TUGAS TRANSLATE JURNAL
The application of ozone in dentistry: A
systematic review of literature
Azarpazhooh, AmirAuthor Information ; Limeback, HardyAuthor Information
. Journal of Dentistry; Oxford36.2 (Feb 2008): 104-16.
(ProQuest)
Penerjemah:
BAMBANG KARTONO
NIM: J2A017999
FAKULTAS KEDOKTERAN GIGI
HASIL TERJEMAHAN
Judul
Penerapan ozon dalam kedokteran gigi: tinjauan literatur yang sistematis
Abstrak
(1) Mengkaji secara klinis aplikasi klinis dan potensi remineralisasi ozon dalam
kedokteran gigi; (2) Meringkas aplikasi ozon dalam kedokteran gigi secara in vitro.
Ovid MEDLINE, CINAHL, dll (sampai dengan April 2007).
Publikasi bahasa Inggris in vitro atau in vivo, studi asli, dan ulasan disertakan.
Dokumen konferensi, abstrak, dan poster tidak disertakan.
Secara in vitro
* Bukti bagus tentang biokompatibilitas ozon dengan sel epitel oral manusia,
fibroblas gingiva, dan sel periodontal;
Bukti yang bertentangan dengan khasiat antimikroba ozon namun beberapa bukti
bahwa ozon efektif dalam menghilangkan mikroorganisme dari saluran air unit gigi,
rongga mulut, dan gigi palsu;
Bukti yang bertentangan untuk penerapan ozon di endodontik;
* Tidak cukup bukti penerapan ozon dalam operasi mulut dan implantologi;
* Bukti bagus penerapan profilaksis ozon dalam kedokteran gigi restoratif sebelum
etsa dan penempatan sealant dan restorasi gigi.
In vivo: Meskipun ada bukti in vitro yang menjanjikan, penerapan klinis ozon
dalam kedokteran gigi (sejauh ini dalam pengelolaan karies gigi dan akar) belum
mencapai tingkat efektivitas dan efektivitas biaya yang kuat.
Naskah Lengkap
Pengantar
Ozon (juga dikenal sebagai triatomic oxygen dan trioxygen) adalah senyawa
alami yang terdiri dari tiga atom oksigen. Ditemukan di alam, dalam bentuk gas di
stratosfer dalam konsentrasi 1-10ppm, terus diciptakan dari dan dihancurkan
menjadi molekul O2. 1 Kedua reaksi kimia ini dikatalisis oleh sinar ultraviolet
frekuensi sangat tinggi dari sinar matahari. Akibatnya radiasi ultraviolet B dan C
berbahaya di stratosfer yang mencapai atmosfer luar dari matahari diserap oleh
ozon.2,3 Oleh karena itu, ozon di stratosfer memiliki peran penting dalam struktur
termal stratosfer maupun kerangka ekologis untuk kehidupan. di permukaan bumi.4
Di sisi lain, ozon di troposfer dianggap beracun untuk saluran pulmonal. Di
troposfer, ozon diproduksi dalam serangkaian reaksi kimia yang rumit yang
melibatkan komponen knalpot mobil (NO2), sinar matahari (terutama di
bulan-bulan musim panas), dan oksigen.
dekarboksilat asam ini menjadi asam asetat. 13 Telah ditunjukkan bahwa
remineralisasi lesi karies yang baru jadi dapat dianjurkan saat produksi asam asetat,
atau asam p Ka lainnya yang ditemukan dalam plak istirahat, cairan plak buffer.
Selama Perang Dunia I, gas ozon digunakan untuk mengobati gangren pasca
trauma traumatis, luka yang terinfeksi, luka bakar gas mustard dan fistula pada
tentara Jerman.15 Terapi ozon diterima sebagai pengobatan alternatif di Amerika
Serikat dari tahun 1880 sampai 1932. Sampai saat ini, ozon terapi telah menjadi
modal pengobatan yang diakui di 16 negara.1 Penggunaannya telah diteliti dalam
pengobatan penyakit mata (seperti neuropati optik, glaukoma, penghalang vena
retina sentral, dan penyakit retina degeneratif), infeksi bakteri, virus dan jamur akut
dan kronis. , penyakit iskemik, degenerasi makula terkait usia, penyakit ortopedi,
dan penyakit dermatologis, paru, ginjal, hematologi dan neurodegeneratif. Hal ini
dapat bereaksi dengan komponen darah (eritrosit, leukosit, trombosit, sel endotel
dan sistem vaskular) dan secara positif mempengaruhi metabolisme oksigen, energi
sel, properti imunomodular, sistem pertahanan antioksidan, dan mikrosirkulasi.
15,16
Dalam kedokteran gigi, Dr. E.A. Fisch (1899-1966) adalah dokter gigi
pertama yang menggunakan air ozonated dalam praktiknya dan mengenalkannya
pada ahli bedah Jerman Dr. Erwin Payr (1871-1946) yang menggunakannya sejak
saat itu dalam operasi dan melaporkan hasilnya di Kongres ke-59 dari German
Surgical Society di Berlin (1935). Pada operasi gigi, air ozonated digunakan untuk
meningkatkan haemostasis, meningkatkan suplai oksigen lokal, dan menghambat
proliferasi bakteri.18 Secara teoritis, ozon dapat mengurangi jumlah bakteri dalam
lesi karies aktif dan oleh karena itu, penangkapan sementara untuk sementara dapat
menghambat perkembangan karies, yang mengakibatkan mencegah atau menunda
kebutuhan akan restorasi gigi.19
digunakan. Tujuan ini akan menjadi penting bagi peneliti masa depan dalam hal apa
yang telah dicoba dan apa potensi penerapan klinis ozon dalam kedokteran gigi.
Metode
2.1 Sumber data
Sebuah pencarian literatur yang komprehensif tentang database Ovid
MEDLINE (R) dan versi sekutunya, Indeks Kumulatif untuk Sastra Kesehatan
Keperawatan & Sekutu, Pengobatan Berbasis Bukti Cochrane Central Register of
Controlled Trials, Database Cochrane of Systematic Reviews, Database Abstrak
Review of Effects , EMBASE, Health and Psychosocial Instruments, HealthSTAR
/ Ovid Healthstar, Abstrak Farmasi Internasional, dan sumber internet dari Google
Scholar (TM) dilakukan (sejak awal hingga 31 April 2007) untuk mengidentifikasi
studi dimana ozon digunakan. Situs-situs perusahaan manufaktur (KaVo Dental
GmbH, Jerman dan CurOzone USA Inc, Aurora, ON, Kanada) juga mencari
publikasi lainnya. Artikel yang diterbitkan dalam literatur bahasa Inggris saja telah
ditinjau. Tabel 2 menunjukkan kata kunci dan kombinasi kata kunci yang
digunakan.
