(Teruplug) wound dressing for tooth extraction site.

(1988), provide evidence for the significant role of technical analysis, especially incooperation with fundamental analysis (Goodhart, 1988). Studies from Allen andTaylor (1989) and Taylor and Allen (1992), provide evidence for the significant roleof technical analysis in foreign exchange markets. Allen and Taylor (1989), surveyedmore than 200 bank foreign dealers in UK. They demonstrated quite interestingresults showing that bank dealers used different tactics in short, medium, and longterm horizons for market forecasting. For the short term horizon, 90% of respondentsused technical analysis, and 60% of them considered technical analysis as importantas fundamental analysis. But as the time horizon increases, this high percentage(90%) starts declining significantly. This result is consistent with Frankel and Froot(1986, 1987, 1990) assertions that the information of technical analysis significantlydetermines the short-term equilibrium prices in foreign exchange market.Technical analysis has been widely used and influenced perceptions andbehaviours of investors acting for other financial markets such as stock market.Shiller (1998) considers technical analysis as a significant factor playing an importantrole for the international stock market crash in October 1997. Wong (1993), provideevidence that technical analysis influence investors’ perceptions in Hong Kong stockmarket. The research community has to demonstrate many studies in the field. Forinstance, Black (1986), Campbell and Kyle (1988), and Shleifer and Summers (1990),De Long et al., (1991), contribute to the role of the traders who do not use ormisperceive the fundamentals (noise traders). Additionally, Frankel and Froot(1990a), and Kirman (1991), demonstrate the relationship between fundamental andnon-fundamental approaches. Recent studies (Wong and Cheung, 1999; Lui andMole, 1988) conducted for Hong Kong market, provide evidence that analysts in thismarket rely more on fundamental and technical analyses and less on portfolioanalysis. The extend to which either the fundamental analysis or technical analysis areused depends on many factors. For instance, analysts from large firms in Hong Kong,especially those with high positions and high experience, rely more on fundamentalanalysis and less on technical analysis. The opposite result concerns analysts inbrokerage firms where they rely more on technical and less on fundamental analysisand portfolio analysis (Wong and Cheung, 1999). The time horizon also playssignificant role on the implementation of fundamental and technical analyses. Atshorter horizons, technical analysis is more frequent used than fundamental analysis6

Fig. 3 Hemostatic effect immediately after tooth extraction (case No.7 of Table 1)a: Indication side, b: Control side Indication side was evaluated as “Effective” andthe control side “Blood stained from around.” Further, in the control side, blood flowwas observed along the gingival ridge of the posterior tooth.At 1 day after tooth extraction, all the 25 patients in indication side and all the 26patients in control side were judged as “hemostasis effect was observed” (Table 5).Furthermore, in a comparison between indication side and control side, all the 25 patientswere judged as “the same hemostasis effect” (Table 6).At 1 week after tooth extraction, all the 26 patients in indication side and all the25 patients in control side were judged as “hemostasis effect was observed” (Table 5).Furthermore, in a comparison between indication side and control side, all the 24 patientswere judged as “the same hemostasis effect” (Table 6).2) Analgesic effectJudgment of analgesic effect immediately after tooth extraction was done after adisappearance of anesthetic effect, and at 1 day after tooth extraction, hearing andjudgment were done through interview for inquiry. Out of all the 17 patients in theindication side, 13 patients (48 %) were judged as “no pain”, 9 (33 %) were judged as“pain of bearable degree “, and 5 patients (19 %) as “marked pain”. While in the controlside, 8 patients (30 %) were judged as “no pain”, 11 (41 %) were judged as “pain ofbearable degree”, and 8 patients (30 %) as “marked pain” (Table 7). Furthermore, acomparison between indication side and control side revealed that 8 patients (30 %) were8

