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Effect of silicate cement and amalgam on the gingiva
E ffect of silicate cem ent and a m alg am on the gingiva
H . A . Zander, M .S., D.D.S., Minneapolis
jacent gingival cuff. This reaction was produced by the existence of a crevice filled with plaque material between the resin restoration and the tooth cavity as well as by plaque material which was found on the surface of the resin filling and in contact with the pocket epithelium. The presence of a poor marginal seal with self-curing acrylic restorations has been well documented .6 From the study by Waerhaug and Zander 5 it may be de duced that this poor marginal seal of self-curing acrylic restorations also may contribute to the reaction of the gingival tissues. A comparison of the gingival re action of self-curing acrylic materials with that of silicate cements and amal gam was made in the study described herein.
A great deal has been written about the effect of filling materials on the dental pulp. Massler,1 in a paper published in 1955, cited 69 references in his bibliog raphy, of which 51 were based on experi mental work performed during the last decade. Many studies have demonstrated that silicate cements produce a severe re action in the dental pulp, characterized by destruction of odontoblasts and the formation of abscesses. When placed in close proximity to the dental pulp, amal gam produces temporary changes in the odontoblasts and round cell infiltration in adjacent pulp tissue.1'3 Although den tin is intimately connected with the dental pulp, it does act to some extent as a protective layer for this tissue. In contrast to the wealth of investiga tions on pulp reactions to filling materials, very little can be found on the reaction of gingival tissues to filling materials be yond the statement that overhanging margins of fillings produce gingival dis ease.4 Since all the varieties of filling materials often are placed beneath the gingival margin and thus contact the gin gival tissues, the question arises whether these materials may elicit a reaction in the gingiva. Waerhaug and Zander5 have studied the reaction of gingival tissues to self curing acrylic restorations and have con cluded that such restorations produce a chronic inflammatory reaction in the ad
This investigation was supported by a research grant from the Division of Research Grants and Fellowships of the National Institutes of Health, United States Public Health Service. Chairman, division of periodontology, School of Den tistry, University of Minnesota. 1. Massler, M. Effects of filling materials on the pulp. J. Tennessee D.A. 35:353 Oct. 1955. 2. Manley, E. B. Preliminary investigation into reac tion of pulp to various filling materials. Brit. D.J. 60:321 A p ril I, 1936. 3. Manley, E. B. Investigations into early effects of various filling materials on the human pulp. D. Record 62:1 Jan. 1942. 4. Report of evaluating committee II (Periodontal workshop). Local factors in periodontal disease. J.A.D.A. 45:16 July 1952. 5. ^Waerhaug, J., and Zander, H. A . Reaction of gingival tissues to self-curing acrylic restorations. J.A.D.A. 54:760 June 1957. 6. Seltzer, S. Penetration of m icroorganisms between tooth and direct resin fillings. J.A.D.A. 51:560 Nov. 1955. II
12 • THE J O U R N A L O F THE A M E R IC A N D ENTA L A S S O C IA T IO N
Fig. I • LL-2. Silicate restoration in place 14 weeks. Left: The silicate cement was under-contoured 0.2 mm. on its gin giva l m argin. Severe inflam m atory reaction in the gingival tissues adjacent to silicate cement. Right: H ig h e r m agnification of crevice between silicate cem ent and dentin floor, 0.04 mm., filled with plaque material
M A T E R IA L A N D
M ETHOD