2.2 Pemilihan studi
Uji coba terkontrol acak dan kuasi-acak terhadap aplikasi ozon dalam
kedokteran gigi disertakan. Studi retrospektif, rangkaian kasus atau laporan kasus,
surat kepada editor (tidak berisi data primer), editorial, review artikel, makalah
konferensi, abstrak, poster dan komentar tidak disertakan namun dibaca untuk
mengidentifikasi studi potensial.
2.3 Pengambilan data
Hasil
Sementara studi in vitro mengenai topik ini penting, tujuan utama dari
tinjauan ini adalah untuk menemukan bukti penerapan klinis ozon dalam
kedokteran gigi. Oleh karena itu, hasil pencarian telah dirangkum dalam dua
bagian:
(1) Studi in vivo: ringkasan informasi yang tersedia dengan evaluasi peninjau dan
komentar penilaian kritis.
(2) Studi in vitro: ringkasan informasi yang tersedia.
3.1 Tujuan utama: Aplikasi klinis ozon dalam kedokteran gigi
3.1.1 Ozon dalam pengelolaan karies baru jadi
Tiga studi in vivo manusia ditemukan untuk mengevaluasi keefektifan ozon
dalam pengelolaan karies baru jadi:
Abu Naba'a et al.20 melakukan uji klinis acak acak split. Mereka termasuk 90
peserta dengan setidaknya dua lesi pit atau fisura primer (tanpa kavitasi) pada gigi
posterior permanen yang dapat diakses melalui prosedur diagnostik. Sebanyak 390
lobus oklusal primer dan lesi fisura termasuk dalam penelitian ini dimana 195 gigi
menerima gas ozon dan 195 tidak. Gigi yang termasuk diacak untuk terapi ozon
(10s gas ozon pada konsentrasi 2100ppm pada awal penelitian, jatuh ke 630ppm,
hanya 30% dari dosis penuh, pada akhirnya) atau hanya pembersihan (tidak ada
ozon), meskipun tidak selalu dalam jumlah yang sama di setiap mulut Dari sampel
ini, 132 lesi (66 dari kelompok ozon dan 66 dari kelompok kontrol) selanjutnya
menerima sealant fissure.
Untuk gigi yang tidak dilubangi pada kedua kelompok, perkembangan
karies dan regresi diukur dengan perubahan skor keparahan klinis, rata-rata log (e)
pembacaan DIAGNOdent dan nilai log rata-rata (e) ECM (tanda karies listrik) pada
Hasil penelitian mereka menunjukkan bahwa rata-rata perubahan dalam pembacaan
ECM adalah 0,337 dan -0,065 untuk kelompok perlakuan dan kontrol. Pada
kunjungan recall pertama, perbedaan antar kelompok secara signifikan lebih baik
pada kelompok ozon (p <0,05). Setelah kunjungan mengingat 3 - 6 bulan,
perubahan tingkat keparahan klinis dan perubahan nilai DIAGNOdent distabilkan
pada kelompok ozon. Pada semua kunjungan ingat nilai-nilai ini lebih tinggi (lebih
buruk) untuk kelompok kontrol daripada kelompok ozon, dengan signifikansi
marjinal (tidak statistik) p = 0,081. Pada gigi yang disegel tersebut, tidak ada
perbedaan yang signifikan dalam retensi sealant jangka pendek.
Dengan menggunakan kuesioner kecemasan, mereka menemukan bahwa
pengobatan ozon memicu keadaan kecemasan paling rendah dibandingkan dengan
kedokteran gigi tradisional (p <0,05). Kecemasan semakin berkurang setelah
subyek menerima pengobatan ozon (p <0,05). Juga, persentase yang tinggi dari
mereka yang senang dengan perawatan ozon (n = 89) disertai dengan kepuasan
untuk menerima perawatan lagi, membayar biaya, menerima komitmen waktu, dan
bahkan merekomendasikannya kepada teman atau keluarga.
Dengan kriteria inklusi / eksklusi yang sama, kelompok penelitian20
melakukan studi percontohan terhadap delapan peserta dengan setidaknya dua
karies primer atau karies retensi (termasuk kavitasi) pada gigi posterior permanen
yang dapat diakses melalui prosedur diagnostik. Mereka termasuk total 38 lubang
oklusal utama dan lesi karies fisura, yang secara acak dibagi dua kelompok
menggunakan tabel acak yang dihasilkan komputer:
(1) Sembilan belas lesi menerima gas ozon selama 40an pada awal, 1, 3, dan 6
bulan.
(2) 19 lesi lainnya tidak menerima ozon.
bahwa secara signifikan lebih banyak lesi yang ditangkap di kelompok ozon
daripada kelompok kontrol. Mereka menyimpulkan bahwa pengobatan ozon untuk
lesi remineralisasi 10s secara signifikan dan dapat diusulkan sebagai pengobatan
alternatif untuk lesi pit atau fisura baru.
