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e-ISSN: 1312-773X<br />

Journal of IMAB<br />

- Annual Proceeding<br />

(Scientific Papers)<br />

<strong>2016</strong><br />

vol. 22, issue 3<br />

(July - September)<br />

ISSN: 1312 773X<br />

J of IMAB. <strong>2016</strong> Jul-Sep;22(3):<br />

DOI: 10.5272/jimab.<strong>2016</strong>223<br />

http://www.journal-imab-bg.org<br />

Publisher:<br />

“Peytchinski, Gospodin Iliev” ET<br />

Pleven, Bulgaria<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1187

Journal of IMAB - Annual Proceeding (Scientific Papers)<br />

Editorial Board<br />

Editor-in-chief:<br />

Prof. Dr. Krassimir Metodiev<br />

Deputy Editor-in-chief:<br />

Assoc. prof. Dr. George Kyuchukov<br />

Editors:<br />

Prof. Dr. Angelina Kisselova-Yaneva (Responsible for part Oral&Dental Medicine)<br />

Assoc. prof. Dr. Liana Gercheva (Responsible for part Medicine)<br />

Associate Editors:<br />

Prof. Dr. Bogdan Petrunov,<br />

Prof. Dr. Bojidar Popov,<br />

Dora Peychinska,<br />

Assoc. prof. Dr. Lyubomir Tzvetanov,<br />

Paula Lazarova,<br />

Prof. Dr. Pencho Kossev;<br />

International Members:<br />

Prof. Dr. Kurt G. Naber - Germany;<br />

Prof. Dr. Mario Di Gioacchino - Italy;<br />

Prof. Dr. Pio Conty - Italy;<br />

Prof. Dr. Dieter Falkenhagen - Austria;<br />

Prof. Dr. Ian Gould - UK;<br />

Prof. Dr. Bulent Berkarda - Turkey;<br />

Prof. Dr. Roman Kozlov - Russia;<br />

Prof. Dr. Dan Engelhard - Israel;<br />

Prof. Dr. Raphael Saginur - Canada;<br />

Part Medicine:<br />

Prof. Dr. Anelia Klissarova<br />

Prof. Dr. Ara Kaprelian<br />

Prof. Dr. Dimitar K. Gospodinov<br />

Prof. Dr. Ekaterina Titianova<br />

Assoc. prof. Dr. Galya Gancheva<br />

Prof. Dr. Iskren Kotzev<br />

Assoc. prof. Dr. Ivelina Yordanova<br />

Assoc. prof. Dr. Mariana Arnaudova<br />

Assoc. prof. Dr. Maya Danovska<br />

Prof. Dr. Snejina Vassileva<br />

Prof. Dr. Snezhanka T. Tisheva<br />

Prof. Dr. Valentin Stoyanov<br />

Prof. Dr. Zaharyi Krastev;<br />

Dr. Katarina Wassilew - Germany<br />

Prof. Dr. Goce Spasovski - Macedonia<br />

Prof. Dr. Sonja Genadieva-Stavric -<br />

Macedonia<br />

Part Oral&Dental Medicine:<br />

Assoc. prof. Dr. Ani Beltcheva,<br />

Assoc. prof. Dr. Assya Krasteva,<br />

Assoc. prof. Donka Kirova,<br />

Prof. Dr. Elka Popova,<br />

Prof. Dr. Hristina Lalabonova,<br />

Prof. Dr. Hristina Mihailova,<br />

Assoc. prof. Dr. Ilyana Stoeva,<br />

Assoc. prof. Dr. Maria Dencheva,<br />

Assoc. prof. Dr. Mariana Dimova,<br />

Assoc. prof. Dr. Metodi Abadjiev,<br />

Prof. Dr. Milena Peneva,<br />

Assoc. prof. Dr. Vladimir Panov,<br />

Prof. Dr. Alexandru Petre - Romania<br />

Dr. Bogdan Calenic - Romania<br />

Prof. Dr. Slave Naumovski - Macedonia,<br />

Executive Director:<br />

Gospodin Peytchinski<br />

Editor-in-chief:<br />

Prof. Dr. Krassimir Metodiev<br />

Headquarters of International Medical Association<br />

Bulgaria (IMAB); 55, M. Drinov str., 9002 Varna,<br />

Bulgaria,<br />

Tel./Fax: +359/52/634 107, 379 777;<br />

Mobile: +359/888 712 407<br />

E-mail: kr.metod@yahoo.com,<br />

kr.metod@gmail.com;<br />

Deputy Editor-in-chief:<br />

Assoc. prof. Dr. George Kyuchukov<br />

E-mail: kyuchger@abv.bg;<br />

Address for correspondence:<br />

Journal of IMAB - <strong>2016</strong> July-September;22(3)<br />

ISSN: 1312-773X; DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223<br />

Publishing house and Editorial office of<br />

the Journal of IMAB:<br />

“Peytchinski, Gospodin Iliev” ET,<br />

compl. Droujba bl. 116, ap. 41;<br />

5806 Pleven, Bulgaria<br />

Phone: +359/64 871 100,<br />

E-mail: publisher_imab@abv.bg, or<br />

publisher.imab@gmail.com,<br />

Publisher: Gospodin Peytchinski<br />

Mobile: +359/888 213 675<br />

1188 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

1. Magnetic Resonance Imaging units (MRI)<br />

The first Magnetic Resonance Imaging unit in Bulgaria<br />

was delivered back in 1966 – MRI spectrometer (JEOL<br />

– Japan 60 MHz) [4]. As seen from the graph, Japan is leading<br />

in terms of quantitative indicators with 45.94 MRI units<br />

per 1 million people, the difference with the other countries<br />

being significant. (Fig.1.) Japan also leads in early diagnohttp://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1189<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />






Svetoslav Garov 1 , Tsvetelina Mihaylova 1 , Galina Makedonska 2<br />

1) Department of Health Policy and Management, Faculty of Public Health, MU<br />

- Sofia, Bulgaria<br />

2) NCRRP (National Center of Radiobiology and Radiation Protection), Ministry<br />

of Health, Bulgaria.<br />


Purpose: to reveal the current condition of medical<br />

equipment in Bulgaria related to those major groups of socially<br />

significant diseases and to make an attempt to define<br />

guidelines for its optimization in view of improving the functioning<br />

and management of the healthcare system in this<br />

field.<br />

Material and methods: The following research methods<br />

have been applied:<br />

1. Document review method – research, processing<br />

and analysis of medical statistical information taken from<br />

data from WHO and annual reports of NRA. The study includes<br />

data from 2009 - 2015.<br />

2. Graphical method – summarizing data in relevant<br />

tables and diagram presentations.<br />

Results: The article analyzes the condition of medical<br />

equipment in the field of oncologic and cardiologic<br />

medical aid in Bulgaria based on data taken from WHO<br />

(World Health Organization) and annual reports of NRA (Nuclear<br />

Regulatory Agency). Six types of diagnostic imaging<br />

and radiation therapy devices have been studied: Magnetic<br />

Resonance Imaging units (MRI); Computed Tomography<br />

Scanners (CT), Positron Emission Tomography Scanners,<br />

Mammographs, Linear accelerators and Telecobalt units (Cobalt-60).<br />

The condition of medical equipment since 2009<br />

has been analyzed, results have been reported and trends –<br />

studied.<br />

Conclusion: The oncologic and cardiologic medical<br />

equipment in Bulgaria has been gradually improving in the<br />

last seven years, but quantitative indicators regarding the<br />

devices studied are still far away from the figures recommended<br />

by WHO with one single exception, i.e. Computed<br />

Tomography Scanners<br />

Key words: Oncologic medical aid, cardiologic medical<br />

aid, Magnetic Resonance Imaging units (MRI), Computed<br />

Tomography Scanners (CT), Positron Emission Tomography<br />

Scanners, Mammographs, Linear accelerators,<br />

Telecobalt units (Cobalt-60),<br />


The greatest challenge that medicine and healthcare<br />

face in XXI century is the increasing costs for socially significant<br />

diseases. The most specific feature of those diseases<br />

is their large scale distribution. They are the result of a<br />

number of reasons, endogenic andexogenic forces acting<br />

throughout one’s life. Those diseases mostly affect middleaged<br />

people, which threatens the social and economic welfare<br />

of individuals, their families and on a more general level<br />

– the welfare of the entire population of a country. A positive<br />

affect regarding those groups of diseases can be achieved<br />

through: limiting major risk factors and taking advantage<br />

of the advance in medical science and practice [1].<br />


The analysis includes data taken from 58 countries<br />

regarding 6 types of medical devices: Magnetic Resonance<br />

Imaging units (MRI); Computed Tomography Scanners<br />

(CT), Positron Emission Tomography Scanners,<br />

Mammographs, Linear accelerators and Telecobalt units (Cobalt-60).<br />

The source of information is WHO (World Health<br />

Organization) and part of the data for Bulgaria is provided<br />

by NCRRP (National Center of Radiobiology and Radiation<br />

Protection) and taken from annual reports of NRA [2, 3].<br />

Countries from five continents take part in the research as<br />

follows: Europe – 25 countries; Asia - 13 countries; North<br />

and South America – 10 countries; Africa- 10 countries. The<br />

costs of medical equipment are related to 1 million inhabitants<br />

with the purpose of possible comparison and therefore<br />

most of them are not whole numbers. The research presents<br />

data from 2009 and in the graphs Bulgaria is marked in red<br />

so that it could be quickly and easily seen. Finally, average<br />

values are presented in tables and graphs for the six types<br />

of devices.<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1189

sis and effective treatment of oncology diseases. Despite using<br />

cutting edge technologies, treatment in Japan is less expensive<br />

than, for example, Germany or Greece. Latest trends<br />

in Japanese medicine, serving as standard for other countries,<br />

are as follows: minimal invasiveness, efficiency and individual<br />

approach to patients. An evidence of the highly efficient<br />

Japanese healthcare system is their record-breaking<br />

life expectancy, directly related to the promotion of healthy<br />

lifestyle, use of cutting edge technical and scientific achievements<br />

and the availability of competent medical experts. In<br />

2015 Japan manufactured and commissioned the most powerful<br />

so far MRI unit with operating frequency of 1020 MHz.<br />

Before that the most powerful and ensuring the most precise<br />

diagnostics device was in Germany, with a frequency<br />

of 1000 MHz and functioning since 2009. Second among<br />

the countries studied is Belgium, having 24.89 MRI units<br />

per 1 million people, followed by Iceland with 21.69 MRI<br />

units per 1 million people, etc. Bulgaria in 2009 had 4.02<br />

devices per 1 million people. This means that Bulgaria, with<br />

its population of 7.25 million, had in 2009 30 MRI units<br />

registered and functioning according to data. The majority<br />

of them are not brand new, but second hand. The main reason<br />

is the high price of brand new equipment and that is<br />

why second hand devices are most often purchased in a relatively<br />

good condition at prices about 800 000 - 1 000 000<br />

BGN. Other reasons include high cost of maintenance, high<br />

operating costs and low return on investment. Profitability<br />

is ensured by a patient flow depending on the regulatory<br />

standards set by NHIF (National Health Insurance Fund) and<br />

on the patients’ solvency. NHIF covers 180 BGN, and the<br />

rest is paid by patients. Financial estimates show that at such<br />

prices it takes 140-145 patients per month so that such kind<br />

of apparatus can be profitable for the medical institution.<br />

The average price of an MRI in Bulgaria in 2015 was 550<br />

BGN with contrast agents and 350 BGN w/o contrast agents.<br />

Fig. 1. MRI units worldwide<br />

in 2009<br />

1190 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

After 1998 the world of oncologic surgery welcomed a<br />

technical revolution thanks to robot-assisted surgery and proton<br />

therapy. Gamma knife was also introduced in 1998 to<br />

perform safe and minimal invasive operations through<br />

gamma ray radiation and with no cuts and bleeding. The device<br />

operates with the expensive radioactive cobalt and is<br />

mainly used in cases of malignant tumors in the head [5, 6, 7].<br />

Cybeknife is a newer generation of equipment and is a<br />

robot-assisted radiosurgery set. It combines a radiation device<br />

attached to a mobile arm of a super precise robot and a<br />

special navigation system. The first European Cyberknife was<br />

made in Germany. Cyberknife operations are used in much<br />

more types and locations of malignant tumors and the apparatus<br />

also successfully treats some kinds of metastasis. The<br />

average duration of a Cyberknife surgery is approximately 1<br />

hour. Cyberknife is famous for its absolute precision and the<br />

therapy itself spares healthy tissues to the maximum possible<br />

extent [8, 9, 10].<br />

Even newer generation of equipment used for nonoperative<br />

treatment of cancer is the so called Trilogy linear<br />

accelerator (Trilogy linac). The apparatus was introduced<br />

by a hi-tech American company and, in contrast to the two<br />

devices described above, operates directly through the electricity<br />

network so the cost of surgery is many times lower and<br />

the treatment become much less expensive [11, 12].<br />

In Bulgaria, before <strong>2016</strong>, Cyberknives were commissioned<br />

for radiosurgery and radiation treatment in Sv. Ivan<br />

Rilski Hospital in Sofia, Tokuda Hospital in Sofia and Sv.<br />

Georgi University Hospital in Plovdiv.<br />

2. Computed Tomography Scanners (CT)<br />

Bulgaria has a quite high number of CT devices –<br />

27.19 per 1 million people. (Fig. 2) Such figures are close<br />

to the ones reported for well-developed countries such as<br />

Austria, Portugal, etc. Japan is the world leader, having<br />

101.75 devices per 1 million people. The total number of<br />

CT sets functioning in Bulgaria in 2009 amounted to 198.<br />

According to their type they are single-slice and multi-slice.<br />

The latter can be subdivided further into 2-slice, 4-slice, 16-<br />

slice and 64-slice. In Bulgaria the majority of CT devices<br />

are manufactured by Siemens. Tests are usually made in four<br />

areas: head, chest, abdomen and pelvis [13, 14]. Their<br />

number has been gradually increasing: 235 in 2010; 237 in<br />

2011; 241 in 2012; 266 in 2013 and 287 in 2014.<br />

Fig. 2. Computed Tomography Scanners worldwide<br />

in 2009.<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1191

3. Positron Emission Tomography Scanners (PET scanners)<br />

Positron Emission Tomography Scanners (or positron<br />

emission tomography) are diagnostic imaging devices that<br />

display biochemical and physiological changes and diagnose<br />

a disease at a very early stage before any morphological<br />

changes have occurred. This makes them different from<br />

MRI and CT devices that register structural anatomical<br />

changes that have already appeared in organs [15, 16]. In<br />

addition, they are used to monitor the effects of antitumor<br />

therapy. A disadvantage is their high price when compared<br />

to other diagnostic imaging tests: 2800 BGN, now entirely<br />

covered by NHIF, registration being subject to approval by<br />

a special medical committee. The first PET scanner was introduced<br />

in Bulgaria in 2009 at Sv. Marina University Hospital<br />

in Varna. Gradually their number increased and by <strong>2016</strong><br />

there were 3 hospitals operating PET scanners: Sv. Marina<br />

University Hospital in Varna, Sv. Georgi University Hospital<br />

in Plovdiv and Aleksandrovska University Hospital in<br />

Sofia.<br />

As seen from the graph the countries covered by the<br />

study that have the greatest number of PET scanners per<br />

capita are Belgium – 26.76 devices per 1 million people,<br />

Denmark – 6.03, Japan – 4.34, etc. (Fig.3.)<br />

To operate, PET scanners need a specific radioactive<br />

isotope consumable called radionuclide fluorine-18. In <strong>2016</strong><br />

Bulgaria had 2 cyclotron sets for their manufacturing: in Sv.<br />

Marina University Hospital in Varna and Aleksandrovska<br />

University Hospital in Sofia. A third set is to be constructed<br />

in INRNE (Institute for Nuclear Research and Nuclear Energy)<br />

at BAS (Bulgarian Academy of Sciences) – Sofia by the<br />

end of 2017. A cyclotron set consists of a mini cyclotron device<br />

producing individual doses of radioactive isotopes for<br />

about 180–200 patients a month. It guarantees constant availability<br />

of the PET scanner consumable. Until then isotopes<br />

for PET scanners will be delivered by air due to their short<br />

period of decay [17, 18].<br />

The radiopharmaceutical most applied is 18F<br />

Fludeoxyglucose (F18 FDG). It is a substance analogous to<br />

glucose used in PET and suitable for testing metabolism of<br />

glucose in the heart, lungs and brain. It is also applied when<br />

monitoring treatment of Hodgkin’s disease, non-Hodgkin’s<br />

lymphoma, colorectal cancer, breast cancer, melanoma, lung<br />

cancer, etc. [19, 20].<br />

Fig. 3. PET scanners worldwide in<br />

2009.<br />

1192 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

4. Mammographs<br />

Each year more than 3500 women are diagnosed with<br />

breast cancer in Bulgaria. The most efficient method of prevention<br />

are the regular check-ups involving X-ray mammography<br />

(X-ray of the mammary glands). Mammography is a<br />

specific imaging method during which the structures forming<br />

the mammary gland are visualized using a relatively low<br />

amount of X-ray radiation [21, 22]. Routine preventive checkups<br />

are meant for women, and those who do not have a family<br />

history should have their first mammography after they become<br />

35-year old. Those who do have a family history should<br />

have their first mammography at about 30. Females up to 35-<br />

year old with no complaints and family history are recommended<br />

to have a echomammography (mammary gland ultrasound),<br />

where no X-rays are used [23, 24]. During mammography<br />

the mammary gland is placed between two planes<br />

and a slight controlled pressure is applied for several seconds.<br />

The X-ray mammography takes two views of the mammary<br />

gland. Bulgaria is well supplied with such equipment,<br />

the leading position being taken by Serbia with 210.18 devices<br />

per 1 million people, followed by Lebanon, Portugal,<br />

Finland, etc. (Fig.4.) The price of a mammography test (mammography<br />

and consultation) in Bulgaria is about 50 BGN<br />

and after the GP issues a medical referral, it is paid by NHIF.<br />

By 2009 the number of mammographs in Bulgaria was 199.<br />

In 2010 their number dropped down to 181. In 2011 they<br />

were 180, in 2012-213, in 2013 - 231 and in 2014 their number<br />

reached 255.<br />

Fig. 4. Mammographs worldwide in 2009.<br />

5. Linear accelerators<br />

Linear accelerators for medical purposes (LINAC) ensure<br />

the opportunity to apply one of the most modern methods<br />

of external radiation therapy. It destroys cancer cells with<br />

minimal effect on healthy tissues surrounding a tumor. It is<br />

followed by a chemotherapy treatment varying in duration<br />

from 5 to 6 months and sometimes such chemotherapy has<br />

to be repeated. LINAC can be used for all radiation sensitive<br />

tumors such as breast, cervix, oral cavity, larynx, nose<br />

and testicles carcinomas; lung, prostate, bladder, stomach<br />

and pancreas cancer, etc. [25, 26, 27].<br />

According to the graph, the country best supplied<br />

with such equipment is Denmark, having 9.87 devices per 1<br />

million people, followed by Finland with 7.51, New Zea-<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1193

land with 6.56, etc. (Fig.5.)<br />

By the end of 2009 Bulgaria had 3 linear accelerators<br />

used for radiation treatment of oncology diseases in Sv.<br />

Georgi University Hospital in Plovdiv, the Specialized Hospital<br />

for Active Treatment in Oncology in Sofia and the new<br />

one located in Tokuda Hospital in Sofia.<br />

In 2014 the total number of linear accelerators used<br />

for medical purposes was 10: 3 in Sofia, 2 in Plovdiv and 2<br />

in the town of Shumen, while 6 were being installed and<br />

tested: two new ones in Sofia, 2 in Varna, 1 in Plovdiv and<br />

1 in the town of Vratsa.<br />

Fig. 5. Linear accelerators worldwide in 2009.<br />

6. 6. Telecobalt units (Cobalt-60)<br />

Cobalt therapy is the use for medical purposes of<br />

gamma rays from cobalt-60 isotope in cases of malignant<br />

tumors. After World War II, cobalt radiation therapy equipment<br />

revolutionized oncology and such devices were widespread<br />

in the 1950s and 1960s. After the introduction of the<br />

medical linear accelerator in the 1970s their role was partially<br />

replaced by linear accelerators. Advantages: medically<br />

efficient, having simple design, less expensive in terms of<br />

purchase price and maintenance costs as compared to modern<br />

linear accelerators. Disadvantages: radioactive waste related<br />

problems; cobalt-60 radioisotope has a half-life of 5.3<br />

years and so it has to be periodically replaced [28, 29].<br />

The modern cobalt therapy is also known as Gamma<br />

Knife therapy and can be applied in oncology for all body<br />

parts and organs. It is extremely precise and so it is used for<br />

1194 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

patients having brain tumors [30, 31, 32].<br />

As seen from the graph from the countries covered by<br />

the study Malta has 2.44 devices, Belarus has 2.33, Mauritania<br />

– 1.55, etc. It is obvious that in countries with welldeveloped<br />

economies linear accelerators prevail instead of<br />

Telecobalt units. ( Fig. 6)<br />

In 2009 the old devices were replaced by new gamma<br />

radiation therapy equipment in the Specialized Hospital for<br />

Active Treatment in Oncology in Sofia and the district oncology<br />

clinics in the towns of Stara Zagora and Ruse. NRA<br />

issued installation and testing permits for the new devices,<br />

approval committees were set up and operation licenses were<br />

granted. In 2010 the medical gamma radiation equipment<br />

in the Oncology Center in the town of Plovdiv was<br />

uninstalled and decommissioned.<br />

Fig. 6. Telecobalt units (Cobalt-60)<br />

worldwide in 2009.<br />

Comparative data of the 6 types of studied diagnostic<br />

imaging and radiation therapy devices used in Bulgaria<br />

is presented, comparing the average figures on the continents<br />

taken into account with the purpose of displaying the general<br />

condition of the infrastructure studied in different countries<br />

worldwide. For better data illustration North and South<br />

America are presented together under a single name, i.e.<br />

America. (Table 1 and Fig.7)<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1195

2009.<br />

Table 1. Average number of the 6 types of medical equipment (per 1 million people) per continents and Bulgaria in<br />

MRI units CT PET scanners Mammographs Linear Telecobalt<br />

accelerators units<br />

EUROPE 8.78 15.84 2.09 81.49 3.13 0.61<br />

ASIA 5.99 13.71 0.58 50.38 0.89 0.3<br />

AMERICA 1.93 4.9 0.116 23.91 0.61 0.69<br />

AFRICA 2.29 4.17 0.08 34.6 0.92 0.397<br />

Bulgaria 4.02 27.19 0.13 26.64 0.4 0.4<br />

Fig. 7. Average number of the 6 types<br />

of medical equipment (per 1 million<br />

people) per continents and Bulgaria in<br />

2009.<br />

Key:<br />

I. MRI units;<br />

II. CT<br />

III. PET scanners<br />

IV. Mammographs<br />

V. Linear accelerators<br />

VI. Telecobalt units<br />


1. As seen from the study, the oncologic and cardiologic<br />

medical equipment in Bulgaria has been gradually improving<br />

in the last seven years, but quantitative indicators<br />

regarding the devices studied are still far away from the figures<br />

recommended by WHO with one single exception, i.e.<br />

CT. For example, WHO recommends a standard of 1 linear<br />

accelerator per 250 000-300 000 people, which means that<br />

our country by <strong>2016</strong> has approximately half of the numbers<br />

required for achieving this standard.<br />

2. There is a considerable difference in those indica-<br />

tors between Bulgaria and the countries with well-developed<br />

economies. However, it has to be emphasized that the results<br />

do show a significant modernization and fast reduction of<br />

those differences, especially during the last three years.<br />

3. The use of modern technologies by medical experts<br />

is directly related to improving the results in terms of diagnostics<br />

and treatment. Therefore, the recent year trend of increasing<br />

material resource has to be continued together with<br />

a steady improvement of medical specialists’ qualification<br />

with the purpose of their adequate adjustment to new technologies.<br />


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Pesheva P, Hristov N, Shipkovenska E,<br />

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Continuous versus step-by-step scanning<br />

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CyberKnife measurements. Appl Radiat<br />

Isot. 2015 Nov;105:88-91. [PubMed]<br />

10. Liu SH, Murovic J, Wallach J,<br />

Cui G, Soltys SG, Gibbs IC, et al. Cyber<br />

Knife radiosurgery for brainstem metastases:<br />

Management and outcomes and<br />

a review of the literature. J Clin Neurosci.<br />

<strong>2016</strong> Mar;25:105-110. [PubMed]<br />

[CrossRef]<br />

11. Vaccara E, Agostinelli S,<br />

Bevegni M, Taccini G. New experience<br />

with breast volumetric modulation ARC<br />

therapy (VMAT) realized with Trilogy<br />

linac: Comparison with tomotherapy,<br />

pros and cons. Physica Medica. <strong>2016</strong><br />

Feb;32(1):67; [CrossRef]<br />

12. Huntzinger C, Friedman W,<br />

Bova F, Fox T, Boushet L, Boeh L. Trilogy<br />

Image-Guided Stereotactic Radiosurgery.<br />

Med Dosim. 2007 Summer;<br />

32(2):121-133. [CrossRef]<br />

13. Nieman K, Coenen A,<br />

Dijkshoorn M. 5 - Computed tomography.<br />

Advanced Cardiac Imaging. 2015;<br />

97-125. [CrossRef]<br />

14. Panetta D. 2.03 – Computed Tomography.<br />

Volume 2: X-Ray and Ultrasound<br />

Imaging. Comprehensive Biomedical<br />

Physics. 2014 Sep;2:65-88.<br />

[CrossRef]<br />

15. Hess S. FDG-PET/CT: Quo<br />

vadis? PET Clinics. 2014 Oct;9(4):xixiii;<br />

[CrossRef]<br />

16. Basu S, Hess S, Braad Nielsen<br />

PE, Olsen BB, Inglev S, Høilund-<br />

Carlsen PF. The basic principles of<br />

FDG-PET/CT imaging. PET Clinics.<br />

2014; 9:355-370. [PubMed] [Cross<br />

Ref]<br />

17. Smirnov V, Vorozhtsov S, Vincent<br />

J. Design study of an ultra-compact<br />

superconducting cyclotron for isotope<br />

production. Nuclear Instruments and<br />

Methods in Physics Research Section A:<br />

Accelerators, Spectrometers, Detectors<br />

and Associated Equipment. 2014 Nov<br />

1;763:6–12. [CrossRef]<br />

18. Shankar M, Rao J. PET- CT<br />

imaging (Positron Emission Tomography<br />

- Computerized Tomography): A<br />

brief overview. Apollo Medicine. 2014<br />

Dec;11(4):311–314. [CrossRef]<br />

19. Buvat I. [Quantification in oncologic<br />

FDG-PET: A scientific overview.]<br />

[in French] Médecine Nucléaire.<br />

2011 May;35(5):320–321. [CrossRef]<br />

20. Tomasi G, Rosso L. PET<br />

imaging: implications for the future of<br />

therapy monitoring with PET/CT in oncology.<br />

Curr Opin Pharmacol. 2012<br />

Oct;12(5):569-575. [PubMed]<br />

21. Lee H, Chen Y. Image based<br />

computer aided diagnosis system for<br />

cancer detection. Expert Systems with<br />

Applications. 2015 July 15;42(12):<br />

5356-5365. [CrossRef]<br />

22. Griff S, Dershaw D. Chapter<br />

16 – Breast Cancer. Oncologic Imaging<br />

(Second Edition). 2002; 265–294.<br />

[CrossRef]<br />

23. Steyerova P, Frybova J, Skovajsova<br />

M. 719 Screening and diagnostic<br />

use of breast ultrasound in young<br />

women. European Journal of Cancer.<br />

2015 Sep;51(3):S133. [CrossRef]<br />

24. An Y, Kim S, Kang BJ, Park<br />

CS, Jung NY, Kim JY. Breast cancer in<br />

very young women (

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1198<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />


Desislava Todorova 1 , Tsvetelina Mihailova 2 , Rumiana Etova 3 , Svetoslav Garov 2<br />

1) Department of Preventive Medicine, Faculty of Public Health, Medical<br />

University - Sofia, Bulgaria<br />

2) Department of Health Policy and Management, Faculty of Public Health,<br />

Medical University - Sofia, Bulgaria<br />

3) Department of Epidemiology and Medicine of disastrous situations, Faculty<br />

of Public Health, Medical University - Plovdiv, Bulgaria<br />


Risk is the probability of an event occurrence at a<br />

certain moment with a negative impact on the population,<br />

territory, environment, cultural values and material valuables.<br />

The management of risk situations is necessary for<br />

any organization in which unforeseen circumstances may<br />

arise. The management of risk situations includes quantitatively<br />

expressing risk and its manifestation; risk assessment<br />

and risk analysis. Effectiveness in dealing with risky<br />

situation coordination is needed to be established between<br />

the management vertical and horizontal structures<br />

in the State. Preventing, controlling and overcoming the<br />

consequences impose an integral process of management<br />

and planning events. The requirements for growing professionalism<br />

in the management of all levels are obvious.<br />

Keywords: management, disaster, risk, planning,<br />

management decisions,<br />


The management of risk situations is necessary for<br />

any organization in which unforeseen circumstances may<br />

arise. Risk is the probability of an event occurrence at a<br />

certain moment with a negative impact on the population,<br />

territory, environment, cultural values and material valuables.<br />

Any disaster, regardless of its nature and scope of<br />

manifestation is characterized by three main elements: surprise,<br />

time and threat.<br />

Surprise is expressed not so much time for the start<br />

of the crisis (the suddenness, according to some authors,<br />

[1] as with the nature of its manifestation and running by<br />

others [2]. The development usually differs from expectations<br />

and the crisis caused events that are not expected.<br />

Threat is any condition or trend in the external environment,<br />

which affects or will affect the activities of the<br />

organization and its results. They can be assessed and<br />

classified according to their seriousness of harming the<br />

organization and likelihood to happen with the help of<br />

“The Matrix of threats”.<br />

In the course of the daily activities of any organization<br />

some unforeseen circumstances can appear that<br />

may largely influence in making managerial decisions<br />

which include the following components:<br />

• Management of the risk situation with its main<br />

points: determining the structure and content of the risk<br />

situation - risk analysis; determining the magnitude of<br />

risk - the risk quantification; making regulatory decisions<br />

concerning the discrepancy between goals and results obtained<br />

as a manifestation of risk;<br />

• Assessing and overcoming risk.<br />


Risk Assessment is a process of collection, analysis<br />

and assessment of the available information to determine<br />

the acceptable levels of risks for the individual,<br />

group contingent, society and the environment. It includes<br />

the identification and characterization of the danger<br />

likely frequency, duration, volume and time of impact [2].<br />

Risk analysis is a detailed study carried out in order<br />

to understand the nature of adverse consequences of<br />

an event, including human life, property and the environment.<br />

It can be defined as an analytical process that provides<br />

information about the likelihood of disaster and the<br />

consequences of an adverse event. [3]<br />

The damages that can occur in an emergency situation<br />

depend both on the parameters of the hazard and<br />

the vulnerability of exposed people, infrastructure, ecosystems<br />

and others. People, flora and fauna, buildings,<br />

material and cultural sites are exposed to risk.. In its simplest<br />

form, the vulnerability is comprised of exposure<br />

(Who / what will be affected?) And sensitivity (how the<br />

affected items will be damaged?). The combination of<br />

danger and vulnerability leads to risk, defined as the probability<br />

of occurrence of some damage within a certain period<br />

of time. [4] (Fig. 1)<br />

1198 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Fig. 1. Risk of emergency situation such as flood (Barredo, [5])<br />

Risk = danger x exposure x vulnera bility<br />

Danger - scenario<br />

exposure-condition of the<br />

endangered areas<br />

Vulnerability-assessment<br />

of the possible damages<br />

In the recent decades, disasters in Europe have become<br />

a growing topic of concern for citizens, public authorities,<br />

insurance companies, businesses and politicians.<br />

The management of disasters is determined by a complex<br />

business of governing bodies of the appropriate management<br />

level [6]. Management is an integral process and<br />

consists of information process and organizational process.<br />

Information includes prevention process; forecasting and<br />

planning; development and utilization plans; publicity and<br />

information; assessment of the situation and decision /<br />

choice of options. Organizational process integrates maintaining<br />

operational readiness; study; storage and use of information;<br />

organization of insurance; monitoring the implementation<br />

of the activities.<br />

Leadership and management in case of emergencies<br />

are carried out according to the conventional country management<br />

system [7]. In Bulgaria the management in emergency<br />

situations is carried out in two directions:<br />

• Management system of state and local administration.<br />

Under the state (executive) power the control is vertical<br />

Council of Ministers - Ministry (whose portfolio is disaster)<br />

- Governor - Mayor of the Municipality - Economic<br />

site.<br />

• Management system of specialized bodies and agencies.<br />

In healthcare the medical insurance of the population<br />

in emergency situations is carried out by: top management<br />

(management at the political level) - represented by<br />

the Ministry of Health and participates in decision making<br />

of national importance; coordinating management (medium<br />

level of management) - Regional health inspections and operational<br />

management - carried out by the heads of medical<br />

institutions. For an effective management coordination is<br />

essential. [8]<br />

Management of events in risky situations:<br />

Management is a focused activity, a process of impact<br />

on the sites of government (structures, forces, units) for<br />

the preparation of actions targeting efforts to achieve certain<br />

goals and completing assigned tasks.<br />

Management is a combination of different types of<br />

principles, decisions and activities resulting in:<br />

• Monitoring of risk factors;<br />

• forecast and early warning of the occurrence;<br />

• determining management objectives in a particular<br />

situation;<br />

• action planning and use of forces and means;<br />

• making decisions in the situation, guide the actions<br />

and control over the results of management;<br />

• preparation and implementation of measures to overcome<br />

the consequences and achieve stability.<br />

Management of events in risky situations goes<br />

through several phases. (Table. 1)<br />

Tab. 1. Phases of management process<br />

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5<br />

Indication Assessment of the crisis Development of options Planning Stability<br />