judged as “indication side had a higher analgesic effect “, 18 (67 %) were judged as “thesame analgesic effect”, and 1 patient (4 %) as “a lower analgesic effect” (Table 8).At 1 day after tooth extraction, out of all the 26 patients in indication side, 23patients (88 %) were judged as “no pain”, 3 (12 %) were judged as “pain of bearabledegree”, and 0 patients (0 %) as “marked pain”. While out of 27 patients in the controlside, 24 patients (89 %) were judged as “no pain”, 3 (11 %) were judged as “pain ofbearable degree”, and 0 patients (0 %) as “marked pain” (Table 7). Furthermore, acomparison between indication side and control side revealed that all 28 patients (30 %)were judged as “the same analgesic effect” (Table 8). Effect judgment for 1 patient whodid not visit clinic was done through interview for inquiry at 1 week after tooth extraction.At 1 week after tooth extraction, all the 26 patients in indication side and all the25 patients in control side were judged as “no pain” (Table 7). Furthermore, acomparison between indication side and control side revealed that all the 24 patients werejudged as “the same analgesic effect” (Table 8).Table 7 Analgesic effectImmediately after 1 day 1 weekIndicationControl sideIndicationControl sideIndicationControlside (%)(%)side (%)(%)side (%)side (%)A: No pain 13 ( 48) 8 ( 30) 23 ( 88) 24 ( 89) 26 (100) 25 (100)B: Bearable pain 9 ( 33) 11 ( 41) 3 ( 12) 3 ( 11) 0 ( 0) 0 ( 0)C: Marked pain 5 ( 19) 8 ( 30) 0 ( 0) 0 ( 0) 0 ( 0) 0 ( 0)Total 27 (100) 27 (100) 25 (100) i) 27 (100) 26 (100) i) 25 (100) ii)i) One case of drop out is excluded., ii) Two cases of drop out are excluded.Table 8Superiority of Teruplug ® in analgesic effectImmediately after (%) 1 day (%) 1 week (%)Better analgesic effect 8 ( 30) 0 ( 0) 0 ( 0)Same analgesic effect 18 ( 67) 26 (100) 24 (100)Poor analgesic effect 1 ( 4) 0 ( 0) 0 ( 0)Total 27 (100) 26 (100) i) 24 (100) ii)i) One case of drop out is excluded., ii) Three cases of drop out are excluded.9

3) Fixation effectJudgment of fixation effect immediately after tooth extraction was done at about10-15 minutes after tooth extraction, putting mild pressure and hemostasis. Out of all the27 patients, in both indication side and control side, all were judged as “no dropout”(Table 9). Furthermore, in a comparison between indication side and control side, all the24 patients were judged as “the same fixation effect” (Table 10).At 1 day after tooth extraction, out of 26 patients in indication side, 25 patients(96 %) were judged as “no dropout”, 0 (0 %) were judged as “partially dropout”, and 1patient (4 %) as “dropped out and its presence is not known” (Fig. 4a). And in thecontrol side, all the 26 patients were judged as “no dropout” (Table 9). Furthermore, acomparison between indication side and control side revealed that out of 26 patients, 0patients (0 %) were judged as “indication side had a higher fixation effect”, 25 (96 %)were judged as “the same fixation effect”, and 1 patient (4 %) as “a lower fixation effect”(Table 10).At 1 week after tooth extraction, out of all the 27 patients in indication side, 26patients (96 %) were judged as “no dropout”, 0 (0 %) were judged as “partially droppedout”, and 1 patient (4 %) as “dropped out and its presence is not known”. And in thecontrol side, 25 patients (93 %) were judged as “no dropout”, 0 (0 %) were judged as“partially dropped out”, and 2 patient (7 %) as “dropped out and its presence is notknown” (Table 9, Fig. 4b). Furthermore, a comparison between indication side andcontrol side revealed that 2 patients (7 %) were judged as “indication side had a higherfixation effect “, 24 (89 %) were judged as “the same fixation effect”, and 1 patient (4 %)as “a lower fixation effect” (Table 10).10

Table 9 Fixation effectImmediately after 1 day 1 weekIndicationControl sideIndicationControl sideIndicationControlside (%)(%)side (%)(%)side (%)side (%)A: No drop outB: Partially dropout27 (100) 27 (100) 25 ( 96) 26 (100) 26 ( 96) 25 ( 93)0 ( 0) 0 ( 0) 0 ( 0) 0 ( 0) 0 ( 0) 0 ( 0)C: Dropped outand unknown0 ( 0) 0 ( 0) 1 ( 4) 0 ( 0) 1 ( 4) 2 ( 7)where it isTotal 27 (100) 27 (100) 26 (100) i) 26 (100) i) 27 (100) 27 (100)i) One case of no visit is excluded.Table 10Superiority of Teruplug ® in fixation effectImmediately after (%) 1 day (%) 1 week (%)Better fixation effect 0 (0) 0 ( 0) 2 ( 7)Same fixation effect 27 (100) 25 ( 96) 24 ( 89)Poor fixation effect 0 (0) 1 ( 4) 1 ( 4)Total 27 (100) 26 (100) i) 27 (100)i) One case of no visit is excluded.Fig. 4Fixation effecta: Teruplug ® drop out patient at 1 day after tooth extraction (case No.15 of Table 1).Teruplug ® was dropped out and unknown where it was, while there was blood clotpartially and depression of the tooth extraction wound was found. b: Spongel ® dropout patient at 1 week after tooth extraction (case No.20 of Table 1). Spongel ® was11