Baru-baru ini, Huth et al.21 melakukan penelitian klinis acak terkontrol
acak untuk mengevaluasi pengaruh gas ozon 40-an (HealOzone [KaVo Dental
GmbH, Jerman]) mengenai perkembangan atau pembalikan karies fisil oklusal awal
yang tidak berkepanjangan. Mereka merekrut 41 pasien (usia rata-rata 7,7 ± 2,2
tahun) dengan 57 pasang lesi pada gigi molar permanen kontra-lateral dan secara
acak menugaskan gigi ini ke dua kelompok: gigi uji menerima pengobatan ozon
sementara gigi kontrol tidak diobati. Pemeriksa buta yang dikalibrasi memantau
perkembangan lesi atau pembalikan dengan menggunakan DIAGNOdent hingga 3
bulan. Secara signifikan pembalikan karies lebih banyak atau penurunan karies
progresi ditemukan di lesi yang diobati dengan ozon daripada pada lesi kontrol yang
tidak diobati di dalam kelompok pasien dengan risiko karies saat ini. Namun, tidak
ada perbedaan signifikansi statistik antara kelompok-kelompok tersebut saat
seluruh populasi penelitian diperiksa.3.1.2 Ozon dalam pengelolaan karies
terbukaSatu studi klinis22 ditemukan yang mengevaluasi keefektifan gas ozon
dalam pembalikan karies pada permukaan tunggal terbuka lesi: 82 lesi permukaan
tunggal terbuka pada 28 anak yang khawatir dan tidak dapat diobati (usia rata-rata
5,96 ± 2,36 tahun) pertama kali digali sampai konsistensi kasar dicatat dan
kemudian ditugaskan ke dua kelompok (maksimum dua pasang per subjek); Lesi
yang lebih besar terkena gas ozon 20-an (HealOzone) sementara lesi yang lebih
kecil tidak diobati sebagai kelompok kontrol. Kekerasan ringan (keras, kasar dan
lunak) dan pembacaan DIAGNOdent dinilai dan perubahan untuk nilai kekerasan
dan DIAGNOdent pada lesi uji. dibandingkan dengan nilai pada lesi kontrol setelah
DIAGNOdent membaik; Namun, peningkatan tersebut tidak signifikan secara
statistik. Selain itu, penggunaan ozon menghasilkan pengurangan rata-rata 13%
nilai DIAGNOdent segera setelah pengobatan ozon. Akhirnya, dengan penggunaan
kuesioner, ditemukan bahwa tingkat ketakutan berkurang sebelum sesi kedua dan
mengikuti sesi terakhir masing-masing sebesar 82% dan 93% anak-anak, sebelum
sesi kedua dan mengikuti sesi terakhir.
3.1.3 Ozon dalam pengelolaan karies akar
Sebanyak tiga penelitian (satu in vitro dan dua in vivo) ditemukan untuk
mengevaluasi efek preventif dan terapeutik ozon dalam pengelolaan karies akar:
Dalam penelitian in vitro, Baysan et al.18 menilai efek antimikroba dari
ozon berair pada lesi karies akar primer (PRCLs). Mereka memanen 40 PRCLs
lunak dari gigi yang baru diekstraksi dan melepaskan separuh lesi dengan
ekskavator steril. Lesi yang tersisa terkena air ozonasi untuk jangka waktu 10 atau
20an (0. 069 atau 0.138mL ozon, masing-masing). Jumlah mikrobiologis yang
dikurangi secara signifikan (p <0,001) diamati pada kelompok yang diberi
perlakuan ozon dibandingkan dengan kelompok kontrol. Mereka juga
menggunakan 40 manik kaca berlapis air liur steril untuk menunjukkan keefektifan
antimikroba spesifik gas ozon 10 (HealOzone) pada Streptococcus mutans dan
Streptococcus sobrinus. Manik-manik kaca dibagi secara acak menjadi dua
kelompok untuk masing-masing mikroorganisme: ozon dan kontrol. Mereka
menemukan pengurangan signifikan (p <0,0001) pada sampel yang diobati dengan
ozon untuk kedua mikroorganisme dibandingkan dengan sampel kontrol.18
Dalam setting in vivo, Baysan dkk.23 melakukan percobaan klinis acak split
mouth. Mereka termasuk 79 peserta, setidaknya 18 tahun, dengan dua atau empat
lesi karies utama (PRCLs). Lesi yang termasuk adalah kulit kasar (indeks keparahan
(1) Pembersihan, 10s gas ozon, dan larutan reduktan (mengandung xylitol
dan fluoride). Intervensi diulangi pada 1 bulan (tanpa ozon), 3 bulan dan 6 bulan
(keduanya dengan ozon 10s).
(2) hanya reductant (dioleskan untuk 5 detik), diulang setelah 1 bulan dan 3
bulan.
(3) Ozon + sealant. Terapi ozon diaplikasikan pada 3 bulan. Sealants
diaplikasikan kembali jika cacatnya sebagian atau seluruhnya.
(4) Sealant saja.
Untuk semua kelompok perkembangan karies dan regresi diukur dengan
perubahan skor keparahan klinis, rata-rata log (e) pembacaan DIAGNOdent, dan
nilai log rata-rata (e) ECM. Mereka juga mencatat intervensi gigi lebih lanjut, rasa
sakit, kepuasan pasien dan efek samping.
Hasil penelitian mereka menunjukkan bahwa dalam follow up 6 bulan,
perubahan rata-rata pada pembacaan ECM secara signifikan lebih tinggi (yaitu,
remineralisasi yang lebih baik) pada kelompok yang diobati dengan ozon daripada
pada kelompok kontrol (5,62 vs 4,92, masing-masing). Selain itu, pengukuran
DIAGNOdent dalam follow up 6 bulan secara signifikan lebih rendah (yaitu,
remineralisasi yang lebih baik) pada kelompok yang diobati dengan ozon daripada
pada kelompok kontrol (10,9 banding 46,4, masing-masing). Dalam 12 bulan 47%
PRCL menjadi keras pada kelompok ozon, sementara tidak ada yang menjadi sulit
dalam kelompok kontrol (p <0,001). Lima puluh dua persen lesi dibalik dari indeks
keparahan 2 banding 1 pada kelompok ozon dibandingkan dengan 11,6% pada
kelompok kontrol (p <0,001).
Dalam uji coba klinis acak lainnya, Holmes12 mengevaluasi efek gas ozon,
dikombinasikan dengan penggunaan kit remineralizing sehari-hari, dengan tingkat
keparahan klinis dari lesi karies akar primer tanpa kavitas (PRCL) pada 89 subjek
kontrol, setelah 3 bulan, 4% menjadi lebih buruk (p <0,01). Pada recall 6 bulan, 8%
lesi yang diobati dengan ozon tetap kasar dan sisanya menjadi sulit. Sebaliknya,
pada kelompok kontrol, 11% lesi menjadi lebih buruk dan hanya satu lesi yang
menjadi keras (p <0,01). Pada recall 12 bulan, pada kelompok ozon, dua lesi tetap
kasar dan sisanya mengeras. Pada periode yang sama, pada kelompok kontrol, 21
lesi menjadi lebih buruk, satu tetap keras, dan sisanya tetap kasar (p <0,01). Pada
recall 18 bulan, pada kelompok ozon, semua lesi telah ditangkap, sementara pada
kelompok kontrol, 37% lesi menjadi lebih buruk, seseorang telah membalik, dan
sisanya tetap kasar (p <0,01). Singkatnya, penelitian ini melaporkan bahwa 100%
PRCLs yang diobati dengan ozon telah berbalik arah selama 18 bulan, sementara
37% PRCLs pada kelompok kontrol telah memburuk dari kulit menjadi lunak dan
1% telah membalikkan.
