatment time was associated with PAR score
change although they contributed to about 17% of
factors (r=.438).

Richmond17 proposed that the mean percentage
reduction in PAR score should be greater than 70%
to be considered a good standard of orthodontic
treatment and that the proportion of patients in the
worse/no different category should ideally be less
than 5%. This was comparable to the present study
where the mean percentage reduction in PAR score
was 82% and only 1.7% cases fell in the worse/ no
different group. Teh et al 28 a reported a low mean
reduction in PAR score of 14.9 (SD10.6) and mean
percentage reduction in PAR of 59% by orthodontic
specialists in the General Dental Service in Scotland.
They attributed the modest improvement in treatment
to the low mean pretreatment PAR score and the
borderline need for treatment in many cases19.

Although there are specific indices for assessing
treatment need like the Index of Orthodontic Treatment
Need (IOTN), pretreatment PAR scores have been
shown to be useful as an indicator for orthodontic
treatment need 1,3,9,11,12,14,15. Firestone et al.14 found
that both the US PAR and UK PAR weighted scores
were excellent predictors of orthodontic treatment
need and suggested that the cutoff point for treatment
need as 17. McGorray et al.12 and Soh et al.15 similarly
showed that the PAR index was highly correlated with
orthodontists subjective/ aesthetic assessment of
treatment need and suggested the optimum cutoff

Mean treatment duration for fixed appliances
in the present study was 18.6 (SD6.47) months.
This was comparable with other studies reporting
mean treatment time from 15- 25 months23,28,29. The
current study showed that a higher pretreatment PAR
score and a greater percent reduction in PAR score
were significantly associated with longer treatment
durations as similarly observed in other studies29,30.
Holman et al.31 reported longer treatment duration for
extraction (29.76.1 months) than non-extraction cases
(26.07.2 months) similar to the current study which
showed statistical significant difference in extraction
(19.56.17 months) compared to non-extraction cases
(11.64.10 months). They observed that pretreatment
PAR scores was a significant factor (p0.0001) in
extraction decisions in contrast to the present study.

The mean percentage reduction in PAR score
was more than 80% in the present study which was
comparable to the above 75% reduction reported in
studies carried out in other countries13,18,19,29,30,32,33.
Onyeaso and Begole33 reported statistically significant
differences between the three improvement groups
for pretreatment PAR scores similar to the present
study. Riedmann and Berg34 reported lower mean
percentage reduction in PAR score in compromised
cases (37%) than ideal cases (73%). The current study
similarly observed statistically significant difference
(p=0.000) in percent improvement in routine (84.7%)
compared with compromised (69.2%) cases, although
the association is low. The average length of treatment
in their ideal cases was 28.8 months which was longer
compared with 18.7 months in the current study.
There was no significant differences in treatment time
between these two groups in the current study but was
halved in compromised cases in their study.

Two-arch treatment produced more greatly
improved results than one-arch 16,35,36. Fox16 reported
that only the appliance type was significantly related
31
CONCLUSION
PAR scores as 17-20. Low IOTN scores may have higher

pretreatment PAR scores especially with mal-alignment
confined to the upper labial segment. This is probably
due to heavier weightings for overjet, centerline and
overbite. In the present study, low pretreatment PAR
scores 17 accounted for less than 3.5% (6 cases) of
the cases treated. This observation combined with the
high mean percentage reduction in PAR score and the
large proportion of greatly improved cases indicates
that the practitioner is treating a great proportion
of cases with a clear need for treatment to a high
standard2,17. This reflects the acceptance of cases for
treatment in accordance with referral guidelines set by
the Ministry of Health Malaysia.

Fox 16 observed that 36.3% of their worst/no
different cases were due to compromised treatment.
Some outliers with unusually long treatment time in
the present sample were attributed to patients failure
to attend regular treatment and frequent appliance
breakages. Robb et al. 37 similarly found that the
number of broken appointments and appliance repairs
accounted for about 46% in additional treatment
time. Difficult cases were characterized by greater
pretreatment malocclusion severity and need
for treatment, greater residual malocclusion posttreatment, problems with hygiene and compliance,
extractions and changes in treatment plan, more
appointments and longer treatment duration29,38.

Hamdan and Rock39 suggested new weightings
for different malocclusion classes due to the high
weightings to overjet in the PAR index. They proposed
the utilization of a combination of point and percentage
reduction in PAR scoring which appear to have better
correlation than the nomogram. Although the US
weightings were modified from the UK weightings
to exclude the lower labial segment, studies have
shown little difference when it was applied to assess
treatment need. But the modified US weightings may
not be appropriate if it was used to appraise treatment
modalities or outcomes which may have relapse of the
lower labial segment40.

Awareness has been growing in recent years
in many countries about the importance of clinical
auditing to provide better orthodontic care for patients
and to safeguard their health7. A new Clinical Outcome
Monitoring Program (COMP) in a software package
designed to facilitate clinical audits and research
appears to be a potentially useful tool for orthodontic
indices like the PAR, ICON and IOTN41.

Treatment standard was high with more than
98% of cases improved or greatly improved in cases
with a clear need for treatment. There was mean
PAR score reduction of 82% and mean postreatment
PAR score of 6.4. Severe malocclusions had larger
mean pretreatment scores and took longer treatment
time. There was statistically significant difference in
pretreatment, post-treatment and reduction in PAR
scores between routine and compromised cases but
not in treatment time. Mean treatment time was 18.6
months (SD 6.47) with extraction cases taking longer
than non-extraction cases. Reduction in PAR score
was highly associated with pretreatment and posttreatment PAR scores. Self-audit using the PAR index is
a simple, pragmatic and invaluable exercise to assess
treatment outcomes and treatment time in different
treatment modalities.
ACKNOWLEDGEMENT

The author would like to thank Dr. Ang Lai Choon
for helping in the data entry and the Ministry of Health
Malaysia for approving this study for publication.
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35. Linklater RA, Fox NA. The long-term benefits of
orthodontic treatment. Br Dent J 2002;192(10):5837
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36. Piskorski D. Efficacy of orthodontic treatment

according to the Peer Assessment Rating index
(abstract) Ann Acad Med Stetin 2003;49:335-51
37. Robb SI, Sadowsky C, Schneider BJ, BeGole
EA. Effectiveness and duration of orthodontic
treatment in adults and adolescents. Am J Orthod
Dentofacial Orthop 1998;14(4):383-6
38. Cassinelli AG, Firestone AR, Beck FM, Vig KW.
Factors associated with orthodontists assessment
of difficulty. Am J Orthod Dentofacial Orthop
2003;123(5):497-502
39. Hamdan AM, Rock WP. An appraisal of the
Peer Assessment Rating (PAR) index and a
suggested new weighting system. Eur J Orthod
1999;21(2):181-92
40. McKnight MM, Daniels CP, Johnston LE Jr. A
retrospective study of two-stage treatment
outcomes assessed with two modified PAR indices.
Angle Orthod 1998 68(6):521-4
41. Weerakone S, Dhopatkar A. Clinical outcome
monitoring program (COMP): a new application
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Orthod Dentofacial Orthop 2003 123(5):503-10
Dr.Loke Shuet Toh
Pakar Perunding Kanan ortodontik
Klinik Pakar Ortodontik Klang
Jln. Tengku Kelana
41000 Klang
Tel: 03-33713811
e-mail: shuetl@yahoo.com
34
Knowledge Of Prescribing Antimicrobial Among Dental