Warnings situation for response Execution restoration<br />

Preventing, controlling and overcoming the consequences<br />

of imposing a single process of management and<br />

planning events.<br />

In emergency situations, planning is a key step in the<br />

management of rescue operations. Success largely depends<br />

on well-developed, effective and comprehensive work plan.<br />

Planning is a complex set of events. Its drawing requires<br />

thorough analysis and preparation for an informed debate<br />

based on the huge amount of data. The planning includes<br />

resource planning, business planning and planning outcome<br />

[9]. There are different types of plans for risk situations: Plan<br />

ready for action; response plan; recovery plan; plan for mitigation.<br />

The plans identify priority projects and activities,<br />

outline responsibilities, provide time, include monitoring<br />

and risk assessment. [10] Planning is an indispensable stage<br />

in the work of the manager and is a key point, as it can save<br />

unnecessary delays and save lives, which is particularly important<br />

in emergency situations. [11]<br />

Besides planning the management of life-events also<br />

covers organizing, managing, leadership, coordination and<br />

control of the institution, organization, institution, etc. to<br />

achieve a goal. The process of managing management<br />

(scheme “PMM”) applies to all levels of healthcare organization<br />

and to all activities. Scheme “PMM” includes (Fig. 2):<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1199

Planning: to determine what will be done, when and<br />

how.<br />

Organization: to provide the necessary resources.<br />

Operational management: to define in detail the<br />

time and cost; to take measures and be guided.<br />

Control: to compare achievements against the plan;<br />

to take appropriate action.<br />

Motivation: inciting subordinates for quality and efficient<br />

work to achieve the objectives.<br />

Fig. 2. Management process (scheme „PMM” in healthcare, 12)<br />

organizing<br />

planning<br />

motivation<br />

operational management<br />

control<br />

The management of the activities carried out in emergency<br />

situations includes both traditional and specific elements:<br />

• Action Plan before, during and after a disaster;<br />

• Assessment of the effectiveness and testing of the<br />

plan;<br />

• Change in the plan during a disaster;<br />

• Good management organization;<br />

• Effective communication;<br />

• Data management;<br />

• Response to the needs of the healthcare system. [13]<br />

For the effective implementation of the plan and readiness<br />

to act in any situation the human resources of the organization<br />

are very important [14]. The selection of staff is<br />

essential to the management of the organization. According<br />

to Lee Iacocca, a very important quality of a manager is to<br />

possess the feeling of the time factor, because the correct decision<br />

becomes wrong, if taken too late. This is absolutely<br />

true in disaster situations where events are moving too fast.<br />

According to Akio Morita among the pillars of a manager,<br />

which gives an idea of the conceptual model of the head,<br />

is his highly appreciated ability to organize people to maximum<br />

dedication, and without the knowledge it is not possible<br />

to generate “the sixth” sense of the manager. Effective<br />

leadership is a function of the correct diagnosis of the situation<br />

that precedes the selection of one or another style by<br />

the Head, managers can adapt to any situation. Managerial<br />

styles are deeply personal, human skills. Openness and willingness<br />

to adapt are perhaps the most important prerequisites<br />

for success in any new venture.<br />

Organizing workflow is important for the efficiency<br />

and quality of work. The manager and his subordinates<br />

should be a team, because only when there is this feeling<br />

subordinates will take effect by the Head. [15] The head<br />

must be confident that it has a sufficient number of people<br />

in his team. Each of them must be qualified enough to undertake<br />

the task, which is inserted and be able to find a solution<br />

to the problems that will almost certainly arise during<br />

the workflow. One problem for management is mutual<br />

influence between managers and subordinates (theories of<br />

“transformation” guide). Only after achieving activity on<br />

behalf of both nations and others organization protection<br />

can be achieved in emergency situations. This is a factor for<br />

dynamic leadership, which is important in disaster situations.<br />

Tanenbaum, Schmidt, Hersey-Blanchard, Vrum-Jensen account<br />

the influence of the environment (situation) on relations<br />

manager-subordinate and general ideas of leadership.<br />

Quality situational theories of leadership (Fiedler, Yedar) display<br />

situation (situation, environment) as the main factor determining<br />

the leadership style that is influenced and depends<br />

on many of the qualities of the head. [16, 17]<br />


• The model of management indicates that any organization<br />

(health and each other) exists not in isolation but in<br />

particular for her external environment is changing in emergency<br />

situations.<br />

• Questions on the management of disasters appear<br />

an advantage of central, together with regional and local governments.<br />

• Preventing, tackling and overcoming the consequences<br />

of disasters impose a single management process.<br />

• The sooner problems are identified, the faster solution<br />

would be found for them.<br />


The effective response in a crisis situation requires<br />

taking the right decisions in terms of chaotic and emotionally<br />

charged environment. Management of disasters can be<br />

successfully implemented on the basis of prior information,<br />

events planning and preparation of the teams, as well as<br />

training and assistance to citizens. Health policy, planning<br />

and management are interrelated and interdependent. The<br />

requirements are obvious for growing professionalism in the<br />

management and use of non-standard approaches in the management<br />

of every area of social life at risk situations.<br />

1200 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/


1. Chakurova R, Mihailova Il. General<br />

characteristics of disasters, Disaster<br />

medicine. Sofia: Arso. 2011, p 17.<br />

[in Bulgarian]<br />

2. Sapundzhiev P. Kostadinov R.<br />

Manual management of medical support<br />

in emergency situations, Plovdiv:<br />

Ik-VAP. 2010. p 20, 21. [in Bulgarian]<br />

3. Levees and National Research<br />

Council. The National Flood Insurance<br />

Program: Improving Policies and<br />

Practices. Washington, D.C.: The National<br />

Academies Press. 2013. p 230-<br />

250 [Internet]<br />

4. Merz B, Thieken A, Kreibich H.<br />

Quantification of Socio-Economic<br />

Flood Risks. In Flood Risk Assessment<br />

and Management: How to Specify Hydrological<br />

Loads, Their Consequences<br />

and Uncertainties. Editor Schumann<br />

AH. Springer Netherlands. 2011;<br />

Capter 11:229-247. [CrossRef]<br />

5. Barredo JI. Major flood disasters<br />

in Europe: 1950-2005. Nat Hazards.<br />

2007 Jul; 42(1):125-148 [CrossRef]<br />

6. Mihailova I. Management of medical<br />

insurance, Disaster medicine. Sofia:<br />

Arso. 2011. p 457. [in Bulgarian]<br />

7. Todorova D. National bodies and<br />

structures for civil protection of the<br />

Member States of the European Union,<br />

Socio-economic aspects of disasters<br />

and protection of the population. Sofia:<br />

CP Center. 2012. p 44-50. [in Bulgarian]<br />

8. Zlatanova T. Management Activities<br />

of General Practitioners in Bulgaria.<br />

Editors: Jeliazko Hristov, John<br />

Kyriopoulos, T.C. Constantinidis. In<br />

Public Health and Health care in<br />

Greece and Bulgaria: The challenge of<br />

the Cross-border collaboration. Athens:<br />

Papazissis Publishers. 2010. p<br />

657-663.<br />

9. Shipkovenska E, Popova S,<br />

Petrova G, Gladilov St, Benisheva T,<br />

Popova Cr, et al. Scientific research<br />

methodology. Sofia: EkoPrint. 2013.<br />

p 63-77. [in Bulgarian]<br />

10. Rasid H, Haider W. Floodplain<br />

Residents’ Preferences for Water Level<br />

Management Options in Flood Control<br />

Projects in Bangladesh. In Flood Problem<br />

and Management in South Asia.<br />

Editors: Qader Mirza MM, Dixit A,<br />

Nishat A. Springer Netherlands. 2003;<br />

Capter 5:101-129. [CrossRef]<br />

11. Vodenitcharov C, Popova S,<br />

Mutafova M, Shipkovenska E. Social<br />

Medicine. Sofia: Gorex Press; 2013.<br />

p. 482-487. [in Bulgarian]<br />

12. Yanachkov Iv, Pencheva M,<br />

Alvasov B. Management in Health. Sofia:<br />

Loren Publishing. 1999. p 39-40.<br />

[in Bulgarian]<br />

13. Wiedrich TW, Sickler<br />

JL, Vossler BL, Pickard SP. Critical<br />

Systems for Public Health Management<br />

of Floods, North Dakota. J Public<br />

Health Manag Pract. 2013 May-<br />

Jun;19(3):259-265. [PubMed]<br />

14. Prodanova J, Zlatanova T,<br />

Cheshmedzhieva A, Zlatanova R.<br />

«Health» workplace, wasted resources<br />

or investments. First National Conference<br />

of the Bulgarian Society for the<br />

Study and combat stress, with international<br />

participation, Plovdiv. 2003. p<br />

331-335. [in Bulgarian]<br />

15. Ivanov I. Key points of success<br />

in management, Fundamentals of Management.<br />

Plovdiv: Macros. 2003. p<br />

324. [in Bulgarian]<br />

16. Petkov A. Management and<br />

Health Management. Kazanluk, Irita.<br />

2009. p 8, 17. [in Bulgarian]<br />

17. Ivanov I. Situational approach,<br />

Fundamentals of Management.<br />

Plovdiv: Macros. 2003. p 68. [in Bulgarian]<br />

Please cite this article as: Todorova D, Mihailova T, Etova R, Garov S. Management of risk situations. J of IMAB. <strong>2016</strong><br />

Jul-Sep;22(3):1198-1201. DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1198<br />

Received: 04/05/<strong>2016</strong>; Published online: 01/07/<strong>2016</strong><br />

Address for correspondence:<br />

Assoc. Prof. DesislavaTodorova, MD<br />

Faculty of Public Health, Medical University - Sofia;<br />

1527, Sofia, 8, Bialo more Str., Bulgaria<br />

e-mail: d.todorova.dm@gmail.com<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1201

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1202<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />



REVIEW<br />

Elitsa G. Deliverska, Milena Petkova.<br />

Department of Oral and Maxillofacial surgery, Faculty of Dental medicine,<br />

Medical University –Sofia, Bulgaria<br />


Third molar surgery is the most common procedure<br />

performed by oral and maxillofacial surgeons worldwide.<br />

This article addresses the incidence of specific complications<br />

and, where possible, offers a preventive or management strategy.<br />

Complications, such as pain, dry socket, swelling,<br />

paresthesia of the lingual or inferior alveolar nerve, bleeding,<br />

and infection are most common. Factors thought to influence<br />

the incidence of complications after third molar removal<br />

include age, gender, medical history, oral contraceptives,<br />

presence of pericoronitis, poor oral hygiene, smoking,<br />

type of impaction, relationship of third molar to the inferior<br />

alveolar nerve, surgical time, surgical technique, surgeon<br />

experience, use of perioperative antibiotics, use of topical<br />

antiseptics, use of intra-socket medications, and anaesthetic<br />

technique.<br />

For the general dental practitioner, as well as the oral<br />

and maxillofacial surgeon, it is important to be familiar with<br />

all the possible complications after this procedure. This improves<br />

patient education and leads to prevention, early recognition<br />

and management.<br />

Key words: third molar surgery, complication, mandible,<br />

maxilla<br />


Surgical removal of impacted third molars is one of<br />

the most common procedures carried out in oral and maxillofacial<br />

surgery. Most third molar surgeries are performed<br />

without complications. However, such procedure can lead<br />

to serious complications to the patient, such as hemorrhage,<br />

persistent pain and swelling, infection, dry socket (alveolar<br />

osteitis), dentoalveolar fracture, paresthesia of the inferior<br />

alveolar nerve and of the lingual nerve, temporomandibular<br />

joint injury and even mandibular fracture. The accident or<br />

complication rates related to third molar extraction may vary<br />

between 2.6 and 30.9 %, being the results influenced by different<br />

factors, such as age and health condition of the patient,<br />

gender, tooth impact level, surgeon’s experience, smoking,<br />

intake of contraceptive medicine, quality of oral hygiene,<br />

and surgical technique among others [1]. The overall<br />

incidence of complication and the severity of these complications<br />

are associated most directly with the depth of impaction<br />

and with the age of the patient [2]. There appears to<br />

be a direct relation between the degree of impaction of the<br />

extracted tooth and the incidence of postoperative complications.<br />

Most of the complications are associated with a<br />

greater degree of impaction. Teeth classified as having IC,<br />

IIC and IIIC impaction have more complications than teeth<br />

classified as having B or A impaction [3]. There is also a<br />

relation between tooth position based on the Winter classification<br />

and the appearance of postoperative complications.<br />

Mesioangular and distoangular impaction are associated<br />

with nearly twice as many complications as the other tooth<br />

positions [3]. Other authors state that horizontal and<br />

distoangular impactions are inclined to develop more complications<br />

[4]. Deep impacted third molar surgery needs a<br />

bigger flap design. Tissues in the neighborhood and muscles<br />

can receive more damage because of this wide and large<br />

access flap [5].<br />

There is a distinctive association between age and<br />

observed postoperative complications. These associations<br />

result from the fact that the intervention in older patients<br />

lasts longer because of increased bone density. Age depended<br />

maturing of tooth root formation and decreased healing capacity<br />

lead to intensive postoperative complications. Bruce<br />

and Chiapasco et al. state that older patients have more pain,<br />

edema and trismus as postoperative complications [5].<br />

It seems that female patients show higher accident and<br />

complication rates [1]. Monaco et al. reported that the incidence<br />

of postoperative edema in female patients (12.7%) is<br />

significantly higher than in male patients (1.4%) [5].<br />

The experience of surgeon also appears to be a determining<br />

factor in the development of postoperative complications<br />

and can result in a longer treatment process, social<br />

and financial difficulties and a corresponding decrease in<br />

patient’s life quality [5].<br />

Prior to any surgical procedure, the patient must be<br />

informed about the possible accidents and/or complications<br />

that may occur during the entire treatment, being aware of<br />

the fact that any unexpected situation should be dealt with<br />

the best possible way [1].<br />

It is thought that complications like pain, edema and<br />

trismus are caused by surgical trauma depending on the inflammatory<br />

process. In surgeries for impacted mandibular<br />

third molar, time of the intervention is thought to be associated<br />

with tooth position, angle and the experience of the<br />

surgeon and these parameters determine the difficulty of the<br />

surgery and are related to the intensity and time of pain,<br />

edema and trismus. Longer surgical interventions are<br />

thought to increase tissue damage and vascular permeability<br />

can cause postoperative edema and affect its intensity.<br />

1202 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

In addition, it was reported that longer surgical interventions<br />

lead to increased surgical trauma [5].<br />

While evaluating the postoperative complications<br />

regarding the width and depth of impaction, pain and<br />

swelling was common in IIIA (37.5%) followed by IIIB<br />

(20%); dry socket was common in IIIA, IA and IIA which<br />

was 12.5%, 5% and 4.8% respectively; trismus occurred<br />

more in Class IIIB (20%), Class IIIA (12.5%) and Class IB<br />

(6.8%) and paresthesia was least common and occurred in<br />

2 patients (0.7%) [4].<br />

Bleeding<br />

Hemorrhage might happen during (accident) or after<br />

(complication) the surgery, being classified as late or recurrent<br />

hemorrhage. In situations of intense bleeding classified<br />

as late, the hemorrhage happens only once, after the end of<br />

the procedure. In recurrent hemorrhages, more than one intense<br />

bleeding situation takes place, even after initially extinguished.<br />

Anatomical variations, tooth proximity to the vascular<br />

nerve bundle of the mandibular canal, and coagulopathy<br />

are the main causes of hemorrhage [1]. Patients who have<br />

known acquired or congenital coagulopathies require extensive<br />

preparation and preoperative planning (eg, determination<br />

of International Normalized Ratio, factor replacement,<br />

hematology consultation) before third molar surgery [2].<br />

Bleeding can be minimized by using a good surgical<br />

technique and by avoiding the tearing of flaps or excessive<br />

trauma to bone and the overlying soft tissue. When a vessel<br />

is cut, the bleeding should be stopped to prevent secondary<br />

hemorrhage following surgery [2].<br />

The most effective way to achieve hemostasis following<br />

surgery is to apply a moist gauze pack directly over the<br />

site of the surgery with adequate pressure for some minutes<br />

or use of bone wax, absorbable hemostats or electrocoagulation.<br />

In some patients, immediate postoperative<br />

hemostasis is difficult. In such situations a variety of techniques<br />

can be employed to help secure local hemostasis,<br />

including over suturing and the application of topical<br />

thrombin on a small piece of absorbable gelatin sponge into<br />

the extraction socket [2].<br />

Some authors affirm that the hemorrhage cases represent<br />

from 0.2 to 5.8% of the accidents/complications and<br />

that the compression technique is safe and reliable in the<br />

control of intense bleeding [1].<br />

In comparing hemorrhage with gender, age, position<br />

of the tooth, classification of the tooth, retention, angle, systemic<br />

conditions, bad habits, use of oral contraceptives and<br />

menstruation, there weren’t any statistically significant differences<br />

[5].<br />

Edema/ postoperative swelling<br />

Postsurgical edema is an expected complication after<br />

third molar surgery. It can be caused by the response of<br />

the tissues to manipulation and trauma caused during surgery.<br />

Its onset is gradual and maximum swelling is present<br />

during 48 h after surgery [6]. Regress of the swelling is expected<br />

by the 4th day and completely resolution occurs in<br />

7 days [7].<br />

In comparing edema with gender, age, position of the<br />

tooth, classification of the tooth, retention, angle, systemic<br />

conditions, bad habits, use of oral contraceptives and menstruation,<br />

statistically significant differences were observed<br />

between edema and classification of the tooth. More edema<br />

was observed in class II than in classes I and III. There was a<br />

statistically significant difference between edema and partial<br />

bony and complete bony impaction [5].<br />

The application of ice packs to the face may make<br />

the patient feel more comfortable but has no effect on the<br />

magnitude of edema [2].<br />

Most of the surgeons prescribe corticosteroids to control<br />

surgical outcomes and yield a comfortable post-surgical<br />

healing period [6].<br />

In the initial phase of the inflammatory process,<br />

corticosteroids acts by suppressing the production of vasoactive<br />

substances such as prostaglandins and leukotrienes. This<br />

reduces fluid transudation and edema. These drugs help to<br />

control mild pain hence they should be used in conjugation<br />

with potent analgesics. Prolonged use can delay healing<br />

and increase patient’s susceptibility to infections. But<br />

in dental extraction the doses are for shorter duration, hence<br />

chances of adverse effects are very rare. [6]<br />

The dose of the drug should be more than the cortisol<br />

released normally by the body. Due to this reason, some<br />

authors consider that 8 mg dexamethasone and 40 mg methylprednisolone<br />

were used which corresponded to 200 mg of<br />

cortisol. [6]<br />

Dexamethasone significantly reduced the incidence<br />

of swelling as compared to methylprednisolone. This is attributed<br />

to the half-life of the drug which is more than methylprednisolone.<br />

The efficacy of dexamethasone is also due<br />

to the reason that it reduces the formation of thromboxane<br />

A2 which in turn reduces the amount of prostaglandin E2<br />

that is formed [6]. Good results were also obtained with 32<br />

mg methylprednisolone and 400 mg ibuprofen administered<br />

12 h before and 12 h after surgery respectively.<br />

Postoperative edema can also be controlled with dexamethasone<br />

administered in the submucosa [8]. Submucosal<br />

administration of 4 mg dexamethasone 1 h before surgery<br />

has been compared with that of 8 mg dexamethasone plus 2<br />

g amoxicillin/clavulanic acid two times a day. Both dosages<br />

improved swelling versus untreated groups, but no differences<br />

were observed between the two dosage regimens.<br />

In striking contrast with this observation, some authors<br />

reported that in patients undergoing surgery for impacted<br />

third molars, administration of 8 mg dexamethasone<br />

1 h before surgery, followed by 750 mg paracetamol every<br />

6 h for 4 days produced a better control of swelling compared<br />

to treatment with 4 mg dexamethasone [9]. Dexamethasone<br />

has also been administered 1 h before surgery (4<br />

mg orally) and 12 h after surgery (4 mg IV), along with<br />

antalgic agents (30 mg ketorolac IV), when pain was present.<br />

[10] In this study, treatment with dexamethasone always produced<br />

a good control of swelling, as measured 24 and 48 h<br />

after surgery.<br />

Elhag et al. [11] reported that administration of 10<br />

mg dexamethasone IM, 1 hour before surgery and 10–18 h<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1203

later together with antibiotic therapy (400 mg oral metronidazole,<br />

administered pre- and post-surgically), significantly<br />

reduces swelling when compared to only postoperative treatment,<br />

without corticosteroids.<br />

Although a significant reduction (50%) of swelling<br />

was observed 2 days after surgery in patients treated with 4<br />

mg dexamethasone IM, no effect was present after 7 days.<br />

However, when administered 5–10 min before surgery, 4 mg<br />

dexamethasone i.v. was not effective in controlling edema<br />

when no antibiotic therapy was associated with it.<br />

The investigated studies showed how the effectiveness<br />

of the corticosteroid administration before surgery could<br />

not be considered as a predictable therapy in order to control<br />

the postoperative swelling and edema of the surgical area.<br />

However, corticosteroids administration during the surgeries<br />

or in the postoperative period seems to give a great benefit<br />

for reducing the swelling and postoperative edema.<br />

Different surgical strategies have been reported in the<br />

literature to reduce the postoperative discomfort after the<br />

third molar surgeries. They can be used either separately or<br />

in association with pre- or postoperative strategies. Different<br />

kinds of flaps have been used during extraction of impacted<br />

third molars, specifically to assess whether a marginal<br />

flap could control postoperative swelling better than a<br />

paramarginal one [12]. No significant difference in the entity<br />

of swelling was observed after using the two kinds of<br />

flaps. However, there were no significant differences between<br />

the marginal and paramarginal flaps in terms of swelling.<br />

In contrast, Kirk et al. [13] reported significant differences,<br />

particularly for swelling and pain, during the 2nd<br />

day post-surgery between a group with a buccal flap and a<br />

group with a triangular flap modified by Szmyd [14]. In the<br />

latter case, an increased swelling was observed. Pasqualini<br />

et al. [15] have compared 100 patients treated with tight suture<br />

with 100 patients sutured after removal of 5–6 mm of<br />

mucosa distally to second molar to allow draining. Using<br />

this procedure, postoperative swelling was reduced especially<br />

on days 2 and 4, while in the group treated with tight suture,<br />

the peak of swelling was observed on day 3.<br />

According to several authors, [16, 17, 18] tight closure<br />

favors edema formation by creating a unidirectional<br />

valve that allows fragments of food to reach the cavity, but<br />

not to leave it easily. This can be the origin of local infection,<br />

inflammation, edema and potential alveolar osteitis and<br />

pain for difficult draining. [19]<br />

According to other authors different factors such as<br />

edema, pain and trismus that follow extraction of impacted<br />

third molars can be related to suture technique and to surgery<br />

length, and the use of a draining tube can be helpful in<br />

reducing or preventing postoperative swelling. [20]. This has<br />

been confirmed in a study specifically designed to compare<br />

postoperative responses in two groups, one treated with suture<br />

and the other with draining. In the latter, a clear reduction<br />

in edema formation was observed. Rakprasitkul and<br />

Pairuchvej [21] obtained similar results. They reported reduced<br />

swelling with suture in the presence of a draining tube<br />

when compared to the primary suture.<br />

In a different study, the effect of draining has been<br />

compared with methylprednisone treatment. [22] Although<br />

no significant differences were reported, pharmacological<br />

treatment reduced swelling and was better tolerated by patients.<br />

It is then reasonable to conclude that most authors<br />

prefer secondary healing and/or draining rather than primary<br />

closure.<br />

Different surgical procedures have also been related<br />

to postoperative swelling. Osteotomy through piezosurgery<br />

has given positive results on tumefaction compared to traditional<br />

techniques. However, often, the studies analyzed did<br />

not involve extraction of impacted third molars, but general<br />

osteotomy of the jaws. [23, 24, 25]<br />

Therapeutic effects of ice applied on a surgery wound<br />

are due to changes of hematic flow and consequent vasoconstriction<br />

and reduced metabolism. In surgery and orthopedics,<br />

in fact, the main function of ice on the treated area<br />

is to produce vasoconstriction and to control bleeding, resulting<br />

in reduced metabolism and control of bacterial<br />

growth. [26] The application of ice does not have to be too<br />

long as this may be responsible for tissue death due to prolonged<br />

vasoconstriction, ischemia and capillary thrombosis<br />

and lymph stasis.<br />

It is interesting to note that low laser dosage (4 J cm2),<br />

applied soon after surgery, produces a good control of swelling,<br />

especially in patients treated with 4 mg dexamethasone<br />

IM [27]<br />

The first physiological response of tissues to cryotherapy<br />

is reduction of local temperature that causes reduced<br />

cellular metabolism. In this way, cells consume less oxygen<br />

and resist longer to ischemia. [28] In the treatment of impacted<br />

third molars, the use of ice shows a good efficacy in<br />

reducing post-surgery swelling and pain. In the postoperative<br />

period, the use of ice pack is largely recognized to provide<br />

good results and it helps the patient to cooperate with<br />

pharmacological treatments and/or intraoperative strategies<br />

in the prevention of edema. All pharmacological therapies<br />

used post-surgery are valid although they differ in the compounds<br />

used and their ways of administration. [29]<br />

Trismus<br />

Trismus is a normal and expected outcome following<br />

third molar surgery.<br />

Trismus is evaluated by the distance between the upper<br />

and lower right central incisors at the maximum mouth<br />

opening; a modification of this method calculates the quotient<br />

between preoperative and postoperative distance. Other<br />

authors simply consider two possible alternatives: presence<br />

or absence of trismus, taking into account a difference of<br />

5mm. There is a reliable and valid patients’ self assessment<br />

of mouth opening using a cardboard scale [9]<br />

Like edema, jaw stiffness usually reaches its peak on<br />

the second day and resolves by the end of the first week. [2]<br />

There is a strong correlation between postoperative<br />

pain and trismus, indicating that pain may be one of the principal<br />

reasons for the limitation of opening after the removal<br />

of impacted third molars. [2]<br />

In comparing trismus with gender, age, position of the<br />

tooth, classification of the tooth, retention, angle, systemic<br />

conditions, bad habits, use of oral contraceptives and menstruation<br />

period, statistically significant differences were<br />

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observed between trismus and partial bony impaction of<br />

tooth. The absence of trismus after the extraction of partial<br />

bony impacted tooth was 49.6%, presence of edema was<br />

62.5%, while these means were 0% and 37.2% for trismus<br />

after the extraction of mucosal impacted teeth and 13.3%<br />

and 37.5% for trismus after the extraction of complete bony<br />

impacted teeth. [5]<br />

Patients who are administered steroids for the control<br />

of edema also tend to have less trismus.[2] Dexamethasone<br />

caused less trismus compared to methylprednisolon. [6]<br />

Pain<br />

Another postsurgical morbidity expected after third<br />

molar surgery is pain. The post surgical pain begins when<br />

the effects of the local anesthesia subsides and reaches peak<br />

levels in 6 to 12 hours postoperatively. 37.7% patients reported<br />

mild pain on the third post-operative day and 43.4%<br />

patients had no pain on the seventh post operative day. [7]<br />

A large variety of analgesics are available for management<br />

of post surgical pain. The most common ones are<br />

combinations of analgetics (Metamizol), Paracetamol and<br />

nonsteroidal anti inflammatory analgesics. Analgesics should<br />

be given before the effect of the local anesthesia subsides.<br />

In this manner, the pain is usually easier to control, requires<br />

less drug, and may require a less potent analgesic. The administration<br />

of nonsteroidal analgesics before surgery may<br />

be beneficial in aiding in the control of postoperative pain.<br />

[2]<br />

Women may be more sensitive to postoperative pain<br />

than men; thus, they require more analgesics. [2]<br />

Swelling, pain and trismus are considered as transient<br />

complications and are expected with surgery. Although transitory,<br />

these conditions can be a source of anxiety for the<br />

patient.[7]<br />

Infection<br />

An uncommon post surgical complication related to<br />

the removal of impacted third molars is infection.<br />

The postoperative infection rate reported in the literature<br />

varies between 1.5% and 5.8%,or between 0.9% and<br />

4.3% depending on the articles consulted. [3]<br />

Infection after removal of mandibular third molars is<br />

not so common complication. About 50% of infections are<br />

localized subperiosteal abscess-type infections, which occur<br />

2 to 4 weeks after a previously uneventful postoperative<br />

course. These are usually attributed to debris that is left under<br />

the mucoperiosteal flap and are easily treated by surgical<br />

debridement and drainage. Of the remaining 50%, few<br />

postoperative infections are significant enough to warrant<br />

surgery, antibiotics, and hospitalization. [2]<br />

Antibiotic prophylaxis reduces the risk of experiencing<br />

infection, alveolar osteitis and pain after third-molar extractions<br />

in healthy adults, but it also results in an increased<br />

risk of mild, transient adverse effects. Given the low risk of<br />

infection after tooth extraction in healthy young adults, substantial<br />

increased risk of experiencing adverse effects, the<br />

potential development of resistant bacteria due to antibiotic<br />

use and the management of infection if it occurs, some authors<br />

did not support routine prescription of antibiotic<br />

prophylaxis for healthy people undergoing extraction of<br />

third molars. [30]<br />

The antibiotic prophylaxis is the most controversial<br />

factor among the others, and some studies highlight that its<br />

use is necessary only when there is exposure of the vascular<br />

nerve bundle of the mandibular canal, increasing the chances<br />

of infection in up to seven times. [1]<br />

Antibiotic therapy to treat established infection or as<br />

prophylactic strategy to prevent distance site infection or<br />

to control postoperative discomfort in third molar surgery<br />

is today a broadly accepted indication with documented efficacy.<br />

[8].<br />

According to the literature review, the use of the antibiotics<br />

before surgery could be considered a predictable<br />

procedure to avoid and control the possible infection related<br />

to the surgery. If infection and inflammation are present in<br />

the surgical area, an antibiotic therapy seems to give a better<br />

clinical compliance of the tissues undergoing surgery.<br />

The antibiotic administration before, during and after surgery<br />

seems to be a better therapeutic choice for controlling<br />

the infection arising in the postoperative period [29]<br />

Factors such as the patient’s age, osteotomy techniques<br />

and/or tooth section, delay in repairing the socket,<br />

previous local inflammation, surgeons with little experience,<br />

and lack of antibiotic prophylaxis are considered to predispose<br />

the infection. [1]<br />

Alveolar Osteitis (AO) [dry socket]<br />

The sequence of normal healing after extraction does<br />

not always occur. In some instances, early clot formation in<br />

the socket is followed by premature clot necrosis or loss, accompanied<br />

by pain and a fetor oris. [31]<br />

The alveolar osteitis (dry socket, alveolitis sicca<br />

dolorosa, localized alveolar osteitis, fibrinolytic alveololitis<br />

is a disturbance in healing that occurs after the formation of<br />

a mature blood clot but before the blood clot is replaced<br />

with granulation tissue. [31] The primary etiology appears<br />

to be one of excess fibrinolysis, with bacteria playing an important<br />

but yet ill-defined role. This fibrinolysis occurs during<br />

the third and fourth days and results in symptoms of pain<br />

and malodor after the third day or so following extraction.<br />

The source of the fibrinolytic agents may be tissue, saliva,<br />

or bacteria. [2]<br />

The reported incidence of alveolitis varies widely,<br />

from as low as 0.5% to as high as 68.4%, but most studies<br />

indicate a rate between 5% and 10%. Diagnostic criteria,<br />

which vary from author to author, might partly explain this<br />

variation. [3] The alveolar osteitis or dry socket is characterized<br />

by an intense and throbbing pain that cannot be controlled<br />

by common pain killers, starting between the second<br />

and fifth days after the surgery, with unpleasant smell and<br />

without incorrupt tissue in the interior of the socket. [1]<br />

Some researchers classified alveolitis as being alveolar<br />

tissue necrosis with exposed bone, with a prolongation<br />

of pain between 5 and 7 days, of a neuralgic character, intense<br />

or severe. Other authors offer a more descriptive definition:<br />

the presence of a gray necrotic clot relative to a bare<br />

area of the socket, along with great stench and pain in the<br />

zone. A further diagnostic criteria was pain and discomfort,<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1205