3.1.4 Kualitas metodologis
Secara umum ada beberapa masalah metodologis dengan studi klinis ini:
Pengukuran hasil: Perlu dicatat bahwa sebagian besar studi klinis yang
ditinjau bergantung pada temuan yang dihasilkan oleh DIAGNOdent dan ECM.
Perangkat ini belum menggantikan deteksi visual, taktil dan radiografi sebagai
metode diagnosis awal karies awal, walaupun validitas dan reliabilitasnya telah
diuji secara luas. 24-38 Juga, skor keparahan klinis
kekerasan taktil) yang digunakan dalam empat penelitian12,20,22,23
bersifat subjektif dan dapat mengakibatkan beberapa tingkat kesalahan pengukuran.
Analisis data: Dalam semua penelitian ini, analisis data dilakukan pada tingkat lesi.
Para peneliti berasumsi bahwa tidak ada variabilitas antara subyek, yaitu, semua
gigi dianalisis secara independen seolah-olah berasal dari subyek yang berbeda.
Pendekatan ini dapat menghasilkan hasil yang signifikan; Namun, literatur
dua penelitian20,23 karena operator dan evaluatornya adalah satu orang pada
kunjungan yang sama. Namun, ini telah diatasi dalam dua penelitian12,21 dimana
pemeriksa yang dikalibrasi dan buta (selain operator) menilai hasilnya. Dalam studi
Holmes, dua dokter gigi mengalokasikan subyek untuk kelompok intervensi dan
menilai tingkat keparahan lesi, dan dokter gigi ketiga menilai reproduktifitas data.
Namun, tidak ada yang diakui di koran atau terdaftar sebagai co-author. Rincian
yang menyilaukan tidak tersedia di Dahnhardt et al. Kuesioner kepuasan dan
kecemasan kepuasan: Hasil ini dilaporkan sebagai tujuan sekunder di Abu Naba'a
et al.20 dan Dahnhardt dkk.22 Namun, tidak ada subjek yang diacak antara
pengobatan ozon atau pengeboran dan pengisian dan dengan demikian, informasi
komparatif mungkin tidak validasi. Durasi penelitian berkisar antara 3 bulan21
sampai 18 bulan.123.1.5 Tinjauan sistematis mengenai ozon dalam kedokteran gigi
klinis Pada tahun 2004, perpustakaan Cochrane19 mengadakan tinjauan sistematis
untuk menilai keefektifan gas ozon dalam menangkap atau membalikkan
perkembangan karies gigi. Penulis termasuk tiga uji coba terkontrol acak yang
relevan (Abu Naba'a, 20 pilot Abu Naba'a, 20 dan studi Baysan seperti yang dibahas
di atas) dengan total gabungan 432 lesi acak dari 137 peserta. Mereka mengevaluasi
penelitian ini dengan risiko bias yang tinggi dan menyimpulkan bahwa bukti yang
dapat dipercaya kurang bahwa penerapan gas ozon ke permukaan gigi yang rusak
membusuk atau membalikkan proses pembusukan dan bahwa tidak ada cukup bukti
kualitas tinggi untuk mendukung penggunaan gas ozon dalam pengaturan
perawatan primer.Baru-baru ini, Brazzelli et al.40 melakukan tinjauan sistematis
untuk menilai efektivitas gas ozon (HealOzone) untuk pengelolaan karies pit dan
fisura, dan karies akar. Mereka mencapai kesimpulan yang sama dengan
perpustakaan Cochrane. Mereka juga membangun model Markov untuk
mengeksplorasi aspek efektivitas biaya HealOzone di samping pengelolaan karies
bukti saat ini tidak cukup untuk menyimpulkan bahwa ini adalah tambahan biaya
yang efektif untuk pengelolaan dan perawatan karies oklusal dan akar.3.2 Tujuan
sekunder: ringkasan penerapan in vitro ozon dalam kedokteran gigi3.2.1 Ozon
dalam mikrobiologi oral (Tabel 3) Empat penelitian6,7,41,42 diidentifikasi untuk
menyelidiki efek bakterisida ozon di rongga mulut. Ozon mungkin berguna untuk
mengendalikan mikroorganisme menular oral pada plak gigi. Namun, bukti yang
ada kontroversial: sementara beberapa peneliti menemukan kemanjuran ozon yang
tidak lengkap (dalam bentuk berair atau gas) dalam menghilangkan bakteri yang
layak, 41,42 yang lain menemukan air ozonated yang efektif untuk membunuh
mikroorganisme oral gram positif dan gram negatif. dan Candida albicans oral.7
Juga, tingkat biokompatibilitas tinggi ozon berair pada sel epitel oral manusia, sel
fibroblas gingiva, dan sel periodontal telah ditemukan.6,43 Hal ini penting untuk
dekontaminasi gigi avul sebelum replantasi.6 Terlebih lagi, empat penelitian
ditemukan yang menunjukkan keefektifan antimikroba in vitro ozon sebagai
pembersih gigi tiruan9,44,45 dengan gas ozon ternyata lebih efektif daripada air
ozonated.46 Oleh karena itu, ozon gas dapat bermanfaat secara klinis untuk
desinfeksi gigi palsu.3.2.2 Ozon dalam endodontik (Tabel 4) Empat penelitian in
vitro5,41,47,48 diidentifikasi untuk menyelidiki efek bakterisida ozon
dibandingkan dengan sodium hipoklorit 2,5%, tegakan ared solusi irigasi di
endodontik. Hasil pada hasil ini kontroversial: sementara Nagayoshi et al., 20045
menemukan aktivitas antimikroba yang hampir sama (terhadap Enterococcus
faecalis dan S. mutans) dan tingkat sitotoksisitas air ozon yang lebih rendah
dibandingkan dengan 2,5% NaOCl; dalam sebuah penelitian oleh Hems dkk., 48
NaOCl ditemukan lebih unggul dari air ozonated dalam membunuh E. faecalis
dalam budaya kaldu dan biofilm sementara ozon gas efek pada biofilm E. faecalis.