Twenty cavities were prepared in the gin gival third of the buccal surfaces of monkeys’ teeth and extended up to 3 mm. beneath the crest of the gingival tissues. Eight cavities were filled with amalgam, 8 with silicate and 4 with self-curing acrylic resin. Amalgam fillings were con toured with pluggers and metal carvers. Amalgam debris was flushed out of the sulcus. Silicate cement was contained in the cavity with a matrix and subsequently coated with cocoa butter. The brush-on technic was used to de velop the acrylic restorations, and an ex cess contour was produced which was corrected later by polishing. One half of the restorations were highly polished one week after insertion, whereas the other half were just finished down with fine garnet disks and left unpolished. The
clinical judgment of the restorations placed was that they ranged from good to excellent. The restorations remained in place for three months. Four teeth without treat ment were studied histologically. Speci mens were obtained of the teeth together with surrounding periodontal tissues. These specimens were fixed in ZenkerFormol solution, decalcified in 5 per cent nitric acid, embedded in celloidin, and 12 micra thick sections were stained with hematoxylin and eosin for microscopic study. RESU LTS
Although the clinical examination of the restorations and the adjacent gingival tissues revealed no specific pathologic changes, histologic examination of the sections showed that most restorations
Z A N D E R .. . V O L U M E 55, JU LY 1957 • 13
Fig. 2 • H ig h e r m agnification of gingival tissues shown in Figure I, left, in contact with silicate cement. N ote inflam m atory cells between epithe lium and silicate cement, many new capillaries, dense diffuse cellular infiltration
tween the silicate cement and the wall of the cavity (Fig. 1, right). Usually this was filled with plaque material and round cells (Fig. 1, right). The reaction of the gingival tissues to amalgam was very similar to their reac tion to silicate cements (Fig. 3 ). In this instance the gingival margin of the amal gam restoration extended 2.3 mm. below the gingival crest. Figure 3, right, is a higher magnification from the tissue ad jacent to the amalgam. The epithelial cells in contact with the amalgam appear altered from normal; there are long ex tensions of strands of epithelium into the connective tissue. The connective tissue is full of diffusely arranged lymphocytes and plasma cells with occasional leuko cytes present. The reaction of the gingival tissues to these two filling materials is similar to that seen to calculus (Fig. 4 ). This illustration was obtained of one of the four teeth that were not treated. D IS C U S S IO N
had a slight overhang or shortage on the gingival margin that amounted to about 0.2 mm. The effect of silicate cement on the adjacent gingival tissues was character ized by a severe inflammatory reaction (Fig. 1, 2 ). The epithelium in contact with the silicate cement was very thin, with many leukocytes and lymphocytes present in the epithelium. The same type of cells had migrated through the epithelium and were in contact with the silicate cement (Fig. 2 ). The connective tissue, or submucous layer, was charac terized by the presence of an unusually large number ol capillaries close to the epithelium. A heavy diffuse accumulation of leukocytes, lymphocytes, and plasma cells was present (Fig. 2 ). Epithelium strands extended deep into this region of cellular infiltration (Fig. 1). A common finding was a crevice at the margin be
Clinical observations7,8 of a chronic in flammatory reaction of the gingival tissues around restorations are confirmed by the present investigation. There is no doubt that not only dental calculus but also the materials used in restorative dentistry may be a contributing factor in gingival disease. The degree of tissue response to such irritation undoubtedly varies with each individual. It may result in “ gingival recession” in the individual with a good oral hygiene regime and good tissue re sponse. It may lead to pocket formation with loss of supporting structures in the individual with poor oral hygiene care or “ pooi- tissue resistance” and “ poor bone lactor.” A comparison of the gingival irritation
7. Miller, S. C. Textbook o f periodontia, ed. 3. Philadelphia, Blakiston Co., 1950, p. 83. 8. Goldman, H. M. Periodontia, ed. 2. St. Louis, C. V. M osby Co., 1949, p. 337.