if medication does not alleviate the pain, and if exposed<br />

bone or necrotic debris is showing in the alveolus. [32]<br />

As possible risk factors, we can include untimely surgical<br />

maneuvers, surgery difficulty level, surgeon’s experience,<br />

tooth position in the arch, smoking, patient’s age, being<br />

a female, use of oral contraceptive and corticoids, use<br />

of local anesthetics with vasoconstrictor, and intrinsic factors<br />

such as coagulopathy among others.[1]<br />

The incidence of postoperative alveolitis in association<br />

with oral contraceptive (OC) use has been investigated<br />

by many authors, with conflicting results. Some studies have<br />

demonstrated an increased rate of alveolitis among women<br />

taking OC but others did not. This discrepancy can be explained<br />

by the lower estrogen concentration in the new generations<br />

of OC. [3]<br />

Cohen et al. suggest, on a literature review of the most<br />

relevant articles, that there are not enough data to consider<br />

oral contraceptive as an important risk factor to dry socket<br />

in elective surgeries to extract third molars. Not enough evidence<br />

was found to affirm that the menstrual cycle influences<br />

the development of dry socket. On the other hand some authors<br />

affirm that women who use oral contraceptive medicine<br />

have five times more chances of developing dry socket<br />

than men. [1] Other considerations that must be pointed out<br />

regarding dry socket is the patient’s age, which might hinder<br />

the repairing process and healing of older patients and<br />

worsen the bone tissue quality. [1] The incidence of dry<br />

socket seems to be higher in patients who smoke. [2]<br />

The occurrence of dry socket can be reduced by several<br />

techniques, most of which are aimed at reducing the bacterial<br />

contamination of the surgical site. Presurgical irrigation<br />

with antimicrobial agents such as chlorhexidine reduces<br />

the incidence of dry socket by up to 50%. Copious irrigation<br />

of the surgical site with large volumes of saline is also<br />

effective in reducing dry socket. Topical placement of small<br />

amounts of antibiotics such as tetracycline or lincomycin<br />

may also decrease the incidence of alveolar osteitis. [2] Maintenance<br />

of the coagulum inside the socket by using appropriate<br />

suture techniques may also help in the prevention of<br />

this complication. [1] To the subject of clot stabilization and<br />

healing, one should consider the use of resorbable substances<br />

such as gelatin sponge, polylactic acid, and methylcellulose<br />

as clotstabilizing socket implants. The record of such substances<br />

in preventing AO is mixed,but the combinations of<br />

these inexpensive materials with topical socket medicaments<br />

may yield a decreased tendency for clot lysis and greater<br />

mechanical strength to the bulk blood clot. [31]<br />

The goal of treatment of dry socket is to relieve the<br />

patient’s pain during the delayed healing process. This is<br />

usually accomplished by irrigation of the involved socket,<br />

gentle mechanical débridement, and placement of an obtundent<br />

dressing, which usually contains eugenol. The dressing<br />

may need to be changed on a daily basis for several days<br />

and then less frequently after that. The pain syndrome usually<br />

resolves within 3 to 5 days, although it may take as long<br />

as 10 to 14 days in some patients. There is some evidence<br />

that topical antibiotics such as metronidazole may hasten<br />

resolution of the dry socket.[2]<br />

Nerve Disturbances<br />

Neurological damage of the lingual or inferior alveolar<br />

nerve (IAN) is one of the least desired complications of<br />

third molar surgery. The incidence of IAN and lingual nerve<br />

injuries reported, ranges from 0.4% to 22% and most of these<br />

injuries undergo spontaneous recovery. [4, 7 ]<br />

Neurosensory deficit after lower third molar surgery<br />

occurs at prevalences of 0.1% to 22% for lingual nerve (LN)<br />

deficit and 0.26% to 8.4% for inferior alveolar nerve (IAN)<br />

deficit. Sensory deficits may present as anesthesia,<br />

hypoesthesia, hyperesthesia, or dysesthesia in the distributions<br />

of the LN or IAN, with or without taste disturbance, if<br />

the LN is also affected. Within 4 - 8 weeks after surgery, 96%<br />

of inferior alveolar nerve (IAN) injuries recover [33], and the<br />

recovery rates are not influenced by gender and only slightly<br />

by age [34]. Some injuries may be permanent, lasting longer<br />

than 6 months, and with varying outcomes ranging from mild<br />

hypoesthesia to complete anaesthesia and neuropathic responses<br />

resulting in chronic pain. The results showed that<br />

after 6 months, recovery seemed to be slight, and confirmed<br />

that permanent IAN dysfunction is more frequent after M3<br />

removal in patients older than 30 years.<br />

One third of neurosensory deficits after third molar<br />

surgery can be permanent. Although some patients can cope<br />

well with mild to moderate hypoesthesia of the affected area,<br />

those who are severely affected often request treatment for<br />

the condition. The quality of life of patients with anesthesia,<br />

severe hypoesthesia, hyperesthesia, dysesthesia, or taste disturbance<br />

of the affected area can be significantly impaired.<br />

Different treatments have been reported in the literature, yet<br />

their efficacies seemed to be variable. [35]<br />

The lingual nerve is most often injured during soft<br />

tissue flap reflection, whereas the inferior alveolar nerve is<br />

injured when the roots of the teeth are manipulated and elevated<br />

from the socket. [2]<br />

There are various neurosensory tests used to evaluate<br />

objectively the severity of nerve injury and monitor recovery<br />

of the sensation. [35]<br />

Risk factors as regards to damage to IAN are the depth<br />

of impaction and dental proximity to alveolar canal.[4] Accordingly,<br />

Blondeau and Daniel [3] recommended that prophylactic<br />

M3 extraction should be avoided in patients aged<br />

24 years or older because of a high possibility of complications<br />

such as permanent neurosensory deficits, infection, and<br />

alveolar osteitis.<br />

The risk factors associated with permanent neurosensory<br />

deficit are Pell and Gregory IC or IIC classification of<br />

impaction, age greater than 24 years, and in females. [3]<br />

When an injury to the lingual or inferior alveolar<br />

nerve is diagnosed in the postoperative period, the surgeon<br />

should begin long-term planning for its management including<br />

consideration of referral to a neurologist and/or<br />

microneurosurgeon. [2]<br />

The available treatment modalities for an LN and IAN<br />

injury after third molar surgery seem to have unpredictable<br />

clinical outcomes and rarely produce complete recovery.<br />

What is more, there is insufficient information to indicate<br />

the best timing for the treatment of nerve injury after third<br />

molar surgery. It has been shown that a significant portion<br />

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of the neurosensory deficit of an LN or IAN after third molar<br />

surgery can recover spontaneously. Therefore, LN or IAN<br />

injuries tend to be treated in a delayed fashion, depending<br />

on the recovery pattern and the extent of disturbance on a<br />

patient’s social life. It was suggested Wallerian degeneration<br />

and a smaller Schwann cell population adjacent to the site<br />

of nerve injury can significantly affect the long-term outcome<br />

of delayed nerve repair. [35]<br />

Surgery (external neurolysis, direct suturing, autogenous<br />

vein graft bridging nerve defect, gore-tex<br />

tubing,bridging nerve defect) remained the mainstream of<br />

treatment of a neurosensory deficit after third molar surgery.<br />

Most subjects who underwent surgical treatment had LN injuries.<br />

This can be explained by the fact that the tongue is a<br />

very sensitive organ and any taste disturbance with an LN<br />

injury might contribute to a higher demand for nerve repair<br />

after an LN injury. Several reports suggested a higher chance<br />

of spontaneous reinnervation and recovery of the nerve<br />

within the inferior alveolar canal. Full recovery of sensation<br />

after surgical treatment of the IAN or LN injury is uncommon.<br />

Fewer than 30% of patients were reported to have<br />

achieved “complete recovery” after external neurolysis of<br />

the injured nerve. [35]<br />

Nonsurgical alternatives for treatment of neurosensory<br />

deficit are vit. B complex, laser therapy (LLLT),<br />

corticosteroids, electrophoresis with nivalin, acupuncture. It<br />

was believed LLLT could decrease scar formation and increase<br />

collagen formation and healing, which are favorable<br />

features in nerve regeneration. [35] Scarring at a site of nerve<br />

repair is thought to impede the regeneration of damaged<br />

nerve fibers. Our recent studies have shown that anti-scarring<br />

agents (such as antibodies to TGFâ1 and 2) can be used<br />

to reduce this problem, and hopefully will result in enhanced<br />

regeneration. [36]<br />

Temporomandibular disorders (TMDs)<br />

Temporomandibular disorders (TMDs) is the term<br />

used to refer to dysfunctions characterized by pain in the<br />

region of the temporomandibular joints and periauricular<br />

area, limitations and deviations in the mandibular movements,<br />

joint noises and an altered occlusal relation<br />

(Dworkin et al, 1990). [37]<br />

The etiology of TMD is multifactorial. When all risk<br />

factors for TMDs are considered individually, the two most<br />

prevalent factors identified on this population were tooth<br />

clenching (77% of the patients) and self-reported stress<br />

(59.3%) followed by antecedents of extraction of wisdom<br />

teeth (34.3%), endotracheal intubation (30.7%), biting habits<br />

(29.3%), gum chewing (28%), and previous orthodontic<br />

treatment (28%) [38]<br />

Third molar removal has been implicated as a precipitating<br />

event for temporomandibular joint disorders. [39, 37]<br />

That is the reason why Deangelis highlights the importance<br />

of including an assessment of the temporomandibular apparatus<br />

in the pre-operative evaluation of patients with impacted<br />

third molars. [39]<br />

The traumatic removal of the mandibular third molar<br />

may promote post surgical consequences such as orofacial<br />

pain and limited mandibular movements. [37]<br />

Another study demonstrated that when compared with<br />

untreated controls, subjects undergoing third molar surgery<br />

have a statistically insignificant increased incidence of TMDs<br />

6 months post-operatively. [40]<br />

Treatment of TMD may involve anterior splints occlusal<br />

splints, splints with posterior occlusal support, occlusal<br />

adjustment, removable therapeutic partial prostheses, although<br />

therapeutic support regimens in the areas of psychology,<br />

NAID(local and per oral), and physical<br />

therapy(exercises) and phisioterapy may be associated depending<br />

on the needs of each patient. [37]<br />

Rare complications include oro-antral fistulas (0.008–<br />

0.25%), maxillary tuberosity fractures (0.6%) and mandibular<br />

fractures (0.0049%) [41]<br />

Maxillary tuberosity fracture and oro-antral communication<br />

Upper third molar lies just in front and within the maxillary<br />

tuberosity. [42]<br />

Maxillary tuberosity fracture is one of the major complications<br />

of maxillary third molar extraction. [42]<br />

The incidence of tuberosity fracture during upper<br />

molar extraction is relatively low. [43] Bertram and al. reported<br />

this incidence to be around 0.6%. [44]<br />

Large fractures of the maxillary tuberosity should be<br />

viewed as a grave complication.[42]<br />

The fracture of a large portion of bone in the maxillary<br />

tuberosity area can result in torrential, life-threatening<br />

hemorrhage due to close proximity of significant vessels to<br />

the area. [42, 44]<br />

Fracture and loss of the maxillary tuberosity not only<br />

risks exposure and tearing of the maxillary sinus lining but<br />

also changes the shape of the alveolus such that subsequent<br />

prosthodontic management may be difficult. [45]<br />

There is a reported case of subconjunctival<br />

hemorrhage after tuberosity fracture. [42]<br />

Cattlin reported that, after maxillary tuberosity fracture,<br />

deafness occurred from the disruption of the pterygoid<br />

hamulus and the tensor veli palatine, in turn collapsing the<br />

opening of the eustachian tube. The patient also suffered permanent<br />

restricted mandibular movements because of the disruption<br />

of the pterygoid muscles and ligaments. [43]<br />

The etiological factors listed in the literature that are<br />

responsible for a fractured maxillary tuberosity during upper<br />

molar extraction include the following: large maxillary<br />

sinus with thin walls/sinus extension into the maxillary tuberosity<br />

and/or large projection lengths of root apices in<br />

the sinus cavity; unerupted maxillary third molar; fusion<br />

between the maxillary third and second molar; teeth with<br />

large divergent roots; teeth with an abnormal number of<br />

roots; teeth with prominent or curved roots; teeth with dental<br />

anomalies, such as tooth fusion and over-eruption;tooth<br />

ankylosis;hypercementosis of upper molar teeth; chronic<br />

periapical infection; excessive force during the tooth luxation<br />

accomplished by the dentist and others. [43]<br />

Upon discovering that a maxillary tuberosity has fractured,<br />

the dentist must first halt the procedure before inadvertent<br />

laceration of the adjoining soft tissue occurs and then<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1207

determine the extent of the fracture by palpating the mobile<br />

fragment. After performing the dissection of the soft tissues,<br />

immediate removal of the small fractures, including the tooth<br />

with small bony fragments, may be the best option, because<br />

of the difficulty incurred when attempting to retain the<br />

bone.When a large bony fragment is present, it is recommended<br />

(i) that the extraction be abandoned and surgical<br />

removal of the tooth be performed using root sectioning, (ii)<br />

that the dentist tries to detach the fractured tuberosity from<br />

the roots, or (iii) that the dentist stabilizes the mobile part(s)<br />

of the bone by means of a rigid fixation technique for 4–6<br />

weeks and, at a future moment, attempts a surgical removal<br />

without the use of a forceps. [43]<br />

Oroantral communication is the consequence of a<br />

loss of continuity between the maxillary sinus and the oral<br />

cavity. Sinus floor perforation occurs due to the close anatomical<br />

relationship between this structure and the distal<br />

teeth. [46]<br />

Oroantral communications (OAC) are common surgical<br />

complications of dental procedures. An oroantral fistula<br />

is a pathological condition in which the oral and antral cavities<br />

have a permanent communication by means of a fibrous<br />

conjunctive tissue fistula coated by epithelium. [47]<br />

Intraoperative fracture of the root, higher degree of<br />

impaction and higher age of the patient are associated with<br />

a greater likelihood of oroantral perforation. [48]<br />

A study of 465 extractions and 592 osteotomies of<br />

the upper third molars revealed that 13% were related directly<br />

to the diagnosis of a perforated maxillary sinus. Acute<br />

oroantral communication occurred as a result of the removal<br />

of completely impacted teeth in 24%, by removal of partially<br />

impacted teeth in 10% and in fully erupted third molars<br />

in 5% of all cases. These differences are significant. In<br />

83%, the diameter of the oroantral perforation was less than<br />

3 mm. In 19% of all sinus openings, a buccal sliding flap<br />

was used to close the extraction wound.[48]<br />

OACs 2 mm in diameter or smaller are likely to close<br />

spontaneously, without the need for surgical intervention.<br />

[47] If the exposure of lining is at the apex of a deep socket<br />

with stable bone walls, and the coagulum is not displaced<br />

or breaks down, then it may not be necessary to make arrangements<br />

for complete soft tissue closure but to simply<br />

inform the patient, give advice on post-operative care and<br />

review as necessary. [45]<br />

It has been recognised for many years that some small<br />

oroantral communications will heal without the formation<br />

of a fistula or chronic sinusitis. However, this will depend<br />

upon many factors including the health of the patient and<br />

their oral soft tissues, the presence or absence of preexisting<br />

infection, the dimensions of the tooth socket and the postoperative<br />

care provided by the patient. [45]<br />

OACs 3 mm in diameter or larger, or OACs associated<br />

with maxillary or periodontal inflammation, may persist , and<br />

surgical closure is recommended. Several techniques have<br />

been used for OAC resolution, such as the use of mucoperiosteal<br />

flaps (vestibular, palatine, lingual or combined), bone<br />

grafts, or buccal fat pad grafts (Bichat ball). [47] Grafting of<br />

the pedicled buccal fat pad is thought to be an efficient, safe<br />

and easy alternative to a larger oroantral fistula closure. Pedicled<br />

buccal fat pad grafting could corrected the defect without<br />

generating any sequelae and/or great postoperative discomfort<br />

to the patient.[47]<br />

Mandibular fractures<br />

Mandibular fractures are a rare but severe complication<br />

of third molar removal. [49]<br />

Reports of mandibular fracture during and after third<br />

molar removal are uncommon. [50]<br />

The incidence is reported to range from 0.0046% to<br />

0.0075%. It may occure, either operatively, as an immediate<br />

complication during surgery or postoperatively as a late<br />

complication, usually within the first 4 weeks post surgery.<br />

[51]<br />

Its occurrence is likely to be multifactorial including:<br />

age, gender, angulation, laterality, extent and degree<br />

of impaction, relative volume of the tooth in the jaw, preexisting<br />

infection and associated pathologies (bone lesions)<br />

contributing to the risk of fracture. [49, 51] Other important<br />

factors are the anatomy of the teeth and the features<br />

of the teeth roots. [52]<br />

Weakening of the mandible as a result of decrease in<br />

its bone elasticity during aging may be the cause of the<br />

higher incidence of fractures reported among patients over<br />

40 years of age at the time of surgery. [51] De Silva reported<br />

that fractures predominantly occur in patients who are older<br />

than 25 years. [52]<br />

Men may be more likely to have late fractures [53].<br />

The effect of gender may be related to biting force. Males<br />

usually show higher levels of biting force as compared to<br />

females. [51]<br />

Patients having full dentition are able to produce peak<br />

levels of biting forces, that are transmitted to the weak mandible<br />

during mastication and consequently the risk of fracture<br />

is high, regardless of gender. [51]<br />

The literature indicates that the risk of pathological<br />

(late) fracture of the mandibular angle after third molar surgery<br />

for total inclusions (class II-III, type C) is twice that of<br />

partial inclusions due to the necessity of ostectomies more<br />

generous than those for partial inclusions. [52]<br />

The true incidence of postoperative mandibular fractures<br />

as a result of the extraction is difficult to establish,<br />

as there are reports on postoperative traumatic mandibular<br />

fractures that could have happened with an intact mandible,<br />

and the occurrence of the two conditions may be just<br />

a coincidence. [51]<br />

Postoperative fractures were more common than<br />

intraoperative fractures (2.7:1) and occurred most frequently<br />

in the second and third weeks (57%). [49] Other studies show<br />

that 67.8% of fracture cases happened in the second and third<br />

week post surgery. [52] A ‘cracking’ noise was the most frequent<br />

presentation (77%). [49] Such cracking noise reported<br />

by the patient should alert to a possible fracture, even if initially<br />

the fracture is radiologically undetectable. [51]<br />

Intraoperative fractures were more frequent among females<br />

(M:F - 1:1.3) [49]<br />

Pathological mandibular fractures were typically located<br />

anterior to the mandibular angle. [54] Wagner et al.<br />

noticed a significant prevalence of fractures on the left side<br />

1208 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

of the patient (70%) over the right side. This was explained<br />

by better visualization and control of the applied force by<br />

the surgeon on the right side of the patient as compared to<br />

the left side.[51] The danger of an immediate jaw fracture<br />

can be avoided by means of proper instrumentation and by<br />

refraining from excessive force on the bone. The tooth should<br />

be sectioned in such a way as to minimize the extent of bone<br />

removal and force caused by instrumentation. [50] It is more<br />

likely to occur with young or less experienced professionals.<br />

[51] The postoperative or late fractures usually occur<br />

during the second or third postoperative week, and are probably<br />

as a result of high level of biting forces during mastication,<br />

when the patient was feeling better. [51]<br />

This is why it is extremely important to always provide<br />

adequate instructions to the patient in order to avoid<br />

early masticatory loads and prevent this complication. [52]<br />

In selective cases, it is recommended that the patient follow<br />

a soft diet for up to 4 weeks after the operation. [54]<br />


Although clinical conditions associated with retained<br />

third molars are well understood, little is known about the<br />

impact of those conditions on the quality of life among affected<br />

patients. There is growing recognition that the impact<br />

of oral conditions on quality of life is an important outcome<br />

that can be quite useful in making treatment decisions.<br />

All the information in this review could be useful for the<br />

clinicians in order to show all the surgical and pharmacologic<br />

parameters that may influence the postoperative discomfort<br />

in the third molar surgeries.<br />


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molar removal. Br Dent J. 1984<br />

Jan;156(1):19-20. [PubMed]<br />

53. Libersa P, Roze D, Cachart T,<br />

Libersa JC. Immediate and late mandibular<br />

fractures after third molar removal.<br />

J Oral Maxillofac Surg. 2002<br />

Feb;60(2):163–5. [PubMed]<br />

54. Wagner KW, Otten JE, Schoen<br />

R, Schmelzeisen R. Pathological mandibular<br />

fractures following third molar<br />

removal. Int J Oral Maxillofac Surg.<br />

2005 Oct;34(7):722-6. [PubMed]<br />

Please cite this article as: Deliverska EG, Petkova M. Complications after extraction of impacted third molars- literature<br />

review. J of IMAB. <strong>2016</strong> Jul-Sep;22(3):1202-1211. DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1202<br />

Received: 04/05/<strong>2016</strong>; Published online: 04/07/<strong>2016</strong><br />

Corresponding author:<br />

Elitsa Georgieva Deliverska – Assoc. prof.,<br />

Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine,<br />

Medical University- Sofia;<br />

1, St. Georgi Sofiiski str., 1431 Sofia, Bulgaria<br />

E-mail: elitsadeliverska@yahoo.com<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1211

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1212<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />




Ivan Chenchev, Radka Cholakova<br />

Department of Oral Surgery, Faculty of Dental Medicine, Medical University –<br />

Plovdiv, Bulgaria<br />


Purpose: The treatment of oral mucosal lesions and<br />

mucosal hypertrophy in particular, is most often achieved<br />

by an excision with or without covering the surface of the<br />

wound. The platelet rich fibrin membrane (PRFm) is an autogenous<br />

product containing platelets and leukocytes and<br />

their secreted growth factors and cytokines. The purpose<br />

of the presented clinical case is to describe a new, recent<br />

technique used for the covering of mucosal wounds left after<br />

the removal of pathological lesions.<br />

Material and Methods: On a single patient mucosal<br />

hypertrophy was removed by an excision with scalpel and<br />

the resulting surgical wound was covered with an autogenous<br />

PRF membrane. Postoperatively the healing process<br />

was followed on the 7th, 14th and 30th day.<br />

Results: The healing period went smoothly with<br />

minimal postoperative discomfort and no complications.<br />

Conclusion: The results of the presented clinical<br />

case demonstrate that the PRF membrane can successfully<br />

be used to cover postoperative mucosal defects.<br />

Key words: oral mucosal hypertrophy, PRF, oral mucosal<br />

reconstruction<br />


The treatment of oral mucosal lesions involves the<br />

elimination of the cause, medical and surgical treatment.[1]<br />

The surgical treatment of different mucosal lesions, and<br />

mucosal hypertrophy in particular, consists of an excision<br />

with or without placing a graft. [2, 3] Platelet rich fibrin<br />

(PRF) is defined as an autogenous, containing increased<br />

amount of leukocytes and platelets, solid biomaterial. [4,<br />

5] For the first time PRF is used in 2001 in France by<br />

Choukroun J, et al. [6] for purpose of the maxillo-facial surgery.<br />

The PRF polymerization is slow and occurs when the<br />

blood is being centrifugated and, due to the autogenous<br />

thrombin, a physiological autogenous fibrin begins its formation.<br />

This is an essential condition for the formation of<br />

the 3D fibrin network. [7] Such configuration suggests the<br />

prolonged survival of the growth factors (GF) and their prolonged<br />

release in the initial healing stages. GFs are available<br />

in situ longer among the surrounding cells and have<br />

more time to stimulate the healing process. [8,9] Release<br />

of the growth factors and matrix glycoproteins<br />

(glycosaminoglycans) may continue for up to 7 days, or<br />

according to other studies – up to 28 days. [10] PRF is<br />

made out of patient’s blood in clinical conditions and does<br />

not contain any chemical or biological supplements. PRF<br />

is used as a stimulating factor for the bone and soft tissue<br />

regeneration in dental implantology and periodontal surgery.[11]<br />

It is used for the healing of extraction wounds,[12]<br />

treatment of interosseous defects, [13] radicular cysts, [14]<br />

influencing the jaw bones in the case of biophosphonate<br />

osteonecrosis, [15] etc. Some authors [16, 17] use PRF membrane<br />

(PRFm) to cover excision defects of the mucosa while<br />

others [18, 19] cover palatinal defects left when taking free<br />

gingival graft (FGG). The aim of the presented clinical case<br />

is to clinically observe a new recently used technology to<br />

cover mucosal wounds left in the treatment of pathological<br />

lesions.<br />


The patient was a woman aged 69 admitted in the<br />

department of oral surgery at the Medical University –<br />

Plovdiv for surgical treatment. The clinical examination<br />

uncovered mucosal hypertrophy on the right side due to<br />

chronic irritation by a denture. There were no other subjective<br />

complaints by the patient – Fig. 1.<br />

Fig. 1.<br />

1212 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

The surgery was held under local anesthetics with<br />

4% Articaine and 1/200 000 Adrenaline. Excision of the<br />

altered tissue was done using a scalpel. The resulting mucosal<br />

wound was covered by PRFm prepared in advance.<br />

PRFm was stitched using resorbable thread 0000 to the<br />

margins of the mucosal defect – Fig. 2 a-c.<br />

Fig. 2c.<br />

Fig. 2a.<br />

Fig. 2b.<br />

The PRF membrane was prepared following the<br />

method of Choukroun J et al. [6] After the venipuncture<br />

of v. cubity with a 10ml vacuum test-tube (Advanced-<br />

PRF), 9ml of blood is taken from the patient. The blood<br />

is then immediately put into a PRF DUO (Processfor<br />

PRF®-France) centrifuge for 8 minutes at 1500 RPM. The<br />

resulting PRF clot is put back into a test-tube using a long,<br />

straight anatomical tweezers and using surgical scissors<br />

or scalpel it is separated from the red part (erythrocytes).<br />

The PRF membrane is formed out of two PRF clots by<br />

putting two of them on top of one another - Fig. 3a, b.<br />

The areas bordering with the red part are put on the opposite<br />

ends and it is then dried in a special for this case box<br />

A-PRF Box® - Fig. 3c.<br />

Fig. 3a.<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1213

Fig. 3b.<br />

surgical intervention. The postoperative pain was measured<br />

using a standard VAS on 24 hours and the 7th day after the<br />

surgery. The value on the 24th hour was 3cm, while the<br />

final value on the 7th day was 2cm. Clinical measurement<br />

of the wound healing was done using the 5-score Clinical<br />

Healing Score. [17] The score on the 7th day after the treatment<br />

was 3 and on the 15th and 30th day it was 0 – Table<br />

1 end Fig. 4 a, b.<br />

Fig. 4a. 7th day after the treatment<br />

Fig. 3c.<br />

Fig. 4b. 30th day after the treatment<br />

Postoperatively the patient was assigned oral intake<br />

of NAIDs (Aulin 0.10g) for a period of 3 days. The patient<br />

was also given instructions for irrigation of the oral cavity<br />

with 0.2% solution of chlorehexidine for 7 days. Checkup<br />

examinations were assigned on the 1st, 7th, 14th and<br />

30th day after the surgery.<br />

RESULTS:<br />

The postoperative period was free of anxiety and<br />

complications. The threads were removed 7 days after the<br />

Table 1. Clinical Healing Score (Sum of 5 criteria)<br />

Criteria Score 7 day 14 day 30 day<br />

Redness absent 0 1 0 0<br />

Redness present 1<br />

Edema absent 0 1 0 0<br />

Edema present 1<br />

Healthy granulation tissue present 0 0 0 0<br />

Healthy granulation tissue absent 1<br />

Signs of epithelization present 0 1 0 0<br />

Signs of epithelization absent 1<br />

Note – The sum of 5 criteria is the clinical healing score; the score is to 0, the better the healing, and vice versa.<br />

1214 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/


Excision of oral lesions is preferred over drug treatment<br />

especially in cases with potential malignancy. [1]<br />

There is a variety of different care options for the resulting<br />

in the process wounds of the mucosa with different results.<br />

Initial covering of adjacent tissues is possible in cases of<br />

mucosal defects with small surface. In the case of bigger<br />

defects this is harder and can lead to complications. The<br />

healing afterwards is associated with a lot of discomfort for<br />

the patient with a possibility of early and late bleeding infections.<br />

[17, 19] The usage of the autogenous mucosal<br />

FGG or dermal graft for the covering of mucosal excision<br />

wounds results in an additional operative trauma. [3] The<br />

covering of postexcision wounds of the mucosa is done by<br />

a variety of auto-plastic material such as hyperdry amniotic<br />

membrane, artificial derma and collagen membrane. [2,<br />

17] PRFm was initially used to cover mucosal defects of<br />

the palate, after taking FGG, with very good results. [16,<br />

18, 19] Pathak H, et al. [17] use PRFm to cover mucosal<br />

defects after excision in different areas of the oral cavity<br />

and report some very good clinical results. The results of<br />

our study coincide with the results published by some<br />

other authors. [16 - 19]<br />


The results of our study allow us to assume that PRF<br />

membrane with its qualities can successfully be used to<br />

cover mucosal wounds for the purposes of the oral surgery.<br />

More and larger studies are necessary for better evaluation<br />

of the effects of the PRFm when covering mucosal wounds.<br />


1. van der Waal I. Potentially malignant<br />

disorders of the oral and<br />

oropharyngeal mucosa; terminology,<br />

classification and present concepts of<br />

management. Oral Oncol. 2009 Apr-<br />

May;45(4-5):317-23. [PubMed]<br />

[CrossRef]<br />

2. Thomas G, Kunnambath R,<br />

Somanathan T, Mathew B, Pandey M,<br />

Rangaswamy S. Long-term outcome of<br />

surgical excision of leukoplakia in a<br />

screening intervention trial, Kerala,<br />

India. J Indian Acad Oral Med Radiol.<br />

2012; 24(2):126-129.<br />

3. Yen DJ. Surgical treatment of<br />

submucous fibrosis. Oral Surg Oral<br />

Med Oral Pathol. 1982 Sep;54(3):<br />

269-72. [PubMed]<br />

4. Dohan Ehrenfest DM,<br />

Rasmusson L, Albrektsson T. Classification<br />

of platelet concentrates: from<br />

pure platelet-rich plasma (P-PRP) to<br />

leucocyte- and platelet-rich fibrin (L-<br />

PRF). Trends Biotechnol. 2009 Mar;<br />

27(3):158–67. [CrossRef]<br />

5. Dohan DM, Choukroun J, Diss A,<br />

Dohan SL, Dohan AJ, Mouhyi J, et al.<br />

Platelet-rich fibrin (PRF): a secondgeneration<br />

platelet concentrate. Part<br />

III: leucocyte activation: a new feature<br />

for platelet concentrates? Oral Surg<br />

Oral Med Oral Pathol Oral Radiol<br />

Endod. 2006 Mar;101(3):e51-5.<br />

[PubMed] [CrossRef]<br />

6. Choukroun J, Adda F, Schoeffer<br />

C, Vervelle A. [PRF: an opportunity in<br />

perio-implantology] [in French].<br />

Implantodontie. 2000; 42:55-62.<br />

7. Dohan Ehrenfest DM, Del Corso<br />

M, Diss A, Mouhyi J, Charrier JB.<br />

Three-dimensional architecture and<br />

cell composition of a Choukroun’s<br />

platelet-rich fibrin clot and membrane.<br />

J Periodontol. 2010 Apr;81(4):546-<br />

555. [PubMed]<br />

8. Dohan DM, Choukroun J, Diss<br />

A, Dohan SL, Dohan AJ, Mouhyi J, et<br />

al. Platelet-rich fibrin (PRF): a secondgeneration<br />

platelet concentrate. Part II:<br />

platelet-related biologic features. Oral<br />

Surg Oral Med Oral Pathol Oral<br />

Radiol Endod. 2006 Mar;101(3):e45-<br />

50. [PubMed] [CrossRef]<br />

9. Dohan Ehrenfest DM, de Peppo<br />

GM, Doglioli P, Sammartino G. Slow<br />

release of growth factors and<br />

thrombospondin-1 in Choukroun’s<br />

platelet-rich fibrin (PRF): A gold<br />

standard to achieve for all surgical<br />

platelet concentrates technologies.<br />

Growth Factors. 2009 Feb;27(1):63-<br />

69. [PubMed]<br />

10. Dohan Ehrenfest DM, Lemo N,<br />

Jimbo R, Sammartino G. Selecting a<br />

relevant animal model for testing the<br />

in vivo effects of Choukroun’s platelet-rich<br />

fibrin (PRF): rabbit tricks and<br />

traps. Oral Surg Oral Med Oral Pathol<br />

Oral RadiolEndod. 2010 Oct;<br />

110(4):413-6. [PubMed] [CrossRef]<br />

11. Dohan Ehrenfest DM. How to<br />

optimize the preparation of leukocyteand<br />

platelet-rich fibrin (L-PRF,<br />

Choukroun’s technique) clots and<br />

membranes: introducing the PRF Box.<br />

Oral Surg Oral Med Oral Pathol Oral<br />

Radiol Endod. 2010 Sep;110(3):275-<br />

278. [PubMed] [CrossRef]<br />

12. Zhao JH, Tsai CH, Chang YC.<br />

Clinical and histologic evaluations of<br />

healing in an extraction socket filled<br />

with platelet-rich fibrin. J Dent Sci.<br />

2011 Jun;6(2):116-122. [CrossRef]<br />

13. Chang YC, Wu KC, Zhao JH.<br />

Clinical application of platelet-rich fibrin<br />

as the sole grafting material in<br />

periodontal intrabony defects. J Dent<br />

Sci. 2011 Sep;6(3):181-188.<br />

[CrossRef]<br />

14. Zhao JH, Tsai CH, Chang YC.<br />

Management of radicular cysts using<br />

platelet-rich fibrin and bioactive glass:<br />

a report of two cases. J Formos Med<br />

Assoc. 2014 Jul;113(7): 470-6.<br />

[PubMed] [CrossRef]<br />

15. Saluja H, Dehane V, Mahindra<br />

U. Platelet-Rich fibrin: A second generation<br />

platelet concentrate and a new<br />

friend of oral and maxillofacial surgeons.<br />

Ann Maxillofac Surg. 2011<br />

Jan;1(1):53-7. [PubMed] [CrossRef]<br />

16. Mohanty S, Pathak H, Dabas J.<br />

Platelet rich fibrin: A new covering<br />

material for oral mucosal defects. J<br />

Oral Biol Craniofac Res. 2014 May-<br />

Aug;4(2):144-6. [PubMed] [CrossRef]<br />

17. Pathak H, Mohanty S, Urs AB,<br />

Dabas J. Treatment of Oral Mucosal<br />

Lesions by Scalpel Excision and Platelet-Rich<br />

Fibrin Membrane Grafting:<br />

A Review of 26 Sites. J Oral Maxillofac<br />

Surg. 2015 Sep; 73(9): 1865-74.<br />

[PubMed] [CrossRef]<br />

18. Kulkarni MR, Thomas BS,<br />

Varghese JM, Bhat GS. Plateletrich<br />

fibrin as an adjunct to palata<br />

wound healingafter harvesting a free<br />

gingival graft: A case series. J Indian<br />

Soc Periodontol. 2014 May;18(3):<br />

399-402. [PubMed] [CrossRef]<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1215