Fig. 5 An extent of epithelization (case No. 26 of Table 1)a: Indication side at 1 day after tooth extraction b: Its the control side c:Indication side at 1 week after tooth extraction d: Its the control sideSuperiority of epithelization in the indication side at 1 day and 1 week after toothextraction was observed.6) Absence or presence of adverse reactionJudgment of absence or presence of adverse reaction was done at 1 week aftertooth extraction and all were judged as “none”. Furthermore, there was no difference ina comparison between indication side and control side (Table 4).7)Superiority of wound depressionSuperiority of wound depression was judged at 1 week after tooth extraction bycomparing the degree of depression between indication side and control side. Sixteenpatients (59 %) were judged as “indication side had smaller depression than control side”(Fig.7, 8), 8 (30 %) were judged as “the same depression as control”, and 0 patients (0 %)as “indication side had larger depression than control”. And there were 3 patients (11 %)who were dropout of Teruplug ® or Spongel ® and who failed in judgment of superiority14

were categorized as “judgment is impossible due to dropout” (Table 13).Fig. 6 An extent of epithelization (case No. 25 of Table 1)a: Indication side at 1 day after tooth extraction b: Its the control side c:Indication side at 1 week after tooth extraction d: Its the control sideSuperiority of epithelization in the indication side at 1 day and 1 week after toothextraction was observed. Epithelization at “c” showed the tendency ofepithelization from the margin of tooth extraction cavity and epithelization fromTeruplug ® at surface of tooth extraction cavity. Epithelization at “d” only showedepithelization from the margin of tooth extraction cavity and epithelization tendencyfrom Spongel ® at the surface of tooth extraction cavity was not observed.15

Fig 7. Superiority of wound depression (case No. 6 of Table 1)a: Indication side b: Control side Tooth extraction cavity in the control side islargely depressed compared to the indication side.Fig. 8 Superiority of wound depression (case No. 14 of Table 1)a: Indication side b: Control side Tooth extraction cavity of the control side isdepressed when compared to that in the indication side.Table 13Superiority of Teruplug ® in wound depression1 week (%)Small depression compared to control 16 (59)The equivalent as control 8 (30)Large depression compared to control 0 (0)Not clear due to drop out 3 (11)Total 27 (100)16

DiscussionCollagen composed of Teruplug ® is atelo-collagen, both ends of whose moleculeare digested by pepsin. Teruplug ® is produced by mixing fibrillar atelo-collagen (FC)and heat denatured atelo-collagen (HAC), which were produced from the above atelocollagen,with a ratio of 9:1 5) and processed so as to readily fit the tooth extraction wound.On the other hand, Spongel ® is a porous gelatin sponge, which are essentially extractedwith heat using water from hybrid collagen that are obtained by processing bone, skin,ligament, and tendon of animals by acid or alkaline.The purpose of both products include blocking of external stimuli, prevention ofinfection, promotion of epithelialization, promotion of granulation formation, alleviationof pain, and good adhesion just like other wound covering materials 5) , but effects varydepending upon each wound covering materials. Among these, it is observed thatTeruplug ® is effective for promotion of epithelialization and granulation formation andsuperior in alleviation of pain and leakage prevention of plasma component 6-9) .Normally convenient tooth extraction is carried out in the premolar. Weselected convenient tooth extraction as subject of this study as part of correction treatmentbecause the same kinds of teeth of the same jaw can be removed concurrently.Furthermore, with regard to extraction site, it was expected that there is a technicaldifference in extraction of a tooth between right and left, so we broke up Teruplug ®indication and the control sides to the left and right sides.In this time, as subjects of convenient tooth extraction, the premolars wereselected and selected Teruplug ® were S and M sizes. For indication of Teruplug ® , onewith a little bit larger size than that of the margin of extraction cavity was selected and itwas pressed or shaped into the morphology to fit the extraction cavity, and inserted intothe extraction cavity because premolars are simple rooted tooth and become thin inproportion to approaching the root apex. However, there was difference of 7 mm indiameter between both sizes, and in some cases, selection of size was difficult.1) With regard to hemostatic effectWith regard to hemostatic effect, as is shown in Table 5, immediately afterextraction, “Effective” was found in 25 patients (93%) in the indication side, and 20patients (74%) in the control side, “Blood stained from around” was observed in 2 patients17