Muller et al., 200741 juga menemukan 5% NaOCl lebih unggul dari ozon gas dalam
diambil11,49-51 yang menilai keefektifan ozon dalam kedokteran gigi restoratif
dan pengaruhnya terhadap bahan gigi. Yang menarik dari penelitian ini adalah
sebagai berikut: (1) Gas ozon dapat diterapkan sebagai pengobatan profilaksis
sebelum etsa dan penempatan sealant tanpa dampak negatif pada sifat fisik enamel
yang baik, termasuk kekakuan permukaan dalam sendok, atau sudut kontak.11 ( 2)
Pemaparan yang lebih lama terhadap gas ozon memiliki efek bakterisida yang kuat
pada mikroorganisme di dalam tubulus dentin dalam rongga dalam, yang dapat
menyebabkan peningkatan keberhasilan restorasi secara klinis, 49 tanpa dampak
negatif pada kekuatan ikatan dentin dan enamel pada perekat restorasi. 50 (3) Ozon
dapat digunakan untuk membersihkan permukaan campuran gigi tiruan parsial yang
dapat dilepas dengan sedikit dampak pada kualitas paduan dalam hal pantulan,
kekasaran permukaan, dan berat.51 Ada juga beberapa bukti mengenai efektivitas
aplikasi ozon berair di tempat tambahan. untuk amino-alkohol untuk dekontaminasi
permukaan implan.523.2.4 Ozon dalam operasi oral dan maxillofacialSebuah studi
ditemukan untuk mengevaluasi efek ozon e gas dalam operasi oral dan
maxillofacial, di mana terapi ozon terbukti bermanfaat untuk pengobatan
osteomielitis refrakter di kepala dan leher di samping pengobatan dengan antibiotik,
operasi dan oksigen hiperbarik. 53 Studi lain di bidang ini sebagian besar
merupakan publikasi non-Inggris dan ditinjau di tempat lain.54
Kesimpulan
Tinjauan literatur menyeluruh tentang penerapan ozon dalam kedokteran
gigi telah mengidentifikasi catatan penutup ini:
1)
Studi klinis yang diidentifikasi dalam tinjauan literatur difokuskan pada
penerapan gas ozon dalam pengelolaan lesi karies oklusal dan akar primer.
Meskipun ada bukti bagus dalam pengaturan in vitro, aplikasi klinis ozon
belum mencapai tingkat efektivitas dan efektivitas biaya yang tinggi.
2)
Ada bukti bagus adanya biokompatibilitas in vitro dari ozon berair dengan sel
epitel oral manusia, sel fibroblas gingiva, dan sel periodontal.
mengeluarkan biofilm. dan mikroorganisme terkait seperti Legionella
pneumophila, Mycobacterium spp., Pseudomonas aeruginosa, dan Candida
spp. dari sistem unit air gigi dan agen bakterisida yang efektif untuk
menghilangkan S. mutans, Staphylococcus aureus yang resisten methicillin,
Candida albicans, dan E. faecalis dari gigi palsu.9,44-46
4)
Ada bukti yang bertentangan dalam aplikasi in vitro ozon di endodontik.
54,41,47,48
5)
Ada bukti bagus penerapan in vitro ozon sebagai pengobatan antimikroba
profilaksis yang berguna sebelum etsa dan penempatan sealant dan restorasi
gigi tanpa interaksi negatif dengan sifat fisik restorasi enamel dan
perekat.11,49,50
6)
Ada bukti bagus penerapan in vitro ozon sebagai pembersih gigi tiruan dengan
sedikit pengaruh pada kualitas paduan tiruan dalam hal pantulan, kekasaran
permukaan, dan berat badan.9,44-46,51
7)
Tidak ada cukup bukti dalam penerapan ozon dalam operasi oral dan
maxillofacial, penyakit mulut, dan terapi implan.
Kesimpulannya, tinjauan ini telah menunjukkan bahwa sementara studi
laboratorium menunjukkan potensi ozon yang menjanjikan dalam kedokteran gigi,
bukti klinis untuk penerapan ozon dalam kedokteran gigi tidak ekstensif. Masih ada
kebutuhan untuk tingkat bukti tertinggi, yaitu uji coba klinis acak buta ganda yang
dirancang dengan baik, dengan ukuran sampel yang memadai, terbatas atau tidak
ada kerugian untuk ditindaklanjuti, dan metode pengukuran dan analisis standar
untuk membenarkan rutinitas. Penggunaan ozon sebagai modalitas pengobatan
dalam kedokteran gigi.
Sumber:
https://search.proquest.com/docview/1030254470/fulltext/2A6E2E64794A4374P
LAMPIRAN:
The application of ozone in dentistry: A
systematic review of literature
Azarpazhooh, AmirAuthor Information ; Limeback, HardyAuthor Information
. Journal of Dentistry; Oxford36.2 (Feb 2008): 104-16.
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(1) To systematically review the clinical application and remineralization potentials of ozone in dentistry; (2) To summarize the available in vitro applications of ozone in dentistry.
Ovid MEDLINE, CINAHL, etc. (up to April 2007).
In vitro or in vivo English language publications, original studies, and reviews were included. Conference papers, abstracts, and posters were excluded.
In vitro _
* Good evidence of ozone biocompatibility with human oral epithelial cells, gingival fibroblast, and periodontal cells;
* Conflicting evidence of antimicrobial efficacy of ozone but some evidence that ozone is effective in removing the microorganisms from dental unit water lines, the oral cavity, and dentures;
* Conflicting evidence for the application of ozone in endodontics;
* Good evidence of the prophylactic application of ozone in restorative dentistry prior to etching and the placement of dental sealants and restorations.
In vivo : Despite the promising in vitro evidence, the clinical application of ozone in dentistry (so far in management of dental and root caries) has not achieved a strong level of efficacy and cost-effectiveness.
While laboratory studies suggest a promising potential of ozone in dentistry, this has not been fully realised in clinical studies to date. More well designed and conducted double-blind randomised clinical trials with adequate sample size, limited or no loss to follow up, and carefully standardised methods of measurement and analyses are needed to evaluate the possible use of ozone as a treatment modality in dentistry.
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1
Introduction
Ozone (also known as triatomic oxygen and trioxygen) is a naturally occurring
compound consisting of three oxygen atoms. It is found in nature, in the form of a gas in the stratosphere in a concentration of 1-10ppm, being continually created from and destroyed into molecular O2. 1 Both these chemical reactions are catalyzed by very high frequency ultraviolet light from sunlight. Consequently harmful B and C
ultraviolet radiations in the stratosphere reaching the outer atmosphere from the sun are absorbed by ozone.2,3Therefore, ozone in stratosphere has a critical role in both the thermal structure of the stratosphere as well as the ecological framework for life on the Earth's surface.4 On the other hand, ozone in the troposphere is considered to be toxic for the pulmonary tract. In the troposphere, ozone is produced in a
complicated series of chemical reactions involving the components of automobile exhaust (NO2), sunlight (especially in hot summer months), and oxygen.