19. Shakir Q, Bhasale P, Pailwan N,<br />

Patil D. Comparison of Effects of PRF<br />

Dressing in Wound Healing of Palatal<br />

Donor Site During Free Gingival Grafting<br />

Procedures with No Dressing at the<br />

Donor Site. J Res Adv Dent 2015;<br />

4:(1):69-74.<br />

Please cite this article as: Chenchev I, Cholakova R. Treatment of Oral Mucosal Lesions by Scalpel Excision and Platelet-Rich<br />

FibrinMembrane Grafting: A case report. J of IMAB. <strong>2016</strong> Jul-Sep;22(3):1212-1216. DOI: http://dx.doi.org/<br />

10.5272/jimab.<strong>2016</strong>223.1212<br />

Received: 15/05/<strong>2016</strong>; Published online: 18/07/<strong>2016</strong><br />

Address for correspondence:<br />

Dr. Ivan Chenchev,<br />

Department of Oral Surgery, Faculty of Dental Medicine, Medical University –<br />

Plovdiv, Bulgaria<br />

E-mail: ivan_chenchev@yahoo.com,<br />

1216 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1217<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />



Radka Cholakova 1 , Ivan Chenchev 1 , Svetla Jordanova 2 , Diana Oncheva 2 ,<br />

Ljubomir Chenchev 3<br />

1) Department of Oral Surgery, Faculty of Dental Medicine, Medical University<br />

– Plovdiv, Bulgaria.<br />

2) Department of Orthodontics, Faculty of Dental Medicine, Medical University<br />

– Plovdiv, Bulgaria.<br />

3) Student in Faculty of Dental Medicine, Medical University – Plovdiv, Bulgaria.<br />

ABSTACT:<br />

Odontomas are formations which are still classified<br />

as benign tumors by the World Health Organization. They<br />

are lesions on any odontogenic tissue – enamel, cement and<br />

dentin, which are affected in different proportions and degree.<br />

We present a case of compound odontoma on upper<br />

jaw, on a 15 year-old girl, causing retention of a permanent<br />

canine tooth. After the extirpation 16 tooth-like structures<br />

were uncovered. The mandible was diagnosed with<br />

hypodontia of both 2nd premolars. Patient’s history showed<br />

that there was a trauma in the area of the upper jaw at<br />

younger age.<br />

In this article we will present the clinical and radiographic<br />

examination, the stages of the complex surgicalorthodontic<br />

treatment and a discussion of the etiology of<br />

the diagnosis, complications and the treatment itself.<br />


In the department of orthodontics of the Faculty of<br />

Dental Medicine - Plovdiv was admitted a 15 year-old girl<br />

with an open bite and a persistent right deciduous maxillary<br />

canine. Patient’s history showed that there was a trauma<br />

in the frontal area at younger age that lead to the devitalization<br />

of tooth 11. The history does not tell of any other<br />

family members with missing teeth and also tells of no other<br />

past diseases. Examination shows that the patient has an<br />

open bite, Angle class II, with a persistent 63 tooth and discoloration<br />

of tooth 11. It is also determined that both mandibular<br />

second premolars are missing. There were no indications<br />

of any other accompanying disease.<br />

Fig. 1. Bite, front<br />

Keywords: compound odontoma, supernumerary<br />

teeth, tooth retention, odontogenic tumors, hypodontia,<br />

complex treatment<br />


Odontomas are formations which are still classified<br />

as benign tumors by the World Health Organization. They<br />

are lesions on any odontogenic tissue – enamel, cement and<br />

dentin, which are affected in different proportions and degree.<br />

[1, 2, 3, 4] Even though they are similar to hamartomas<br />

and malformations, the compound odontoma consists<br />

of multiple small tooth-like structures often firmly adapted<br />

to one another and covered by more or less continuous connective<br />

tissue capsule. [1, 5] Odontomas are usually small<br />

in size but when bigger they can contain up to a thousand<br />

denticles. The complex odontoma consists of homogenous<br />

amorphous mass of mature odontogenic tissues with some<br />

kind of structural organization. The degree of morphological<br />

differentiation varies for each lesion. A major part of<br />

some is calcified matrix, while in other cases there are sections<br />

of pulp tissue in association with cords and buds.<br />

Hypodontia is a condition of missing up to six tooth<br />

germs, while if there are more than six missing germs, excluding<br />

wisdom teeth, it is called oligodontia. Hypodontia<br />

is assumed to be a hereditary disease which most often affects<br />

wisdom teeth, 2nd premolars and lateral incisors. The<br />

absence of permanent teeth is called anodontia.<br />

Fig. 2. Bite, right profile<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1217

Fig. 3. Bite, left profile<br />

Orthopantomography and 3D cone beam tomography revealed:<br />

Fig. 4. Panorama view and display of retained 23 tooth and 63 tooth<br />

Fig. 5. 3D cone beam tomography – showing palatinal location of the odontoma<br />

Radiographic assessment:<br />

· X-ray diagnose<br />

· Hypodontia 35, 45<br />

· Impacted canine 23<br />

· Diagnose of lateral cephalometry<br />

· Hyperdivergent type of growth<br />

· Skeletal Class I<br />

· Radiographic diagnose (3D cone beam tomography)<br />

- compound odontoma.<br />

Presence of a limited by a radiopaque unstructured<br />

matter with tooth-like formations on the upper jaw in the<br />

area of the right canine, located palatinally and occlusally<br />

1218 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

from its germ. Missing germs of second mandibular<br />

premolars.<br />

The patient was directed to the Department of Oral<br />

Surgery for the extraction of the primary canine and extirpation<br />

of the formation. Under the effect of local anesthetics<br />

tooth 63 was extracted, while a vestibular and palatinal<br />

flaps were made. A capsulated formation was revealed containing<br />

multiple rudimental tooth-like formations which<br />

were removed in portions as the capsule was ruptured. There<br />

was a total of 16 such “teeth” with irregular form and size<br />

at different stage of differentiation. Histological study revealed<br />

a compound odontoma<br />

Fig. 8. Stitched operative wound<br />

Fig. 6. Vestibular and palatal mucoperiosteal flap<br />

Fig. 7. Tooth-like formation<br />


Odontomas are found at a frequency of 0.24% to<br />

1.12% according to some authors and 0.64% out of all biopsies<br />

in maxillo-facial surgery. They account for 30.4%<br />

of all diagnosed odontogenic tumors. [4] Complex odontomas<br />

are a little more common than the compound ones<br />

at a proportion of 1:0.96. Men and women are almost<br />

equally likely to be affected, but there is a characteristic<br />

gender distribution for some nations (for Egyptians it is<br />

0.37:1 for men/women, while for Japanese it is 1:0.65 for<br />

men/women). The complex odontoma is common for people<br />

about the age of 19.25±2.9 years, while the compound<br />

odontoma is diagnosed at an older age – 25.14±4.8 years<br />

old. Maxillary odontomas are most commonly located in<br />

the frontal area, while the mandibular ones are usually located<br />

in the molar area. [6] The etiology of the odontomas<br />

is vaguely known. [4, 7] They can be formed from the tooth<br />

germ or the teeth during their growth period induced by a<br />

local trauma, infection, odontoblast hyperactivity, genetic<br />

mutations. [2, 4, 7, 8, 9, 10] Odontomas are classified as<br />

tumors but usually stop growing in size when the tissues<br />

they are made of are fully mineralized. Their clinical<br />

behavior differs from that of other body tumors as it is characteristic<br />

for all non-tumor lesions which have dysplastic,<br />

hemartoma and malformation traits.<br />

Hypodontia in the deciduous dentition has a rate of<br />

about 0.4-0.9% for the European population. For the permanent<br />

dentition it differs for each continent: Europe - men<br />

4.6%, women 6.3%; Australia - men 5.5%, women 7.6%;<br />

North American white race - men 3.2%, women 4.6%. Overall<br />

tooth agenesis for women is 1.37 times more common<br />

than it is for men. [11, 12] Second mandibular premolar is<br />

the most often affected, followed by the lateral maxillary<br />

incisor and the second maxillary molar. [11, 13, 14, 15] It<br />

is often observed as unilateral than it is as bilateral with<br />

the exception of the lateral incisors which are usually affected<br />

bilaterally. Genetics and environmental factors can<br />

influence the development of the tooth germs. Mutations<br />

of the homeobox gene MSX 1 leads to hypo-/oligodontia<br />

of the premolars and molars. [11] External factors include<br />

inflammation, chemotherapeutics or dioxin. However, many<br />

cases are caused by genetic factors. Familial predisposition<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1219

association between odontomas and the<br />

gubernaculum tracts. Oral Surg Oral<br />

Med Oral Pathol Oral Radiol. <strong>2016</strong><br />

Jan;121(1):91-5. [PubMed]<br />

9. Tarjan I, Gyulai SG, Soos A,<br />

Rozsa N. Tuberculate and odontoma<br />

type supernumerary teeth. J Craniofac<br />

Surg. 2005 Nov;16(6):1098-102.<br />

[PubMed]<br />

10. Yoda T, Ishii Y, Honma Y, Sakai<br />

E, Enomoto S. Multiple macrodonts<br />

with odontoma in a mother and son—a<br />

variant of Ekman-Westborg-Julin syndrome.<br />

Report of a case. Oral Surg Oral<br />

Med Oral Pathol Oral Radiol Endod.<br />

1998 Mar;85(3):301-3. [PubMed]<br />

11. Bailleul-Forestier Is, Molla M,<br />

Verloes Al, Berdal Ar. The genetic basis<br />

of inherited anomalies of the teeth:<br />

Part 1: Clinical and molecular aspects<br />

of non-syndromic dental disorders. Eur<br />

J Med Genet. 2008 Jul-Aug; 51(4):273-<br />

9151. [PubMed]<br />

12. Das G, Sarkar S, Bhattacharya B,<br />

Saha N. Coexistent partial anodontia<br />

and supernumerary tooth in the mandibular<br />

arch: A rare case. J Indian Soc<br />

Pedod Prev Dent. 2006 May; 24(Suppl<br />

1):S33-34. [PubMed]<br />

13. Gabris K, Fabian G, Kaan M,<br />

Rozsa N, Tarjan I. Prevalence of hypodontia<br />

and hyperdontia in paedodontic<br />

and orthodontic patients in Budacan<br />

be confirmed by the fact that hypodontia is a lot more<br />

common for monozygotic twins in comparison to dizygotic<br />

ones. [16, 17, 18]<br />


Overall the etiology of the odontomas is unknown.<br />

They can be formations of the tooth germ or the tooth itself.<br />

In this case there is the tendency of suppression of the<br />

development of the dental lamina and a development of<br />

hypodontia. The stimulated growth of the maxilla is probably<br />

caused by the local trauma during the development<br />

period of the tooth germs. The disturbance in the migration,<br />

proliferation and differentiation of the neural crest<br />

cells and the interaction between the epithelial and mesenchymal<br />

cells in the initial stages of the development of<br />

the dentition can be a possible cause for the simultaneous<br />

appearance of odontoma and hypodontia.<br />


1. Atanasov D. (Editor) Oral surgery.<br />

Tafprint. Plovdiv. 2011: 755-760.<br />

2. Chrcanovic BR, Jaeger F, Freire-<br />

Maia B. Two-stage surgical removal of<br />

large complex odontoma. Oral Maxillofac<br />

Surg. 2010 Dec;14(4): 247-252.<br />

[PubMed] [CrossRef]<br />

3. Kumazawa Y, Kawai T, Shirase<br />

T,Yagishita H. Multiple calcifying lesions<br />

in the maxilla and mandible of a<br />

4-year-old girl: report of a rare case and<br />

literature review. Oral Radiol. 2014<br />

Sep;30(3):259-264. [CrossRef]<br />

4. Pippi R. Odontomas and supernumerary<br />

teeth: is there a common<br />

origin?. Int J Med Sci. 2014 Nov;<br />

11(12):1282-1297. [PubMed]<br />

5. Meetkamal, Kaur P. Odontoma<br />

with non-syndrome multiple supplemental<br />

supernumerary teeth. JCDR.<br />

2011 Feb;5(1):142-145.<br />

6. Nelson BL, Thompson LD. Compound<br />

odontoma. Head and Neck<br />

Pathol. 2010 Dec;4(4):290-291.<br />

[PubMed]<br />

7. Kobayashi TY, Gurgel CV, Cota<br />

AL, Rios D, Machado MA, Oliveira<br />

TM. The usefulness of cone beam computed<br />

tomography for treatment of<br />

complex odontoma. Eur Arch Paediatr<br />

Dent. 2013 Jun;14(3):185-189.<br />

[PubMed]<br />

8. Oda M, Miyamoto I, Nishida I,<br />

Tanaka T, Kito S, Seta Y, et al. A spatial<br />

pest. Community Dent Health. 2006;<br />

23(2): 80-2. [PubMed]<br />

14.Yanagida I, Mori S. [Statistical<br />

studies on numerical anomalies of teeth<br />

in children using orthopantomograms.<br />

Hyperdontia]. [in Japanese] Osaka<br />

Daigaku Shigaku Zasshi. 1990 Dec;<br />

35(2):564-79. [PubMed]<br />

15. Yanagida I, Mori S. [Statistical<br />

studies on numerical anomalies of teeth<br />

in children using orthopantomograms.<br />

Congenital coexistence of hyperdontia<br />

and hypodontia]. [in Japanese] Osaka<br />

Daigaku Shigaku Zasshi. 1990<br />

Jun;35(1):6-12. [PubMed]<br />

16. Temilola DO, Folayan MO,<br />

Fatusi O, Chukwumah NM, Onyejaka<br />

N, Oziegbe E, et al. The prevalence, pattern<br />

and clinical presentation of developmental<br />

dental hard-tissue anomalies<br />

in children with primary and mix dentition<br />

from Ile-Ife, Nigeria. BMC Oral<br />

Health. 2014 Oct;14:125. [PubMed]<br />

17. Thesleff I. Epithelial-mesenchymal<br />

signalling regulating tooth morphogenesis,<br />

J Cell Sci. 2003 May;<br />

116(Pt 9):1647-1648. [PubMed]<br />

18. Townsend G, Bockmann M,<br />

Hughes T, Brook A. Genetic, environmental<br />

and epigenetic influences on<br />

variation in human tooth number, size<br />

and shape. Odontology. 2012 Jan;<br />

100(1):1-9. [PubMed]<br />

Please cite this article as: Cholakova R, Chenchev I, Jordanova S, Oncheva D, Chenchev L. A case of compound maxillary<br />

odontoma and mandibular hypodontia. J of IMAB. <strong>2016</strong> Jul-Sep;22(3):1217-1220.<br />

DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1217<br />

Received: 15/05/<strong>2016</strong>; Published online: 18/07/<strong>2016</strong><br />

Address for correspondence:<br />

Dr. Radka Cholakova,<br />

Department of Oral Surgery, Faculty of Dental Medicine,<br />

Medical University – Plovdiv, Bulgaria<br />

E-mail: r_cholakova1978@abv.bg,<br />

1220 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1221<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />



Filka Georgieva<br />

Department of Dermatology and Venereology, Faculty of Medicine, Medical<br />

University- Varna, Bulgaria<br />


Background Lichen Simplex Chronicus (LSC) is a<br />

common extremely pruritic dermatoses affecting seriously<br />

the wellbeing of patients. Although the diagnosis is easily<br />

confirmed the therapy is still a challenge for specialists.<br />

The aim of the study was to update the epidemiology<br />

of LSC.<br />

Objective and Methods To assess the tendencies in<br />

distribution of LSC were analyzed data collected from registers<br />

of Medical Centre “St. Anna” Varna from January<br />

2007 till July 2015. Data include reports of 39968 outpatients<br />

with different skin problems. The model of the study<br />

was retrospective and investigates the total morbidity, gender<br />

distribution, age distribution, peak condition and place<br />

of the disease in the structure of selected chronic recurrent<br />

dermatoses with negative impact on quality of life. Data<br />

were collected and processed after obtaining written permission<br />

from the leadership of MC “St. Anna” Varna.<br />

Results. The overall frequency of LSC was 4.04%.<br />

It increased from 2.59% (2007) to 4.62% (2015). Results<br />

show a tendency of rejuvenation of LSH with two peaks of<br />

morbidity: over 65 years of age 11.87% and second in the<br />

range 25-30 years -10.77%.The the ratio female / male is<br />

established to 1.2: 1.The distribution analysis shows the<br />

prevalence of LSC in winter season – January 5.14%, February<br />

– 4.57% and low morbidity in summer mouths - July<br />

1.92% and August 0.66%. (p = 0.001) The distribution of<br />

LSC was compared with that of several skin diseases with<br />

a chronic course and a negative influence on the quality<br />

of life of patients. Results show increasing of LSC from<br />

3.36% (2008) to 4.55% (2014) (p = 0.001).<br />

Conclusion This is the first study in our country,<br />

which aims to update the epidemiology of LSC.<br />

Key words Epidemiology, Lichen simplex<br />

chronicus, morbidity<br />


Lichen simplex chronicus (LSC) is a chronic skin<br />

condition occurring as a result of traumatic injury (scratching)<br />

of the skin. Constant irritation due to strong and uncontrollable<br />

itching formed infiltrated plaques [1]. The<br />

condition has been estimated to occur in 12% of the population<br />

[2]. The highest prevalence is middle to late adulthood,<br />

with a peak at 30-50 years. Pathogenesis of this dermatosis<br />

is not well distinguished. Disorders of skin barrier<br />

are described as a trigger or enhance pathological symptoms<br />

of LSC [3]. On the other hand, in the pathogenesis of<br />

LSC an important role have psychological factors. [4] The<br />

dominant symptom in LSC is pruritus. [1] Although LSC<br />

is quite common disease with strong impact on quality of<br />

patients’ life there are not recent studies on its distribution<br />

and morbidity. The purpose of this study was to update the<br />

epidemiology of LSC.<br />


To assess the tendencies in distribution of LSC were<br />

analyzed data collected from registers of Medical Centre<br />

“St. Anna” Varna from January 2007 till July 2015. Data<br />

include reports of 39968 outpatients with different skin<br />

problems. Taking into account the specifics of LSC all patients<br />

younger than 18 years of age were excluded and finally<br />

observed data include 31 981 dermatologic outpatients.<br />

Diagnosis LSC was placed in 1305 cases (4.08%).<br />

Data were collected and processed after obtaining<br />

written permission from the leadership of MC “St. Anna”<br />

Varna<br />

The model of the study was retrospective study. We<br />

analyzed the total morbidity, gender distribution, age distribution,<br />

peak condition and place of the disease in the<br />

structure of selected chronic recurrent dermatoses with<br />

negative impact on quality of life.<br />

The statistical analysis was performed with SPSS<br />

v.21.0 for Windows. Hypotheses were tested using ÷²-criteria<br />

(for the descriptive profile data). Results with p

Fig. 1. Morbidity of LSH<br />

The distribution according the gender show the ratio<br />

female / male to 1.2: 1 For a period of 102 months 571<br />

( 54.79% ) female and 471 (45.20%) male at first visit and<br />

141 (53.61%) female and 122 (46.38%) male at checkup<br />

were diagnosed with LSH (Table 1)<br />

Table 1. Gender distribution<br />

period<br />

LSH<br />

LSH<br />

female male<br />

female male female male<br />

First<br />

chec<br />

total<br />

n/% n/%<br />

n/% n/%<br />

n/% n/%<br />

visit<br />

kup<br />

2007 51 28(54,90) 23(45.09) 13 7(53.84) 6(46.15) 64 35(54.69) 29(45.31)<br />

2008 90 49(54,44) 41(45.55) 36 20(55.56) 16(44.44) 126 69(54.76) 57(45.23)<br />

2009 136 73(53,67) 63(46.32) 36 20(55.55) 16(44.44) 172 93(54.06) 79(45.93)<br />

2010 141 80(56,73) 61(43.26) 43 24(55.81) 19(44.19) 184 104(56.52) 80(43.34)<br />

2011 183 104(56,83) 79(43.17) 36 20(55.55) 16(44.44) 219 124(56.62) 95(43.37)<br />

2012 137 73 (53.47) 64 (46.55) 35 19(54.28) 16(45.71) 172 92(53.48) 80(46.51)<br />

2013 94 50 (53.19) 44 (46.80) 10 5(50) 5(50) 104 55(52.88) 49(47.11)<br />

2014 137 72 (52.55) 65 (47.77) 37 17(45.94) 20(54.05) 174 89(51.14) 85(48.85)<br />

july<br />

2015<br />

73 42 (57.53) 31 (42.46) 17 9(52,94) 8(47,05) 90 51(56.66) 39(43.44)<br />

total 1042 571(54.79) 471(45.20) 263 141(53,61) 122(46.38) 1305 712(54.55) 593(45,45)<br />

Results from distribution according the age show<br />

two peaks of LSH: over 65 years of age 11.87% and second<br />

in the range 25-30 years -10.75% .The exact distributions<br />

is shown on figure 2<br />

Fig. 2. Distribution according age<br />

1222 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

The results of the comparison of age and gender of<br />

the patients show that in younger age groups most of patients<br />

are female and this ratio changes with increasing of<br />

age in favor of male. In group 25-30 years the ratio female /<br />

male is 1.7: 1, and at the age 65 up years, this ratio has been<br />

1: 2.3, which is dominated by male patients. (Figure 3)<br />

Fig. 3. Distribution according crossing age and gender<br />

In analyzing the possible seasonal distribution of the<br />

disease the following results were reported. We estimate a<br />

peak of morbidity during the autumn- winter season, and a<br />

strong reduction in July and August. The highest rate is<br />

found during the months January mean 5.14% ( range 2.7%<br />

-6.6% ) , February –mean 4.57% ( range 2.81% -5.17% )<br />

and - December mean 4.44% (range 3.63% -6.14% ) The<br />

lowest morbidity was in July mean1.92% ( range0,92 % -<br />

2.28% ) and August mean0.66% . (range0 % -1.85%) (figure<br />

4)<br />

Fig. 4. Distribution by months<br />

The frequency of LSC was compared with that of several<br />

chronic skin diseases with influence on the quality of<br />

life of patients including – seborrheic dermatitis, atopic<br />

dermatitis 18up years, lichen planus, eczema. The morbidity<br />

of LSC was mean 3.98% with a range of 2.53% for 2007<br />

to 4.55% for 2014. (Figure 5)<br />

Fig. 5. The distribution of LSC in group of similar skin disorders<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1223


Although the disease is common in the literature<br />

there are no comprehensive studies on it epidemiology [5]<br />

The different authors indicate prevalence between 2% to<br />

12% [1,5] In the study of 1732 disabled people (aged 50<br />

up ), Williams W (2008) establishes that 33% of them suffer<br />

from skin disease , as 13 % are diagnosed with LSC[6].<br />

Liao YH, et al (2014) reported the distribution of LSC in<br />

the range of 0.1 -0.5% [7]. Shukla S. et al (1984) found the<br />

distribution of LSC to 2% [8]. This study finds incidence<br />

of LSC- 4.04%. This correlates most to data pointed out in<br />

study of Khaitan et al (1999) [9]. Relatively large range in<br />

incidence of the disease could be explained by the different<br />

target groups, who were included in studies. For example<br />

Cybulski M. and co-authors (2015) reported that the<br />

disease commits 12% of patients, but they study the distribution<br />

of skin diseases among elderly patients [10] while<br />

we involved patients from different ages.<br />

In a conducted retrospective study we established,<br />

significant though slight trend of increasing morbidity over<br />

the years (p=0.002). As in 2007 frequency was 2.59%, and<br />

in 2014- 4.62%. The primary visits were respectively 2.54%<br />

for 2007 and 4.55% for 2014, and checkup - 4.08% for<br />

2007 and 5.01% for 2014.In literature we did not find such<br />

studies, which gives us reason to assume that this is the<br />

first study till now.<br />

Many data suggest that the peak of the disease is<br />

between 35 and 50 years of age with more prevalent in female<br />

than male and the ratio being 2:1[3]. Controversially<br />

there are data pointing out that LSC is more common in<br />

adults, with a peak above 65 years of age at the same distribution<br />

by gender. [10] The data obtained in our study<br />

showed a ratio of female / male, being 1.2: 1. The distribution<br />

by age showed two peaks of the disease: over 65 years<br />

of age 11.87% and second in the range 25-30 years -<br />

10.77%. The results of the peak of the disease in patients<br />

over 65 years correlate with the exported data that LSC is<br />

a dermatosis of adulthood. [1, 10, 11] In the literature we<br />

met no reports of “rejuvenation of the disease.” We assume<br />

that the peak in the age 25-30 years is due to the increased<br />

physical and mental stress, which is one of the major<br />

pathogenetic mechanisms of the disease [3]. It was further<br />

investigated the addiction between age groups and gender<br />

of the patients. In younger ages most of patients were female<br />

while with the increasing of the age number of male<br />

predominated. So in age group 25-30 years the ratio female<br />

/ male was 1.7: 1, and in age group 65up years this ratio<br />

was 1: 2.3.<br />

Results are discussed in the light of other dermatological<br />

pathologies which have similar characteristics with<br />

LSC. The distribution of LSC compared with that of several<br />

skin diseases with a chronic course and a negative influence<br />

on the quality of life of patients show increasing<br />

of LSC from 3.36% (2008) to 4.55% (2014) (p = 0.001).<br />

The seasonal modulation in LSC should be expected<br />

because etiopathogenetic mechanisms of the disease [12,<br />

13]. Link between skin hydration and cold seasons been<br />

known long ago [14] Boulter E.et al (2013) published data<br />

on the relationship between homeostasis of skin barrier<br />

(corneal layer) and the age and season. [15]. Slominski and<br />

colleagues (2013) found seasonal variations in hormonal<br />

activity [16] Several studies show an increased risk of depression<br />

and suicide attempts during the cold seasons and<br />

in countries with lower levels of sun [17] .All these data<br />

explain established in our study seasonal modulation in<br />

LSC. The results showed peak of the disease during the autumn-<br />

winter season, and a significant reduction in July and<br />

August. Most high percentage was recorded in January an<br />

average of 5.14 %, 4.57 % in February and 4.44% in December.<br />

Lowest was morbidity in July 1.92% and August<br />

0.66%.<br />


Lichen Simplex Chronicus (LSC) is a skin disorder<br />

characterized by itching, which seems to have a marked<br />

psychological component. The disease is quite common.<br />

However, the epidemiological futures are few investigated<br />

so far. This is the first study in our country, which aims to<br />

update the epidemiology of LSC- including social, demographic,<br />

and disease related futures.<br />


1. James WD, Berger TG, Elston DM.<br />

Andrew’s Diseases of the Skin. International<br />

edition. 12th Ed., Clinical Dermatology.<br />

Elsevier. May 2015. [Internet]<br />

2. Lotti T, Buggiani G, Prignano F.<br />

Prurigo nodularis and lichen simplex<br />

chronicus. Dermatol Ther. 2008 Jan-Feb;<br />

21(1):42-6. [PubMed] [CrossRef]<br />

3. Martin-Brufau R, Corbalan- Berna<br />

J, Ramirez-Andreo A, Brufau-Redondro<br />

C, Liminana- Gras R. Personality differences<br />

between patiens with lichen simplex<br />

chronicus and normal population:<br />

A study of pruritus. Eur J Dermatol. 2010<br />

May-Jun;20(3):359-563. [PubMed]<br />

[CrossRef]<br />

4. McKoy K. Lichen Simplex<br />

Chronicus (Neurodermmatitis). Merck<br />

Manual, 2012 [Internet]<br />

5. Rajalakshmi R, Thappa DM,<br />

Jaisankar TJ, Nath AK. Lichen simplex<br />

chronicus of anogenital region: A<br />

clinico-etiological study. Indian J Dermatol<br />

Venereol Leprol. 2011 Jan-Feb;<br />

77(1):28-36. [PubMed] [CrossRef]<br />

6. Williams W, Steward A, von<br />

Muitus E, Cookson W, Anderson HR. Is<br />

eczema really on the increase world-<br />

wide? J Allergy Clin Immunol. 2008<br />

Apr;121(4):947-54. [CrossRef]<br />

7. Liao YH, Lin CC, Tsai PP, Shen<br />

WC, Sung FS, Kao CH Increased risk of<br />

lichen simplex chronicus in people with<br />

anxiety disorders:a nationwide population-based<br />

retrospective cohort study Br<br />

J Dermatol. 2014 Apr;170(4):890-894.<br />

[PubMed]<br />

8. Shukla S, Mukherjee S. Lichen<br />

simplex chronicus during lithium treatment.<br />

Am J Psychiatry. 1984 Jul;141(7):<br />

909-10. [PubMed]<br />

9. Khaitan BK, Sood A, Singh MK.<br />

1224 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Lichen simplex chronicus with a cutaneous<br />

horn. Acta Derm Venereol. 1999<br />

May;79(3):243. [PubMed]<br />

10. Cybulski M, Krajewska-Kulak E.<br />

Skin diseases among elderly inhabitants<br />

of Bialystok, Poland. Clin Interv Aging.<br />

2015 Dec;10:1937–1943. [PubMed]<br />

11. Grundmann SA, Stonder S.<br />

Evaluation of chronic pruritus in older<br />

patients. Aging Health. 2010 Feb:6(1):<br />

53-66. [CrossRef]<br />

12. Schaefer H, Redelmeier TE. Skin<br />

Barrier: Principles of Percutaneous<br />

Absorbtion. Basel:Karger, 2006: 310-<br />

336<br />

13. Rawlings AV, Harding CR. Moisturization<br />

and skin bappier function.<br />

Dermatol Ther. 2014 Feb; 17(Suppl 1):<br />

43-48. [PubMed] [CrossRef]<br />

14. Rogers JS, Harding CR, Mayo A,<br />

Rawling AV. Stratum corneum lipids: the<br />

effect of aging and the seasons. Arch<br />

Derrmatol Res. 1996 Nov;288(12);765-<br />

770. [PubMed]<br />

15. Boulter E, Estrach S, Errante A,<br />

Pons C, Cailleteau L, Tissot F, et al.<br />

CD98hc(SLC3A2) regulation of skin<br />

homeostasis wanes with age. J Exp Med.<br />

2013 Jan;210(1):173-190. [PubMed]<br />

[CrossRef]<br />

16. Slominski A, Zbytec B,<br />

Nikolakis G, Manna PR, Skobowiat C,<br />

Zmijewski M, at al. Steroidogenesis in<br />

the skin:Implication for local immune<br />

functions. J Steroid Biochem Mol Biol.<br />

2013 Sept;137:107-123. [PubMed]<br />

[CrossRef]<br />

17. Fang YX, He M, Lin JY, Ma KJ,<br />

Zhao H, Hong Z, et al. Suicidal drownings<br />

with psychiatric disorders in Shanghai:<br />

a retrospective study from 2010.1<br />

to 2014.6. PLoS One. 2015 Apr 27;10(4):<br />

e0121050. [PubMed] [CrossRef]<br />

Please cite this article as: Georgieva F. Current Epidemiology of Lichen Simplex Chronicus. J of IMAB. <strong>2016</strong> Jul-<br />

Sep;22(3):1221-1225. DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1221<br />

Received: 14/05/<strong>2016</strong>; Published online: 25/07/<strong>2016</strong><br />

Address for correspondence:<br />

Filka Georgieva<br />

74b, Tzar Assen str., 9002 Varna Bulgaria<br />

Tel.: +359 888 513565<br />

E-mail: filka@abv.bg,<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1225

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1226<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />




Desislava Konstantinova 1 , Mariana Dimova 2<br />

1) Department of Prosthetic Dental Medicine and Orthodontics, Faculty of Dental<br />

Medicine, Medical University - Varna, Bulgaria<br />

2) Department of Prosthetic Dental Medicine, Faculty of Dental Medicine, Medical<br />