(7%) in the indication side and 7 patients (26%) in the control side, and “Not effective”was not found in any patient. With regard to superiority of Teruplug ® in hemostaticeffect immediately after tooth extraction, as is shown in Table 6, “Better hemostaticeffect” was found in 6 patients (22%) and “Poor hemostatic effect” in 1 patient (4%).Based on the above, it is considered that Teruplug ® has a markedly excellent hemostaticeffect (Fig. 3).Teruplug ® is atelo-collagen: its collagen is digested by pepsin, and it is said tohave an excellent hemostatic effect due to platelet aggregation reaction of collagen 7) . Inaddition of these biochemical hemostatic actions, it is said that collagen has physicalaction including holding of hematoma efficiently within collagen sponge 6) , and increasedarea contacting the air within collagen sponge. This may be better hemostatic effect dueto adhesion to the margin of tooth extraction wound, which differs from the effect bypressure from the above just like hemostatic splint.2) With regard to analgesic effectWith analgesic effect, as is shown in Table 7, immediately after tooth extraction,“No pain” was found in 13 patients (48%) in the indication side and 8 patients (30%) inthe control side. “Bearable pain” was observed in 9 patients (33%) in the indication sideand 11 patients (41%) in the control side, while “Marked pain” was in 5 patients (19%) inthe indication side and 8 patients (30%) in the control side. With regard to superiority ofTeruplug ® in analgesic effect, as is shown in Table 8, “Better analgesic effect” was foundin 8 patients (30%) and “Poor analgesic effect” in 1 patient (4%). Furthermore, with thepassage of time, immediately after tooth extraction, at 1 day and 1 week after toothextraction, effect was changed into “No pain” and “Same analgesic effect.” suggestinglower superiority with time. Based on the above, superiority of Teruplug ® in analgesiceffect immediately after tooth extraction was observed, and good analgesic effect wasobtained. This may be caused by promotion of wound healing from earlier stageimmediately after tooth extraction, in addition to physical covering of the tooth extractioncavity, blocking of the external stimuli, and increased sealing of the margin just like at thetime of use of hemostatic splint.With administration of analgesic, as is shown in Table 4, among patients whoshowed “Bearable pain” in either the indication side or control side and showed “No pain”in the contralateral side as well as patients who developed “Bearable pain” in both sides,18

there were 4 patients who were administered analgesic, while 6 patients were not. Out ofpatients who developed “Marked pain” in either or both sides, all the 9 patients receivedanalgesic. Analgesic was not administered at 1 day and 1 week after tooth extraction.The reason why analgesic was administered or not to patients with bearable pain maydepend on the consciousness of patients for drug in general and correspondence for pain.3) With fixation effectWith fixation effect, as is shown in Table 9, there were 1 completely drop outpatient evaluated as “Dropped out, unknown where it is”, in the indication side at 1 dayafter extraction and 2 such patients in the control side at 1 week after extraction. Ineither time, drop out patients were less, suggesting superiority in fixation effect.Furthermore, as is shown in Table 10, superiority of Teruplug ® was not observed, partlybecause there were less drop out patients. However, fixation effect was largely reducedbecause Teruplug ® drop out patients were patients with single rooted tooth and patientswith displacement to the palatal side (Fig. 4a).As the method for strengthening fixation effect, there are physical characteristicsincluding selection of size or availability to give morphology fitted to the tooth extractioncavity as well as infiltration of blood by pressing with fingers which is performed at thetime of indication. Teruplug ® is a composite made by mixing fibrillar atelo-collagen andheat denatured atelo-collagen with a ratio of 9:1 and has excellent cellular invasivenessand cellular activity, that is, biostability as well as mechanic strength 10) , which maycontribute to good fixation effect.4) Presence or absence of infection after tooth extractionAs is shown in Table 4, infection due to Teruplug ® or Spongel ® after toothextraction was not observed in any patient at 1 day or 1 week after tooth extraction. Thereason may be that subjects were limited to premolars and only healthy teeth wereextracted. Generally, if infection occurs, removal of applied material, cleaning of toothextraction wound, and gargling of the buccal cavity will be sufficient treatment.5) With regard to epithelizationWith regard to epithelization, as is shown in Table 11, at 1 day after extraction19