14 • THE J O U R N A L O F THE A M E R IC A N D EN T A L A S S O C IA T IO N
SB
Fig. 3 • UR-5. Polished am algam restoration in place 14 weeks. Dense diffuse cellular infiltration in gingival tissue adjacent to restoration. Right: H ig h e r m agnification o f gingiva l tissue adjacent to am algam
Fig. 4 • LR-6. Untreated tooth of same monkey as shown in other figures. Reaction of gingival tissues to calculus
from silicate cement, amalgam, and acrylic restorations shows that all of these materials produce a chronic inflamma tion. It is difficult to decide whether differences exist in the degree of inflam mation produced by these materials, with the possible exception of a somewhat lesser degree of response to the acrylic resin. An overhang or underhang of 0.2 mm. is not detectable with the clinical instruments used in dental practice, and the mere act of polishing or finishing a restoration will create such a discrepancy. No differences were apparent between the gingival reaction to the polished restorations and the reaction to finishing with garnet disks only. It is important for the dental practi tioner to understand the shortcomings of restorative dentistry and the biological properties of the materials used in restora tive dentistry, both in regard to their effect on the dental pulp and on the gingival tissues. Ordinarily, the type of tissue reaction found in this investigation may be tolerated for a long time without the appearance of definite clinical symp toms. In patients in whom such clinical
Z IP K IN
symptoms as chronic gingivitis, recurrent necrotizing ulcerative gingivitis and periodontal pockets do appear, such con ditions can sometimes be treated success fully only by removal of gingival tissues
. V O L U M E 55, JU LY 1957 • 15
below the margin of dental restorations. The institution of a good oral hygiene regime will keep the gingival margins clean for the patients and prevent the recurrence of secondary caries.
E ffect of sodium lauroyl sarcosinate and d eh yd roacetic acid on sulcal and sm ooth surface caries (b u cca l-lin g u a l) in the w hite ra t
I. Zipkin * Ph.D., and F. J. McClure * Ph.D., Bethesda, M d.
A number o f diverse chemical agents have been studied previously for their in hibitory effect on dental caries.1 The evi dence is extensive that fluorides inhibit caries in the rat2-6 as well as in the hu man being .713 In addition, iodoacetic acid 2,3 and the antibiotics, penicillin ,14’ 15 bacitracin, chloramphenicol, chlortetracycline and streptomycin 15 are effective in varying degrees as inhibitors of rat caries. The cariostatic efficacy o f penicillin in the human being appears to be equivo cal .16’17 In 1953, sodium dehydroacetate and sodium lauroyl sarcosinate were proposed as caries inhibiting agents in the human ,18 and a clinical report has appeared on the efficacy of the latter compound when in corporated in a dentifrice .19 It was the primary purpose of the cur rent studies to test the efficacy of sodium lauroyl sarcosinate (SLS) and dehydro acetic acid (D H A ) on both sulcal and smooth surface caries by adding these substances to the diet of the white rat. The relation of the well-known detergent property of sodium lauroyl sarcosinate20 to its possible cariostatic effect was
evaluated by studying the caries inhibit ing effect of another widely used deter gent, sodium lauryl sulfate (SLSO 4) .21 P L A N O F E X P E R IM E N T
The general organization and results of the studies made by the authors are
♦National • Institute of Dental Research, National In stitutes of Health. 1. Hein, J. W . Effect of various agents on experi mental caries. In Advances in experimental caries re search, Sognnaes, R. F.( editor. Washington, D. C. American Association for the Advancem ent of Science, 1955. 2. Miller, B. F. Inhibition of experimental dental caries in the rat by fluoride and iodoacetic acid. Proc. Soc. Exper. Biol. & M ed. 39:389 Nov. 1938. 3. McClure, F. J., and Arnold, F. A . Observations on induced dental caries in rats. I. Reduction by fluorides and iodoacetic acid. J.D. Res. 20:97 A p ril 1941. 4. Zipkin, I., and McClure, F. J. Com plex fluorides. Caries reduction and fluoride retention in the bones and teeth of white rats. Pub. Health Rep. 66:1523 Nov. 23, 1951. 5. Zipkin, I., and McClure, F. J. Cariostatic effect and metabolism of ammonium fluosilicate. Pub. Health Rep. 69:730 A u g . 1954. 6. Muhler, J. C.; Nebergall, W . H., and Day, H. G. Studies on stannous fluoride and other fluorides in rela tion to solubility of enamel in acid and the prevention of experimental dental caries. J.D. Res. 33:33 Feb. 1954. 7. Knutson, J. W., and Arm strong, W . D. Effect of topically applied sodium fluoride on dental carles experience. Pub. Health Rep. 58:1701 Nov. 19, 1943.