University - Sofia, Bulgaria<br />


Gnathodynamometric methods prove to be the oldest<br />

means available of obtaining an objective quantitative evaluation<br />

of masticatory efficiency. On the basis of data collected<br />

using these methods static methods were later introduced and<br />

in early 20th century functional dynamic methods were first<br />

applied. Referring to dental literature records, the authors’<br />

objective was to provide a review of available historical facts<br />

about the origin, development and application of<br />

gnathodynamometers in the study of masticatory function.<br />

Fig. 1. Borelli’s gnathodynamometer [3]<br />

Keywords: gnathodynamometer, study of masticatory<br />

force, bite force, masticatory force<br />

Gnathodynamometric methods appear to be historically<br />

the oldest of all methods for the study of masticatory<br />

function [1]. They equip the dental clinician with information<br />

about the strength of the muscles of mastication, periodontal<br />

reactivity as well as the functional and physiological balance<br />

of teeth. The data can be obtained using a<br />

gnathodynamometer, a instrument for measuring the muscles<br />

which elevate or depress the mandible during mastication [2].<br />

The aim of the present review is to explore the origin,<br />

development and application of gnathodynamometers in the<br />

study of masticatory function.<br />


For the purposes of retrieving literature data a thorough<br />

analysis was initially carried out on currently available<br />

relevant literature. Search Method: Over the period March -<br />

October 2015 the search was performed in stages based on<br />

the electronic data bases Pub-Med, Science-Direct, Scopus<br />

in English, German and Russian. Parallel to that search a<br />

manual literature search was implemented for paper sources<br />

in Bulgarian, English, German and Russian at the University<br />

Libraries in Varna and Sofia. The following key words were<br />

used for the purpose: gnathodynamometer, study of masticatory<br />

force, bite force, masticatory force.<br />

As far back as 1681 Borelli, a professor of anatomy in<br />

Rome first estimated the force of the muscles of mastication<br />

[1]. The scientist’s method of procedure was to transversely<br />

pass a loop of cord over the molar teeth of the open mandible<br />

and under the patient’s chin, onto which he then attached<br />

various weights (Figure 1).<br />

The best-known name in connection with<br />

gnathodynamometers is that of G. V. Black, who worked at<br />

the subject as far back as 1893. The chapter, „The Force in<br />

Mastication “ in his “Operative Dental Surgery” contains a<br />

concise, although by no means exhaustive, account of the<br />

subject. In 1900 Black constructed the first intraoral device<br />

for measuring the interplay of forces between the upper and<br />

lower dentition. He performed this study not only on natural<br />

but also on plastic teeth of plate dentures. It was established<br />

that the latter endured 1/4 to 1/3 of the pressure habitually<br />

exerted by natural teeth. Later Black created an instrument<br />

which he called a phagodynamometer, consisting of two rugged<br />

plates, between which he placed the test food, to estimate<br />

the force required for crushing.<br />

Much interest caused Haber’s book entitled “Die<br />

Aufgaben der Kaudruckmessung und der Zahndruck-<br />

Priifing” which comprised all known research on the subject<br />

until that time [4].<br />

Gnathodynamometers may be divided into three<br />

classes according to the method of their construction:-<br />

1. Those which act directly on to the jaw or by means<br />

1226 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

of a simple lever (Hebelkonstruktion),<br />

2. Those which contain a spring (Federkonstruktion),<br />

3. Those which combine lever and spring, or lever,<br />

spring and manometer (Kombinietekonstruktion).<br />

A fourth group is described in which splints are placed<br />

upon the teeth and a steel stud impinges upon lead<br />

(Kugelkonstruktion).<br />

GROUP I is represented by Borelli’s<br />

gnathodynamometer, which is a loop of cord passed over the<br />

open mandible with various weights from 60 kg to 200 kg attached<br />

to it. According to the weight which could be raised<br />

by closing the jaw, he estimated the force of the muscles of<br />

mastication. Haber gave a translation in German of the original<br />

Italian in which the weight was defined between 90-242<br />

kg, suggesting that the neck muscles came into play in addition<br />

to the muscles of mastication.<br />

A hundred years later, Sauer used the same method<br />

by placing a flat strip of iron across the molar teeth, of sufficient<br />

length to project beyond the corners of the mouth. A<br />

hole was bored, through which a cord was passed and secured.<br />

The end of the cords was attached to a weight standing<br />

on the floor and it was so arranged that with the mouth<br />

open the cord was quite tense. By elevation of the jaw, the<br />

weight, if not too heavy, was lifted and by means of suitable<br />

additions or subtractions the exact weight was found which<br />

could be raised and the force of the muscles accordingly estimated.<br />

In 1911 Eckermann assumed that a firmly closed jaw<br />

needed the same force to overcome the muscular effort as<br />

was exerted to achieve contact between the occlusal surfaces<br />

of the teeth. The apparatus he created, entirely made of steel,<br />

was quite simple and shaped like a pair of pliers. The jaws of<br />

the pliers, covered with a softer material on the outer side,<br />

were gripped between the teeth. Based on his research he<br />

prepared a formula to make the measurement easier. This<br />

method of estimation was untrustworthy since although it<br />

might be possible to build a model which would give results<br />

according to Eckermann’s formula, the individual characteristics<br />

of the patient, their speicific bite, root canals and so<br />

on change the values of the proposed formula, thus rendering<br />

the results unreliable.<br />

In 1920 Gysi introduced a new test food (spinach or<br />

cereals) and observed that in mastication there was “a working<br />

side” and “a balancing side” of the jaw. He created a<br />

wooden model representing the muscles of the body and this<br />

proved that in measuring the force exerted by the muscles of<br />

mastication, the muscles of both sides should be included.<br />

GROUP II was represented by gnathodynamometers<br />

which operate by means of a spring.<br />

Dr. Black used an instrument consisting of two bars,<br />

one of which is rigid, the other a strong flat spring. He made<br />

a trial of the force of the teeth among the students in his<br />

classes. In the tabulation of the results of 1,000 persons the<br />

average force was 64 kg. on the molar teeth, and considerably<br />

less on premolars and incisors. Black was the first to<br />

recognize the importance of the periodontium and the<br />

receptors located in it.<br />

Head criticized Black for testing only the forces transmitted<br />

vertically, arising from the vertical movement of the<br />

mandible, and not all the forces involved in a natural mastication<br />

process. He did not take into consideration the role of<br />

periodontium. Morelli compensated that by using Collin’s<br />

dynamometer to measure the forces between the pair of antagonists’<br />

teeth and up to the moment the periodontium became<br />

tender. The time and force multiplied together gave a<br />

Pressure Constant figure. Observing the area of the root surfaces<br />

and the pressure constant, he found out that the tolerance<br />

of the periodontium is proportional to the area of the<br />

root surface. Morella and later Vesky explained the mechanism<br />

thanks to which the periodontium endured such pressure<br />

by comparing it to a hydraulic system.<br />

Kristiansen (1925, Copenhagen) utilized the principle<br />

of the parallel pliers. The jaws of the pliers were separated in<br />

the condition of rest. By compression of the biting plates the<br />

spiral spring was stretched and the amount of force used was<br />

registered.<br />

Haber devoted a considerable amount of time and energy<br />

to popularizing the use of the gnathodynamometer both<br />

for the specialist and for the general practitioner. He constructed<br />

three patterns of gnathodynamometers. Two of them<br />

belong to the group of gnathodynamometers which operate<br />

by means of a Spring (Figures 2 and 3).<br />

Fig. 2. Haber’s gnathodynamometer in box, together with „biting plate” for estimating the pressure of single teeth [4].<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1227

Fig. 3. Haber’s gnathodynamometer in use on the right-band side of the mouth [4]<br />

The two patterns are made, one to record up to 50 kg,<br />

the other up to 150 kg.<br />

GROUP III was represented by Gnathodynamometers<br />

which operate by means of more than one of the three factors<br />

- Spring, Lever and Manometer.<br />

In 1920 Giinther bored a hole through each of the<br />

shorter ends or jaws of the pliers in which the pin was received<br />

and attached to the interchangeable biting plates. The<br />

plates were of varying sizes according to the tooth which was<br />

to be tested. As a protection to the teeth each plate was covered<br />

by a felt pad which could be renewed.<br />

Each of the subsequently created gnathodynamometers<br />

was more advanced than the previous one.<br />

Fig. 5. Gomis’s gnathodynamometer [5].<br />

Fig. 4. Johnson’s gnathodynamometer (1930)<br />

Fig. 6. Measurement of the central incisor’s masticatory<br />

force of a patient with progenism as per Suzuki [6].<br />

Gnathodynamometers are also used in modern-day experimental<br />

studies (Figures 5 and 6) [5, 6, 7].<br />

1228 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Fig. 7. Gnathodynamometer for animal testing [7].<br />


The historical review of gnathodynamometric methods<br />

enables us to draw the following conclusions:<br />

Gnathodynamometric studies are objective methods for<br />

quantitative evaluation of the state of the masticatory apparatus.<br />

However, they demand specialized equipment, time-consuming<br />

procedures and therefore are quite costly. More accurate<br />

results of the study of masticatory function can be<br />

obtained by complementing gnathodynamometric methods<br />

with another method of examination of the masticatory apparatus.<br />


1. Rowlett AE. The gnathodynamometer<br />

and its use in dentistry. In: Proc<br />

R Soc Med. 26. ed 9. 1932–1933 :463.<br />

2. Ortuð G. A new device for measuring<br />

mastication force (Gnathodynamometer).<br />

Ann Anat. 2002 Jul;184(4):<br />

393-396. [PubMed]<br />

3. Uhlig H. Über die Kaukraft.<br />

Dtsch Zahnärztl Z. 1953; 8:30-45.<br />

4. Haber G. Die Aufgaben Der<br />

Kaudruck-Messung- und der Zahndruck-Prüfung.<br />

Berlin: Eigenverlag.<br />

1926.<br />

5. Rovira-Lastra B, Flores-Orozco<br />

EI, Salsench J, Peraire M, Martinez-<br />

Gomis J. Is the side with the best masticatory<br />

performance selected for<br />

chewing?. Arch Oral Biol. 2014 Dec;<br />

59(12):1316-1320. [PubMed]<br />

[CrossRef]<br />

6. Suzuki EY, Suzuki B. Assessment<br />

of Maxillary Distraction Forces<br />

in Cleft Lip and Palate Patients.<br />

Intech. 2011 Chapter 2. [CrossRef]<br />

7. Doliñski J. [How much bite lizards?].<br />

[in Polish] Elektronika<br />

praktyczna. 2015; 8:92-94.<br />

Please cite this article as: Konstantinova D, Dimova M. HISTORICAL REVIEW OF GNATHODYNAMOMETRIC METH-<br />

ODS USED FOR THE ASSESSMENT OF MASTICATORY FUNCTION. J of IMAB. <strong>2016</strong> Jul-Sep;22(3):1226-1229.<br />

DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1226<br />

Received: 21/05/<strong>2016</strong>; Published online: 25/07/<strong>2016</strong><br />

Address for correspondence:<br />

Desislava Konstantinova,<br />

84, Tzar Osvoboditel bul., 9000 Varna, Bulgaria.<br />

E-mail: konstantinovadesi@yahoo.com<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1229

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1230<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />





Desislava Konstantinova 1 , Mariana Dimova 2 , Darina Naydenova 3<br />

1) Department of Prosthetic Dental Medicine and Orthodontics, Faculty of<br />

Dental Medicine, Medical University - Varna, Bulgaria<br />

2) Department of Prosthetic Dental Medicine, Faculty of Dental Medicine,<br />

Medical University - Sofia, Bulgaria<br />

3) Department of Preclinical and Clinical Sciences, Faculty of Pharmacy,<br />

Medical University - Varna, Bulgaria<br />


Food can have a mighty biological, therapeutic and<br />

preventive effect, yet its breakdown can provide the perfect<br />

setting for tooth decay and its implications, diseases<br />

of the periodontium and the oral mucosa. Due to the high<br />

incidence of periodontal and hard dental tissues<br />

pathologies among adolescents they have been ranked as<br />

socially significant diseases. A damaged dental-jaw apparatus<br />

may lead to forming unhealthy eating habits, more<br />

sensitive food preferences and nutritional deficiency.<br />

The objective was to explore the prevalence of those<br />

diseases and the dental hygiene among final year high<br />

school students as well as to seek any correlation with their<br />

eating habits and preferences.<br />

Materials and Methods: The study involved 121<br />

students who underwent extraoral and intraoral examination<br />

in order to establish the state of the masticatory apparatus<br />

whereas the state of oral hygiene was measured as<br />

per Silness-Löe plaque index. A questionnaire filled out by<br />

the students provided data on the individual characteristics<br />

of the masticatory process, eating habits and frequency<br />

of consumption of certain cariogenic and anticariogenic<br />

foods and beverages.<br />

Results: The findings revealed unhealthy food preferences<br />

in the target group. The unsatisfactory oral hygiene<br />

habits and food preferences account for the high percentage<br />

of dental caries.<br />

Conclusion: Oral health of children and adolescents<br />

is problematic worldwide and can be resolved with the benefits<br />

of a balanced diet as well as personal and professional<br />

oral hygiene, etc. Teaching children the importance of<br />

proper oral care before reaching adolescence can build<br />

anticariogenic habits in them for a lifetime.<br />

Keywords: dental caries, eating habits, cariogenic<br />

foods and beverages, anticariogenic foods<br />

Diseases of the masticatory apparatus are among the<br />

most common chronic diseases and have become a significant<br />

public health issue owing to the increasing number<br />

of patients affected by them and the correlation with a<br />

number of other common diseases. [1] Due to the high incidence<br />

of periodontal and hard dental tissues pathologies<br />

among adolescents they have been ranked as socially significant<br />

diseases. [2] These issues play an important role<br />

in the etiology of many infectious, cardio-vascular, metabolic<br />

diseases, etc. [3] Evidence pointing to the fact that<br />

more and more teenagers enter adolescence with an already<br />

impaired dental-jaw apparatus is quite alarming. The relationship<br />

between dietary preferences and masticatory efficiency<br />

has been investigated by a number of authors. [3,<br />

4] The link between the beneficial effect of certain foods,<br />

among which fish, nuts, vegetables, etc., and the proper<br />

functioning of the human body have long been acknowledged.<br />

[5, 6, 7, 8, 9] Those studies urged us to shift our<br />

attention to the potential link between food preferences of<br />

young patients and their oral health.<br />

The objective was to explore the prevalence of dental<br />

caries and the level of dental hygiene among final year<br />

high school students as well as to seek any correlation with<br />

their eating habits and preferences.<br />


A pilot screening was performed targeted at final<br />

year high school students to establish the state of their masticatory<br />

apparatus and their food preferences. The study involved<br />

121 students in overall good health, whose participation<br />

was random and voluntary. The target group underwent<br />

a laboratory analysis of serum concentrations of vitamin<br />

D3, extraoral and intraoral examination to detect the<br />

presence of hard dental tissues pathologies whereas the<br />

level of oral hygiene was measured using Silness-Löe<br />

plaque index. A questionnaire filled out by the students<br />

provided data on the individual characteristics of the masticatory<br />

process, eating habits and frequency of consumption<br />

of certain cariogenic and anticariogenic foods and beverages.<br />

The data were analyzed using SPSS software for epidemiological<br />

and clinical research (Windows, V 17.0.0,<br />

Aug. 2008). The following statistical methods were applied:<br />

frequency and percentage distribution of data, correlation<br />

analysis, graphical representation of data.<br />

1230 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/


The findings revealed an unhealthy trend of food<br />

preferences in the target group. Hard nuts and fish are<br />

among the foods having strong protective effect on dental<br />

health. Fish is a good dietary source of complete protein,<br />

essential fats and vitamin D. Each of these nutrients is related<br />

to dental health. We studied the amount of fish consumption<br />

among students in Varna, a city of traditions in<br />

the consumption of seafood. The findings showed that only<br />

16.7% of students consumed fish two or more times a week,<br />

as recommended [6, 7], while with more than half of the<br />

surveyed (55% of the students) fish consumption was so<br />

low that there was a potential risk of Hypovitaminosis D<br />

during the winter season (Figure 1). Fish consumption in<br />

that period is the most important in the protection of dental<br />

health.<br />

Fig. 1. Percentage distribution of respondents in the questionnaire on fish consumption<br />

Our findings strongly matched the results reported<br />

by other authors. The study of eating habits of students in<br />

10 th grade from Sofia revealed that only 7% of them consumed<br />

fish on a weekly basis [1]. The analysis of fish consumption<br />

data obtained from Varna students indicated those<br />

consuming least fish were young people aged under 20<br />

years, whereas the population over the age of 60 had fish<br />

most often most [5]. It is quite alarming that in a city of<br />

culinary traditions in fish consumption there is a tendency<br />

for low fish consumption by children and young people.<br />

This shift in food patterns increases the risk of Hypovitaminosis<br />

D among the young generation and thus exposes<br />

it to a number of socially significant diseases, such as dental<br />

caries [4]. A laboratory analysis of serum concentrations<br />

revealed that in 11% of respondents (13 adolescents) there<br />

was a serious deficiency of vitamin D3 (25-OH), for 46%<br />

of students the values were below 12.0 ng/ml, and in 30.7%<br />

the deficit was 12-30 ng/ml (n=4). Satisfactory levels of vitamin<br />

D3 (above 30 ng/ml) were measured in only 3 final<br />

year students (23.3%).<br />

Nuts are among the so called anticariogenic foods<br />

[10, 11, 12]. They are rich in protein and essential fats and<br />

contain a small amount of complex carbohydrates and fiber.<br />

Their nutritional value accounts for their most beneficial<br />

effect on dental health [8]. The results of the survey<br />

showed that 7.5% of students consumed nuts every day,<br />

32% - at least twice weekly, 31% - once a week, 23% - 1-2<br />

times a month, and 5.5% consumed less or no fish at all.<br />

The most preferred nuts appeared to be peanuts, almonds<br />

and hazelnuts (69%, 42%, 38%, respectively). Less frequently<br />

young people reached for nuts and sunflower seeds<br />

(33%, 27%, respectively). A small proportion of respondents<br />

chose raw and unsalted nuts (28%), most favoured<br />

salted (85%), roasted (79%) or fried (6%) nuts.<br />

The consumption of nuts within the target group was<br />

satisfactory. However, young people’s preference for salted<br />

and processed nuts to raw nuts was unsatisfactory as those<br />

processes diminish their health benefits.<br />

Students’ preference for soft drinks is also important<br />

to consider. About 34% of students (1/3) quenched their<br />

thirst with water, 31% of them mostly consumed unsweetened<br />

milk and yogurt drinks, 25% had sweetened drinks<br />

(tea, juice, sweetened/fruit-flavoured milk), and 11% preferred<br />

carbonated and energy drinks.<br />

Raw vegetables have protective effect against dental<br />

caries. They are part of the daily diet of 2/3 of students<br />

(74%). 23% of respondents shared that their vegetable intake<br />

was several times a week, while 13% had them less<br />

frequently. 48% of students consumed fresh fruit daily,<br />

whereas 40% had them several times a week. Only 12% of<br />

respondents did not have fruit regularly. Every third student<br />

drank processed fruit juices and nectars daily. 37% of<br />

children admitted to having juices regularly throughout the<br />

week, whereas about 1/3 of the respondents consumed them<br />

less frequently or thoroughly avoided them. (Figure 2)<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1231

Fig. 2. Percentage distribution of respondents in the questionnaire on drink preferences when thirsty<br />

Nearly half of the students (47%) drank carbonated drinks daily, while 42% consumed them several times a week.<br />

Only 11% avoided them. (Figure 3)<br />

Fig. 3. Percentage distribution of respondents in the questionnaire on intake frequency of certain foods and drinks<br />

The hectic lifestyle nowadays has an inevitable impact on the eating stereotype of young people. Nearly 57% of<br />

them realized that they ate quickly without chewing the food enough times prior to swallowing. (Figure 4)<br />

Fig. 4. Percentage distribution of respondents in the questionnaire on their chewing patterns<br />

1232 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Nowadays the quite common fast chewing pattern is often implicated in the fast food preferences of young people.<br />

80% of polled adolescents preferred soft-textured foods; 7.60% chose normal textured foods, 12.40% consumed<br />

food with any texture and an alarming rate of 0.00% preferred solid food.<br />

The consumption of foods in their natural form (fruits, vegetables, nuts) is recommended to stimulate the natural<br />

self-cleansing action of the mouth. Personal oral hygiene is undoubtedly the main factor in oral health. The findings on<br />

the oral hygiene state of patients surveyed are quite worrying. (Figure 5)<br />

Fig. 5. The state of oral hygiene measured using Silness-Löe plaque index.<br />

The Silness-Löe plaque indices obtained in our study<br />

showed that nearly half of respondents (42.80%) were given<br />

Index 3, i.e. plenty of soft material was scraped off the<br />

probe. 30% displayed moderate buildup of plaque and were<br />

assigned Index 2. 25.20% had Index 1, i.e. there was no<br />

visible plaque, still a small amount was scraped. Only 2%<br />

of all patients surveyed were given Index 0.<br />

The data showed that 91.94% of patients had never<br />

been subjected to professional oral hygiene, 4.03% reported<br />

that once every 3-4 years they resorted to professional care,<br />

while 4.03% visited the dentist for regular checkups as well<br />

as professional oral hygiene every 6 months.<br />

The unsatisfactory oral hygiene habits and food preferences<br />

for cariogenic foods account for the high percentage<br />

of dental caries. The following disturbing trend was<br />

observed: 83.60% of boys surveyed and 78.90% of girls<br />

had at least one dental caries. A statistically significant<br />

correlation between young people’s oral hygiene state and<br />

the presence of active carious lesions was noted (P = 0.020).<br />

As findings showed, negligence of basic<br />

anticariogenic factors naturally led to a large percentage<br />

of subsequent complications (35%), including deep fractured<br />

teeth, radix reliqua (21%) and tooth loss (14%).<br />


The results obtained from the study disclosed a high<br />

incidence of dental caries and poor oral hygiene habits.<br />

The trend towards unhealthy food preferences was<br />

implicated in the etiology of dental caries: 30% of students<br />

drank sweetened juices daily and 47% had sweetened carbonated<br />

beverages. The study also established insufficient<br />

consumption of fish and nuts, which are foods with proven<br />

anticariogenic effect. Fish was part of the daily diet in<br />

16.7% of students surveyed, whereas nuts were often consumed<br />

by nearly 32% of them. Most young people (85%)<br />

preferred salted and roasted nuts to natural raw nuts, thus<br />

diminishing their dental health benefits. A significant part<br />

of students daily consumed fresh fruit (48%) and vegetables<br />

(74%).<br />


Oral health of children and young people has been<br />

a serious issue worldwide. It can be resolved with the benefits<br />

of a balanced diet as well as personal and professional<br />

oral hygiene, etc. This implies the collaboration of parents,<br />

teachers, dentists and nutritionists. Teaching children the<br />

importance of proper oral care before reaching adolescence<br />

can build anticariogenic habits in them for a lifetime.<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1233


1. Kiryakova S. [Dietary behavior<br />

of students as prevention of chronic<br />

non-infectious diseases]. [in Bulgarian]<br />

Science dietet. 2011; 3:18-20.<br />

2. American Academy of Pediatric<br />

Dentistry. Policy on Oral Health Care<br />

Programs for Infants, Children, and<br />

Adolescents. Oral Health Policies. revised<br />

2011. [Internet]<br />

3. Neill D. The relationship between<br />

masticatory performance and<br />

diet. Proc Roy Soc Med. 1973<br />

Jun;66(6):598-599. [PubMed]<br />

4. Holick MF. Vitamin D deficiency.<br />

New Engl J Med. 2007<br />

Jul;357(3):266-281. [PubMed]<br />

5. Naydenova D, Porozhanova S,<br />

Kavaldzhieva B, Dimitrova E, Gerov T.<br />

[Fish products as part of the daily diet<br />

of the Black Sea population]. [in Bulgarian]<br />

Science dietet. 2011; 3(4):19-<br />

23.<br />

6. Food and Nutrition National Action<br />

Plan (2005 - 2010) Republic of<br />

Bulgaria, Ministry of Health. [in Bulgarian].<br />

7. Penchev P. [Rational and preventive<br />

professional nutrition]. [in Bulgarian]<br />

Sofia: Meditsina I Fizkultura.<br />

1974; 227.<br />

8. Allen LH. Priority areas for research<br />

on the intake, composition, and<br />

health effects of tree Nuts and peanuts.<br />

J Nutr. 2008 Sep;138(9):1763S-1765S.<br />

[PubMed]<br />

9. Delikostadinov SG. [Properties<br />

of the Bulgarian varieties of peanuts].<br />

[in Bulgarian] Agriculture Magazine.<br />

2009; 3:4.<br />

10. Griel AE, Kris-Etherton PM,<br />

Hilpert KF, Zhao G, West SG, Corwin<br />

RL. An increase in dietary n-3 fatty acids<br />

decreases a marker of bone<br />

resorption in humans. Nutr J. 2007 Jan<br />

16;6:2. [PubMed] [CrossRef].<br />

11. Fraser G, Sabaté J , Beeson W,<br />

Strahan T. A possible protective effect<br />

of nut consumption on risk of coronary<br />

heart disease. Arch Intern Med.<br />

1992 Jul;152(7):1416-1424. [PubMed]<br />

12. McKiernan F, Mattes RD. Effects<br />

of Peanut Processing on Masticatory<br />

Performance during Variable Appetitive<br />

States. J Nutr Metab. 2010<br />

(2010), 487301, 6. [CrossRef]<br />

Please cite this article as: Konstantinova D, Dimova M, Naydenova D. IMPACT OF FOOD PREFERENCES ON THE<br />


IMAB. <strong>2016</strong> Jul-Sep;22(3):1230-1234. DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1230<br />

Received: 21/05/<strong>2016</strong>; Published online: 25/07/<strong>2016</strong><br />

Address for correspondence:<br />

Desislava Konstantinova,<br />

84, Tzar Osvoboditel bul., 9000 Varna, Bulgaria.<br />

E-mail: konstantinovadesi@yahoo.com<br />

1234 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1235<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />




Veselin Valkov 1 , Dobrin Kalchev 1 , Atanas Kostadinov 1 , Branimir Kanazirev 2<br />

1) First Clinic of Cardiology, UMHAT “St. Marina”, Varna,<br />

2) Department of Internal Medicine, UMHAT “St. Marina”, Varna,<br />

Medical University, Varna, Bulgaria<br />


The management of carotid artery disease in patients<br />

with severe aortic stenosis referred for transcatheter aortic<br />

valve implantation is challenging. By reviewing the very<br />

limited amount of literature we will try to answer the question<br />

should we perform carotid revascularization before or<br />

after the TAVI procedure.<br />

Keywords: Transcatheter aortic-valve implantation<br />

(TAVI), aortic artery stenosis, carotid stenosis, carotid artery<br />

stenting (CAS), carotid endarterectomy (CEA)<br />


Combination of aortic stenosis and carotid artery stenosis<br />

is not uncommon.<br />

Aortic stenosis is a disease with a long latency period,<br />

followed by fast progression of the symptoms with a<br />

high rate of death.<br />

The classic symptoms of aortic stenosis are: angina<br />

pectoris – usually during physical effort and relieved by rest;<br />

heart failure - typically presents with paroxysmal nocturnal<br />

dyspnea, orthopnea, dyspnea during exertion, and shortness<br />

of breath; syncope occurs upon physical stress. Syncope is<br />

caused by vasodilatation in the presence of a fixed stroke volume<br />

and inability of the left ventricle to compensate for a sudden<br />

drop of BP when standing up. Less common reason for<br />

syncope are AV-blocks and short lasting arrhythmias, due to<br />

ischemic arias in hypertrophied myocardium [1, 2, 3].<br />

The atherosclerotic plaques consist of cholesterol crystals,<br />

necrotic sells and lipids. When present in carotid arteries<br />

they can lead to thrombosis and embolization. Atherosclerotic<br />

disease of the carotid artery is usually associated<br />

with focal neurological deficit (such as by ipsilateral visual<br />

loss, motor skills deficit) caused by transient ischemic attacks<br />

(TIAs), strokes and cerebral infarctions [4].<br />

The main indication for carotid revascularization is<br />

stroke prevention. It is contraindicated in patients with a severe<br />

neurological deficit with cerebral infarction, patients<br />

with totally occluded carotid artery and concurrent diseases<br />

that reduce the patient’s life expectancy.<br />

Patients with severe and symptomatic stenoses have<br />

a higher risk of stroke.<br />

According to the North American Symptomatic Carotid<br />

Endarterectomy Trial (NASCET) symptomatic patents<br />

with >70% stenoses respond good to the treatment; In symptomatic<br />

patients with 50 – 69 % stenoses the profit is negli-<br />

gible and appears to be greater for males. Asymptomatic patients<br />

with greater than 60% narrowing profit significantly<br />

less than first group [5].<br />

Depending on the periprocedural risk carotid endarterectomy<br />

(CEA) or carotid artery stenting (CAS) is chosen.<br />

Anatomical (bilateral stenosis, postoperative restenosis) and<br />

clinical (cardiopulmonary diseases, prior cranial injury) factors<br />

can increase the risk during an operation. For stenting<br />

they are as follows: anatomical (complex aortic arch and<br />

brachiocephalic arterial anatomy, presence of thrombus, and<br />

heavy calcification) and clinical (need for heart surgery<br />

within 30 days) [6].<br />

“Carotid artery stenosis occurs in 8–13 % of patients<br />

with degenerative aortic stenosis. The risk of new postoperative<br />

stroke after cardiac surgery is thought to be two- to<br />

four-fold higher in patients with concomitant carotid stenosis”<br />

[7, 8].<br />

AIM of the study:<br />

The aim of this study is to analyze retrospectively additional<br />

database containing patients who suffer from aortic<br />

and carotid stenosis simultaneously, undergoing TAVI. By<br />

reviewing the very limited amount of literature we will try<br />

to answer the question should we perform carotid revascularization<br />

before or after the TAVI procedure.We try to determine<br />

what is the proper way to treat those patient even when<br />

they are completely asymptomatic and the carotid stenosis<br />

was an accidental finding during the preparational studies<br />

for TAVI.<br />

Carotid artery stenting is performed in order to reduce<br />

the number of ischemic episodes. It has been proven that<br />

operative revascularization is highly beneficial for symptomatic<br />

patients. Interventional treatment has an advantage<br />

over operational when it comes to asymptomatic patients [9].<br />

CAS has evolved rapidly over the last 15 years. Randomized<br />

trials comparing stenting with conservative treatment<br />

are not available. The role of stenting is not yet clear<br />

despite the existence of several studies comparing interventional<br />

with operational techniques. CAS should be considered<br />

in high surgical risk patients requiring revascularization<br />

according to the SAPPHIRE study results [7, 10].<br />

It is recommended by the European Society of Cardiology<br />

(ESC) guidelines that symptomatic patients with high<br />

surgical risk undergo CAS (Class IIa). It is reasonable to perform<br />

CAS on asymptomatic patients with other indications<br />

for revascularizaion in high-volume centers with low rates<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1235