Practitioners In Klang Valley Region
Huda Kh. AbdulKader

Faculty of Pharmacy, Universiti Teknologi MARA, Bandar Puncak Alam, 42300, Selangor, Malaysia.
Salmiah Mohd Ali
Mohamed Ibrahim Abu Hassan
Faculty of Dentistry, Universiti Teknologi MARA, Shah Alam, 40450, Selangor, Malaysia.
Mohamed Mansor Manan
ABSTRACT
There is a major concern about the increased use of antibiotics in dental practice and the emergence of
resistant bacterial strains. In recent years, dentists have reported a shift from narrow-spectrum to
broad-spectrum antibiotic prescriptions due to increasing antibiotic resistance. The aims of this study are to
investigate the prescribing patterns of the therapeutic and prophylactic use for antibiotics in various dental
situations by dental practitioners. The study also specifically investigates the prescribing habits of dental
practitioners regarding certain cardiac conditions and related dental procedures in patients predisposed to
infective endocarditis. This study utilized a questionnaire which was designed to investigate the antibiotic prescribing
patterns by dental practitioners in the Klang Valley region. The returned questionnaires were analyzed using
SPSS, to identify compliance to antibiotic guidelines by Malaysia National Clinical Guidelines (MNCG) (2003) and
American Heart Association Guidelines (AHAG) (2008). 217 dentists responded to the questionnaire and the
responses show that there is a wide variety of antibiotic prescriptions among dentists and there is also misuse
of antibiotics in some clinical dental conditions. The results also show that there is a large variation in the
antibiotic prescriptions patterns for prophylaxis against infective endocarditis. Furthermore, there is uncertainty as
to which cardiac conditions required prophylaxis and for which particular dental procedures. This study concludes
that there is a clear need for the development of prescribing guidelines, regular monitoring of antibiotic prescriptions
by dental practitioners and educational initiatives to encourage the rational and appropriate use of the antibiotics.
Key Words: Antibiotics, dental practitioners, therapeutics, prophylactic.
Introduction
The objectives of this study are to:

1) investigate the antibiotic dose, frequency and
duration of treatment (days) that the practitioners
would prescribe for patients with an acute dental
infection, with and without allergy to penicillin;
2) investigate the use of antibiotics for clinical dental
conditions;
3) determine dentists prescription habits of
antibiotic prophylaxis for some cardiac conditions
and
4) determine their prescription habits of antibiotic
prophylaxis for some dental procedures in patients
at risk of infective endocarditis (I.E.).

Antibiotics along with analgesics are the most
common drugs used in dentistry; their judicious use
can shorten the course of infection and minimize
associated risks such as the spread of infection to
adjacent anatomical spaces or systemic involvement.
There is a widespread concern about the exaggerated
use of antibiotics in dental practice and the
emergence of resistant bacterial strains 1. In recent
years, dentists have reported a shift from narrowspectrum to broad-spectrum antibiotic prescriptions
due to increasing antibiotic resistance 2. There are
evidences which suggest that antibiotic prescriptions
by dental practitioners for therapeutic purpose differ
significantly and prophylactic antibiotics are prescribed
inappropriately, both for surgical procedures and for
patients at risk from endocarditis 1, 3, 4, 5, 6, 7.
35

METHODOLOGY
RESULTS

This study utilized a questionnaire which was
designed to investigate the antibiotic prescribing
patterns by dental practitioners in the Klang valley
region. To prepare the questionnaire, references were
made to studies such as, Palmer et al, Jaunay et al
and Thompson et al 1,3,4,5 and the questionnaire was
modified after a pilot study.

There are around 1300 dentists registered in the
Klang valley region. For this population, the sample
size is 20%, assuming a response rate of 70% or more 8.
Due to the low response rate, typical for questionnaire
study 5, 9, over sampling should be considered to
bring the number of answers to the desired
value 10, 11. 706 questionnaires were distributed to the
dental practitioners. The distribution method and the
response rate are demonstrated in Table 1.

The returned questionnaires were analyzed
using SPSS to identify the compliance to antibiotic
guidelines: MNCG 2003 and AHAG 2008. The Defined
Daily Dose (DDD) was also calculated.

The actual data collection was carried out from
January to July 2009. This survey was answered by 217
dentists. The demographics of the practitioners are
represented in Table 2.
Table 2: The demographics of the respondents
Gender
50
25
50
University Malaya
100
18
18
University Teknologi
MARA
38
19
50
University
Kebangsaan Malaysia
30
6.6
Malaysian Dental
Association
conference
225
69
30.6
UiTM conference
43
21
48.83
By post
160
37
23.12
Self administration
60
26
43.33
Total
706
217
30.7
28%
Female
72%
Principle work
Clinical dentists
81%
Lecturers
10%
Researchers
3%
Others
6%
< 5 years
26%
5-10 years
32%
10 < years
42%
Years of
experience

Copies Retured Response

given answers rate (%)
Pilot study
Male
Table 1: Response rate

Location

Choice of Antibiotics for Treatment of Acute

Dentoalveolar Infection

Table 3 shows the daily frequency of dosage
and the length of the course for antibiotic choice for
patients not allergic to penicillin. Amoxicillin is the
antibiotic of choice in 25.8% of practitioners. The
normal dosage of amoxicillin used is 500 mg 3 times
daily for 5 days (7.5 DDDs for each prescription).
36
Huda Kh / Salmiah / Mohamed Ibrahim / Mohamed Mansor
Table 3: Antibiotic prescription by dentists for acute dentoalveolar infection showing frequency of dosage and
number of days for patients not allergic to penicillin
Drug type

Antibiotic
Daily Frequency
Numbers of days
Dosage (mg) 1
Amoxicillin

250
500
3000
1
1
0
1
8
1
50 15 6
93 5
9
0
0
0
7
5
0
53 0
84 0
1
0
1
9
0
67
107
1
Amoxicillin
Clavulinate
615
11 0
15
Penicillin

250
500
0
0
0
1
1
1
2
3
0
0
0
0
2
5
0
0
1
0
3
5
Cephalaxin

125
1000
0
1
0
0
2
1
0
0
0
2
0
0
2
0
0
0
0
0
2
2
Erythromycin
250
Metronidazole 200

400
1
1
1
13 6
15 45 5
4
5
3
4
13 1
47 4
0
6
21
66
Tetracycline
250
Others
Total
39 213 38 27 20 221 5
20
295

Total
Figure 2: Antibiotics prescribed by dentists (n=217) for

treatment of acute dentoalveolar infection
for patients allergic to penicillin
Figure 1 shows the antibiotics prescribed by

practitioners for adults with an acute dentoalveolar
infection for patients not allergic to penicillin.
Figure 1: Antibiotics prescribed by dentists (n=217) for
treatment of acute dentoalveolar infection
for patients not allergic to penicillin.
Prescribing Antibiotics for Specific Clinical Conditions

The percentages of dentists prescribing
antibiotics for specific dental conditions are shown in
Figure 3, with the majority prescribing antibiotics for
acute periodontal abscess, pericoronitis, dry socket
and acute periapical infection (API) before and after
drainage.

The choices of therapeutic antibiotic for patients
allergic to penicillin are shown in Figure 2. Table 4 shows
the daily frequency and number of days for antibiotics
choice for patients allergic to penicillin. Erythromycin
(250 mg) is used by 21.2% of practitioners, 3 times
daily for 5 days (5 DDDs).
37
Table 4: Antibiotic prescription by dentists for acute dentoalveolar infection showing frequency of dosage and
number of days for patients allergic to penicillin
Drug type

Antibiotic
Daily Frequency
Numbers of days
Dosage (mg) 1
Amoxicillin

250
500
1
0
0
0
1
1
0
0
1
0
0
0
1
1
0
0
0
0
2
1
Amoxicillin
Clavulinate
625
Cephalaxin
125
Azithromycin
500
Erythromycin

250
500
0
0
2
8
24 27 4
14 6
0
4
4
40 1
24 0
4
0
53
28
EES
400
16 13 2
22 0
31
Clarithromycin 250
Clindamycin

150
450
0
0
1
2
7
2
11 1
0
0
3
2
7
0
10 0
0
2
10
14
Metronidazole 200

400
1
0
2
18 3
11 48 0
2
7
4
1
18 0
45 4
0
2
24
59
Tetracycline
250
Others
Total
49 142 50 22 23 179 6
131
243
Figure 3: Percentage of dentists prescribing antibiotics

for specific dental conditions

Total
Figure 4: Dentists choices of antibiotics for the specific

dental conditions for patients medically well
and not allergic to penicillin

The dentists choices of antibiotics for the
surveyed dental conditions for medically fit patients
and not allergic to penicillin are shown in Figure
4. The three most used antibiotics are amoxicillin,
metronidazole and a combination of the two antibiotics.
For cellulitis in particular, the results show that there
is a wide variation of antibiotic prescriptions for this
condition (Figure 5).
38
Figure 5: Other antibiotic choices by dentists for

cellulitis
Table 6: Dentists responses to the type of dental

procedure requiring antibiotic prophylaxis
for patients at risk of I.E
Antibiotic Prophylaxis for Patients at Risk of Infective