The reliable microbiologic and metabolic properties of ozone, in either the gaseous or aqueous phases, make it a useful disinfectant with a wide range of activity (Table 1).
walls and cytoplasmic membranes of bacteria and fungi. During this process, ozone attacks glycoproteins, glycolipids, and other amino acids and inhibits and blocks the enzymatic control system of the cell. 11 This results in increases in membrane permeability, the key element of cell viability, leading to immediate functional cessation. Then ozone molecules can readily enter the cell and cause the
microorganism to die.7,9,12 Also, ozone can attack many biomolecules, such as the cysteine, methionine, and the histidine residues of proteins.12 By oxidizing the biomolecules featured in dental diseases, ozone has a severely disruptive effect on cariogenic bacteria, resulting in elimination of acidogenic bacteria. The strongest naturally occurring acid, produced by acidogenic bacteria during cariogenesis is pyruvic acid. Ozone can decarboxylate this acid to acetic acid. 13 It has been shown that remineralization of incipient carious lesions can be encouraged when the production of acetic acid, or other high p Ka acids found in resting plaque, buffers plaque fluid.14
During World War I, ozone gas was used for treating gaseous post-traumatic gangrene, infected wounds, mustard gas burns and fistulas in German
soldiers.15 Ozone therapy was accepted as an alternative medicine in the USA from 1880 until 1932. To date, ozone therapy has been a recognized treatment modality in 16 countries.1 Its use has been investigated in treatment of ocular diseases (such as optic neuropathies, glaucoma, central retinal vein obstructions, and degenerative retinal diseases), acute and chronic bacterial, viral and fungal infections, ischemic diseases, age-related macular degeneration, orthopedic diseases, and
dermatological, pulmonary, renal, hematological and neurodegenerative diseases. It can react with blood components (erythrocytes, leukocytes, platelets, endothelial cells and the vascular system) and positively affect oxygen metabolism, cell energy, the immunomodular property, antioxidant defence system, and microcirculation. 15,16
progression of caries, resulting in prevention or delaying the need for tooth restorations.19
The primary objective of this article was to systematically review the clinical
application and remineralization potentials of ozone in dentistry. More specifically, the report attempts to answer the following focused question: "How effective is ozone gas in prevention of dental caries?". Our secondary objective was to summarize the available in vitro studies in dentistry in which ozone has been used. This objective would be of importance to future researchers in terms of what has been tried and what the potentials are for the clinical application of ozone in dentistry.
2
Methods
2.1 Data sources
A comprehensive literature search of databases Ovid MEDLINE(R) and its allied versions, Cumulative Index to Nursing & Allied Health Literature, Evidence-Based Medicine of Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, EMBASE, Health and Psychosocial Instruments, HealthSTAR/Ovid Healthstar, International
Pharmaceutical Abstracts, and internet resource of Google Scholar(TM) was carried out (from their inception until 31 April 2007) to identify studies where ozone was used. The websites of the manufacturing company (KaVo Dental GmbH, Germany and CurOzone USA Inc, Aurora, ON, Canada) were also searched for any other publication. Articles published in the English literature alone were reviewed. Table 2 shows the keywords and combinations of the keywords used.
2.2 Study selection
Randomised and quasi-randomised controlled trials of ozone application
in dentistry were included. Retrospective studies, case series or case reports, letters to editors (not containing primary data), editorials, review articles, conference papers, abstracts, posters and commentaries were excluded but were read to identify
potential studies.
After removing duplicates as well as reviewing the titles and abstracts of the retrieved articles, 45 articles were found to be relevant for our objectives. Reference lists of the retrieved articles were also searched to identify any other articles relevant to the research question, which may have provided additional information, resulting in identifying eight more studies.
3
Results
While the in vitro studies on this topic are important, the primary objective of this review was to find the evidence for the clinical application of ozone in dentistry. Therefore, the results of the search have been summarized in two sections:
(1) In vivo studies: a summary of available information with the reviewers' evaluation and critical appraisal comments.
(2) In vitro studies: a summary of available information.
3.1 Primary objective: Clinical applications of ozone in dentistry
3.1.1 Ozone in the management of incipient caries
Three human in vivo studies were found to evaluate the efficacy of ozone in the management of incipient caries:
Abu Naba'a et al.20 conducted a split mouth randomised clinical trial. They included 90 participants with at least two primary pit or fissure lesions (without cavitation) in permanent posterior teeth accessible to diagnostic procedures. A total of 390 primary occlusal pit and fissure carious lesions were included in this study where 195 teeth received ozone gas and 195 did not. Included teeth were randomised to either ozone therapy (10s of ozone gas at 2100ppm concentration at the start of the study, falling to 630ppm, only 30% of the full dose, by the end) or only cleaning (no ozone), though not always in equal numbers in every mouth. Of these samples, 132 lesions (66 from the ozone group and 66 from the control group) further received a fissure sealant.
and mean log(e) ECM (electric caries meter) scores at baseline, 1, 3, 6, 9, and 12 months. For those sealed teeth, the quality of sealants was checked at each recall. Patient satisfaction was also assessed. They also requested participants to report their anxiety using a questionnaire and to compare ozone treatment to usual dental interventions including dental injection, drilling, filling, and scaling and polishing.
Their results showed that the mean changes in ECM readings were 0.337 and -0.065 for the treatment and control groups, respectively. At the first recall visit, the
difference between groups was significantly better in the ozone group (p <0.05). After the 3- and 6-month recall visits, the change in the clinical severity and the change in the DIAGNOdent scores were stabilised in the ozone group, respectively. At all recall visits these values were higher (worse) for the control group than for the ozone group, with a marginal (not statistical) significance of p =0.081. In those sealed teeth, there was no significant difference in the short-term retention of sealants.
Using the anxiety questionnaire, they found that ozone treatment provoked the least state of anxiety comparing to traditional dentistry(p <0.05). The anxiety was further reduced after the subjects received the ozone treatment (p <0.05). Also, a high percentage of those happy with the ozone treatment (n =89) were accompanied with satisfaction to receive the treatment again, paying for the costs, accepting time commitments, and even recommending it to a friend or relative.