of periprocedural stroke (50 000 [13].<br />

The Placement of Aortic Transcatheter Valves (PART-<br />

NER) trial is the largest study comparing SAVR and TAVI.<br />

Stroke is considered one of the most important periprocedural<br />

complication of both procedures. “Stroke is defined<br />

as an acute episode of focal or global neurological dysfunction<br />

caused by the brain, spinal cord, or retinal vascular injury<br />

as a result of hemorrhage or infarction.” [16].<br />

Sometimes the occurrence of stroke happens late after<br />

the TAVI procedure and can be attributed to other factors<br />

such as preexisting carotid stenosis and atrial fibrillation<br />

[16]. In those cases the direct cause of the stroke is hard to<br />

determine but reevaluation of the antithrombotic medication<br />

and stenting of a known carotid lesion is reasonable.<br />

When performing TAVI, strokes are related to debris,<br />

breaking off the aorta when crossing its arch and when passing<br />

the valve and deploying the valve. Improving the design<br />

and reducing the size of the implantable valves and the<br />

delivery systems leads to significant reduction in periprocedural<br />

stroke rates [17]. According to the STS database stroke<br />

occured in 1.5 % of the patients that underwent cardiac surgery<br />

[18]. The earlier TAVI trials showed higher incidence<br />

of stroke compared to SAVR but in PARTNER II trial where<br />

the new Sapien 3 valve was used only 0.9% had disabling<br />

stoke at 30 days after the procedure [17, 18].<br />

The Cardiology department of Pomeranian Medical<br />

University in Poland conducted a study in which 246 patients<br />

underwent CAS. 14 of those had aortic stenosis and 2<br />

of those had procedure-related deaths which is higher mortality<br />

rate than the rest of the group. This study suggests that<br />

patients who undergo CAS and have aortic stenosis as a<br />

comorbidity are at higher risk of death [7].<br />

Hospital of the University of Pennsylvania is described<br />

129 postoperative patients after SAVR. MRI study<br />

was performed on all of them and it was revealed that 60<br />

patients (46%) have embolic infarcts, watershed had 2 of<br />

them (2%), and both - 17 (13%). There was an association<br />

between watershed infarct and the presence of internal carotid<br />

artery stenosis ≥70% [19].<br />

An American study described 294 TAVI patients, 51<br />

of which (19%) had at least 50% stenosis of a carotid or vertebral<br />

artery. Transfemoral access was less common in the<br />

carotid and vertebral artery disease group (55 % vs 77 %).<br />

Stroke had 6.8% of patients within 30 days after the procedure.<br />

None of the patients in the carotid and vertebral artery<br />

disease group had a stroke. Mortality and overall survival<br />

rate in the next 30 days in both groups was the same [20].<br />

In Departments of Cardiology and Neurology, Tel-<br />

Aviv Medical Center in Israel a study included 171 patients<br />

with CAS in patients undergoing TAVI. Carotid plaques had<br />

164 (96 %) of the patients, severe stenoses (≥70 % stenosis)<br />

were present in 15 (9 %) patients. CAS was not associated<br />

with higher 30-day mortality or stroke rates [21].<br />

Study of 52 patients by Kar et al. evaluated carotid<br />

interventions in patients with aortic valve stenosis. The procedure<br />

was successful in 51 cases. None of them had a stroke<br />

in 30 day follow up. Five patients (10%) died before AVR.<br />


Many of the patients with aortic and carotid stenosis<br />

are in the high risk group for both TAVI and SAVR.<br />

Stroke rate after cardiac surgery is 0.8 – 4 % . Combined<br />

procedures (SAVR and CABG) are more risky. The risk<br />

of stroke is much higher when a CS is present. Carotid<br />

revascularization before cardiac surgery is a common practice<br />

and a lot of data supports this approach.<br />

CAS and CEA both can lead to cardiovascular instability,<br />

whch can significantly worsen the condition of patients<br />

suffering from degenerative aortic stenosis (DAS). Particularly<br />

undesirable are any drops in systolic blood pressure<br />

which are more common and long lasting when performing<br />

CEA.<br />


The prevalence of CAS in patients undergoing TAVI<br />

is high. The presence or absence of carotid or vertebral artery<br />

stenosis was not significantly related to the occurrence<br />

of TAVI procedure related stroke. Routine screening for carotid<br />

and vertebral artery stenoses before TAVI does appear<br />

justified but always treating them first does not.<br />


1. Emergency Medicine: A Comprehensive<br />

Study Guide. 6th edition 6th<br />

Edition by Tintinalli JE, Kelen GD,<br />

Stapczynski J. (2003) [Amazon]<br />

2. Ren X. Aortic Stenosis Clinical<br />

Presentation. Nov 10, 2014.<br />

[Medscape]<br />

3. Bonow RO, Carabello BA,<br />

Chatterjee K, de Leon AC Jr, Faxon DP,<br />

Freed MD, et al. ACC/AHA 2006 guidelines<br />

for the management of patients<br />

with valvular heart disease: a report of<br />

the American College of Cardiology/<br />

American Heart Association Task Force<br />

on Practice Guidelines (writing Committee<br />

to Revise the 1998 guidelines for<br />

the management of patients with valvular<br />

heart disease) developed in collaboration<br />

with the Society of Cardiovascular<br />

Anesthesiologists endorsed by the<br />

Society for Cardiovascular Angiography<br />

and Interventions and the Society of<br />

Thoracic Surgeons. Circulation. 2006<br />

Aug 1;114(5):e84-231. [PubMed]<br />

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[CrossRef]<br />

4. Rodriguez AL. Atherosclerotic<br />

Disease of the Carotid Artery. Apr 08,<br />

<strong>2016</strong> [Medscape]<br />

5. North American Symptomatic Carotid<br />

Endarterectomy Trial Collaborators.<br />

Beneficial effect of carotid endarterectomy<br />

in symptomatic patients with<br />

high-grade carotid stenosis. N Engl J<br />

Med. 1991 Aug 15;325(7):445-53.<br />

[PubMed] [CrossRef]<br />

6. Safian RD. Treatment strategies<br />

for carotid stenosis in patients at increased<br />

risk for surgery. Prog Cardiovasc<br />

Dis. 2011 Jul-Aug;54(1):22-8.<br />

[PubMed] [CrossRef]<br />

7. Oledzki S, Goracy J, Lewandowski<br />

M, Widecka-Ostrowska K,<br />

Modrzejewski A, Kornacewicz-Jach Z.<br />

Carotid Artery Stenosis in Patients with<br />

Aortic Valve Stenosis Short-Term Outcomes<br />

after Carotid Artery Stenting.<br />

Arhives of Medicine. 2015; 7(5):7.<br />

[Internet]<br />

8. Kablak-Ziembicka A, Przewlocki<br />

T, Hlawaty M, Stopa I, Roslawiecka A,<br />

Kozanecki A, et al. Internal carotid artery<br />

stenosis in patients with degenerative<br />

aortic stenosis. Kardiol Pol. 2008<br />

Aug;66(8):837-42; discussion 843-4.<br />

[PubMed]<br />

9. Barnett HJ, Taylor DW, Eliasziw<br />

M, Fox AJ, Ferguson GG, Haynes RB,<br />

et al. Benefit of carotid endarterectomy<br />

in patients with symptomatic moderate<br />

or severe stenosis. North American<br />

Symptomatic Carotid Endarterectomy<br />

Trial Collaborators. N Engl J Med.<br />

1998 Nov;339(20):1415-1425.<br />

10. Yadav JS, Wholey MH, Kuntz<br />

RE, Fayad P, Katzen BT, Mishkel GJ,<br />

et al. Protected carotid-artery stenting<br />

versus endarterectomy in high-risk patients.<br />

N Engl J Med. 2004 Oct;351<br />

(15):1493-1501. [PubMed] [CrossRef]<br />

11. Lund O. Preoperative risk evaluation<br />

and stratification of long-term survival<br />

after valve replacement for aortic<br />

stenosis. Reasons for earlier operative<br />

intervention. Circulation. 1990 Jul;<br />

82(1):124-39. [PubMed] [CrossRef]<br />

12. European Stroke Organisation,<br />

Tendera M, Aboyans V, Bartelink ML,<br />

Baumgartner I, Clement D, et al. ESC<br />

Guidelines on the diagnosis and treatment<br />

of peripheral artery diseases: Document<br />

covering atherosclerotic disease of<br />

extracranial carotid and vertebral, mesenteric,<br />

renal, upper and lower extremity<br />

arteries: the Task Force on the Diagnosis<br />

and Treatment of Peripheral Artery<br />

Diseases of the European Society of<br />

Cardiology (ESC). Eur Heart J. 2011<br />

Nov;32(22):2851-2906. [PubMed]<br />

[CrossRef]<br />

13. Leon MB, Smith CR, Mack M,<br />

Miller DC, Moses JW, Svensson LG, et<br />

al. Transcatheter aortic-valve implantation<br />

for aortic stenosis in patients who<br />

cannot undergo surgery. N Engl J Med.<br />

2010 Oct 21;363(17):1597-607.<br />

[PubMed] [CrossRef]<br />

14. Cribier A, Eltchaninoff H, Bash<br />

A, Borenstein N, Tron C, Bauer F, et al.<br />

Percutaneous transcatheter implantation<br />

of an aortic valve prosthesis for calcific<br />

aortic stenosis: first human case description.<br />

Circulation 2002 Dec 10;106(24):<br />

3006-3008. [PubMed] [CrossRef]<br />

15. Cribier A, Eltchaninoff H, Tron<br />

C, Bauer F, Agatiello C, Sebagh L, et al.<br />

Early experience with percutaneous<br />

transcatheter implantation of heart<br />

valve prosthesis for the treatment of endstage<br />

inoperable patients with calcific<br />

aortic stenosis. J Am Coll Cardiol. 2004<br />

Feb;43(4):698-703 [PubMed]<br />

[CrossRef]<br />

16. Kappetein AP, Head SJ, Genereux<br />

P, Piazza N, van Mieghem NM, Blackstone<br />

EH, et al. Updated standardized<br />

endpoint definitions for transcatheter<br />

aortic valve implantation: the Valve Academic<br />

Research Consortium-2 consensus<br />

document. Eur Heart J. 2012 Oct;33<br />

(19):2403-18. [PubMed] [CrossRef]<br />

17. New Sapien 3 Transcatheter<br />

Valve Impresses with Low 30-Day Stroke<br />

and Mortality Rates: PARTNER II.<br />

Medscape. Mar 15, 2015. [Medscape]<br />

18. Jones BM, Tuzcu EM, Krishnaswamy<br />

A, Kapadia SR. Incidence and<br />

Prevention of Strokes in TAVI. AIMS<br />

Medical Science, 2015; 2(1):51-64.<br />

[CrossRef]<br />

19 Massaro A, Messe SR, Acker MA,<br />

Kasner SE, Torres J, Fanning M, et al.<br />

Pathogenesis and Risk Factors for Cerebral<br />

Infarct After Surgical Aortic Valve<br />

Replacement. Stroke. <strong>2016</strong> Jul 5. pii:<br />

STROKEAHA.116.013970. [PubMed]<br />

[CrossRef]<br />

20. Huded CP, Youmans QR, Puthumana<br />

JJ, Sweis RN, Ricciardi MJ, MD,<br />

Malaisrie SC, et al. Lack of Association<br />

Between Extracranial Carotid and Vertebral<br />

Artery Disease and Stroke After<br />

Transcatheter Aortic Valve Replacement.<br />

Can J Cardiol. <strong>2016</strong> Mar 29. pii:<br />

S0828-282X(16)00251-8. [PubMed]<br />

[CrossRef]<br />

21. Steinvil A, Leshem-Rubinow E,<br />

Abramowitz Y, Shacham Y, Arbel Y, Banai<br />

S, et al. Prevalence and predictors of<br />

carotid artery stenosis in patients with<br />

severe aortic stenosis undergoing transcatheter<br />

aortic valve implantation. Catheter<br />

Cardiovasc Interv. 2014 Nov 15;<br />

84(6):1007-12. [PubMed] [CrossRef]<br />

Please cite this article as: Valkov V, Kalchev D, Kostadinov A, Kanazirev B. Performing transcatheter aortic valve implantation<br />

in patients with carotid stenosis. J of IMAB. <strong>2016</strong> Jul-Sep;22(3):1235-1237.<br />

DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1235<br />

Received: 21/05/<strong>2016</strong>; Published online: 26/07/<strong>2016</strong><br />

Address for correspondence:<br />

Veselin Valkov,<br />

First Clinic of Cardiology,Department of Internal Medicine, UMHAT St.Marina,<br />

Varna; 1, Hr. Smirnensky blvd., Varna, Bulgaria<br />

Mob: +359889232505<br />

E-mail: vd.valkoff@abv.bg<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1237

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

disease requires a genetic predisposition that interacts with<br />

the environment to result in illness. Imbalanced brain chemistry,<br />

specifically in the neurotransmitters dopamine and<br />

glutamate may also play a role in the development of AD.<br />

As the world’s population ages the number of people with<br />

AD is rising dramatically. Additional risks are female gender,<br />

history of head trauma, a low level of education [1].<br />

People suffering from dementia exhibit two main<br />

types of symptoms: cognitive and neuropsychiatric. The decline<br />

in cognition involves one or more cognitive domains<br />

(learning and memory, language, executive function, complex<br />

attention, perceptual-motor, social cognition) [3].<br />

Behavioural and Psychic Symptoms of dementia<br />

(BPSD) include hallucinations, delusions and different types<br />

of agitated behaviours [4, 5].<br />

The treatment of AD addresses [6]:<br />

· Cognitive enhancers (cholinesterase inhibitor<br />

therapy; NMDA-receptor antagonists) to improve, temporally<br />

stabilize or slow the rate of cognitive decline<br />

· Disease-modifying factors to reduce progression (antioxidants,<br />

selegiline, ginkgo biloba, etc.)<br />

· Psychotropic agents to treat BPSD [7, 8]<br />

· Treatment of non-psychiatric comorbidity [9,10]<br />

· Working with caregivers –education, emotional and<br />

social support, etc.<br />

Neurotransmitter enhancement therapy with<br />

cholinesterase inhibitors (ChE-Is) improve cholinergic function<br />

in AD by inhibiting the destruction of intrasynaptic acetylcholine<br />

by acetyl-cholinesterase, thus increase cholinergic<br />

synaptic transmission by inhibiting acetylcholinesterase<br />

in the synaptic cleft. They still represent the mainstay of<br />

symptomatic treatment in AD. Three medications belonging<br />

to this class are currently widely available and are approved<br />

for the symptomatic treatment of AD for mild to moderate<br />

dementia: donepezil, rivastigmine, and galantamine. Several<br />

randomised, controlled trials (RCTs) of ChE-Is in AD have<br />

demonstrated variable rates of improvement, ranging between<br />

18 and 48 per cent [11]. The authors discuss that their<br />

beneficial effects, demonstrated through meta-analyses, are<br />

modest in terms of cognitive and global measures of response.<br />

A number of adverse effects associated with ChE-Is<br />

are not benign and may limit their use in individual patients.<br />

Another point of discussion concerns costs [12]. In a review<br />

Birks (2015) discussed the results of 10 randomized, douhttp://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1238<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />




Mariana Arnaoudova 1 , Anna Todorova 2 , Antoaneta Tsvetkova 3 ,<br />

1) Department of psychiatry and medical psychology, Medical University, Varna,<br />

2) Faculty of Pharmacy, Medical University, Varna, Bulgaria<br />

3) Medical College, Medical University, Varna, Bulgaria.<br />


Background: Alzheimer’s disease (AD) is a progressive<br />

neurodegenerative disorder and presents a great burden<br />

for the person, family and society as a whole. Since 2012,<br />

in Bulgaria, AD is accepted as a disorder of a great socioeconomic<br />

significance and the drugs for home treatment are<br />

included in the reimbursement list of the National Health<br />

Insurance Fund (NHIF).<br />

Objective: To trace the access to treatment of Alzheimer’s<br />

in-home patients, as a result of generic substitution<br />

on the base of share distribution of the original and generic<br />

products.<br />

Methods: We collected data for the sales of pharmaceutical<br />

products (PP’s), containing donepezil hydrochloride<br />

and memantine hydrochloride from a distributor for the<br />

Northeast region of Bulgaria (Varna) in the period 2014-<br />

2015. An analysis of the percentage share distribution of the<br />

original and generic products was conducted.<br />

Results: According to our results original product<br />

Aricept accounts for only 4%, while the market share for its<br />

generics is 96%. In this group the share to be paid from NHIF<br />

is 25%, the remaining 75% from the cost is paid by the patients.<br />

The original product Axura occupies 8% market share,<br />

the generics- 92%. In this group the share to be paid from<br />

NHIF is 50% for generics, while Axura was removed from<br />

the Positive reimbursement list. We comment the significant<br />

differences in the sale shares in several directions.<br />

Conclusion: The reduction of expenses, with the use<br />

of generics, would help more patients to receive an optimal<br />

treatment and the savings could be redirected for other costly<br />

treatments.<br />

Key words: Alzheimer’s disease, cholinesterase inhibitors,<br />

memantine, financial costs, generics<br />

Introduction:<br />

Alzheimer’s disease (AD) is the most common cause<br />

of dementia among people aged 65 and older and accounts<br />

for 60%-70% of all cases [1]. In Bulgaria they are about 60<br />

000 [2]. AD is a progressive neurodegenerative disorder and<br />

presents a great burden for the person, family and society as<br />

a whole. The underlying causes of Alzheimer’s dementia<br />

(AD) remain unclear, but it most likely results from a combination<br />

of genetic and environmental factors, meaning the<br />

1238 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

le blind, placebo controlled trials. They demonstrate that<br />

treatment for 6 months, with donepezil, galantamine or<br />

rivastigmine at the recommended dose for people with mild,<br />

moderate or severe dementia due to Alzheimer’s disease, produced<br />

improvements in cognitive function. Benefits of treatment<br />

were also seen on measures of activities of daily living<br />

and behaviour. None of these treatment effects are large<br />

[13].<br />

A dysfunction of glutamatergic neurotransmission,<br />

manifested as neuronal excitotoxicity, is hypothesized to be<br />

involved in the etiology of Alzheimer’s disease. Targeting<br />

the glutamatergic system, specifically NMDA receptors, offers<br />

a novel approach to treatment. Memantine is the first in<br />

a novel class of AD medications acting on the glutamatergic<br />

system by blocking NMDA receptors. Memory loss in Alzheimer’s<br />

disease is due to a disturbance of message signals in<br />

the brain. Memantine hydrochloride acts on these (NMDA)-<br />

receptors improving the transmission of nerve signals and<br />

the memory. Memantine hydrochloride is used for the treatment<br />

of patients with moderate to severe Alzheimer’s disease.<br />

Treatment with the cognitive enhancers should start<br />

as the diagnosis of AD is established and should be continued<br />

in advanced phases [5].<br />

The long duration and pervasive social impact of the<br />

disease is reflected in the breakdown of the overall cost. ADassociated<br />

costs include direct medical costs such as medications,<br />

non-medication in-home or institutional care and<br />

indirect costs such as lost productivity of both patient and<br />

members of the family.<br />

Patients’ clinical characteristics include cognitive status,<br />

functional capacity, psychotic symptoms, behavioral<br />

problems, depressive symptoms, comorbidities, and duration<br />

of illness [14].<br />

Since 2012, in Bulgaria, AD is accepted as a disorder<br />

of a great socio-economic significance and the drugs for<br />

home treatment are included in the reimbursement list of the<br />

National Health Insurance Fund (NHIF).<br />

Paying for care is a big concern during the course<br />

of AD. The type and level of care needed change over time.<br />

Some in-home care costs include:<br />

· Ongoing medical treatment for Alzheimer’s-related<br />

symptoms<br />

· Treatment for other medical conditions<br />

· Prescription drugs<br />

· Personal care supplies<br />

· In-home care services<br />

According to Rice et al. (2001) opportunities exist<br />

through patient management programs targeted toward<br />

early diagnosis, effective use of medications, control of<br />

comorbidities, and patient and family support to partially<br />

offset these costs while providing quality patient care [15].<br />

The cost of dementia could be significantly reduced.<br />

Improvements in diagnosis, treatment and care and support<br />

for people with dementia and their carers would help planning,<br />

avoidance of future admissions and improved clinical<br />

management [16]. A great deal of cost savings come<br />

from generic substitution of drugs.<br />

The aim of our study is to trace the access to treatment<br />

of Alzheimer’s in-home patients, as a result of generic<br />

substitution on the base of share distribution of the original<br />

and generic products.<br />

METHODS:<br />

We collected data for the sales of pharmaceutical products<br />

(PP’s), containing donepezil hydrochloride and<br />

memantine hydrochloride from a distributor for the Northeast<br />

region of Bulgaria (Varna) in the period 2014-2015. An<br />

analysis of the percentage share distribution of the original<br />

and generic products was conducted. We chose to report sale<br />

rates shares because of the different distributors and the frequent<br />

updating in the prices of the PP’s in the reimbursement<br />

list, which limits the accuracy of the analysis.<br />


According to our results original product Aricept accounts<br />

for only 4%, while the market share for its generics<br />

is 96% (Fig. 1). In this group the share to be paid from NHIF<br />

is 25%, the remaining 75% from the cost is paid by the patients.<br />

Fig. 1. Market shares of Aricept and its generics<br />

The original product Axura occupies 8% market share,<br />

the generics- 92% (Fig. 2). In this group the share to be paid<br />

from NHIF is 50% for generics, while Axura was removed<br />

from the Positive reimbursement list.<br />

Fig. 2. Market shares of Axura and its generics<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1239

We comment the significant differences of the sale<br />

shares in several directions. First, the considerable price<br />

differentials between original and generic PP’s. Cheaper<br />

does not mean lower quality. Secondly, the low reimbursement<br />

rate from the NHIF. Thirdly, the removal of the original<br />

PP from the Positive reimbursement list.<br />

Treatment tendencies of AD patients are aligned<br />

with the Rational Drug Policy, which is a part of the National<br />

Health Strategy and are prerequisites for successful<br />

access of the patients to medications, reimbursed by NHIF.<br />

The final goal is an expanded access to effective treatment<br />

and to meet the drug therapy needs of all health insured<br />

persons. The efforts are aimed at protecting the interests of<br />

patients through creating financial savings through generics<br />

and biosimilars and the generated resources to be redirected<br />

to expensive, modern and innovative therapies.<br />

It is not possible to develop adequate drug therapy<br />

without the base of generics. Generic drugs are required to<br />

have the same active ingredient, strength, dosage form, and<br />

route of administration as the brand name product.<br />

The stimulation of generics’ production and distribution<br />

after the expiry of patent protection of the original<br />

product is a part of the Drug policy and targets a facilitated<br />

access at a lower price for the patients and the society.<br />

Availability of generics’ drug treatment consists in their<br />

cost, which is between 20% and 90% lower in comparison<br />

with the original products [17].<br />

Generic drug policy includes a number of measures<br />

to encourage physicians and pharmacists in prescribing and<br />

dispensing generic drugs as well as for patients receiving<br />

their free system for reimbursement. For countries like Bulgaria,<br />

where incomes are low, encouraging the use of generics<br />

is essential to improve patient access to treatment.<br />

Patients’ preference may depend on a number of factors,<br />

including knowledge about generics and branded drugs,<br />

drugs the patient is now using or has used in the past and<br />

financial incentives to use generic drugs [18].<br />

Data from WHO show that the presence of generic<br />

competition for five years decreased drug prices by 3 times<br />

while in the absence of such policies drug prices remained<br />

almost unchanged [19].<br />

We would like to give some recommendations: A<br />

consistent and coherent generic drug policy should be introduced.<br />

The automatic approval of a price, inclusion in<br />

the reimbursement list and a status of substitution for the<br />

generic drugs, as soon as they have received marketing authorization,<br />

in cases where the declared value is lower than<br />

the original product compared, to be enabled. Reimbursement<br />

should be performed according to more clear criteria<br />

among clinical adequacy and pharmacotherapeutic evaluation<br />

of one product to another and thus ensuring no replacement<br />

with pseudo-innovative products with the same<br />

characteristics and a high price on account of cheaper generic<br />

products. Physicians should be encouraged to prescribe<br />

generics and share information for successful prescription<br />

practices. Provision of information and promotion<br />

to patients to demand generic drugs.<br />


Neurotransmitter enhancement therapy with ChEIs<br />

and NMDA-receptor antagonists is a treatment approach for<br />

patients with mild to moderate and severe AD. Treatments<br />

slow cognitive decline, facilitate the care and delay placement<br />

of the patients in a nursing home, thus having economic<br />

benefits. The reduction of expenses, with the use of<br />

generics, would help more patients to receive an optimal<br />

treatment and the savings could be redirected for other<br />

costly treatments. The implementation of the above recommendations<br />

would lead to increased market competition<br />

between producers of original products and generics, in<br />

terms of production and distribution, and of price regulation.<br />


1. American Psychiatric Association.<br />

Diagnostic and Statistical<br />

Manual of Mental Disorders, Fifth<br />

Edition (DSM-5), American Psychiatric<br />

Association, Arlington 2013<br />

[CrossRef]<br />

2. National Consensus on dementia<br />

diagnosis, treatment and care. Bulgarian<br />

Society of Dementia. 2015.<br />

[Internet]<br />

3. Larson EB. Evaluation of cognitive<br />

impairment and dementia. Editors<br />

DeKosky ST, Schmader KE, Eichel AF.<br />

Up to Date. <strong>2016</strong> Apr, last updated:<br />

2015 Oct 28. [Internet].<br />

4. Finkel S, Burns A, Cohen G.<br />

Behavioral and Psychological symptoms<br />

of Dementia /BPSD/: A Clinical<br />

and Research Update. Overview. Int<br />

Psychogeriatr 2000; 12 /Suppl. 1/:13-<br />

18.<br />

5. Cummings J. The Neuropsychiatry<br />

of Alzheimer’s Disease and Related<br />

Dementias. London: Martin Dunitz<br />

Ltd. 2003. 309 p.<br />

6. Ballard C, Corbett A. Management<br />

of neuropsychiatric symptoms in<br />

people with dementia. CNS Drugs.<br />

2010 Sep; 24(9):729-739. [PubMed]<br />

7. Rosenberg PB, Mielke MM, Han<br />

D, Leoutsakos JS, Lyketsos CG, Rabins<br />

PV, et al. The association of psychotropic<br />

medication use with the cognitive,<br />

functional, and neuropsychiatric<br />

trajectory of Alzheimer’s disease. Int J<br />

Geriatr Psychiatry. 2012 Dec;27(12):<br />

1248-57. [PubMed]<br />

8. Maust DT, Kim HM, Seyfried LS,<br />

Chiang C, Kavanagh J, Schneider LS,<br />

et al. Antipsychotics, Other Psychotropics,<br />

and the Risk of Death in Patients<br />

With Dementia Number Needed<br />

to Harm. JAMA Psychiatry. 2015 May;<br />

72(5): 438-445. [PubMed]<br />

9. Poblador-Plou B, Calderón-<br />

Larrañaga A, Marta-Moreno J, Hancco-<br />

Saavedra Sicras-Mainar A, Soljak M, et<br />

al. Comorbidity of dementia: a crosssectional<br />

study of primary care older<br />

patients. BMC Psychiatry. 2014 Mar;<br />

14:84. [PubMed]<br />

10. Duthie A, Chew D, Soiza RL.<br />

Non-psychiatric comorbidity associated<br />

with Alzheimer’s disease. QJM.<br />

2011 Nov;104(11):913-20. [PubMed].<br />

11. Lanctot KL, Herrmann N, Yau<br />

KK, Khan LR, Liu BA, LouLou MA,<br />

1240 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

et al. Efficacy and safety of cholinesterase<br />

inhibitors in Alzheimer’s disease:<br />

A meta-analysis. CMAJ. 2003 Sep16;<br />

169(6):557-564.<br />

12. Loveman E, Green C, Kirby J,<br />

Takeda A, Picot J, Payne E, et al. The<br />

clinical and cost-effectiveness of donepezil,<br />

rivastigmine, galantamine and<br />

memantine for Alzheimer’s disease.<br />

Health Technol Assess. 2006 Jan;<br />

10(1):iii-iv. ix-xi: 1-160. [PubMed]<br />

13. Birks JS. Cholinesterase inhibitors<br />

for Alzheimer’s disease. Cochrane<br />

Database of Systematic Reviews, 2015.<br />

[CrossRef]<br />

14. Zhu W, Scarmeas N, Torgan R,<br />

Albert M, Brandt J, Blacker D, et al.<br />

Clinical features associated with costs<br />

in early AD. Neurology. 2006 Apr;<br />

66(7):1021-1028. [PubMed]<br />

15. Rice DP, Fillit HM, Max W,<br />

Knopman DS, Lloyd JR, Duttagupta S.<br />

Prevalence, costs, and treatment of<br />

Alzheimer’s disease and related dementia:<br />

a managed care perspective.<br />

Am J Manag Care. 2001 Aug;7(8):809-<br />

18. [PubMed]<br />

16. Living Well With Dementia: a<br />

national dementia strategy. Guidance.<br />

3 Feb 2009. [Internet]<br />

17. Ess SM, Schneeweiss S, Szucs<br />

TD. European healthcare policies for<br />

controlling drug expenditure.<br />

Pharmacoeconomics. 2003;21(2):89-<br />

103. [PubMed]<br />

18. ASPE ISSUE BRIEF. Expanding<br />

the Use of Generic Drugs. ASPE<br />

Staff. December 1, 2010 [Internet]<br />

19. Fischer MA, Avorn J. Economic<br />

consequences of underuse of<br />

generic drugs: evidence from Medicaid<br />

and implications for prescription<br />

drug benefit plans. Health Serv Res.<br />

2003 Aug;38(4):1051-63. [PubMed]<br />

Please cite this article as: Arnaoudova M, Todorova A, Tsvetkova A. Financial availability of in-home medical treatment<br />

of patients with Alzheimer’s disease. J of IMAB. <strong>2016</strong> Jul-Sep;22(3):1238-1241.<br />

DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1238<br />

Received: 19/05/<strong>2016</strong>; Published online: 30/07/<strong>2016</strong><br />

Address for correspondence<br />

Assoc. prof. Arnaoudova Mariana, MD, PhD<br />

Department of psychiatry and medical psychology, Medical University,<br />

55, Marin Drinov str. 9002 Varna, Bulgaria<br />

Mobile: +359 888 512 627<br />

e-mail: marnaudova@hotmail.com<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1241

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1242<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />




Mariana Dimova 1 , Hristina Arnautska 2 , Desislava Konstantinova 2 , Ivan<br />

Gerdzhikov 1 , Tihomir Georgiev 3 , Dimitar Yovchev 4<br />

1) Department of Prosthetic dentistry, Faculty of Dental Medicine, Medical<br />

University - Sofia, Bulgaria<br />

2) Department of Prosthetic dentistry and orthodontics, Faculty of Dental<br />

Medicine, Medical University - Varna, Bulgaria<br />

3) Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine,<br />

Medical University - Varna, Bulgaria<br />

4) Department of Imaging and Oral Diagnostics, Faculty of Dental Medicine,<br />

Medical University - Sofia, Bulgaria<br />


The aim of this study was to investigate and analyze<br />

the possible correlations between findings by manual functional<br />

analysis and clinical occlusal analysis in TMD-patients.<br />

Material and methods: Material of this study are<br />

111 TMD-patients selected after visual diagnostics, functional<br />

brief review under Ahlers Jakstatt, intraoral examination<br />

and taking periodontal status. In the period September<br />

2014 - March <strong>2016</strong> all patients were subjected to<br />

manual functional analysis and clinical occlusal analysis.<br />

17 people (10 women and 7 men) underwent imaging with<br />

cone-beam computed tomography.<br />

Results: There were found many statistically significant<br />

correlations between tests of the structural analysis that<br />

indicate the relationships between findings.<br />

Conclusion: The presence of statistically significant<br />

correlations between occlusal relationships, freedom in the<br />

centric and condition of the muscle complex of masticatory<br />

system and TMJ confirm the relationship between the<br />

state of occlusal components and TMD.<br />

Key words: freedom in the centric, deep bite, TMD<br />

Specialized literature abounds with epidemiological<br />

studies [1, 2, 3, 4], according to which, 50% to 70% of the<br />

general population have one or more symptoms of functional<br />

disorders of the masticatory muscles, temporomandibular<br />

joints (TMJs), teeth or periodontal ligaments. Depending<br />

on the population studied, methods applied and<br />

criteria set, subjective symptoms and complaints (reported<br />

by the patients) with frequency of 60%, or objective findings<br />

(of clinical functional examinations) with possible frequency<br />

of up to 90% have been observed [5].<br />

Okeson [6] summarizes that according to data of epidemiological<br />

studies, at least one objective symptom of<br />

functional disorders of the masticatory system, e.g. pain on<br />

palpation of the masticatory muscles, has been clinically<br />

confirmed in 40% to 75% of the adult population. According<br />

to the scientific researches of Rugh et al. [7] and<br />

Gremillion et al. [8], 50% to 70% of the general<br />

populations have at least one symptom of functional disorders.<br />

According to modern German scientific literature [9],<br />

the percentage of people suffering from craniomandibular<br />

disorders (CMDs) is even higher - 70% to 80% among the<br />

patients in Germany, with at least one clinical finding in<br />

58% of the studied patients on average.<br />

Last 10 years have marked a breakthrough in the scientific<br />

understanding of craniomandibular disorders and<br />

their relationships with the whole body. This gives grounds<br />

to Brocker [10] to conclude that 43% of the patients with<br />

orofacial pain have complaints and pain in five or more<br />

areas of the body.<br />

The signs and symptoms of CMDs frequently correlate;<br />

therefore, correct diagnosis of CMDs requires thorough<br />

knowledge of neurophysiology of pain [11, 12] and<br />

neuroanatomic convergencies [12, 13], and suggests an analytical<br />

diagnostic approach when interpreting the clinical<br />

findings of structural analysis tests.<br />

The aim of this study was to investigate and analyze<br />

possible correlations between the findings of manual functional<br />

analysis and clinical occlusal analysis in patients<br />

with CMDs.<br />


The study included 111 patients with CMDs (82<br />

women and 29 men) (Fig. 1 à, b), selected from five specialized<br />

dental practices (2 in Prosthetic dentistry, 1 in Orthodontics<br />

and 1 in Oral surgery), after taking the medical<br />

history and conducting visual diagnosis, brief functional<br />

examination according to Ahlers Jakstatt and intraoral examination.<br />

1242 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Fig. 1a b.<br />

In the period September 2014 - March <strong>2016</strong>, all selected<br />

patients were subjected to manual functional analysis<br />

and clinical occlusal analysis, conducted by Dimova in<br />

conformity with the algorithm of AFDT at DGZMK [14]. The<br />

following findings were considered positive: presence of discomfort<br />

(+/-); mild pain (+), severe pain (++) or extremely<br />

severe pain (+++). In assessing the TMJ, positive findings<br />

included noises (crackling in the joint) during the tests for<br />

traction, translation and dynamic compression in the TMJ.<br />

For assessing freedom in centric, the patients were<br />

asked to close slowly to the first interdental contact, to hold<br />

a few seconds in this position, and then to clench the teeth.<br />

The patients performed in triplicate these movements, to exercise<br />

them; then, clinical correlations between the jaws in<br />

centric relation (CR) and central occlusion (CO) were registered<br />

by using: Shimstock foil; blue articulation paper<br />

PROGRESS 100 ì; red articulation foil Bausch®Arti-Fol® 8 ì<br />

(Bausch /Dr. Jean Bausch GmbH & Co. KG) and bilateral<br />

colored markings in the premolar regions. The following<br />

were considered normal findings: presence of bilateral contacts<br />

in CR when swallowing; coincidence between CO and<br />

CR; path of 0.5-1 mm between the two positions, directed<br />

anteriorly along the sagittal plane.<br />

17 patients (10 women and 7 men) were subjected to<br />

diagnostic imaging of the TMJ, by using cone-beam computed<br />

tomography.<br />

The resulting examination findings were systematized<br />

and subjected to statistical processing with the package of<br />

applied programs for data analysis of epidemiological and<br />

clinical studies SPSS for Windows, version 16.00 (15/11/<br />

2007). Frequency analysis, cross-tabulation and graphical<br />

methods were used for data presentation; the method of c2-<br />

criteria (chi-square) or Fisher‘s exact (two-tail) test was used<br />

for identifying correlation between two qualitative variables.<br />


The “Play in the joint” test, conducted as a part of<br />

the manual analysis, enabled the clinical diagnosis of the<br />

TMJ. Individual articular areas or the articular capsule were<br />

subjected to dosed pressure or traction, resulting in positive<br />

findings, observed in one or both TMJs (in 50.9% or 57 of<br />

the patients studied), which depended statistically significantly<br />

from the freedom in centric, documented in the occlusal<br />

analysis (P=0.013) (Table 1).<br />

Table 1. Distribution of patients by findings of the tests for traction and translation, and freedom in centric<br />