Endocarditis

The prophylactic antibiotic regimes used by
dentists for patients not allergic to penicillin are shown
in Figure 6. The antibiotic regimes used by dentists for
patients allergic to penicillin are shown in Figure 7.
Table 5 shows that the majority of dentists prescribed
antibiotics for patients with previous I.E., prosthetic
heart valve, unrepaired cyanotic heart disease and
mitral valve incompetence. Table 6 represents dentists
responses regarding which dental procedure required
antibiotic prophylaxis in patients at risk from I.E.
Table 5: Dentists responses to which cardiac
conditions require antibiotic prophylaxis in
adult patients for invasive dental procedure
Patients conditions

Yes
response
(%)
Didnt
know
(%)
Unrepaired
cyanotic congenital
heart disease
70.0
8.3
Previous I.E.
94.9
0.9
Prosthetic
heart valve
86.6
1.8
Mitral valve
incompetence
70.0
5.1
Innocent heart
murmur
13.0
4.2
Recent MI
27.2
6.9
Rheumatic fever
51.2
3.2
Old MI
12.0
3.2
Pacemaker or an
implantable cardiac
defibrillator
41.7
7.4
Procedures

Yes
Do not
response do it
(%)
(%)
Do Not
know
Placement of
rubber dam
20.3
16.1
Tooth extraction
98.2
Placement of
orthodontic band
27.2
9.7
0.5
Placement of
orthodontic bracket
9.2
10.1
0.5
Endodontic
debridement
where instruments
are not passed
through the
root apex
29.6
4.1
0.5
Endodontic
obturation
(post placement
and build up)
14.3
3.7
0.9
Taking of oral
radiograph
8.3
0.5
Bleeding from
trauma to the
lips or oral mucosa
69.9
0.9
0.5
Figure 6: Antibiotic prophylaxis regimes used by

dentists (n=217) for patients predisposed to
I.E., not allergic to penicillin
39
Figure 7: A ntibiotic prophylaxis regimes used by

dentists (n=217) for patients predisposed to
I.E. allergic to penicillin
that the wide use of erythromycin in different parts

of the world may be related to its recommendation in
previous literatures and its low price 19.

Although DDDs of the prescribed antibiotic
complies with the MNCG 2003, there is still a wide
variation in the antibiotic prescribing patterns among
surveyed dental practitioners.

The reason for this diverse antibiotic
prescriptions is unclear. Previous studies suggested
that the prescription is influenced by undergraduate
and postgraduate education and the pharmaceutical
industry 3.

Other factors which may influence the
dental practitioners prescriptions include: patients
expectation, the inability to make a definitive diagnosis
or the treatment had to be delayed. However, the
decision to prescribe antibiotics must be based on
a thorough medical history, clinical examination and
accurate diagnosis 1, 20, 21.
DISCUSSION
Choice of Antibiotics for Treatment of Acute
Dentoalveolar Infection

This study found that amoxicillin is the
most frequently prescribed antibiotics for acute
dentoalveolar infection for patients not allergic
to penicillin. Although there are some studies
recommended amoxicillin or amoxicillin calvulanate
for treatment of dental infection 12, 13 but the MNCG
2003 14 still recommend phenoxymethyl penicillin 250500 mg as the first choice for the treatment of acute
dentoalveolar infection, and this may be due to its
efficacy in polymicrobial infections, relatively narrow
spectrum for bacteria than amoxicillin and amoxicillin/
clavulanate low toxicity and low cost 12.

Compared with other studies, amoxicillin has
also been prescribed by the dental practitioners in
England and Australia and there was a tendency
towards a lower dosage over a long period of time 1, 3.
However in Norway, Al-Haroni and Skaug reported that
dentists preferred to prescribe penicillin and narrow
spectrum antibiotics, leading to a low prevalence of
antibiotic resistance among oral bacteria15.

Some practitioners used amoxicillin in
combination with metronidazole. The combination
antibiotic therapy should be avoided, as the use of
combination therapy resulted to a broad spectrum
exposure that led to depression of the normal host
flora and increased opportunity for resistant bacteria
to merge. For routine infections the disadvantages
of combination therapy outweigh the advantages 16.
Recent guidelines published by the Commission of the
Federation Dentiare International recommend that
combination therapy should be avoided whenever
possible in dentistry 17.

The dentists antibiotic choices for treatment
of acute dentoalveolar infection for patients allergic
to penicillin comply with the MNCG 2003 guidelines 14.
Erythromycin is also widely used in the medical field
in Malaysia18 in spitc of its resistance which can even
develop during a course 3, 13. Kakoei et al suggested
Prescribing Antibiotics for Specific Dental Conditions

The treatment of acute pulpitis includes
extraction, endodontic treatment or pulp capping.
According to Cochrane systematic reviews, there was
no evidence which support the use of antibiotics for
pain relief in pulpitis 22-24 and the Malaysian guidelines
also did not mention antibiotics for acute pulpitis. In
this study, about 40% of dental practitioners surveyed
prescribed antibiotics for this condition.

About 80% used antibiotics for acute periapical
infection (API) before drainage and 60.5% prescribed
antibiotics after drainage was established. Systematic
literature on the effectiveness of antibiotics intervention
in the management of API indicated that the use of
antibiotics has no additional benefit, unless there are
systemic complications (e.g. fever, lymphadenopathy
or cellulitis). Drainage of an infection is necessary in
the majority of uncomplicated swellings 25-28.

The majority of dental practitioners surveyed in
the study routinely prescribed antibiotics for dry socket,
pericoronitis and periodontal abscesses although these
three conditions can be effectively treated by local
measures and antibiotics are only indicated for large
spreading infections or systemic involvement 29-35.

In case of chronic periodontitis the use of
topical antibiotics as an adjunct to scaling and root
planning is sufficient to resolve this condition 36. In this
study however, 20% prescribed antibiotics for chronic
periodontitis.

The use of antibiotics in implant dentistry is
controversial; the scientific evidence is not sufficient
to either recommend or discourage the use of
preoperative systemic antibiotics to prevent dental
implant complications or failure 37-41, and prophylaxis
antibiotics are recommended in subjects with risk
factors including immune suppressed patients with
metabolic disorders 42; however, in this current study,
only 20% of practitioners prescribed antibiotics for this
condition.
40

The majority of dental practitioners surveyed
prescribed antibiotics for cellulitis, and there is a wide
variety of antibiotics used for this condition as shown
in Figure 5. However, penicillin (250-500 mg) 4 times
a day has been recommended to treat this condition
43, 44
. The results of this survey have shown that the
prescribing of antibiotics by dental practitioners is
often not based on sound clinical principles, most of
those surveyed used antibiotics routinely for conditions
where local treatment would be sufficient.

These results support the conclusion that there
is overprescribing of antibiotics in dental practice
and this might be due to the fact that there are
only general guidelines on prescribing rather than a
definitive regimen. The dental practitioners need clear
and practical guidelines on when to prescribe, what to
prescribe, the duration and in what dose1.
by surveyed dental practitioners who prescribed

antibiotics for bleeding from trauma to the lip or
oral mucosa and for orthodontic band placement for
patients at risk of I.E. These findings are also reported
by Thompson et al as there is a similar confusion
among Welsh dentists as to which particular dental
procedures required prophylaxis 5.

The results show that there is confusion as to
which cardiac conditions require prophylaxis and for
which particular dental procedures. There is a need to
update dentists knowledge with the recent antibiotic
guidelines and make these guidelines readily accessible
by dentists and physicians as many dentists consult
physicians regarding the need for prophylaxis and the
application of current regimen before performing a
dental procedure 47.
Antibiotic Prophylaxis for Patients at Risk of Infective

Endocarditis

This study found that 66.4% of dental
practitioners follow the AHA guidelines (2008) 45 in
their prophylaxis prescription for patients not allergic
to penicillin who were at risk of I.E. For patients
allergic to penicillin, a majority of dentists surveyed
follow AHA guidelines45. On the other hand, there
were 3% of surveyed dentists who used amoxicillin for
patients allergic to penicillin, and this is contraindicated
because of anaphylaxis and hypersensitivity reactions.