H . A . Zander, M .S., D.D.S., Minneapolis
jacent gingival cuff. This reaction was produced by the existence of a crevice filled with plaque material between the resin restoration and the tooth cavity as well as by plaque material which was found on the surface of the resin filling and in contact with the pocket epithelium. The presence of a poor marginal seal with self-curing acrylic restorations has been well documented .6 From the study by Waerhaug and Zander 5 it may be de duced that this poor marginal seal of self-curing acrylic restorations also may contribute to the reaction of the gingival tissues. A comparison of the gingival re action of self-curing acrylic materials with that of silicate cements and amal gam was made in the study described herein.
A great deal has been written about the effect of filling materials on the dental pulp. Massler,1 in a paper published in 1955, cited 69 references in his bibliog raphy, of which 51 were based on experi mental work performed during the last decade. Many studies have demonstrated that silicate cements produce a severe re action in the dental pulp, characterized by destruction of odontoblasts and the formation of abscesses. When placed in close proximity to the dental pulp, amal gam produces temporary changes in the odontoblasts and round cell infiltration in adjacent pulp tissue.1'3 Although den tin is intimately connected with the dental pulp, it does act to some extent as a protective layer for this tissue. In contrast to the wealth of investiga tions on pulp reactions to filling materials, very little can be found on the reaction of gingival tissues to filling materials be yond the statement that overhanging margins of fillings produce gingival dis ease.4 Since all the varieties of filling materials often are placed beneath the gingival margin and thus contact the gin gival tissues, the question arises whether these materials may elicit a reaction in the gingiva. Waerhaug and Zander5 have studied the reaction of gingival tissues to self curing acrylic restorations and have con cluded that such restorations produce a chronic inflammatory reaction in the ad
This investigation was supported by a research grant from the Division of Research Grants and Fellowships of the National Institutes of Health, United States Public Health Service. Chairman, division of periodontology, School of Den tistry, University of Minnesota. 1. Massler, M. Effects of filling materials on the pulp. J. Tennessee D.A. 35:353 Oct. 1955. 2. Manley, E. B. Preliminary investigation into reac tion of pulp to various filling materials. Brit. D.J. 60:321 A p ril I, 1936. 3. Manley, E. B. Investigations into early effects of various filling materials on the human pulp. D. Record 62:1 Jan. 1942. 4. Report of evaluating committee II (Periodontal workshop). Local factors in periodontal disease. J.A.D.A. 45:16 July 1952. 5. ^Waerhaug, J., and Zander, H. A . Reaction of gingival tissues to self-curing acrylic restorations. J.A.D.A. 54:760 June 1957. 6. Seltzer, S. Penetration of m icroorganisms between tooth and direct resin fillings. J.A.D.A. 51:560 Nov. 1955. II
12 • THE J O U R N A L O F THE A M E R IC A N D ENTA L A S S O C IA T IO N
Fig. I • LL-2. Silicate restoration in place 14 weeks. Left: The silicate cement was under-contoured 0.2 mm. on its gin giva l m argin. Severe inflam m atory reaction in the gingival tissues adjacent to silicate cement. Right: H ig h e r m agnification of crevice between silicate cem ent and dentin floor, 0.04 mm., filled with plaque material
M A T E R IA L A N D
M ETHOD
Twenty cavities were prepared in the gin gival third of the buccal surfaces of monkeys’ teeth and extended up to 3 mm. beneath the crest of the gingival tissues. Eight cavities were filled with amalgam, 8 with silicate and 4 with self-curing acrylic resin. Amalgam fillings were con toured with pluggers and metal carvers. Amalgam debris was flushed out of the sulcus. Silicate cement was contained in the cavity with a matrix and subsequently coated with cocoa butter. The brush-on technic was used to de velop the acrylic restorations, and an ex cess contour was produced which was corrected later by polishing. One half of the restorations were highly polished one week after insertion, whereas the other half were just finished down with fine garnet disks and left unpolished. The