Freedom in centric<br />

CO and Sliding Sliding Sliding to Total<br />

CRcoincide to the left anteriorly the right number<br />

Number 20 50 8 9 87<br />

Positive findings of the tests Absent % by row 23.0% 57.5% 9.2% 10.3% 100.0%<br />

for traction and translation % by column 100.0% 75.8% 80.0% 60.0% 78.4%<br />

in the left TMJ Number 0 16 2 6 24<br />

Present % by row .0% 66.7% 8.3% 25.0% 100.0%<br />

% by column .0% 24.2% 20.0% 40.0% 21.6%<br />

Number 20 66 10 15 111<br />

Total number % by row 18.0% 59.5% 9.0% 13.5% 100.0%<br />

% by column 100.0% 100.0% 100.0% 100.0% 100.0%<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1243

It is noteworthy that in 23.0% of the patients studied,<br />

in whom the positions of CO and CR coincided, the tests<br />

for traction and translation of the joint were asymptomatic.<br />

In the other patients, who had positive findings of the tests<br />

when passing from CR to CO, only 8.3% (2 patients) slipped<br />

anteriorly the mandible, and 91.7% deviated the mandible<br />

to the left or to the right. These movements away from the<br />

sagittal plane are coercive and occlusally conditioned by<br />

the presence of leading facettes or blockages in the occlusoarticulation<br />

relationships. The correlation between the presence<br />

of occluso-articulation disorders and the positive findings<br />

of the tests for traction and translation was also statistically<br />

significant (P=0.006).<br />

Statistical analysis of the data has shown a significant<br />

correlation between the freedom in centric and the results<br />

obtained from the tests for abduction (P=0.001), adduction<br />

(P=0.001) and isometric mediotrusion (P=0.005). These<br />

results confirm the interdependence between the presented<br />

or obstructed freedom in centric and the relevant state of the<br />

muscle complex of the masticatory system and the TMJ, and<br />

refute the opinions of some authors [15, 16, 17] for a lack of<br />

causality between the occlusal components and CMDs. The<br />

lateral deviation, recorded on the teeth, most frequently corresponded<br />

to the deviation of the ipsilateral articular head<br />

in the lateral and dorsal direction. The reaction in the joint<br />

was the resultant of the extent and direction of the deviation,<br />

the duration of the influence and compensatory capabilities<br />

of the body. For example, among the studied patients<br />

with CMDs and sliding to the left when passing from CR to<br />

CO, 75.8% had no symptoms during the tests for traction<br />

and translation. However, 24.2% of them reacted with pain<br />

of various intensities. The correlation between the occlusoarticulation<br />

disorders and the test results for traction and<br />

translation was statistically significant (P=0.006).<br />

Statistically significant correlations were also found<br />

between the presence or absence of freedom in centric and<br />

the test results for passive compression (P=0.041), dynamic<br />

compression and translation of the TMJ (P

A significant correlation (P=0.001) between the presence<br />

of deep bite and arthrosis of the TMJ was also found<br />

(Fig. 4, Table 2).<br />

Fig. 4. Patient À.S., aged 30 yrs. CBCT – osteo-arthrosis<br />

changes in the left TMJ<br />

Table 2.<br />

Distribution of patients by the presence of arthrosis in the TMJ and deep bite<br />

Deep bite<br />

Absent Present<br />

Total number<br />

Arthrosis in the TMJ<br />

Absent<br />

Number 24 15 39<br />

% by row 61.5% 38.5% 100.0%<br />

Present<br />

Number 2 15 17<br />

% by row 11.8% 88.2% 100.0%<br />

Total number<br />

Number 26 30 56<br />

% by row 46.4% 53.6% 100.0%<br />

It is interesting that the presence of deep bite is significantly<br />

dependent (P

Kobayashi and Hansson’s experiments on animals in 1988<br />

[18] to present researches of modern scholars [2, 9, 14].<br />

The results confirm the need of modelling the occlusion<br />

in a way, protective against the TMJ. This means that<br />

in both central occlusion and articulation, the TMJ should<br />

not be influenced by retrusively acting forces that subject<br />

articular ligaments and the bilaminar zone to overload and<br />

subsequent damage, and produce hypertone in the masticatory<br />

muscles that resist these forces - m. pterygoideus lateralis,<br />

m. masseter pars superior and m. pterygoideus medialis.<br />

Examined with tests for isometric tension, these muscles<br />

react with pain, graded subjectively by the patients on the<br />

proposed scale.<br />

Knowing and understanding of the described correlations<br />

is essential for the medical practice of professionals<br />

in General dentistry, Prosthetics and Orthodontics, since the<br />

nature of their clinical work involves changes in the occlusal<br />

relationships that result in functional effects on the structures<br />

of craniomandibular and craniocervical systems (Fig.<br />

5 - 7).<br />

Fig. 6. Patient M.P., aged 31 yrs. Treatment with fixed<br />

appliances in the upper and lower jaw with intrusion of the<br />

upper front teeth<br />

Fig. 5. Patient M.P., aged 31 yrs. First clinical examination<br />

– traumatic deep bite, Angle’s class II<br />

Fig. 7. Patient M.P., aged 31 yrs. Intraoral view after<br />

completion of the orthodontic treatment<br />

1246 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/


Manual functional analysis of the masticatory system<br />

is a set of tests for isometric muscle tensions, tractions, translations<br />

and dynamic compressions of the TMJs that upgrade<br />

the evidence obtained from palpation of the structures of<br />

masticatory system.<br />

The results, obtained from the manual analysis, should<br />

be considered in conjunction with the findings of clinical<br />

occlusal analysis. Such an analytical approach would allow<br />

a complete diagnosis of the masticatory system in the context<br />

of its functional unity and interdependence.<br />


1. Dorland, Newman WA. Dorland’s<br />

Illustrated medical dictionary. 27th ed.<br />

WB Saunders, 1988. 565<br />

2. Freesmeyer WB, Noack MJ.<br />

Quintessenz Focus Zahnmedizin:<br />

Funktionsdiagnostik und -therapie.<br />

Quintessenz Verlags-GmbH. 2009.<br />

3. Nilner M, Lassing SA. Prevalence<br />

of functional disturbances and diseases<br />

of the stomatognathic system in 7-14<br />

year olds. Swed Dent J. 1981; 5(5-<br />

6):173-87. [PubMed]<br />

4. Pullinger AG, Seligman DA,<br />

Solberg WK. Temporomandibular disorders:<br />

Part I. Functional status, dentomorphologic<br />

features, and sex differences<br />

in a nonpatient population. J<br />

Prosthet Dent. 1988 Feb;59(2):228-35.<br />

[PubMed]<br />

5. Nilner M. Epidemiologic studies<br />

in TMD. In: McNiell C. Current Controversies<br />

in Temporomandibular Disorders.<br />

1st Edition. Quintessence.<br />

1992; p.21-26.<br />

6. Okeson JP. Bell’s Orofacial Pains.<br />

The Clinical Management of Orofacial<br />

Pain. 6th ed. Carol Stream, IL: Quintessence<br />

Publishing Co, Inc; 2005.<br />

7. Rugh JD, Solberg WK. Oral<br />

health status in the United States: tem-<br />

poromandibular disorders. J Dent Educ.<br />

1985 Jun;49(6):398-406. [PubMed]<br />

8. Gremillion HA. The prevalence<br />

and etiology of temporomandibular<br />

disorders and orofacial pain. Tex Dent<br />

J. 2000 Jul;117(7):30-9. [PubMed]<br />

9. Ahlers MO, Freesmeyer WB, Göz<br />

G, Jakstat HA, Koeck B, Meyer G, et al.<br />

Instrumentelle, bildgebende und<br />

konsiliarische Verfahren zur CMD-<br />

Diagnostik (Stellungnahme der<br />

DGZMK und der AFDT). Zahnärztl<br />

Mitt. 2003; 93:1744.<br />

10. Brocker A, von Ow D.<br />

Craniomandibuläre Dysfunktionen -<br />

Wechselwirkungen mit dem Becken.<br />

[Diplomarbeit] Zürich. 2-2007; p.8-23.<br />

11. Gutowski A, Bauer A. Funktionsanalyse<br />

und Funktionstherapie im<br />

stomatognathen System. Berlin:<br />

Quintessenz; 1982.<br />

12. Köneke Ch. Craniomandibuläre<br />

Dysfunktion. Interdisziplinäre Diagnostik<br />

und Therapie. Quintessenz<br />

Verlag, Berlin. 2010<br />

13. Boisserée W, Schupp W. Kraniomandibuläres<br />

und musculoskelettales<br />

System. Quintessenz Verlag. 2012;<br />

Teile 2:83-126<br />

14. Dimova M. Contemporary tendencies<br />

and gnathological preconditions<br />

in diagnosis and rehabilitation of<br />

craniomandibular disorders. [Dissertation]<br />

Medical University Sofia, Bulgaria.<br />

2015; pp.136-142. [?in Bulgarian?]<br />

15. Cacchiotti DA, Plesh O, Bianchi<br />

P, McNeill C. Signs and symptoms in<br />

samples with and without temporomandibular<br />

disorders. J Craniomandib<br />

Disord. 1991 Summer;5(3):167-72.<br />

[PubMed]<br />

16. Pullinger AG, Seligman DA. The<br />

degree to which attrition characterizes<br />

differentiated patient groups of temporomandibular<br />

disorders. J Orofac Pain.<br />

1993 Spring;7(2):196-208. [PubMed]<br />

17. Pullinger AG, Seligman DA,<br />

Gornbein JA. A multiple logistic regression<br />

analysis of the risk and relative<br />

odds of temporomandibular disorders<br />

as a function of common occlusal features.<br />

J Dent Res. 1993 Jun;72(6):968-<br />

79. [PubMed] [CrossRef]<br />

18. Kobayashi Y, Hansson TL.<br />

Auswirkung der Okklusion auf den<br />

menschlichen Körper. Phillip J Restaur<br />

Zahnmed. 1988; 5(5)255-261.<br />

Please cite this article as: Dimova M, Arnautska H, Konstantinova D, Gerdzhikov I, Georgiev T, Yovchev D. CORRELA-<br />


Sep;22(3):1242-1247. DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1242<br />

Received: 21/05/<strong>2016</strong>; Published online: 05/08/<strong>2016</strong><br />

Address for correspondence:<br />

Assoc. Prof. Mariana Dimova, PhD, DSc<br />

Department of Prosthetic dentistry, Faculty of Dental Medicine, Medical<br />

University - Sofia<br />

1, St. George Sofiyski blvd., 1431 Sofia, Bulgaria.<br />

E-mail: marianadimova@abv.bg<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1247

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1248<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />








Atanas Petkov 1 , Yana Kashilska 2 , Angel Uchikov 1 , Dean Batzelov 3<br />

1) Department of Special Surgery, Faculty of Medicine, Medical University of<br />

Plovdiv, Bulgaria.<br />

2) Department of Health care management, Faculty of Public health, Medical<br />

University of Plovdiv, Bulgaria.<br />

3) Student in Faculty of Medicine, Medical University of Plovdiv, Bulgaria.<br />


Objective: To examine the damaged symptoms and<br />

functional disorders in women with secondary<br />

lymph>edema after breast cancer surgery in which to evaluate<br />

the therapeutic benefits of treatment with low intensity<br />

and extremely low frequency electrostatic fields reproduced<br />

by the - Deep Oscillation® with the program for a manual<br />

lymphatic drainage.<br />

Methods: Twenty-one patients, divided into two<br />

randomized groups. The first group of women consists of<br />

11 women treated with 10 session’s lymphatic drainage with<br />

Deep Oscillation. And second control group included 10<br />

women having undergone only standard lymphatic drainage.<br />

Subjective assessment includes pain and swelling;<br />

range of motion in the shoulder joint; movement of the<br />

neck and an analysis of the volume of the chest using a<br />

3D system measuring.<br />

Results: At the beginning of therapy, patients<br />

had high scores for sensation of pain; swelling of the<br />

extremities; restricted movement in the shoulder joint;<br />

restriction in the movement of the spine in the neck<br />

portion. In the course of treatment the pain reduces its<br />

intensity, the volume of movement in the shoulder joint<br />

is returns, but in the study group, which is subjected to<br />

lymph drainage with low-frequency electrostatic fields<br />

of apparatus - Deep Oscillation® indicators are much better.<br />

Moreover, significantly pain reduces. Subjective reduce<br />

swelling in both groups was confirmed objectively by 3D<br />

measuring only in the treatment group.<br />

Conclusion: Manual lymph drainage with deep oscillation<br />

leads to a significant reduction in pain relief and<br />

reduce swelling in patients with lymphoedema average<br />

breast compared with standard mechanical lymphatic drainage.<br />

Keywords: breast cancer, pain, swelling, lymphatic<br />

drainage, low intensity and low frequency electrostatic<br />

fields,<br />


Specialized Hospital for Rehabilitation - Banya,<br />

Karlovo District is the only health institution on the territory<br />

of the country where the Physical and Rehabilitation<br />

Program for women operated on breast carcinoma is successfully<br />

developed. The program is 10 days and is held<br />

in groups of 8 women. It is performed by a multidisciplinary<br />

team of specialists that includes: Physicians in physical and<br />

rehabilitation medicine; physiotherapists<br />

(kinesiotherapists, rehabilitation therapists, occupational<br />

therapists); oncologists; dieticians; clinical psychologists,<br />

and art-therapists.<br />

Patients undergoing organ sparing surgery interventions<br />

respond by amplification of the breast fibrosis, i.e.<br />

fibrosis of the skin. Goffmann and others. [1] detect breast<br />

lymphoedema in 9.8% of their patients. They formulate a<br />

definition for breast lymphoedema: swelling of the breast<br />

and formation of “orange peel” skin, combined with the<br />

sensation of heaviness and pain. The largest study included<br />

160 patients conducted by Rönkä and others [2]. The authors<br />

found breast swelling in 34% of the patients, orange<br />

skin in 3.8%, and sensitivity to palpation of the breast in<br />

59% of the cases. They noticed that the risk of developing<br />

lymphedema increases with the severity of axillary trauma<br />

in lymph node dissection, namely by increasing the number<br />

of the removed lymph nodes under m. pectoralis major.<br />

1248 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Fig. 1. Quadrantectomy with lymph node dissection<br />

In lymphedema of the breast the patients experience<br />

a chronic pain of medium to high intensity, discomfort,<br />

which leads to deterioration in their quality of life.<br />

Velanovich & Szymanski [3] investigated the quality of life<br />

in patients with secondary lymphedema. In their study they<br />

reached to the conclusion that a better treatment of the<br />

lymphedema is needed to ensure adequate quality of life in<br />

the operated patients. The diagnosis is usually focused on<br />

the lymphedema of the arm while the breast lymphedema<br />

recedes into the background. The degree of lymphedema of<br />

the arm can be quantitatively reproduced by manually measuring<br />

the circumference of the arm. The only objective way<br />

to study the lymphedema of the breast is the altered thickness<br />

of the skin flap. This parameter, however, is poorly reproducible<br />

and unreliable.<br />

The objectives of this study are to examine the damaged<br />

symptoms and functional disorders in women with secondary<br />

lymphedema after surgical treatment in which to<br />

evaluate the benefits of the therapeutic treatment with low<br />

intensity and extremely low frequency electrostatic fields<br />

reproduced by the apparatus - Deep Oscillation® with a program<br />

for performing a manual lymph drainage versus the effect<br />

of treatment with a standard apparatus lymphatic drainage<br />

technique.<br />

To study the objectives set we established clear inclusion<br />

criteria for the test group as criteria in studies:<br />

Carlson LE, and others [4] and Moadel AB, et al. [5],<br />

namely:<br />

1. Patients who underwent organ sparing surgery due<br />

to breast carcinoma, completed active treatment; on adjuvant<br />

therapy, 3 months after the surgical treatment at the earliest.<br />

2. Women with classification of the tumor according<br />

to TNM as follows: pT1 pN0 M0; pT2 pN0 M0; pT4<br />

pN0 M0, with lymph node dissection L0, without distant<br />

metastases M0, i.e. in the 1st; 2nd A, and 3rd A stage.<br />

3. The ten-day treatment period is at least 20 days<br />

after radiotherapy, or 10 days after chemotherapy in succession.<br />

Exclusion criteria were:<br />

1. Conducted Deep Oscillation® treatment within<br />

3 months prior to study.<br />

2. Acute inflammation; acute thrombosis; cardiovascular<br />

diseases; electronic implant; pregnancy; subjective sensitivity<br />

to electrical fields.<br />

To objectify the targeted objectives we created special<br />

measurement forms they are in studies Egan MY and<br />

others [6] and Eifel P, et al. [7], that include: Scoring VAS for<br />

assessment of the pain; lymphatic drainage analysis of the<br />

upper limb; Kinesiological analysis of the upper limb for the<br />

range of motion in the shoulder joint, as well as for the range<br />

of motion in the neck (for reference limits of normal movement<br />

we accept the following indicators: lateral flexion at<br />

45°, rotation 60°, anteflexion 40°, retroflexion 30°); 3D measurement<br />

of the volume of the operated breast with calliper for<br />

craniometry in anthropological research; oncohematological<br />

analysis. The indicators are filled on admission and discharge<br />

of the patient.<br />

We grouped and evaluated these objective indicators<br />

so that we can measure the quality of life of patients in absolute<br />

values analogically to our earlier article about the quality<br />

of life in patients operated for breast cancer after rehabilitation<br />

in the Specialized Hospital for Rehabilitation - Banya,<br />

Karlovo District.<br />


Deep Oscillation® is a therapeutic approach which<br />

consists in applying intermittent electrostatic field of low<br />

intensity (U = 100-400V; I = 150¼A) and extremely low frequency<br />

(30-200Hz, biphasic rectangular) to the target zone.<br />

The electrostatic field attracts and releases the patient’s tissue<br />

in the selected frequency, resulting in deep and permanently<br />

resonant vibrations. When the patient and the therapist<br />

are connected to the Deep Oscillation® device, serving<br />

as a voltage source of high internal resistance, a special glove<br />

serves as an insulator. The impulse of the voltage causes an<br />

electrostatic force of attraction of the tissues and leads to a<br />

higher frictional force while the swelling is massaged. Each<br />

session is for the duration of 30 minutes, starting with 15-<br />

minute procedures.<br />

At this point we should clarify the principle and the<br />

effect of the action of Deep Oscillation® which are expressed<br />

in two aspects.<br />

The first aspect - the ability to relax the edema is due<br />

to the deep and lasting vibrations caused by the electrostatic<br />

low intensity field, which is acting on the tissue level, and<br />

the accumulated toxins and sub-products in the extracellular<br />

space are released and drained by the lymphatic system.<br />

The second aspect - the reduction of the swelling is<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1249

due to the created electrostatic field, which changes the polarity<br />

of the cell membrane, and instead if the chemical influences<br />

in a physical way the cell channels, and in its turn<br />

this makes them open and release the free radicals and metabolic<br />

sub-products accumulated in the cytoplasm of the cell<br />

into the extracellular space, from where the lymphatic system<br />

picks them up.<br />

The device has the following physical characteristics:<br />

low intensity U = 100-400V, low current I = 150¼A (about<br />

10 times less than in batteries of our mobile phones) and<br />

extremely low frequency 30-200Hz with a biphase rectangular<br />

sinusoid, so that the activation of the cells, either its<br />

own, or of eventual metastatic ones is not possible, thus making<br />

the therapy with this apparatus in these characteristics<br />

safe for patients who underwent surgery due to breast cancer,<br />

as well as for other cancer patients.<br />

Fig. 2. Manual technique with Deep Oscillation®<br />

To achieve the objective measurement in the control<br />

group and the test group we fill the obtained results in the<br />

table of Quality of Life and compare its absolute values.<br />

The assessment of each criterion allows for the objective<br />

inclusion of the patients in the created Total Life Quality<br />

Scale. According to it, each criterion can be assessed with<br />

three answers that give – 0; 1 or 2 points. With a score from 0<br />

to 3 points - there is no improvement in the quality of life.<br />

With a score from 4 to 7 points the assessment of the improvement<br />

in the quality of life is “Good”. “Very good” is the<br />

assessment of the improvement in the quality of life with a<br />

score from 8 to 10 points.<br />

Table 1. TLQ scale and table for determining the Quality of Life in women who underwent oncological surgery due<br />

to breast cancer.<br />


Mild pains 0-4 0<br />

1 Pain Severity (VAS) Moderate pains 5-7 1<br />

Severe pains 8-10 2<br />

No change 0<br />

2 Swelling of the limb Functional improvement 1<br />

Functional and cosmetic improvement 2<br />

No change – up to 90° 0<br />

3 Range of motion in the shoulder joint Increase – up to 120° 1<br />

Increase – over 120° 2<br />

No change 0<br />

4 Range of motion in the neck Increase – up to 45° 1<br />

Increase – over 45° 2<br />

3D anthropological measurement of No change 0<br />

5 the volume of the breast Reduction in one size 1<br />

Reduction in two sizes 2<br />

TOTAL:<br />

1250 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

RESULTS:<br />

The performed study covered 21 women with breast<br />

cancer. Their ages ranged between 29 and 61 years. The<br />

average age was 45 years. Organ sparing surgery –<br />

quadrantectomy with lymph node dissection was performed<br />

in all patients who are with secondary lymph>edema in the<br />

area of the breast. Surgery on the left breast was performed<br />

in nine patients, and the on the right in 12 patients. The<br />

mean postoperative time is 2 years and one month. All patients<br />

had had adjuvant radiotherapy 4 to 5 months prior<br />

to study.<br />

Table 2. Stages of the patients included in the study according to the TNM classification.<br />


TNM-classification Number % TNM-classification Number %<br />

I pT1 pN0 M0 7 96% pT1 pN0 M0 9 90%<br />

I I A pT2 pN0 M0 3 3.1% pT2 pN0 M0 1 10%<br />

I II B pT4 pN0 M0 1 0.9% pT4 pN0 M0 - 0 %<br />

1. The evaluation of the moderate pain and the<br />

severity in all patients in both groups was 4.9 based on a<br />

visual analogue scale (VAS). The result of swelling is 5.9.<br />

There were no significant differences between the two<br />

groups.<br />

2. The lymph stasis of the upper extremity<br />

homolateral occurred in all the 11 operated women. The<br />

conducted low intensity and extremely low frequency<br />

electrostatic fields reproduced by the apparatus - Deep<br />

Oscillation® with program for performing a manual lymph<br />

drainage after instructions of the oncologist at the 11 patients<br />

with lymph stasis has led to 100% improvement in all of<br />

them. In 2, 18.5% of the cases a reduction in the<br />

circumference of the affected limb with 1 cm is observed –<br />

functional improvement, and in the rest 9 women, the 81.5%<br />

reduction in the swollen limb is by 1.5 to 3 cm, thus<br />

proportionality in the both limbs has been achieved –<br />

functionally and cosmetically.<br />

3. Increase in the range of motion in the affected<br />

shoulder joint of up to 50% was observed in 2 patients, 18.5<br />

%, and in 9 women, 81.5% and over 50% - which led to<br />

reference values of the motion in the joint.<br />

4. The mobility in the neck area is impaired in all<br />

patients. Only in the test group after the administration of<br />

the Deep Oscillation® this lead to a significant reduction in<br />

the pain.<br />

5. The subjective sensations of reduce in the swelling<br />

in both groups was confirmed objectively by the 3D<br />

measurement only in the group treated with Deep<br />

Oscillation®<br />

After analyzing the results achieved according to the<br />

TLQ-scale in the test group 1 female, 0.9% is with “Good”<br />

improvement in her quality of life, while the other 10 women,<br />

99.1% are with “Very Good” improvement in their quality<br />

of life. The results in the control group are 3 women, 30%<br />

with “Good” improvement in their quality of life, while the<br />

other 7 women, 70% are with “Very Good” improvement in<br />

their quality of life. We have not had patients with no<br />

improvement in their quality of life.<br />

We attribute the differences mainly to the fifth<br />

indicator, namely the change in the volume of the<br />

lymphedema breast in the test group, which was influenced<br />

by therapeutic low-intensity and extremely low frequency<br />

electrostatic fields, while on the control group a standard<br />

vacuum-machine lymph drainage was applied only in the<br />

area of the affected unilateral for operation upper limb.<br />


The Psychosocial Rehabilitation Program of the<br />

Specialized Hospital for Rehabilitation – Banya, Karlovo<br />

District with the participation of precise specialists,<br />

working in a team and in the underlying consistency of<br />

work and consultations with the women operated for breast<br />

cancer leads to:<br />

- Influenced the negative effects of the chemo- and<br />

radiotherapy.<br />

- Improving the physical activity of the affected upper<br />

limb, the general physical activity, and the overall condition<br />

of the body.<br />

- Improvement in muscle tone and the muscle strength.<br />

Improvement of the affected fine movements of the hand<br />

and the fingers.<br />

- Disappearance of the heaviness and pain in the hand,<br />

erysipelas of the affected limb.<br />

- In the therapeutic treatment of low intensity and<br />

extremely low frequency electrostatic fields reproduced by<br />

the apparatus - Deep Oscillation® with a program for<br />

performing a manual lymph drainage both the burden and<br />

the pain disappeared, as well as the erysipelas of the affected<br />

breast and its lymph stasis.<br />

The increase in the quality of life in the test group<br />

takes precedence over the increase in the quality of live in<br />

the control group. The difference is due to the administered<br />

therapy with low intensity and extremely low-frequency<br />

electrostatic fields versus a standard vacuum-machine lymph<br />

drainage in the control group.<br />

The apparatus used in the study is of innovative<br />

nature to our country, but our team will continue to work<br />

in this direction while we will gradually cover larger groups<br />

of patients while safe keeping their health and in the name<br />

of the better and modern treatment. The performed study<br />

and evidence material support the improvement of the<br />

quality of life of patients with breast carcinoma after<br />

treatment under the Physical and Rehabilitation Program<br />

of the Specialized Hospital for Rehabilitation – Banya,<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1251

Karlovo District. We express our gratitude to Acad. Dr<br />

Damyan Damyanov, MD and Prof. Dr. Elena Ilieva, MD<br />

without the efforts of which hundreds of women operated<br />

for breast cancer could not receive an adequate<br />

postoperative rehabilitation treatment.<br />


1. Goffman TE, Laronga C, Wilson<br />

L, Elkins D. Lymphedema of the arm<br />

and breast in irradiated breast cancer<br />

patients: risks in an ear of dramatically<br />

changing axillary surgery. Breast J. 2004<br />

Sep-Oct;10(5):405-411. [PubMed]<br />

2. Rönkä RH, Pamilo MS, von Smitten<br />

KA, Leidenius MH. Breast<br />

lymphedema after breast conserving<br />

treatment. Acta Oncol. 2004;43(6):551-7.<br />

[PubMed]<br />

3. Velanovich V, Szymansky W. Quality<br />

of life of breast cancer patients with<br />

lymphedema. Am J Surg. 1999 Mar;<br />

177(3):184-188. [PubMed]<br />

4. Carlson LE, Speca M, Patel KD,<br />

Goodey E. Mindfulness-based stress reduction<br />

in relation to quality of life, mood,<br />

symptoms of stress, and immune parameters<br />

in breast and prostate cancer outpatients.<br />

Psychosom Med. 2003 Jul-<br />

Aug;65(4):571-81. [PubMed]<br />

5. Moadel AB, Shah C, Wylie-Rosett<br />

J, Harris MS, Patel SR, Hall CB, et al.<br />

Randomized controlled trial of yoga<br />

among a multiethnic sample of breast<br />

cancer patients: effects on quality of life.<br />

J Clin Oncol. 2007 Oct 1;25(28):4387-95.<br />

[PubMed]<br />

6. Egan MY, McEwencd S, Sikorae L,<br />

Chasenfg M, Fitchh M, Eldredi S. Perspectives<br />

in Rehabilitation. Rehabilitation<br />

following cancer treatment. Disabil<br />

Rehabil. 2013; 35(26):2245-2258.<br />

[PubMed]<br />

7. Eifel P, Axelson JA, Costa J,<br />

Crowley J, Curran WJ Jr, Deshler A, et al.<br />

National Institutes of Health Consensus<br />

Development Conference Statement:<br />

adjuvant therapy for breast cancer, November<br />

1-3, 2000. J Natl Cancer Inst. 2001<br />

Jul;93(13):979-89. [PubMed]<br />

Please cite this article as: Petkov A, Kashilska Y, Uchikov A, Batzelov D. IMPROVING THE QUALITY OF LIFE THROUGH<br />



TREATED WITH STANDARD LYMPH EQUIPMENT. J of IMAB. <strong>2016</strong> Jul-Sep;22(2):1248-1252.<br />

DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1248<br />

Received: 14/05/<strong>2016</strong>; Published online: 05/08/<strong>2016</strong><br />

Address for correspondence:<br />

Dr Atanas Petkov PhD,<br />

One day surgery,<br />

bul. Peshtersko roud 66, 1-st floor, Plovdiv, Bulgaria,<br />

Mobile: +359898493554<br />

E-mail: tumbavw@abv.bg,<br />

1252 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1253<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />



Biserka I. Vasileva 1 , Milena D. Karcheva 2 , Vanya A. Birdanova 3 , Metodi V. Valkov 4 ,<br />

Georgi N. Nikolov 5 , Alexandar V. Valkov 5<br />

1) Department of Therapeutic Care, Faculty of Health Care, Medical University-<br />

Pleven, Bulgaria<br />

2) Department of Epidemiology, Faculty of Public Health, Medical University-<br />

Pleven, Bulgaria<br />

3) Department of Hygiene, Medical Ecology, Occupational Diseases and Disaster<br />