“Almost completed epithelization” or “About 3/4 epithelization” were not found in anypatient either in the indication side or the control side, while “No epithelization” wasobserved in 11 patients (44%) in the indication side and in 19 patients (73%) in the controlside. At 1 week after extraction, either “Almost completed epithelization” or “About 3/4epithelization” was observed in 16 patients (62%) in the indication side and in 8 patients(32%) in the control side, while “No epithelization” was not observed in any patient.With time passage, immediately after tooth extraction, at 1 day and at 1 week after toothextraction, increased degree of epithelization was observed. It was also noted that degreeof epithelization was more advanced in the indication side than that in the control side.With regard to superiority of Teruplug ® in an extent of epithelization, as is shownin Table 12, at 1 day after extraction, “Higher extent of epithelization” was found in 11patients (44%), and “Lower extent of epithelization” was not found in any patient (0%).At 1 week after tooth extraction, “Higher extent of epithelization” was found in 11patients (46%), and “Lower extent of epithelization” was found in 3 patients (13%). Soit was recognized that either at 1 day or at 1 week after tooth extraction, Teruplug ®indication patients showed higher extent of epithelization (Figs. 5 and 6).Observation of epithelization process for both agents was as follows: inTeruplug ® indication patients, one-layer granulation tissue was formed on Teruplug ®surface immediately after tooth extraction, then it started epithelization, while in Spongel ®indication patients, granulation tissue was not formed on Spongel ® surface.Epithelization gradually advanced from the marginal gingiva around the tooth extractioncavity, then finally the epithelium covers tooth extraction cavity. In some of Teruplug ®indication patients, both epithelization from the margin of tooth extraction cavity,similarly to Spongel ® indication patients, and epithelization from Teruplug ® surface wereobserved. This reason may be as follows: at the time of indication of Teruplug ® , if themargin of Teruplug ® is indicated with the same level of the marginal gingiva,epithelization from Teruplug ® surface will advance, while if the margin of Teruplug ® isindicated lower, both epithelization from the margin and epithelization from Teruplug ®surface will advance. In all the Spongel ® indication patients, epithelization from themargin advanced, while epithelization from Spongel ® surface was not observed.Generally, healing of tooth extraction cavity develops from blood clot stage, andadvances to granulation tissue stage, porosis stage, and healing stage. Epithelization ofsurface of tooth extraction cavity advances concurrently with formation of granulation20

tissue 1, 2) . Teruplug ® is excellent in this granulation formation, so in Teruplug ® indicationpatients, epithelization may advance comparatively earlier stage, and in Spongel ®indication patients, granulation formation 12) within the tooth extraction cavity may be slowcompared to that in Teruplug ® . Epithelization from the margin develops in advance, soepithelization from the tooth extraction cavity surface may be delayed when compared tothat in Teruplug ® indication patients.6) Presence or absence of adverse reactionPresence or absence of adverse reaction was examined in localized extraction siteat 1 week after tooth extraction as is shown in Table 4. Both in the indication side andthe control side, all through the period from immediately after tooth extraction to 1 weekafter tooth extraction, no patients showed symptoms suggesting adverse reactions. Thus,there are no problems in safety at localized tooth extraction site in either agents.7) With regard to superiority of wound depressionSuperiority of Teruplug ® in wound depression was evaluated at 1 week aftertooth extraction. As is shown in Table 13, “Smaller depression compared to control”was observed in 16 patients (59%) and “Larger depression compared to control” was notobserved in any patient (0%), which indicates superiority of Teruplug ® indication patientsin wound depression (Figs. 7 and 8).In Spongel ® indication patients, epithelization from Spongel ® surface was notobserved. Epithelization gradually advanced from the marginal gingiva around the toothextraction cavity, finally epithelium covered the tooth extraction cavity. These indicatemechanism as follows: Spongel ® surface is exposed for a long time, during which itssurface is scraped due to saliva or food debris, and after that epithelization from themargin occurs, which may cause the wound depression.Whereas, in Teruplug ® indication patients, collagen portion of Teruplug ® hassuperiority in cellular invasiveness or cellular activity, that is, biostability 10) so granulationis formed on Teruplug ® surface in earlier stage and epithelization advances withoutscraping Teruplug ® surface, which produces smaller wound depression.ConclusionBullet atelo-collagen sponge (Teruplug ® ) and gelatin sponge (Spongel ® ) that are21

atelo-collagen materials suggesting effective for bone defect were indicated to toothextraction after convenient extraction that is usually performed in correction treatment andits clinical usefulness was compared.Among evaluation variables that were examined this time, Teruplug ® showedhigher value in hemostatic effect, analgesic effect, an extent of epithelization of toothextraction wound surface, and wound depression when compared with Spongel ® , and itmay be more useful medical material than Spongel ® . Postoperative infection and adversereaction were not found in any patient applied either Teruplug ® or Spongel ® locally, thus itwas suggested that both agents may be safe materials, so clinically more useful materialswhen compared to hemostatic splint with complicated operability.22