With the same inclusion/exclusion criteria, the research group20 conducted a pilot study on eight participants with at least two primary pit or fissure caries (including cavitation) in permanent posterior teeth accessible to diagnostic procedures. They included a total of 38 primary occlusal pit and fissure carious lesions, which were individually randomised to two groups using a computer generated random tables:
(1) Nineteen lesions received ozone gas for 40s at baseline, 1, 3, and 6 months.
(2) Another 19 lesions did not receive ozone.
arrested in the ozone group than the control group. They concluded that ozone treatment for 10s significantly remineralised lesions and could be proposed as an alternative treatment for new pit or fissure lesions.
Recently, Huth et al.21 conducted a split mouth randomised controlled clinical study to evaluate the effect of 40s ozone gas (HealOzone [KaVo Dental GmbH, Germany]) on the progression or reversal of non-cavitated initial occlusal fissure caries. They recruited 41 patients (mean age 7.7±2.2 years) with 57 pairs of lesions on contra-lateral permanent molars and randomly assigned these teeth to two groups: the test tooth received the ozone treatment while the control tooth was left untreated. A calibrated blinded examiner monitored lesion progression or reversal using
DIAGNOdent for up to 3 months. Significantly more caries reversal or reduced caries progression was found in the ozone-treated lesions than in the untreated control lesions within the group of patients at high current caries risk. However, there was no statistical significance difference between the groups when the whole study
population was examined.
3.1.2 Ozone in management of the open caries
One clinical study22 was found which evaluated the efficacy of ozone gas in the reversal of caries in open single-surface lesions: 82 open single-surface lesions in 28 apprehensive and non-treatable children (mean age 5.96±2.36 years) were first excavated until a leathery consistency was recorded and then assigned to two groups (maximum two pairs per subject); the larger lesion was exposed to 20s ozone gas (HealOzone) while the smaller lesion was left untreated as the control group.
Tactile hardness (hard, leathery and soft) and DIAGNOdent readings were assessed and the changes for hardness and DIAGNOdent values in the test lesion were compared with the values in the control lesion after 2, 4, 6, and 8 months.
Finally, with the use of questionnaire, it was found that the level of fear was reduced prior to the second session and following the last session by 82% and 93% of children, respectively, prior to the second session and following the last session.
3.1.3 Ozone in management of root caries
A total of three studies (one in vitro and two in vivo ) were found to evaluate the preventive and therapeutic effect of ozone in the management of root caries:
In an in vitro study, Baysan et al.18 assessed the antimicrobial effect of aqueous ozone on primary root carious lesions (PRCLs). They harvested 40 soft PRCLs from freshly extracted teeth and removed half of a lesion with a sterile excavator. The remaining lesion was exposed to ozonated water for a period of either 10 or 20s (0. 069 or 0.138mL of ozone, respectively). A significantly reduced microbiological count ( p <0.001) was observed in the ozone-treated groups compared with the control groups. They also used 40 sterile saliva-coated glass beads to demonstrate the specific antimicrobial efficacy of 10s ozone gas (HealOzone) on Streptococcus mutans and Streptococcus sobrinus . The glass beads were randomly divided into two groups for each microorganism: ozone and control. They found a significant (p <0.0001) reduction in ozone-treated samples for both microorganisms compared with the control samples.18
In an in vivo setting, Baysan et al.23 conducted a split mouth randomised clinical trial. They included 79 participants, at least 18 years old, with either two or four primary root carious lesions (PRCLs). The included lesions were leathery (severity index two) and accessible to treatment. The lesions were randomised with equal numbers of intervention and control, in each mouth in a way that each participant had equal numbers of intervention and control lesions (two or four in total):
(1) Cleaning, 10s of ozone gas, and reductant solution (containing xylitol and
fluoride). The intervention was repeated at 1 month (with no ozone), 3 months and 6 months (both with ozone for 10s).
(2) Reductant only (applied for 5s), repeated after 1 month and 3 months.
(4) Sealant only.
For all groups caries progression and regression were measured by the change in clinical severity scores, mean log(e) DIAGNOdent readings, and mean log(e) ECM scores. They also recorded further dental interventions, pain, patient satisfaction and adverse events.
Their results showed that in the 6-month follow up, the mean changes in ECM readings were significantly higher (i.e., better remineralization) in the ozone-treated group than in the control group (5.62 vs. 4.92, respectively). Also, DIAGNOdent measurements in 6-month follow up were significantly lower (i.e., better
remineralization) in the ozone-treated group than in the control group (10.9 vs. 46.4, respectively). In 12 months 47% of PRCLs became hard in the ozone group, while none became hard in the control group ( p<0.001). Fifty-two percent of lesions reversed from severity index of 2 to 1 in the ozone group compared with 11.6% in the control group (p <0.001).
3.1.4 Methodological quality
In general there are some methodological concerns with these clinical studies:
Outcome measurement : It should be noted that the majority of the clinical studies that are reviewed depended on findings produced by the DIAGNOdent and ECM. These devices have not yet replaced visual, tactile and radiographic detection as a routine method of early caries diagnosis, although their validity and reliability have been extensively tested. 24-38 Also, the clinical severity score (tactile hardness) used in four studies12,20,22,23 is subjective and could result in some level of measurement error.
Data analysis : In all these studies, the data analyses were conducted at the level of the lesion. The researchers assumed that there was no variability between subjects, i.e., all these teeth were analysed independently as if they were from different subjects. This approach may produce a significant result; however, the literature demonstrates its lack of validity. 39,19
Blinding : All these studies lack an appropriate method of blinding as no placebo ozone treatment was given and thus subjects and/or their parents were not blinded to the study. The exception is Holmes12 in which the allocation process was described as double-blinded. Blinding of outcome evaluators is unclear in two studies20,23 as the operator and the evaluator are one person at the same visit. However, this has been overcome in two studies12,21 where a calibrated and blind examiner (other than the operator) assessed the outcome. In the Holmes study, two dentists allocated subjects to intervention groups and assessed the severity of lesions, and the third dentist assessed the reproducibility of data. However, none were acknowledged in the paper or listed as co-authors. The details of the blinding is not provided in Dahnhardt et al. 22
Patients satisfaction and anxiety questionnaire : These outcomes were reported as the secondary objectives in Abu Naba'a et al.20 and Dahnhardt et al.22 However, no subject was randomised between ozone or drilling and filling treatments and thus, the comparative information may not be valid.