In general, compliance with antibiotic
prophylaxis regimens does seem to be a problem
world wide. According to Seymour et al (2000),
compliance to recommended antibiotic dose,
identifying at risk patient and providing cover for
the appropriate dental procedure range from 15-35%
46
.
The results of this survey reflect the antibiotic

prescriptions patterns of dental practitioners for
therapeutic and prophylactic purposes and can be
used as a basis to improve the current guidelines
and introduce more detailed guidelines for various
dental conditions. The results show that there is a
large variation in the antibiotic prescriptions patterns
for therapeutic and prophylactic purposes and there
is confusion as to which cardiac conditions require
prophylaxis and for which particular dental procedures.
This study confirms that there is a need for educational
intervention such as training intervention, revising
and distributing the antibiotic guidelines, individual
outreach visits and antibiotic audit to encourage the
rational and appropriate use of the antibiotics.
Antibiotic Prophylaxis for Cardiac Conditions

The results demonstrate that there is a tendency
to use antibiotics unnecessarily in some cardiac
conditions. More than 10% of surveyed dentists
prescribed antibiotics for patients who have old
myocardial infarction where antibiotic prophylaxis is
not recommended and there is a tendency to prescribe
antibiotics for patients with pacemakers in which
antibiotic prophylaxis is not recommended 45. These
findings are similarly reported by Thompson et al
who concluded that the knowledge of Welsh dentists
regarding cardiac conditions varied widely 5.
CONCLUSION
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44 Fung HB, Chang JY, Kuczynski S. A practical guide
to the treatment of complicated skin and soft
tissue infections. DRUGS 2003; 63(14): 14591480.
45 Wilson W, Taubert KA, Gewitz M, et al. Prevention
of infective endocarditis: Guidelines from the
American Heart Association. JADA 2008; 139:
3S-24S.
46 Seymour RA, Lowry R, Whitworth JM, Martin MV.
Infective endocarditis, dentistry and antibiotic
prophylaxis; time to rethink? Br Dent J 2000; 189:
610-616.
47 Lauber C, Grace M, MacDougall. Antibiotic
prophylaxis practices in dentistry: A survey of
dentists and physicians. JCDA 2007; 73: 263263e.
Huda Kh. AbdulKader
Faculty of Pharmacy
Universiti Teknologi MARA
Bandar Puncak Alam, 42300
Selangor, Malaysia.
E mail address: huda_hannon@hotmail.com
Telephone number: + (60)3-89940598
43
Refining Occlusion With Muscle Balance To Enhance Long-Term

Orthodontic Stability
Derek Mahony
BDS(Syd) MScOrth(Lon) DOrthRCS(Edin) MDOrthRCPS(Glas) MOrthRCS(Eng) MOrthRCS(Edin)
ABSTRACT
The primary objective of orthodontic treatment is the movement of teeth into a more ideal relationship, not only
for aesthetic, but also for functional considerations. Another very important objective, often not given enough
consideration, is the need to finish the case with the muscles of mastication in equilibrium. If muscle balance
is not achieved, an endless procession of retainers, is required for retention. In simple terms, if the occlusal
forces in maximum intercuspation are unevenly distributed around the arch, tooth movement will most likely
occur. However, today it is possible to precisely measure the relative force of each occlusal contact, the timing of
the occlusal contacts and specific muscle contraction levels, all simultaneously. This technological breakthrough
represents a new opportunity for orthodontists everywhere.
Key Words:
Introduction
Muscle Balance and Occlusion

Many well respected orthodontists agree
that there is more to occlusion than just teeth.
Temporomandibular joint function and the maxillomandibular relation are as much a part of occlusion
as are the teeth. Consequently, when a malfunction
occurs within the TM joints or a maxillo-mandibular
mal-relation exists, a compensatory response is elicited
from the stomatognathic musculature. Most often that
response can be measured through electromyography
(EMG).

Over 50 years ago one orthodontist began to
record muscle activity through surface electromyography
in an effort to better understand the functions of the
muscles of mastication.1 In the intervening years
since, surface EMG has revealed several key facts
about the relationship between the muscles and a
patients occlusion. Today we can routinely record up
to 8 channels of EMG data, right in the clinic. And, data
interpretation can lead us to a better understanding of
our patients specific condition.

Figure 1: An 8 channel Electromyograph
44
Derek Mahony
Figure 2: a) relaxed, quite muscles
b) hyperactive muscles

In figure 2. we see muscles that are; a) relaxed
at rest (the normal condition) b) hyperactive at rest
(indicating a maxillo-mandibular malrelation) or 3)
exhibiting a neurological abnormality (large motor-unit
firing). While these factors routinely go unmeasured,
their contribution to a precise diagnosis can be highly
significant, even to the long-term outcome of a
particular case.2-5
Figure 3. a) balanced clench
c) large motor-unit firing

Determining muscle balance in function is an
easy task for EMG.6-13 Typically, the patient is asked to
clench in maximum intercuspation and then swallow.
The clench will appear balanced (fig. 3a.) or unbalanced
(fig. 3b.). The swallow will either be with the teeth
together (fig. 3c.) or with a tongue-thrust (fig. 3d.)
Then, if an appliance is utilized, muscle activity can
be recorded before, during and after adjustment of
the appliance. This will immediately demonstrate the
effectiveness of the appliance.14-20
b) unbalanced clench
c) normal swallow
d) aberrant swallow

If we see that the muscles are balanced, we know we have a result that will remain stable. But, if the
muscles are not in balance, we cant tell from the EMG recordings along exactly what to do about it. While much
has been learned about muscle hyperactivity and the various conditions of imbalance that can exist within the
masticatory musculature, EMG is not, nor will it likely ever be, adequate to the task of directing case treatment by
itself. While surface EMG is a fast, easy and reliable way to record the relative contraction levels of the muscles
at rest or in function, it has a low sensitivity to occlusal force locations and the timing of tooth contacts.
T-Scan II
position, followed by a clench. Other recordings can

also be taken in centric relation, lateral excursions and
protrusion.

The simplest solution to the problem of
evaluating the timing and force of occlusal contacts is
the T-Scan II.21-23 It provides a very sensitive measure
of contact force and a moving picture of the order in
which the contacts occur.24-32 It is the only technology
available to the clinician that can show precisely the
order in which contacts occur and simultaneously, the
relative force of each distinct contact. The new high
density sensors are flexible, more precise and very
durable (usable for up to 30 registrations).

A bite-force recording is taken by having the
patient bite down several times on the T-Scan wafer
to condition it. This allows it to conform to the
shape of the arch. Then a recording is taken with the
patient closing from rest position into the intercuspal
Figure 4: The T-Scan II

45
Refining Occlusion with Muscle Balance to Enhance Long-term Orthodontic Stability
A Map of the Sequence from Initial Anterior Contact to Bilateral Contact
Figure 5: a) 1st contact
b) 1st Posterior Contact
c) 1st Left Posterior Contact
In the recording in Figure 5. the initial contact points occur only on the incisors. As the patient continues to close
a contact appears on the right area of the second molar. Eventually a contact appears on the left second molar
creating a tripod effect.
Figure 6: Force movie frames

When the recording is replayed as a force movie a three dimensional graph is displayed showing the
relative force at each point of contact. Again we see that the initial contacts are on the incisors, then the right
posterior and finally the left second molars. What is also evident is that in full closure, the highest contact force
is actually on the left second molar, (indicated by the tallest spike) despite the lateness of the contact. Further
inspection clearly suggests that the reason the excessive force is being born by the left second molar is due to a
lack of solid contacts on the left first molar and bicuspids. In spite of the large number of contact points around
the arch, this is an occlusion badly in need of adjustment.

However, as we analyze the tracing above, as clear as the picture of occlusion of this case is, we realize
that we do not and cannot from this information understand what the musculature is doing to accommodate.
But there is a way to do both.
Why the T-Scan wafer at 85 microns is not too thick.