clinical judgment of the restorations placed was that they ranged from good to excellent. The restorations remained in place for three months. Four teeth without treat ment were studied histologically. Speci mens were obtained of the teeth together with surrounding periodontal tissues. These specimens were fixed in ZenkerFormol solution, decalcified in 5 per cent nitric acid, embedded in celloidin, and 12 micra thick sections were stained with hematoxylin and eosin for microscopic study. RESU LTS
Although the clinical examination of the restorations and the adjacent gingival tissues revealed no specific pathologic changes, histologic examination of the sections showed that most restorations
Z A N D E R .. . V O L U M E 55, JU LY 1957 • 13
Fig. 2 • H ig h e r m agnification of gingival tissues shown in Figure I, left, in contact with silicate cement. N ote inflam m atory cells between epithe lium and silicate cement, many new capillaries, dense diffuse cellular infiltration
tween the silicate cement and the wall of the cavity (Fig. 1, right). Usually this was filled with plaque material and round cells (Fig. 1, right). The reaction of the gingival tissues to amalgam was very similar to their reac tion to silicate cements (Fig. 3 ). In this instance the gingival margin of the amal gam restoration extended 2.3 mm. below the gingival crest. Figure 3, right, is a higher magnification from the tissue ad jacent to the amalgam. The epithelial cells in contact with the amalgam appear altered from normal; there are long ex tensions of strands of epithelium into the connective tissue. The connective tissue is full of diffusely arranged lymphocytes and plasma cells with occasional leuko cytes present. The reaction of the gingival tissues to these two filling materials is similar to that seen to calculus (Fig. 4 ). This illustration was obtained of one of the four teeth that were not treated. D IS C U S S IO N
had a slight overhang or shortage on the gingival margin that amounted to about 0.2 mm. The effect of silicate cement on the adjacent gingival tissues was character ized by a severe inflammatory reaction (Fig. 1, 2 ). The epithelium in contact with the silicate cement was very thin, with many leukocytes and lymphocytes present in the epithelium. The same type of cells had migrated through the epithelium and were in contact with the silicate cement (Fig. 2 ). The connective tissue, or submucous layer, was charac terized by the presence of an unusually large number ol capillaries close to the epithelium. A heavy diffuse accumulation of leukocytes, lymphocytes, and plasma cells was present (Fig. 2 ). Epithelium strands extended deep into this region of cellular infiltration (Fig. 1). A common finding was a crevice at the margin be
Clinical observations7,8 of a chronic in flammatory reaction of the gingival tissues around restorations are confirmed by the present investigation. There is no doubt that not only dental calculus but also the materials used in restorative dentistry may be a contributing factor in gingival disease. The degree of tissue response to such irritation undoubtedly varies with each individual. It may result in “ gingival recession” in the individual with a good oral hygiene regime and good tissue re sponse. It may lead to pocket formation with loss of supporting structures in the individual with poor oral hygiene care or “ pooi- tissue resistance” and “ poor bone lactor.” A comparison of the gingival irritation
7. Miller, S. C. Textbook o f periodontia, ed. 3. Philadelphia, Blakiston Co., 1950, p. 83. 8. Goldman, H. M. Periodontia, ed. 2. St. Louis, C. V. M osby Co., 1949, p. 337.