Duration : The length of studies ranged from 3 months21 to 18 months.12
In 2004, the Cochrane library19 hosted a systematic review to assess the
effectiveness of ozone gas in arresting or reversing the progression of dental caries. The authors included three relevant randomised controlled trials (Abu Naba'a,20 Abu Naba'a Pilot,20 and Baysan studies as discussed above) with a combined total of 432 randomised lesions from 137 participants. They evaluated these studies at high risk of bias and concluded that reliable evidence is lacking that the application of ozone gas to the surface of decayed teeth stops or reverses the decay process and that there is not enough high quality evidence to support the use of ozone gas in a primary care setting.
Recently, Brazzelli et al.40 conducted a systematic review to assess the effectiveness of ozone gas (HealOzone) for the management of pit and fissure caries, and root caries. They reached a similar conclusion to that of the Cochrane library. They also constructed a Markov model to explore possible cost-effectiveness aspects of HealOzone in addition to current management of dental caries over a 5-year period. They found that treatment using current management plus HealOzone cost more than current management alone for non-cavitated pit and fissure caries (£40.49 vs. £24.78), but cost less for non-cavitated root caries (£14.63 vs. £21.45). They stated that the current evidence is insufficient to conclude that it is a cost-effective addition to the management and treatment of occlusal and root caries.
3.2 Secondary objective: a summary of the in vitro application of ozone
in dentistry
3.2.1 Ozone in oral microbiology ( Table 3 )
cleaners9,44,45 with ozone gas was found to be more effective than ozonated
water.46Therefore, gaseous ozone can be clinically useful for disinfection of dentures.
3.2.2 Ozone in endodontics ( Table 4 )
Four in vitro studies5,41,47,48 were identified investigating the bactericidal effect of ozone as compared to 2.5% sodium hypochlorite, the standard irrigation solution in
endodontics. The results on this outcome are controversial: while Nagayoshi et al., 20045 found nearly the same antimicrobial activity (against Enterococcus
faecalis and S. mutans ) and a lower level of cytotoxicity of ozonated water as compared to 2.5% NaOCl; in a study by Hems et al.,48 NaOCl was found to be superior to ozonated water in killing E. faecalis in broth culture and in biofilms while gaseous ozone had no effect on the E. faecalis biofilm. Muller et al., 200741 has also found 5% NaOCl superior to gaseous ozone in eliminating microorganisms organised in a cariogenic biofilm. Moreover, a recent study has found that the irrigation of infected human root canals with ozonated water, 2.5% NaOCl, 2% chlorhexidine and the application of gaseous ozone for 20min was not sufficient to inactivate E.
faecalis .47
3.2.3 Ozone in prosthodontics ( Table 5 )
There were three retrieved studies11,49-51 that assessed the efficacy of ozone in
restorative dentistry and its effect on dental materials. The highlights of these studies are as follows:
(1) Ozone gas can be applied as a prophylactic treatment prior to etching and the placement of sealant with no negative impact on sound enamel physical properties, including knoop surface microhardness, or contact angle.11
(2) The longer exposure to ozone gas has a strong bactericidal effect on
microorganisms within the dentinal tubules of deep cavities, which could result in increasing the clinical success of restorations,49 with no negative impact on dentin and enamel shear bond strength to adhesive restoration.50
There is also some evidence on the effectiveness of aqueous ozone application in adjunct to amino-alcohol for decontamination of the implant surfaces.52
3.2.4 Ozone in oral and maxillofacial surgery
One study was found to evaluate the effect of ozone gas in oral and maxillofacial surgery, where ozone therapy was found to be beneficial for the treatment of the refractory osteomyelitis in the head and neck in addition to treatment with antibiotics, surgery and hyperbaric oxygen. 53 Other studies on this area are mostly non-English publication and were reviewed elsewhere.54
4
Conclusion
A thorough literature review on the application of ozone in dentistry has identified these concluding notes:
(1) The clinical studies identified in the literature review focused on the application of
ozone gas in the management of primary occlusal and root carious lesions. Despite the good evidence in in vitro settings, the clinical application of ozone has not achieved strong level of efficacy and cost-effectiveness.
(2) There is good evidence of in vitro biocompatibility of aqueous ozone with human oral epithelial cells, gingival fibroblast cells, and periodontal cells.6,43
(3) There is conflicting evidence of antimicrobial efficacy of ozone in in
vitro settings;6,7,41,42 however, there is some evidence that ozone (in both gaseous or aqueous phase) is a potentially effective disinfectant agent for removing the biofilms and the related microorganisms such as Legionella
pneumophila , Mycobacterium spp., Pseudomonas aeruginosa , and Candida spp. from dental unit water system and an effective bactericidal agent for removing S. mutans , methicillin-resistant Staphylococcus aureus , Candida albicans , and E. faecalis from dentures.9,44-46
(5) There is good evidence of in vitro application of ozone as a useful prophylactic antimicrobial treatment prior to etching and the placement of dental sealants and restorations with no negative interaction with the physical property of enamel and adhesive restorations.11,49,50
(6) There is good evidence of the in vitro application of ozone as a denture cleaner with little impact on the quality of denture alloy in terms of reflectance, surface roughness, and weight.9,44-46,51
(7) There is insufficient evidence in the application of ozone in oral and maxillofacial surgery, oral diseases, and implant therapy.
In conclusion, this review has demonstrated that while laboratory studies suggest a promising potential of ozone in dentistry, the clinical evidence for application of ozone in dentistry is not extensive. There is still a need for the highest level of evidence, i.e., well designed, double-blind randomised clinical trials with adequate sample size, limited or no loss to follow up, and carefully standardised methods of measurement and analysis in order to justify the routine use of ozone as a treatment modality in dentistry.
Acknowledgements
The authors would like to thank Dr. Edward D. Fillery, Department of Oral Microbiology and Dr. Herenia P. Lawrence, Department of Community Dentistry, Faculty of Dentistry, University of Toronto for proof reading the manuscript.
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Amir Azarpazhooh. Department of Endodontics and Community Dental Health Services Research Unit, Faculty of Dentistry, University of Toronto, Room #521A, 124 Edward Street, Toronto, ON, M5G 1G6 Canada; Corresponding author . Tel.: +1 416 979 4907x4429; fax: +1 416 979 4936.
Hardy Limeback. Department of Preventive Dentistry, Faculty of Dentistry, University of Toronto, 124 Edward Street, Toronto, ON, M5G 1G6 Canada