According to the latest research on mandibular function (Gallo et al) we now know that the sagittal path
of closure is more complicated than a simple hinge movement. In fact, the "helical axis of rotation" moves
from the vicinity of the angle of the mandible (early in opening) to about mid-ramus (late in opening) in
close proximity to where the inferior alveolar nerve enters the mandibular foramen. For a voluntary closure
between rest and occlusion (2 - 3 mm) the average amount of rotation has been measured at 0.7 degrees
(Lewin A. and Moss C.). For an 85 micron change that's about 0.02 degrees of rotation (about 1.5 minutes of
arc). If the A/P distance between the incisors and the 2nd molars is 40 mm, 1.5 minutes of arc translates to
an 18 micron difference in This is a very small difference in comparison to the size of an occlusal adjustment
being made and well within the adaptive capacity of the system. Another benefit of placing the T-Scan wafer
between the arches ... it that it reduces the acuity of proprioception, which reduces, but doesn't eliminate,
the ability of the central nervous system to avoid any existing prematurities
46
Derek Mahony
T-SCAN II BioEMG II
to synchronize their respective data streams. This

is accomplished by having either program act as a
master while the other program acts as a slave to it.
That is, a dentist can Run the T-Scan program and the
BioEMG II program will dutifully follow it. Or, he/
she can Run the BioEMG II program and the T-Scan II
program will follow it. This is true in recording as well
as in playback analysis.

Previous studies have attempted to correlate
T-Scan data with EMG data.33,34 Recently the two
companies who separately manufacture the T-Scan
II and the BioEMG II have created a milestone by
making their programs talk to each other.35 This is not
something that happens often in dentistry, but the
synergy created now offers a unique opportunity for
dentists to more clearly understand their patients
occlusal conditions comprehensively. The reason that
the programs needed to talk to each other was
Figure 7: The Simultaneous Recording of Occlusal Force, Timing and Muscle Activity- One high force point on
the left bicuspids, right anterior temporalis hyperactivity
Analyzing the Combined Traces
the temporomandibular joints, the mandible is able

to move freely forward and back, left and right. The
same elevator muscles that apply vertical forces
can and do apply horizontal forces to the mandible as
needed for function. In figure 7. then, we can see that
while the left side muscles are applying more force in
the vertical direction, the right side temporalis must
be applying a significant amount of its force in a nonvertical (horizontal) direction. However, with some
extra effort, it is possible to achieve a muscle and force
balanced occlusion. See Figure 8.

When we see that the highest force of contact
is on the left can we assume that the greatest muscle
activity will be the same? Not at all. Figure 7. shows
an example of a patient with a higher force level on the
left side (63% of total), focused in the bicuspid area.
At the same time we clearly see that the right anterior
temporalis is firing at nearly twice the level of the left
one. It is also apparent that the combined activities of
the right masseter and temporalis are far greater than
the same muscles on the left. How is this possible?

Not one of the muscles of mastication that
elevates the mandible is positioned such that
there is a straight vertical relationship between the
origin and the insertion. Each elevator muscle has
a horizontal component to its direction of applied
force. Due to the ginglymo-arthroidial structure of
47
Figure 8: Both the forces and the activities of the muscles are balanced in this patient
Balanced Forces do not Guarantee Balanced Muscles

Sometimes we can record a relatively even balance of forces between the right and left sides, but the
patient is still not comfortable. Even with adequate stable contacts on both sides some patients still complain.
The patient in Figure 9. had regular temporal headaches. The left-right force balance was rather good at 56%
right to 44% left. It is evident that the initial contact is on the left side (see the center of force vector), that
during the closure the force passes to the right side before reaching its balanced force condition at maximum
intercuspation. However, notice that the temporalis muscles are contracting 2 times greater levels than the
masseter muscles. Soon after a repositioning appliance was placed that balanced both the muscle and the
forces, the headaches were relieved.
48
Derek Mahony
Figure 9: By the time the total force has reached 93.5% of maximum, the center of force has returned to the
midline and the vertical muscle forces are even between left and right sides. However, it is clear that
the temporalis muscles are overloaded compared to the masseters.

With the technology that is available today an ordinary practicing dentist has the ability to more thoroughly
evaluate the masticatory system than ever before. It is now possible to routinely adjust an occlusion, not only to
equalize the occlusal forces, but also to create an environment where the muscles can function in harmony with
each other.
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Thompson JR: Concepts regarding the function

of the stomatognathic system. JADA 1954 Jun;
48:626-637
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Gervais RO, Fitzsimmons GW, Thomas NR.

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Kamyszek G, Ketcham R, Garcia R Jr, Radke

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Electromyographic evidence of reduced
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Belser UC, Hannam AG. The influence of altered

working-side occlusal guidance on masticatory
muscles and related jaw movement. J Prosthet
Dent. 1985 Mar;53(3):406-13
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McCarroll RS, Naeije M, Hansson TL. Balance in

masticatory muscle activity during natural chewing
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Visser A, McCarroll RS, Oosting J, Naeije M.

Masticatory electromyographic activity in healthy
young adults and myogenous craniomandibular
disorder patients.
J Oral Rehabil. 1994
Jan;21(1):67-76.
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Christensen LV, Rassouli NM. Experimental

occlusal interferences. Part I. A review. J Oral
Rehabil. 1995 Jul;22(7):515-20.
10. Christensen LV, Rassouli NM. Experimental

occlusal interferences. Part II. Masseteric EMG
responses to an intercuspal interference. J Oral
Rehabil. 1995 Jul;22(7):521-31.
20. Roark AL, Glaros AG, O'Mahony AM. Effects of

interocclusal appliances on EMG activity during
parafunctional tooth contact. J Oral Rehabil. 2003
Jun;30(6):573-7.
11. Borromeo GL, Suvinen TI, Reade PC. A comparison

of the effects of group function and canine
guidance interocclusal device on masseter muscle
electromyographic activity in normal subjects. J
Prosthet Dent. 1995 Aug;74(2):174-80.
21. Maness WL, Podoloff R. Distribution of occlusal

contacts in maximum intercuspation. J Prosthet
Dent. 1989 Aug;62(2):238-42.
22. Maness WL. Laboratory comparison of three
occlusal registration methods for identification of
induced interceptive contacts. J Prosthet Dent.
1991 Apr;65(4):483-7.
12. Christensen LV, Mohamed SE. Bilateral masseteric

contractile activity in unilateral gum chewing:
differential calculus.
Sep;23(9):638-47.
23. Reza Moini M, Neff PA. Reproducibility of occlusal

contacts utilizing a computerized instrument.
Quintessence Int. 1991 May;22(5):357-60.
13. Saifuddin M, Miyamoto K, Ueda HM, Shikata N,

Tanne K. An electromyographic evaluation of
the bilateral symmetry and nature of masticatory
muscle activity in jaw deformity patients during
normal daily activities. J Oral Rehabil. 2003
Jun;30(6):578-86.
24. Mizui M, Nabeshima F, Tosa J, Tanaka M, Kawazoe

T. Quantitative analysis of occlusal balance in
intercuspal position using the T-Scan system. Int
J Prosthodont. 1994 Jan-Feb;7(1):62-71.
14. McCarroll RS, Naeije M, Kim YK, Hansson TL.

Short-term effect of a stabilization splint on the
asymmetry of submaximal masticatory muscle
activity. J Oral Rehabil. 1989 Mar;16(2):171-6.
25. Gonzalez Sequeros O, Garrido Garcia VC, Garcia

Cartagena A. Study of occlusal contact variability
within individuals in a position of maximum
intercuspation using the T-SCAN system. J Oral
Rehabil. 1997 Apr;24(4):287-90.
15. Naeije M, Hansson TL. Short-term effect of

the stabilization appliance on masticatory
muscle activity in myogenous craniomandibular
disorder patients. J Craniomandib Disord. 1991
Fall;5(4):245-50.
26. Garcia Cartagena A, Gonzalez Sequeros O, Garrido

Garcia VC. Analysis of two methods for occlusal
contact registration with the T-Scan system. J
Oral Rehabil. 1997 Jun;24(6):426-32.
16. Lobbezoo F, van der Glas HW, van Kampen FM,

Bosman F. The effect of an occlusal stabilization
splint and the mode of visual feedback on the
activity balance between jaw-elevator muscles
during isometric contraction. J Dent Res. 1993
May;72(5):876-82. Erratum in: J Dent Res 1993
Aug;72(8):1264.
27. Suda S, Matsugishi K, Seki Y, Sakurai K, Suzuki T,

Morita S, Hanada K, Hara K. A multiparametric
analysis of occlusal and periodontal jaw reflex
characteristics in young adults with normal
occlusion. J Oral Rehabil. 1997 Aug;24(8):610-3.
28. Garrido Garcia VC, Garcia Cartagena A, Gonzalez
Sequeros O. Evaluation of occlusal contacts in
maximum intercuspation using the T-Scan system.
J Oral Rehabil. 1997 Dec;24(12):899-903.
17. Visser A, Naeije M, Hansson TL. The temporal/

masseter co-contraction: an electromyographic
and clinical evaluation of short-term stabilization
splint therapy in myogenous CMD patients. J Oral
Rehabil. 1995 May;22(5):387-9.
29. Kirveskari P. Assessment of occlusal stability by

measuring contact time and centric slide. J Oral
Rehabil. 1999 Oct;26(10):763-6.
18. al-Quran FA, Lyons MF.The immediate effect of

hard and soft splints on the EMG activity of the
masseter and temporalis muscles. J Oral Rehabil.
1999 Jul;26(7):559-63.
30. Kerstein RB. Improving the delivery of a fixed

bridge. Dent Today. 1999 May;18(5):82-4, 86-7.
31. Suda S, MacHida N, Momose M, Yamaki M, Seki
Y, Yoshie H, Hanada K, Hara K. A multiparametric
analysis of occlusal and periodontal jaw reflex
characteristics in adult skeletal mandibular
protrusion before and after orthognathic surgery.
J Oral Rehabil. 1999 Aug;26(8):686-90.
19. Ferrario VF, Sforza C, Tartaglia GM, Dellavia C.