14 • THE J O U R N A L O F THE A M E R IC A N D EN T A L A S S O C IA T IO N
SB
Fig. 3 • UR-5. Polished am algam restoration in place 14 weeks. Dense diffuse cellular infiltration in gingival tissue adjacent to restoration. Right: H ig h e r m agnification o f gingiva l tissue adjacent to am algam
Fig. 4 • LR-6. Untreated tooth of same monkey as shown in other figures. Reaction of gingival tissues to calculus
from silicate cement, amalgam, and acrylic restorations shows that all of these materials produce a chronic inflamma tion. It is difficult to decide whether differences exist in the degree of inflam mation produced by these materials, with the possible exception of a somewhat lesser degree of response to the acrylic resin. An overhang or underhang of 0.2 mm. is not detectable with the clinical instruments used in dental practice, and the mere act of polishing or finishing a restoration will create such a discrepancy. No differences were apparent between the gingival reaction to the polished restorations and the reaction to finishing with garnet disks only. It is important for the dental practi tioner to understand the shortcomings of restorative dentistry and the biological properties of the materials used in restora tive dentistry, both in regard to their effect on the dental pulp and on the gingival tissues. Ordinarily, the type of tissue reaction found in this investigation may be tolerated for a long time without the appearance of definite clinical symp toms. In patients in whom such clinical
Z IP K IN
symptoms as chronic gingivitis, recurrent necrotizing ulcerative gingivitis and periodontal pockets do appear, such con ditions can sometimes be treated success fully only by removal of gingival tissues
. V O L U M E 55, JU LY 1957 • 15
below the margin of dental restorations. The institution of a good oral hygiene regime will keep the gingival margins clean for the patients and prevent the recurrence of secondary caries.
E ffect of sodium lauroyl sarcosinate and d eh yd roacetic acid on sulcal and sm ooth surface caries (b u cca l-lin g u a l) in the w hite ra t
I. Zipkin * Ph.D., and F. J. McClure * Ph.D., Bethesda, M d.
A number o f diverse chemical agents have been studied previously for their in hibitory effect on dental caries.1 The evi dence is extensive that fluorides inhibit caries in the rat2-6 as well as in the hu man being .713 In addition, iodoacetic acid 2,3 and the antibiotics, penicillin ,14’ 15 bacitracin, chloramphenicol, chlortetracycline and streptomycin 15 are effective in varying degrees as inhibitors of rat caries. The cariostatic efficacy o f penicillin in the human being appears to be equivo cal .16’17 In 1953, sodium dehydroacetate and sodium lauroyl sarcosinate were proposed as caries inhibiting agents in the human ,18 and a clinical report has appeared on the efficacy of the latter compound when in corporated in a dentifrice .19 It was the primary purpose of the cur rent studies to test the efficacy of sodium lauroyl sarcosinate (SLS) and dehydro acetic acid (D H A ) on both sulcal and smooth surface caries by adding these substances to the diet of the white rat. The relation of the well-known detergent property of sodium lauroyl sarcosinate20 to its possible cariostatic effect was
evaluated by studying the caries inhibit ing effect of another widely used deter gent, sodium lauryl sulfate (SLSO 4) .21 P L A N O F E X P E R IM E N T
The general organization and results of the studies made by the authors are
♦National • Institute of Dental Research, National In stitutes of Health. 1. Hein, J. W . Effect of various agents on experi mental caries. In Advances in experimental caries re search, Sognnaes, R. F.( editor. Washington, D. C. American Association for the Advancem ent of Science, 1955. 2. Miller, B. F. Inhibition of experimental dental caries in the rat by fluoride and iodoacetic acid. Proc. Soc. Exper. Biol. & M ed. 39:389 Nov. 1938. 3. McClure, F. J., and Arnold, F. A . Observations on induced dental caries in rats. I. Reduction by fluorides and iodoacetic acid. J.D. Res. 20:97 A p ril 1941. 4. Zipkin, I., and McClure, F. J. Com plex fluorides. Caries reduction and fluoride retention in the bones and teeth of white rats. Pub. Health Rep. 66:1523 Nov. 23, 1951. 5. Zipkin, I., and McClure, F. J. Cariostatic effect and metabolism of ammonium fluosilicate. Pub. Health Rep. 69:730 A u g . 1954. 6. Muhler, J. C.; Nebergall, W . H., and Day, H. G. Studies on stannous fluoride and other fluorides in rela tion to solubility of enamel in acid and the prevention of experimental dental caries. J.D. Res. 33:33 Feb. 1954. 7. Knutson, J. W., and Arm strong, W . D. Effect of topically applied sodium fluoride on dental carles experience. Pub. Health Rep. 58:1701 Nov. 19, 1943.