Immediate effect of a stabilization splint on
masticatory muscle activity in temporomandibular
disorder patients.
Sep;29(9):810-5.
50
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32. Saracoglu A, Ozpinar B. In vivo and in vitro

evaluation of occlusal indicator sensitivity. J
Prosthet Dent. 2002 Nov;88(5):522-6. Comment
in: J Prosthet Dent. 2003 Sep;90(3):310; author
reply 310-1.
33. Kerstein RB, Wright NR. Electromyographic and
computer analyses of patients suffering from
chronic myofascial pain-dysfunction syndrome:
before and after treatment with immediate
complete anterior guidance development. J
Prosthet Dent. 1991 Nov;66(5):677-86. Comment
in: J Prosthet Dent. 1993 Jul;70(1):99-100.
34. Hidaka O, Iwasaki M, Saito M, Morimoto T.
Influence of clenching intensity on bite force
balance, occlusal contact area, and average bite
pressure. J Dent Res. 1999 Jul;78(7):1336-44.
35. Kerstein RB.
Combining technologies: A
computerized occlusal system synchronized with
a computerized electromyograhic system. Cranio.
2004 Apr;22(2):96-109.
Dr Derek Mahony
Specialist Orthodontist
49 Botany Street
Randwick NSW 2031
Australia
Ph: +61-2-9314 5533
Fax: +61-2-9314 5936
Email: info@derekmahony.com
51
Microleakage Of Class II Cavities Restored Using Composite

Resins
Normaliza Ab. Malik

BDS, MClinDent, Faculty of Dentistry, University Sains Islam Malaysia, Malaysia
Marhazlinda Binti Jamaludin
BDS, MSc, Informatics Unit, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
Seow Liang Lin
BDS, MSc, FDSRCS, PhD, School of Dentistry, International Medical University, Kuala Lumpur, Malaysia
ABSTRACT
Objectives: To evaluate the marginal microleakage of Class II cavities restored with various types of composite
resins. Materials and Methods: Standard Class II slot cavities were prepared at the proximal surfaces of 40 intact
premolars which were divided into 4 groups. Four types of composite resins (Esthet-X-Denstply, USA, FiltekTMZ3503M ESPE, USA, Beautifil- Shofu, Japan and Solare P-GC, Japan) were used to restore the slot cavities. All the
specimens were thermocycled and immersed in 0.5% basic fuschin dye for 24 hours. The specimens were then
sectioned in mesio-distal direction. The marginal microleakage at the occlusal and cervical margin was scored
using the ISO microleakage scoring system. Data was entered using SPSS Version 12.0 and analyzed using STATA
software programme. Results and discussion: All composite resins exhibited worse microleakage at the cervical
margin compared to occlusal margin. Esthet-X showed significantly better microleakage score at the occlusal margin
compared to Beautifil and Solare P. FiltekTMZ350 and Beautifil showed mainly microleakage into enamel only at
the occlusal margin. Solare P demostrated better resistance against microleakage at the cervical margin compared
to other composite resin tested. Esthet-X, Filtek Z350 and Beautiful is not significantly different from each other
in terms of microleakage at the cervical margin. Conclusion: This study showed that none of the materials used in
this study is able to eliminate microleakage. Composite resin restorations exhibited worse micorleakage at cervical
margin in comparison to occlusal margin.
Key Words: Microleakage, composite resin, Class II cavities, occlusal margin, cervical margin
secondary caries formation3, marginal staining and

post-operative sensitivity2. These may subsequently
lead to failure of the restoration and development of
pulpal pathology. Therefore, it is important to minimize
or eliminate microleakage to ensure longevity of the
restorations. This in vitro study aims to evaluate the
marginal microleakage in Class II cavities restored with
various types of composite resins. The microleakage at
occlusal and cervical margin was evaluated.
Introduction

Composite resins have gained popularity in the
last decade and have been used in the posterior region
as direct or indirect restorations. This tooth-coloured
restorative material is a popular substitute to replace
amalgam and metallic restorations due to fear of
mercury toxicity, aesthetic concern and conservation
of tooth structure1.

The clinical longevity of posterior composite
resin restorations still posts a concern. In the
past years, many studies have been carried out to
evaluate the physical and mechanical properties of
various composite resins. Improvements in its filler
technology and resin matrix have increased its used
in the posterior stress-bearing areas. Although the
physical and mechanical properties of composite resins
have improved, polymerization shrinkage remains one
of the major concern leading to failure of direct
composite resin 2. Polymerization shrinkage results
in the formation of microscopic marginal gap at the
tooth-restoration interface which increase the risk of

Materials and Methods

Forty intact and non-carious maxillary premolars
extracted due to orthodontic treatment or periodontal
problems were collected. Class II slot cavities were
prepared on the mesial proximal surface of the 40
premolars (Figure 1). The cavities have standard depth
of 2.0mm and 3.0mm in bucco-palatal width. The
cervical margin of the cavities is placed 1.0mm below
the cemento-enamel junction (CEJ) (Figure 1). The
teeth were randomly divided into four groups with 10
specimens in each group.
52
Normaliza / Marhazlinda / Seow
Four types of composite resins were used to restore the

prepared cavities: (1) Esthet-X (Denstply Caulk, USA); (2)
FiltekTMZ350 (3M ESPE, USA); (3) Beautifil (Shofu Dental
Corporation, Japan) and (4) Solare P (GC Corporation,
Japan). The cavities were etched and bond using the
respective companys dentine bonding agents and
following the manufacturers recommendations. The
composite resins were adapted using narrow siqveland
matrix band to ensure appropriate contouring of the
material at proximal areas. The restorations were
cured incrementally according to the manufacturers
instructions using a light curing device Spectrum
800 (470 nm wavelength) (Denstply Caulk, USA). This
device has a built-in, digital radiometer that is able to
confirm the light unit output. The occlusal and proximal
surfaces of the restorations were finished using the
medium and fine Soflex disc (3M ESPE, USA).
reading was taken for analysis. Data was entered using

SPSS Version 12.0 and analyzed using STATA software
programme.
Occlusal Score
Cervical Score
Score 0 No dye
penetration
Score 0 No dye
penetration
Score 1 Dye
penetration
into enamel
Score 1 Dye
penetration
into of the
cervical wall
Score 2 Dye
penetration
into the
dentine, not
including the
pulpal wall/
gingival floor
Score 2 Dye
penetration
into all the
cervical wall
Score 3 Dye
penetration
into the
dentine
including the
pulpal wall
Score 3 Dye
penetration
into cervical
and axial wall
Table 1: Scoring system for the extent of

microleakage
RESULTS
Figure 1: Class II slot cavity on mesial surface
Table 2 showed the microleakage score at the

occlusal and cervical margins of the specimens. Fisher
Exact Test was carried out to compare the microleakage
in the Class II slot cavities at the occlusal and cervical
margins (Tables 3 & 4). It showed that in general the
occlusal margin demonstrated better microleakage
score than at the cervical margin; with most specimens
having no leakage or only leakage into enamel at the
occlusal aspect while most specimens have leakage
into the whole of cervical wall and also axial wall at
the cervical aspect. At the occlusal margin, Esthet-X
demonstrated the least microleakage with nine
specimens scored no leakage in comparison to other
groups (Figures 2 & 4). Esthet-X showed significantly
better microleakage score at the occlusal margin
compared to Beautifil and Solare P (Table 3). Filtek
Z350 is not significantly different from Esthet-X in
terms of microleakage at the occlusal margin (Table 3).
Solare P exhibited the highest frequency of specimens
showing dye penetration or microleakage extends into
the dentine including the pulpal wall. Filtek TMZ350 and
Beautifil showed mainly microleakage into enamel only
at the occlusal margin (Figures 2, 6 & 7).

It was found that the microleakage pattern at
the cervical margin showed a different scenario with
Solare P having better resistance against microleakage

All the specimens were thermocycled at 5oC and
55oC for 500 cycles. Two layers of varnish were then
applied 1.0mm away from the cavity margins prior to
immersion in dye for microleakage evaluation to avoid
leakage of dye through other channels. The specimens
were immersed in 0.5% basic fuschin dye for 24 hours.
All the specimens were then rinsed with distilled water
and dried. Two mesio-distal sectioning were obtained
and dye penetration on both surfaces of the middle
section was evaluated and the worst score for dye
penetration was taken for data analysis. The extent of
the microleakage was scored using image analyser. The
ISO microleakage scoring system (ISO/TS 11405:2003)
was used to record the extent of microleakage as in
Table 1.

All the specimens were evaluated by one single
examiner. Intra examiner reliability was obtained using
STATA statistical software by computing weighted
kappa. The values of weighted kappa were 0.66 for
occlusal margin and 0.72 for cervical margin. These
kappa values were in acceptable range that indicated
an acceptable level of consistency for the examiner.
Three readings were taken for the occlusal and cervical
margins respectively for each specimen and the worst
53
Microleakage of Class II cavities restored using composite resins
Figure 2: Microleakage Score at Occlusal Margin in

Control Group
at the cervical margin compared to other composite

resin tested; i.e four of the Solare P specimens showing
no leakage (Figure 3). Interestingly, Esthet-X which
demonstrated good microleakage score at occlusal
margin has became the worst with all of the samples
having microleakage into cervical and axial wall (Figure
3). Pos hoc test revealed that the microleakage score
for Esthet-X at the cervical margin was significantly
worse than Solare P (Table 4). Esthet-X, Filtek Z350 and
Beautiful were not significantly different from each
other in terms of microleakage at the cervical margin
(Table 4).
Table 2: Microleakage score at occlusal and cervical
margin
Type of composite resins
Microleakage
score (n)
Solare P
10
Beautifil
10
10
Esthet-X
10
Solare P
10
Beautifil
10
10
10
10
Filtek
TM
Z350
Figure 3: Microleakage Score at Cervical Margin in

Control Group
Occlusal margin
Cervical margin
Filtek
TM
Z350
Esthet-X
Table 3: Pos hoc test for pairwise comparison a for

microleakage at the occlusal margin
Pairwise
comparison
Esthet_X
Esthet_X
Filtek Z
350
Beautiful
Solare P
NS
<0.001
<0.001
NS
NS
Filtek Z 350
NS
Beautiful
<0.001
NS
Solare P
<0.001
NS
Figure 4: Microleakage score for Esthet-X

Score 0
NS
NS
a. Fisher Exact Test with Bonferroni correction was

done, significant at p < 0.05
Table 4: Pos hoc test for pairwise comparison a for
microleakage at the cervical margin
Pairwise
comparison
Esthet_X
Esthet_X
Filtek Z 350
Filtek Z
350
Beautiful
Solare P
NS
NS
0.018
NS
NS
NS
Beautiful
NS
NS
Solare P
0.018
NS
Score 3

NS
NS
a. Fisher Exact Test with Bonferroni correction was

done, significant at p < 0.05
54
Figure 5: Microleakage score for Solare P
and Solare P. Class II restorations were chosen due to

the increased demand for posterior composite resin
restoration.

Microleakage at cervical margin of Class II
restorations has been a problem and remains one of
the main causes for failure of posterior composite resin
restorations. Numerous researches on microleakage
have been carried out with a view to improve the
performance of various restorative materials in clinical
service. Yazici et. al. (2004)4 have mentioned that
differences in the results may be related to the
different types of materials used, the location, type
and size of the cavities, the operator factors (i.e.
professional skills during the restorative procedures)
and research methodology. Fraunhofer et. al. (2000) 5
also stated that various tooth prepration has influence
on the microleakage behaviour. It is therefore difficult
to make direct comparison amongst various research
findings. Nevertheless, the findings in this study can
serve as a guide to the extent of microleakage that will
occur with the materials investigated.

Microleakage is a three dimensional phenomenon,
different location and angles of sectioning may result
in a different degree of dye penetration 6. Gwinnet
et. al.6 claimed that the amount of microleakage in a
single section will be underestimated. In the present
study, two mesio-distal sectioning were obtained and
dye penetration on both surfaces of the middle section
was evaluated and the worst score for dye penetration
was taken for data analysis. It is hoped that by doing
so more representative scores would be obtained.
Precautions have been taken to reduce the errors
in measurement, evaluation was carried out by one
assessor (to eliminate inter examiner variability) and
the set up of the image analyzer was standardized.

In general, the composite resins investigated
in the present study (Esthet-X , Beautifil and FiltekTM
Z350) demonstrated more microleakage at the
cervical margin compared to occlusal margin.. This
finding is similar to findings by other researchers 2,
7
. Leevailoj et. al., (2001)7 used four different types
of packable composite resins (Alert-Jeneric, SurefilDentsply, Pyramid-BISCO and Solitaire-Heraeus Kulzer)
and one conventional composite resin (Renew-BISCO)
with their respective manufacturers bonding agent
and they found that significantly higher leakage was
noted at the cervical margin in Class II cavities with
cervical margin placed 1mm below the cementoenamel junction. Peutzfeldt & Asmussen (2002) 2 also
demonstrated higher leakage at the cervical margin
than the occlusal margin when Class II cavities were
restored with hybrid composite resin (Renew).

Esthet-X was highly viscous and difficult to adapt
to the tooth surfaces. This may have attributed to the
high degree of leakage at the cervical margin. The high
viscosity also resulted in the observation of voids in the
body of Esthet-X materials when viewed under image
analyser with 2.0 X magnification. The presence of
Score 1
Score 0

Figure 6: Microleakage score for Filtek Z350
Score 1
Score 2
Figure 7: Microleakage score for Beautifi
Score 1
Score 3
DISCUSSION

This study was conducted to evaluate and
compare the extent of marginal microleakage in Class
II slot cavities restored with four different types of
composite resins: Esthet-X, FiltexTM Z350, Beautifil
55
Microleakage of Class II cavities restored using composite resins
This observation may explain the worse microleakage

score in Esthet-X at the cervical margin. On the other
hand it may also explain the least microleakage score
in Solare P. The self-etching primer did not totally
remove the smear layer in comparison to the total
etch technique. Therefore the tubules remain sealed.
However, to confirm this, further study should be done
at microscopic level.
voids in a material may be due to the resin properties

such as high viscosity, polymerization shrinkage, high
modulus of elasticity, poor wettability and the depth
of cure8. This may lead to lower resistance to fatique
and decreased wear resistance. The voids may be
detected on radiographs and voids that present at the
margin may be responsible for marginal discoloration
and gross microleakage9. At the occlusal margin where
visibility is good, the marginal adaptation can be
improved by burnishing the material.

It was also found that majority of Solare P
specimens had dye penetration into half of the dentine
and pulp wall at the occlusal margin. The poorer
microleakage score for Solare P may be due to the
inability of the self-etching primer to adequately etch
the enamel surface. Generally the self-etching primers
use weaker acid with pH range from 1.8 to 2.5 10.
The separate acid etching step used for Esthet-X and
FiltekTMZ350 may effectively etch the enamel to form
resin tags and contribute to less microleakage.

On the other hand, Belli et. al. (2001) 11 found
that there was no significant difference at the
interfaces tested (occlusal enamel-resin, cervical
enamel-resin and dentin-resin) with different etchant.
They found that the used of 37% phosphoric acid
on the enamel surface did not produce better seal
compared to the used of self-etching primer. Indeed,
a study carried out by Pashley (1992)12 revealed
that self-etching primer actually has the ability to
bond well to roughen or prepared enamel but not
to unprepared enamel, and the unprepared enamel
must be etched first with standard phosphoric acid.
Furthermore, Oliveira et. al., (2003) 13 showed that selfetching primer yielded higher bond strength than totaletch system regardless different surface preparation
methods. However, whether higher bond strength was
related to lower microleakage is not known.

At the cervical margin, Solare P showed less extent
of microleakage where only three of the specimens
showed penetration of the dye into the cervical and
axial wall compared to the other types of composite
resin tested. In contrast, Esthet-X demonstrated the
worst microleakage which resulted in dye penetration
into the cervical and axial wall for all specimens. This
is because at the cervical margin, there was absence
of enamel prism and therefore less mineralized than
at the occlusal margin. This has resulted in less
predictable etching pattern and more microleakage14.
In the present study, Solare P demonstrated lower
leakage at the cervical compared to other composite
resins probably due to the ability of the weaker selfetching primer in producing a conducive etch pattern
at the cervical margin compared to the stronger
phosphoric acid.

A study done by Pashley (1992)12 noted that the
present of smear layer and smear plugs are able to
reduce dentine permeability and removing this layer
may have resulted in increased dentine permeability.
CONCLUSION

Within the limitations of the present study, it
is concluded that composite resin material exhibited
better marginal seal at occlusal margin in comparison to
cervical margin. In this study, Esthet-X has demonstrated
better marginal seal at occlusal margin compared to
other composite resin investigated. If margin of cavity
is very deep and subgingival, placement of cavity
margin below the CEJ may affect the longevity of the
restoration due to high incidence of micorleakage.
ACKNOWLEDGEMENT

This research project was supported by Research
Grant Vot F: F0104/2005C from the University of
Malaya.
REFERENCES
1. Manhart, J. Chen, H. Y. Hamm, G. and Hickel,
R. Review of the Clinical Survival of Direct and
Indirect Restorations in Posterior Teeth of the
Permanent Dentition. Operative Dentistry. 2004;
29(5).481-508
2. Peutzfeldt, A. and Asmussen, E. Composite
Restoration: Influence of Flowable and Self-Curing
Resin Composite Linings on Microleakage in Vitro.
Operative Dentistry. 2002; 27.569-575.
3. Neme, A.L. Maxson, B.B. Pink, F.E and Aksu,
M. N. Microleakage of Class II packable resin
composites lined with flowables: an in vitro study.
Operative Dentistry. 2002; 27.600-605
4. Yazici, A.R.Celik, C. and Ozgunaltay, G.
Microleakage of different resin composite types.
Quintessence International. 2004; 35(10).790794
5. Fraunhofer, JA von. Adachi, EI. Barnes, DM. and
Romberg, EM. The Effect of Tooth Preparation
on Microleakage Behaviour. 2000; Operative
Dentistry. 25.526-533
56
6. Gwinnett, J.A. and Tay, F. R.Comparison of three

methods of critical evaluation of microleakage
along restorative interfaces. Journal of Prosthetic
Dentistry. 1995; 74(6); 575-585
7. Leevailoj, C. Cochran, M.A. Matis, B.A. Moore,
B.K. Platt, J..A. Microleakage of posterior packable
resin composites with and without flowable
liners. Operative Dentistry. . 2001; 26.302-307
8. Estafan, D. Estafan, F. Leinfelder, K.F. Cavity wall
adaptation of resin-based composites lined
with flowable composites. American Journal of
Denistry. 2000; 13.192-194
9. Civelek, A. Ersoy, M. Hotelier, EL. Soyman, M.
and Say, EC. Polymerization Shrinkage and
Microleakage in Class II Cavities of Various Resin
Composites. Operative Dentistry 2003; 28(5):
635-641
10. Tani, C. and Finger, W.J. Effect of smear layer
thickness on bond strength mediated by three
all-in-one self-etching priming adhesives. Journal
of Adhesive Dentistry. 2002; 4.283-289
11. Belli, S. Inokoshi, S.Ozer, F. Pereira, P.N.R. Ogata,
M. and Tagami, J. The Effect of Additional Enamel
Etching and a Flowable Composite to the
Interfacial Integrity of Class II Adhesive Composite
Restorations. Operative Dentistry. 2001; 26. 70-75
12. Pashley, D. H. The effect of acid etching on the
pulpodentin complex. Operative Dentistry. . 1992;
17(6).229-42
13. Oliveira, S.S.A. Pugach, M.K., Hilton, J. F. et. al. The
influence of the dentin smear layer on adhesion:a
self-etching primer vs. total-etch system. Dental
Materials. 2003; 19.758-767
14. Gale, M. S. Darvell, B.W. Dentine permeability and
tracer tests. Journal of Dentistry. 1999; 27.1-11
Dr. Normaliza Ab. Malik
Faculty of Dentistry
University Sains Islam Malaysia (USIM)
Aras 15-17, Menara B
Persiaran MPAJ, Jalan Pandan Utama,
Pandan Indah, 55100 Kuala Lumpur
e-mail: liza_arie2004@yahoo.com
57
Aim And Scope

The 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.
Publication
The Malaysian Dental Journal is an official publication of the Malaysian Dental Association and is published half
yearly (KDN PP4069/12/98)
Instructions to contributors
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Editor,
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Jan - June 2010 KDN PP 4069

MALAYSIAN DENTAL ASSOCIATION

Malaysian Dental Journal

MALAYSIAN DENTAL JOURNAL

Associate Professor Dr. Seow Liang Lin

Dr. Shahida Mohd Said

Dr. Mohamad Muzafar Hamirudin

Editorial Advisory Board:

Professor Dr. Rosnah Mohd Zain

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

Malaysian Dental Association Council 2009-2010

Dr Lee Soon Boon

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

MALAYSIAN DENTAL JOURNAL

Aim And Scope

Membership and change of address

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

MALAYSIAN DENTAL JOURNAL

Clinical parameters of periodontal abscess: a case series of 14 abscesses

What Dental Students Think About Fixed Prosthodontics e-Learning (FPeL)

Knowledge Of Prescribing Antimicrobial Among Dental Practitioners In Klang Valley Region

Refining Occlusion With Muscle Balance To Enhance Long-Term Orthodontic Stability

Microleakage Of Class Il Cavities Restored Using Composite Resins

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

MALAYSIAN DENTAL JOURNAL

EDITORIAL: Magnification in Dentistry

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

Clinical parameters of periodontal abscess: a case series of 14

Key Words: Periodontal abscess, pocket, periodontitis, clinical features

This is a descriptive study of patients with periodontal

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

Upper, posterior teeth and buccal sites were found

Periodontal abscess was found to occur more in the

American Academy of Periodontology. Parameters

Address for correspondence:

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

Prosthodontic Management Of A Malpositioned Endosseous

Key Words: Malpositioned implants, anterior maxilla, prosthodontic management

Daylene Leong / Ansgar Cheng / Elvin Leong / Neo / Helena Lee

periodontium responds to implant placement, 22,23 thus

Fig. 1: OPG during orthodontic treatment prior to

Fig. 2: OPG of bonded composite resin pontic as

Fig. 3: Implant placement excessively inclined towards

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

Fig. 6: Abutment screw access hole was filled up with

Fig. 4: Full contour sculpture of tooth fabricated using

Fig. 7: Post-cementation of provisional crown

Fig. 5: Custom abutment casted in type III yellow gold

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

Fig. 8: Post-cementation of definitive all-ceramic crown

Fig. 9: Post-operative frontal view of patients smile

Daylene Leong / Ansgar Cheng / Elvin Leong / Neo / Helena Lee

Fig. 10: OPG of implant with definitive PFM crown

Fig. 11: PA xray of implant with definitive PFM crown

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

Solakoglu O, Cooper LF. Immediate implant

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

et al. Crestal bone changes around titanium

24. Goaslind GD, Robertson PB, Mahan CJ, et

Daylene Leong / Ansgar Cheng / Elvin Leong / Neo / Helena Lee

Malaysian Dental Journal Jan-June 2010 Vol 31 No 1

Pattern of Toothpaste Usage in Children Under Six Years Old

Key Words: Toothpaste, Fluoride, Pattern