Medicine, Faculty of Public Health, Medical University-Pleven, Bulgaria<br />

4) Regional Health Inspectorate-Pleven, Bulgaria<br />

5) Department of Otolaryngology, Faculty of Medicine, Medical University-<br />

Pleven, Bulgaria<br />


Background: Brucellosis is an infectious and contagious<br />

disease caused by bacterial species of the genus<br />

Brucella. It is a major zoonosis with an important social<br />

and economic impact.<br />

Objective: The objective of this study was to investigate<br />

and analyze the measures application for control and<br />

eradication of brucellosis occurred in the region of Pleven.<br />

Methods: We conducted a retrospective epidemiological<br />

study. Respective documents were reviewed. We<br />

analyzed Case report form and Questionnaire for persons<br />

suspected of having brucellosis. Conclusions were made of<br />

the possible source of the disease and the risk factors leading<br />

to infection of humans.<br />

Results: A focus of Brucellosis among the animals<br />

to private goat farm in August was detected. The connection<br />

to other existing in the country focuses has been<br />

proved. Two of the persons, having had contacts with the<br />

animals developed clinical symptoms of the disease; referenced<br />

persons have consumed fresh goat cheese and milk.<br />

A joint epidemiological investigation with representatives<br />

of responsible authorities was carried out and measures undertook<br />

to restrict and liquidate the focus.<br />

Conclusion: Brucellosis in man can only be prevented<br />

effectively by elimination of the animal reservoir.<br />

This necessitates a close interaction between the medical<br />

authorities concerned with public health authorities on the<br />

one hand and the veterinary authorities on the other.<br />

Key words: brucellosis, epidemiological investigation,<br />

measures,<br />


Brucellosis is a zoonosis and the infection is transmitted<br />

by direct or indirect contact with infected animals<br />

or their products. It affects people of all age groups and of<br />

both sexes. The disease affects people in many parts of the<br />

world – Mediterranean countries of Europe, North and East<br />

Africa, the Middle East, South and Central Asia and Central<br />

and South America [1, 2]. The importance of brucellosis<br />

for public health is associated with expanded trade in<br />

animals and animal products [3, 4]. The reduced control of<br />

hygienic measures poses a risk of spreading the disease and<br />

return into Brucella-free regions.<br />

According to the data of Surveillance report (Annual<br />

epidemiological report 2014 – food- and waterborne diseases<br />

and zoonoses) in 2012, 376 confirmed cases of brucellosis<br />

were reported by 27 European Union (EU) and European<br />

Economic Area (EEA) countries (all except Denmark,<br />

Liechtenstein and Iceland). The overall rate was 0.08<br />

cases per 100 000. Greece, Spain, Italy and Portugal were<br />

the countries that reported a higher number of cases, accounting<br />

for 73% of all reported confirmed cases. Maleto-female<br />

ratio was 2:1 in 2012. The majority of the cases<br />

were adults over 25 years [5]. About 20% of the cases are<br />

related to traveling abroad. France, Germany and Sweden<br />

were among the countries with higher proportion of imported<br />

cases. Seasonality was with case peaks were reported<br />

from May to August. The morbidity rate among people in<br />

Bulgaria is sporadic. Sporadic cases have been recorded –<br />

8 (2008), 3 (2009), 2 (2010), 2 (2011), 1 (2012), 1 (2013),<br />

2 (2014). In 2015 an epidemic situation occurs in<br />

Kyustendil district, tenths of people falling ill (37) on the<br />

background of occurred epizooty among domestic animals.<br />

It was suspected that the contagious disease was spread out<br />

by illegally transported animals from neighboring countries..<br />

Brucellosis is a disease of animals caused by bacteria<br />

of the genus Brucella. Main reservoirs of bacteria are<br />

sheep and goats (B. melitensis), cattle (B. abortus), swine<br />

(B. suis), dogs (B. canis). In endemic areas, reservoirs can<br />

be bison, buffalo, camels, dogs, horses, rodents and other<br />

animals. B. neotomae has been isolated on few occasions<br />

and has never been implicated in human disease. Brucellosis<br />

may produce abortion in goats or sheep at about the<br />

fourth month of pregnancy [3]. Brucella melitensis is a major<br />

problem in many countries [1, s2]. The possible means<br />

of acquisition of brucellosis include: infection from a con-<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1253

taminated environment, occupational exposure usually resulting<br />

from direct contact with infected animals, and food<br />

borne transmission, bacteria breathing, person-to-person<br />

transmission (extremely rare). Food borne transmission is<br />

usually the main source of brucellosis for urban<br />

populations [5]. The objective of this study was to investigate<br />

and analyze the measures application for control and<br />

eradication of brucellosis occurred in the region of Pleven.<br />


We conducted a retrospective epidemiological study.<br />

Respective documents were reviewed. We analyzed Case<br />

report form (2 forms) and Questionnaire, suspected for brucellosis<br />

– 11 contact persons were interviewed. Data collection<br />

form containing questions about age, sex, residence<br />

place, occupation, education, contact with animals, food<br />

consumption, risk habits, geographical risk. Conclusions<br />

are made of the possible source of the disease and the risk<br />

factors leading to infection of humans.<br />


In August 2015 on the territory of Pleven district<br />

there broke out a focus of brucellosis among animals in<br />

private farm, Rakita village, Cherven Bryag municipality.<br />

Competent authorities were notified – Regional Health Inspectorate-Pleven<br />

and Regional Food Safety Authority-<br />

Pleven. Representatives of those authorities conducted together<br />

epidemiological investigation and established the<br />

following: there are 60 goats in the farm; 25 bought from<br />

Rila town, where in spring a focus of brucellosis was recorded.<br />

Three of newly purchased animals died within the<br />

period May-August. The laboratory examinations of veterinary<br />

authorities discover brucellosis. The remaining 22<br />

goats were also positive to the disease. Meeting was summoned<br />

of district and municipal epizootic commissions.<br />

Following measures were undertaken:<br />

I Regarding the animals<br />

• Prohibition the movement of big, small ruminating<br />

and odd-toed animals to and from the affected area..<br />

• Identification of animals and recording in Information<br />

System of Bulgarian Food safety agency (BFSA)<br />

was done.<br />

• Epizootic investigation to establish the source of<br />

infection was carried out.<br />

• Traceability of big and small ruminating animals’<br />

movement to and from the village was performed in order<br />

to discover focus of the disease.<br />

• Serological examination of all animals in the settlement<br />

was done. The new samples from animals in Rakita<br />

village proved to be negative, so the disease brucellosis<br />

remained localized only to the initial site. Samples were<br />

taken from the neighboring village Radomirtsi.<br />

• Killing of all positive for brucellosis small ruminating<br />

animals and burning out in incinerating furnace in<br />

good practice was ordered.<br />

• Sending of fetuses to miscarried animals for examination<br />

in National reference laboratory in brucellosis, National<br />

Diagnostic Science-and-Research Veterinary Medical<br />

Institute – Sofia.<br />

• Sending blood samples for serological examination<br />

of animals within 15 days after proven miscarriage.<br />

• Forbidding the slaughtering of sheep and goats<br />

from inflicted area.<br />

II Regarding animal products and exterior environment<br />

• Available milk and milk products, own production<br />

with positive reaction to brucellosis animals to be demolished<br />

according requirements of Regulation (EO) 1069/<br />

2004 dated 21 October 2009.<br />

• The milk, produced from big and small ruminating<br />

animals, intended for personal consumption, to be used<br />

for consumption or for production of milk products with<br />

ripening period at least 60 days or upon thermal processing<br />

- pasteurization at min. 72 degrees for 15 sec or at 63<br />

degrees for 30 minutes.<br />

• The milk, produced from big and small ruminating<br />

animals, intended for processing in milk processing enterprises,<br />

should be used in compliance to specific hygienic<br />

rules, regarding the foodstuffs from animal origin.<br />

• Disinfection of yards, premises, inventories and<br />

dunghills in agricultural areas with positive reaction to brucellosis<br />

animals.<br />

At the herein above described focus, 15 persons<br />

have been in contact with sick animals who consumed fresh<br />

goat cheese and milk. At the time of survey two persons<br />

with symptoms of the disease since a week (temperature,<br />

headache, fatigue, night sweating, muscle and joint pains).<br />

Blood for hemoculture was taken from those persons and<br />

directed for consultation and treatment. Three of contaminated<br />

persons left the settlement and for their new residencies<br />

the respective Regional health authority being notified.<br />

Blood was taken from remaining 11 persons for serological<br />

examination in NRL for Biohazard Level III Infections.<br />

Two of the samples were positive (of the persons with<br />

symptoms). Health-promotion activities were performed to<br />

the stock-breeders of the village. GP doctors in the municipality<br />

were notified for occurred epidemiological situation.<br />

As a result of described measures the seat of contamination<br />

was restricted and liquidated.<br />


To the 40-ies of XX century the brucellosis among<br />

animals in Bulgaria had endemic nature and widely spread<br />

out. The first case with a person was diagnosed in 1903.<br />

Since then to the beginning of present century, single, sporadic<br />

cases among people have been registered. Distinguished<br />

merits in that regard is the contribution of strict<br />

veterinary control on brucellosis in animal farms as well<br />

border veterinary-medical control. The disease was liquidated<br />

among animals and only imported cases were registered<br />

with people. After 2007 when the country became a<br />

member of EU there came into force the principle for free<br />

movement of goods, capitals, services and people. So there<br />

were imported from Greece on the territory of South Bulgaria<br />

animals, contaminated with brucellosis [6]. They were<br />

sold in various areas of the country and renewed the en-<br />

1254 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

demic nature of the diseases and respectively the risk for<br />

people, the evidence for that, registered cases in 2015. As<br />

in neighboring countries the disease is widely spread, the<br />

risk to import the contamination is always existing. Restriction<br />

shall be achieved by measures to liquidate the seats<br />

among animals as well prevent illegal import of such animals.<br />

Presented evidence about described focus of brucellosis<br />

place on the current agenda two basic issues:<br />

• probable source of infections are goats, bought<br />

from area where a focus of brucellosis has been identified<br />

[7];<br />

• the persons, suffering from brucellosis have consumed<br />

fresh goat cheese and milk which is the main reason<br />

for the alimentary way become a means of contamination<br />

[8].<br />

Common routes of infection include direct inoculation<br />

through cuts and abrasions in the skin, inoculation via<br />

the conjunctiva sac of the eyes, inhalation of infectious<br />

aerosols, and ingestion of infectious unpasteurized milk or<br />

other dairy products [9]. Blood transfusion, tissue transplantation<br />

and sexual transmission are possible but rare routes<br />

of infection.<br />

In countries with moderate or cold climates there is<br />

a marked seasonal variation in the incidence of acute brucellosis,<br />

with most cases occurring in spring and summer.<br />

This coincides with the peak period for abortions and<br />

parturitions among farm animals and hence for the highest<br />

level of exposure of those attending the animals and consuming<br />

their milk.<br />

So the prophylactic measures should envisage all<br />

possible manners of contamination. The recommendations<br />

in that regard are:<br />

• Public health education. Training of health workers<br />

and farm staff [10].<br />

• Personal hygiene. All persons carrying out highrisk<br />

procedures should wear adequate protective clothing.<br />

This includes an overall or coat, rubber or plastic apron,<br />

rubber gloves and boots and eye protection (face shield,<br />

goggles or respirator). The hands should be rinsed in disinfectant,<br />

washed in soap and water and then treated with<br />

cream. Eye protection is particularly important as conjunctival<br />

contamination carries a high risk of infection. Should<br />

any infectious material enter the eye, it should be removed<br />

under clean or aseptic conditions away from the working<br />

area. The eye should be thoroughly rinsed with running<br />

water and chloramphenicol or tetracycline eye drops or<br />

ointment applied. Respiratory contamination is also a high<br />

risk in heavily infected environments. Inhalation of dust<br />

or aerosols derived from dried excreta or tissues released<br />

at abortion, parturition or slaughter should be prevented<br />

by the use of suitable respirators [10].<br />

• Prevention of foodborne brucellosis. Boiling or<br />

high temperature pasteurization will kill Brucella in row<br />

milk [11, 12]. Ideally all milk produced in areas in which<br />

brucellosis is present should be pasteurized. If pasteurization<br />

facilities are not available, the milk should be heated<br />

to a minimum temperature of 80 - 85°C and the temperature<br />

held at that level for at least several minutes, or boiled.<br />

Cheese from non-pasteurized row milk should not be produced<br />

[13].<br />

• Strengthening veterinary and epidemiological<br />

control in private farms [2, 9, 14].<br />

• Ensure an accurate diagnosis - serological and<br />

microbiological and adequate therapy [15].<br />

The lack of safe, effective, widely available vaccines<br />

approved for human use means that prophylaxis currently<br />

plays little part in the prevention of human disease.<br />


Expansion of international travel, urbanization, the<br />

lack of hygienic measures in animal husbandry and in food<br />

handling partly account for brucellosis remaining a public<br />

health hazard. The disease in man can only be prevented<br />

effectively by elimination of the animal reservoir. This necessitates<br />

a close interaction between the medical authorities<br />

concerned with public health authorities on the one<br />

hand and the veterinary authorities on the other. Surveillance<br />

in animals and humans is an important step on the<br />

success of the eradication program.<br />


1. Aloufi AD, Memish ZA, Assiri<br />

AM, McNabb SJ. Trends of reported<br />

human cases of brucellosis, Kingdom<br />

of Saudi Arabia, 2004–2012. J<br />

Epidemiol Glob Health. <strong>2016</strong> Mar;<br />

6(1):11-8. [PubMed].<br />

2. Kassiri H, Amani H, Lotfi M. Epidemiological,<br />

laboratory, diagnostic<br />

and public health aspects of human brucellosis<br />

in western Iran. Asian Pac J<br />

Trop Biomed. 2013 Aug;3(8):589-594.<br />

[PubMed]<br />

3. Gul S, Khan A. Epidemiology and<br />

epizootology of brucellosis: a review.<br />

Pakistan Vet J. 2007;27(3):145-151.<br />

4. CDC Brucellosis [Internet]<br />

5. Asencio MA, Herraez O, Tenias<br />

JM, Garduão E, Huertas M, Carranza,<br />

R. et al. Seroprevalence survey of zoonoses<br />

in extremadura, southwestern<br />

Spain, 2002-2003. Jpn J Infect Dis.<br />

2015; 68 (2):106-112. [PubMed]<br />

6. Tzaneva V, Ivanova S, Georgieva<br />

M, Tasheva E. Investigation of the<br />

spread of brucellosis among human and<br />

animal populations in southeastern<br />

Bulgaria, 2007. Euro Surveill. 2009<br />

Apr;14(17):pii:19187. [PubMed]<br />

7. Rajala EL, Grahn C, Ljung I,<br />

Sattorov N, Boqvist S, Magnusson U.<br />

Prevalence and risk factors for Brucella<br />

seropositivity among sheep and goats<br />

in a peri-urban region of Tajikistan. Trop<br />

Anim Health Prod. <strong>2016</strong> Mar;48(3):<br />

553-558. [PubMed]<br />

8. Karagiannis I, Mellou K,<br />

Gkolfinopoulou K, Dougas G,<br />

Theocharopoulos G, Vourvidis D et al.<br />

Outbreak of brucellosis in Thassos,<br />

Greece, 2008. Euro Surveill. 2012<br />

Mar;17(11):pii:20116. [PubMed]<br />

9. Ganter M. Zoonotic risks from<br />

small ruminants. Vet Microbiol. 2015<br />

Dec;181(1-2):53-65. [PubMed]<br />

10. Corbel MJ. Brucellosis in hu-<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1255

mans and animals. WHO/CDS/EPR/<br />

2006.7:89. [Internet]<br />

11. Harvey RA, Cornelissen CN,<br />

Fisher BD. Microbiology. 3rd ed.<br />

Lippincott Williams & Wilkins. c2013.<br />

p.129-149.<br />

12. Enikova RK. Hygiene of nutrition.<br />

1st ed. Pleven:Medical University.<br />

EA-AD. 2014; p.151-157 [in Bulgarian]<br />

13. Enikova RK. [Microbiological<br />

processes and safety of Bulgarian white<br />

cheese]. [in Bulgarian] Bulgarian National<br />

Focal Point of EFSA. 2010; 36<br />

p. [Internet]<br />

14. European commission health<br />

and consumers directorate-general.<br />

Working Document on Eradication of<br />

Bovine, Sheep and Goats Brucellosis<br />

in the EU. SANCO/6095/2009.<br />

15. Denk A, Demirdag K, Kalkan A,<br />

Ozden M, Cetinkaya B, Kilic S. In vitro<br />

activity of Brucella melitensis isolates<br />

to various antimicrobials in Turkey.<br />

Infect Dis (Lond). 2015 Jun;47(6):364-<br />

369. [PubMed]<br />

Please cite this article as: Vasileva BI, Karcheva MD, Birdanova VA, Valkov MV, Nikolov GN, Valkov AV. Outbreak<br />

investigation and control of Brucellosis. J of IMAB. <strong>2016</strong> Jul-Sep;22(3):1253-1255.<br />

DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1253<br />

Received: 08/06/<strong>2016</strong>; Published online: 08/08/<strong>2016</strong><br />

Correspondence to:<br />

Milena Karcheva, MD, PhD;<br />

Department of Epidemiology, Medical University-Pleven, Bulgaria;<br />

e-mail: milena_karcheva@abv.bg<br />

1256 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1257<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />




Antoaneta Mlachkova 1 , Velitchka Dosseva-Panova 1 , Christina Popova 1 , Maya<br />

Kicheva 2<br />

1) Department of Periodontology, Faculty of Dental Medicine, Medical University<br />

of Sofia, Bulgaria;<br />

2) PhD, biochemist, Progene Ltd., Sofia<br />

SUMMARY:<br />

Chronic periodontitis is a multifactorial disease that<br />

is characterized by attachment loss and loss of alveolar<br />

bone. Periodontal pathogens from the subgingival<br />

microbiota are suggested as a major etiological factor for<br />

the periodontitis. The host inflammatory response against<br />

bacteria and their virulence factors underlies the current<br />

understanding of the pathogenesis of chronic periodontitis.<br />

The destructive immune response was shown to be associated<br />

with an extremely increased production of inflammatory<br />

cytokines in periodontal tissues. The expression of<br />

several cytokines likeIL-1β and IL-6 is responsible for alveolar<br />

bone resorption, and loss of connective tissue attachment<br />

in chronic periodontitis.<br />

Authors reported a reduction in the levels of inflammatory<br />

cytokines after successful periodontal therapy.<br />

Measuring the levels of inflammatory factors may be diagnostic<br />

approach to assess the effectiveness of the therapy<br />

of periodontitis.<br />

Keywords: chronic periodontitis, cytokines, IL-1β,<br />

IL-6, periodontal therapy, periodontal diagnosis.<br />


Inflammatory periodontal diseases are related with<br />

a response to complex dental biofilm that result in destruction<br />

of connective tissue attachment and alveolar bone [1,<br />

2, 3, 4]. Different periodontal diseases showed some variations<br />

in the histological and biochemical characteristics,<br />

but the molecular mediators and destructive mechanisms<br />

of pathological processes are similar. In the gingival tissue<br />

and the gingival crevicularfluid of patients with<br />

chronic periodontitis were detected high levels of pro-inflammatory<br />

factors: RANKL - (Receptor activator of NF-<br />

KB ligand), pro-inflammatory cytokines such as: IL-1β and<br />

IL-6 and TNF-α [1, 5, 6].<br />

Studies on the expression levels of IL-1β and IL-6<br />

in relation to the periodontal treatment will lead to: completing<br />

the understanding of the pathogenesis of periodontal<br />

destruction, assessing the severity of periodontitis, assessing<br />

the effectiveness of therapy or refractory, prediction<br />

of a recurrence and determination of progression of<br />

periodontitis.<br />

There is evidence that non-surgical therapy of<br />

chronic periodontitis is effective leading to reduction of<br />

bacteria load and pathogenic species levels in periodontal<br />

pockets, elimination of inflammation and significant reduction<br />

of periodontal pockets depth. This also results in a shift<br />

of the local destructive response including expression levels<br />

of some pro - inflammatory factors IL- 1β and IL-6. Their<br />

evaluation may serve to evaluate the effectiveness of nonsurgical<br />

therapy [1, 2, 6, 7].<br />

AIM:<br />

‣ Assessment of the effectiveness of non-surgical<br />

periodontal therapy in chronic periodontitis IL-1β and IL-<br />

6 gingival gene expression.<br />


In this study were used the following assessment<br />

methods:<br />

1. Clinical methods: Selection of patients - 20 patients<br />

with diagnosis chronic moderate to severe periodontitis.<br />

Including criteria:<br />

• presence of a minimum of 20 teeth,<br />

• presence of periodontal pockets with PPD ≤7 mm<br />

to ≥7 mm,<br />

• patients without periodontal therapy in the past 6<br />

months,<br />

• patients without systemic antimicrobial treatment<br />

in last 6 months.<br />

Survey excluded: pregnant women, patients with<br />

systemic diseases and systemic medication.<br />

Clinical parameters:<br />

Hygiene Index (HI); Bleeding on probing (BOP);<br />

Periodontal pocket depth (PPD); Clinical attachment loss<br />

(CAL); Gingival recession (R); Furcation degree - Hamp<br />

1975 classification (F).<br />

2. Molecular methods:<br />

‣ Gene expressionof IL-6 and IL-1β in the gingival<br />

tissue was determined by comparative quantitative analysis<br />


SCRIPT PCR) method.<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1257

• Gingival biopsies were taken for assessment of<br />

gene expression of IL-6 and IL-1β (in relation to the pockets<br />

with depth ≥7 mm- before and after the non-surgical<br />

periodontal treatment).<br />

3. Statistical methods:<br />

• Descriptive analysis<br />

• Test c2 and exact Fisher test<br />

• nonparametric Shapiro-Wilk test<br />

RESULTS:<br />

In this study was assessed the effectiveness of mechanical<br />

treatment of chronic periodontitis. The average<br />

age of the participants in the study was 47.9 years with<br />

standard deviation 10.5 SD (12 women and 8 men); the severity<br />

of periodontitis was assessed including the prevalence<br />

of periodontal sites with different pocket depth (3-5<br />

mm, 5-7mm and over 7 mm).<br />

The results of the study are shown on histograms,<br />

presenting the periodontal measurements in the initial diagnosis<br />

and after periodontal treatment as well as biochemical<br />

measurements. The data from the histograms are displayed<br />

as rectangles. The horizontal axis (the axis X)<br />

presents the research categories of data (e.g. quantitative<br />

or biochemical parameter). The vertical axis (the axis Y)<br />

describes the distribution of the presented parameter (patient’s<br />

contribution in the study). The height of the rectangle<br />

represents the frequency or density of the cases. The<br />

highest point of the curve shows the average frequency of<br />

the distribution of the monitored parameter.<br />

Histograms in the Figure 1 and Figure 2 represent<br />

hygiene status and the associated with dental plaque<br />

gingival inflammation, expressed by bleeding on probing.<br />

It is seen that in the majority of patients with severe chronic<br />

periodontitis the percentage of free plaque surfaces is less<br />

than 10% (HI 7 mm).<br />

Fig. 3. Reduction of sites with PD

Fig. 5. Reduction of sites with PD>7mm from 2.50%<br />

to 1.50%<br />

Fig. 6. Reduction of the gene expression of IL-1β<br />

Presented on the charts data clearly show that the<br />

therapy (non-surgical) results in a reduction in the number<br />

(expressed as a percentage) of periodontal sites with pocket<br />

depth 5-7mm and sites with pocket depth more than 7 mm<br />

(Figure 4 and Figure 5). Figure 3 presents reduction of sites<br />

with periodontal probing depth 3-5 mm.<br />

In Figures 6 and 7 are shown the changes in gene<br />

expression of the two studied cytokines - IL-1β and IL-6<br />

after the non-surgical periodontal therapy compared to<br />

initial levels. The reduction of gingival expression of investigated<br />

markers is associated with improving the<br />

gingival status and confirms the effectiveness of the nonsurgical<br />

periodontal treatment in patients with chronic<br />

periodontitis.<br />

Fig. 7. Reduction of the gene expression of IL-6<br />



Table 1 presents the statistically significant differences<br />

in examined parameters before and after non-surgical<br />

periodontal therapy in the current study. From our results<br />

it becomes clear that statistically significant differences<br />

in clinical parameters were found: HI (hygiene index),<br />

BOP (bleeding on probing), PD - 5mm, PD 5 - 7mm<br />

and PD> 7mm.<br />

Table 1. Statistically significant differences in studied<br />

clinical parameters before and after non-surgical periodontal<br />

treatment<br />




HI < 0,01<br />

BOP-distribution < 0,01<br />

PD-5 mm < 0,01<br />

PD5-7 mm < 0,01<br />

PD >7 mm 0,03<br />




Table 2 shows statistically significant correlations<br />

between investigated parameters in this study in patients<br />

with chronic periodontitis. There was established a significant<br />

correlation between gene expression of interleukin-6<br />

(expressed as Ct-value) and parameters: bleeding<br />

on probing (BOP) and periodontal pockets (PD) 5-7<br />

mm. Furthermore, the change in gene expression of<br />

interleukin-6 (expressed as dCt- IL6) was found to correlate<br />

with bleeding on probing, and also the change in gene<br />

expression of interleukin-6 (expressed as dCt -ILβ) correlates<br />

with the parameter - periodontal pockets with probing<br />

depth (PD) 5-7 mm (p

Table 2. Statistically significant correlations between evaluated in this study clinical and biochemical parameters<br />



Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1261<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />



CENTERS IN VARNA (absolute indicators)<br />

Lyubomira Koeva-Dimitrova,<br />

Department of Health Economics and Management, Medical University-Varna,<br />

Bulgaria<br />

SUMMARY:<br />

The capital structure analysis of medical institutions<br />

is related to the assessment of their financial sustainability.<br />

The degree of their financial sustainability indicates the extent<br />

to which the medical institution is exposed to financial<br />

risk. This financial risk is related to the use of foreign capital<br />

(debts, loans, etc.) and it is defined as the probability of insolvency<br />

and possible bankruptcy due to the existence of debts<br />

which could not be repaid at some point in the foreseeable<br />

future.<br />

Objective: To analyze the capital structure of the medical<br />

diagnostic-consultative centers in Varna city and on this<br />

basis to assess their long-term solvency and existence of financial<br />

risk.<br />

Materials and Methods: The materials for the study<br />

are the published annual financial statements (up to 05. 01.<br />

<strong>2016</strong>) in the Commercial Register for the period from year<br />

2008 to 2014 of all MDCCs (Medical Diagnostic Consultative<br />

centers), registered in Varna - 9 in total.<br />

In the study are applied logical-mathematical methods<br />

(comparison, grouping, detail, graphical method); financial<br />

and accounting analysis (balance sheet analysis; analysis<br />

of absolute ratios for financial sustainability).<br />

Results: Upon analysis of the capital structure of<br />

MDCC’s are studied the main absolute indicators characterizing<br />

the conditions for financial sustainability and the existence<br />

of financial risk regarding the solvency. A table represents<br />

the overall assessment of the degree of financial<br />

sustainability of the companies according to the type and<br />

structure of the fulfilled criteria. It was ascertained that for<br />

year 2014, DCC 3, 4, 5 and 8 have met all the conditions and<br />

according to them these hospitals have very high financial<br />

sustainability. DCC 7 has an average financial sustainability,<br />

DCC 1 and 2 are in a financial crisis and DCC 6 and 9 are<br />

facing bankruptcy. It must be emphasized that nearly half of<br />

the studied health care organizations (DCC 1, 2, 6 and 9)<br />

need urgent intervention by the owners regarding the preparation<br />

of remedial measures and programs, revaluation of assets,<br />

reduction of capital, reorganization, restructuring and<br />

others. Regarding the Municipal DCC’s that have the same<br />

owner - Varna Municipality, an individual approach for each<br />

consultative center should be applied, depending on the different<br />

nature and specifics of the activity. A strict monitoring<br />

of the financial performance and discipline is necessary.<br />

Conclusion: The capital structure analysis allows to<br />

all interested external users of information to evaluate the<br />

financial sustainability of the health care organizations, as<br />

well as their ability for debts repayment in the future.<br />

Keywords: analysis, capital structure, financial<br />

sustainability, financial risk, diagnostic- consultative centers,<br />

health care organizations, Varna<br />


The capital structure analysis of medical institutions<br />

is related to the assessment of their financial sustainability.<br />

The degree of their financial sustainability indicates the extent<br />

to which the medical institution is exposed to financial<br />

risk. This financial risk is related to the use of foreign capital<br />

(debts, loans, etc.) and it is defined as the probability of insolvency<br />

and possible bankruptcy due to the existence of debts<br />

which could not be repaid at some point in the foreseeable<br />

future.<br />


The aim of this article is to analyze the capital structure<br />

of the medical diagnostic-consultative centers in Varna<br />

city and on this basis to assess their financial sustainability,<br />

solvency and existence of financial risk.<br />

The relevant tasks to achieve the objective are: to<br />

present and analyze relevant indicators for analysis of capital<br />

stability; to make an overall analysis of the capital structure<br />

of DCCs based on the calculated indicators. To assess<br />

the capital stability and the existence of capital risk solvency.<br />


The materials for the study are the published annual<br />

financial statements (up to 05.01.<strong>2016</strong>) in the Commercial<br />

Register for the period from year 2008 to year 2014 of all<br />

MDCCs (Medical Diagnostic Consultative centers), registered<br />

in Varna - 9 in total [1]. There is no published data for<br />

DCC 2 for year 2009 and for DCC 9 for year 2014. For the<br />

purpose of this study, numbers from 1 to 9 have been assigned<br />

to the health care organizations. DCC from 1 to 7<br />

are Varna Municipality property, one of them is state property.<br />

DCC 8 and 9 are private property.<br />

In the study are applied logical-mathematical methods<br />

(comparison, grouping, detail, graphical method); financial<br />

and accounting analysis (balance sheet analysis; analysis<br />

of absolute ratios for financial sustainability).<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1261


The analysis of the capital structure of DCCs is performed<br />

by calculating the absolute and/or relative indicators,<br />

based on which their financial stability (sustainability)<br />

is assessed. The group of absolute indicators relates to so<br />

called “Indicators - conditions for financial stability.” The<br />

study results of the second group (relative indicators) are not<br />

included in this article, but their values and their interpretation<br />

confirm the results and the conclusions made. They<br />

include all indicators that are obtained as a ratio of different<br />

elements or combination of elements (ratios and relative<br />

shares) of financial data. Indicators for financial independence<br />

and financial autonomy are calculated.<br />

Upon the analysis of the absolute indicators it is considered<br />

[2, 3, 4, 5, 6, 7] that in order to define the company<br />

as financially stable, the following conditions should be met:<br />

1. Total Assets – Total Liabilities > 0 i.e.<br />

Total Equity > 0, where Total E = Equity (E) + Funding<br />

+ Deferred Income<br />

2. Total Assets (TA) – Total Liabilities (TL) > Total<br />

Liabilities, i.e.(TA-TL)-TL>0<br />

3. Equity (E)+ Long term Debts (LD) > Fixed Assets<br />

(FA), i.e. (E+LD)-FA>0<br />

4. Current Assets – Current Liabilities > 0, i.e<br />

Working Capital (W) > 0, or Current Assets > Current<br />

Liabilities<br />

5. Working Capital + Short-term Loans > Inventories<br />

6.Current Assets – Current Liabilities > Inventories<br />

According to the first condition, total assets minus<br />

total liabilities should be greater than zero, i.e. the equity<br />

should have positive value. The balance sheet equality reveals<br />

that in this case, the total equity will include: Equity<br />

+ Funding + Deferred Income. There are cases where<br />

the equity of the company has negative value – DCC 6 (-9<br />

000 lv for 2014) and DCC 9 (-11 000 for 2011, -26 000 lv<br />

– 2012 and -45 000 for 2013.). The reason for that is their<br />

very high degree of deleveraging. Over several consecutive<br />

years, the companies’ reported losses and the accumulated<br />

negative financial result exceed the equity and the<br />

reserves. Usually, the financial situation of such companies<br />

is extremely severe and often they fall into bankruptcy. The<br />

fact that the equity is negative means that the financial obligations<br />

of these companies are greater than the book<br />

value of their assets. This explains situations where companies<br />

possessing assets for millions are sold at a symbolic<br />

price of BGN 1[2, p.2].<br />

The second condition is related to the financial<br />

structure of the company. In general, the debt financing increases<br />

the financial risk. In order to control this risk within<br />

reasonable limits, it is recommended that the equity exceeds<br />

the financial obligations (Total Assets – Total Liabilities ><br />

Total Liabilities). DCCs 1, 2, 6, 7 8 9 do not meet this requirement<br />

(fig. 1).<br />

Fig. 1. Indicator’s values according to Condition 2<br />

1262 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

The third condition is related to the sources of investment<br />

financing in the company. According to it, the<br />

sum of the equity and long-term liabilities must exceed the<br />

amount of fixed assets. This is a basic requirement in terms<br />

of return on capital and return on borrowings of the company<br />

(liabilities). If the above mentioned inequality is not<br />

satisfied, this means that the company has used short-term<br />

sources for creating a part of the fixed assets. Given that the<br />

fixed assets have slow liquidity this can lead to difficulties<br />

or even impossibility of the company to return the borrowed<br />

short-term liabilities, such as falling into arrears and insolvency,<br />

with all the negative consequences for the company.<br />

Figure 2 reveals that this condition is not met in DCCs 1, 2,<br />

6 and 9 during the last analyzed years.<br />

Fig. 2. Indicator’s values according to Condition 3<br />

The fourth condition is linked to third one. According<br />

to it, the working capital (W) must be positive or Current<br />

Assets - Current liabilities > 0. Let’s mention again that<br />

the W represents in absolute value the portion of the current<br />

assets that is funded by long-term sources of capital -<br />

own or borrowed. If the fourth condition is not met, this<br />

means that the entire working capital was financed by shortterm<br />

obligations. This could be a signal for financial problems<br />

like delay of payments to suppliers, staff, banks and<br />

others. If the fourth condition is not met, this automatically<br />

means that the third condition is also not met, and vice versa.<br />

This is due to the fact that the W equals the difference between<br />

the long-term sources of capital (E+LD) and fixed assets<br />

(FA), i.e. (E+LD) - FA=W.<br />

The graphic reveals that his condition has not been<br />

met for DCC 1, 2, 6 and 9 for the last analyzed years (fig. 2).<br />

The fifth condition is related to the funding sources<br />

of the usual operating activity of the company and in particular<br />

to the funding of the inventories. Usually, they are<br />

financed with long-term sources in the form of W and shortterm<br />

sources like bank and commercial loans. Failure to meet<br />

this condition means that one part of the inventory is financed<br />

by interest-free current liabilities, for example - to<br />

suppliers, customers, staff and others. This could be a signal<br />

for financial problems related to working capital shortage<br />

and is a cause for delay of payments to contractors, employees,<br />

etc.<br />

Because of the small amounts of inventories in the<br />

majority of the DCCs, the fifth and the sixth conditions are<br />

usually met (in the cases where W is positive) and are not<br />

crucial in the determination of their financial situation and<br />

sustainability.<br />

The sixth condition is similar to the fifth, but sets<br />

more strict requirements for the financial stability compared<br />

to the fifth one - W to exceed the amount of inventories.<br />

DCCs with negative value of W usually do not fulfill the<br />

sixth condition. This is why it is not surprising that DCCs<br />

1, 2, 6 and 9 again do not meet the last two conditions.<br />

Practically speaking, few companies satisfy this condition<br />

as the current activity is rarely funded solely by longterm<br />

sources of capital (E and LD). Great part of the companies<br />

overcomes the working capital shortage by using shortterm<br />

loans.<br />

In its publication, Todorov uses a table to determine<br />

the financial sustainability [2, p. 3-4]. Based on this, we have<br />

specified the financial stability degree of the DCCs (Table 1).<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1263

Table 1. Determination of degrees for companies’ financial sustainability<br />

Degree of financial Fulfillment of financial sustainability conditions 2013 2014<br />

sustainability<br />

Very high All conditions are met DCC 3; 4; 5; 8 DCC 3; 4;5;8<br />

High<br />

6th condition is not met only<br />

Average<br />

First option: 5th and 6th conditions are not met<br />

Second option: 2ond condition is not met DCC 7 DCC7<br />

Low<br />

First option: 3rd, 4th, 5th and 6th conditions are not met<br />

Second option: 2ond, 5th and 6th conditions are not met<br />

Lack of sustainability<br />

(financial crisis)<br />

2nd, 3rd, 4th, 5th and 6th conditions are not met DCC 1;2;6 DCC 1;2<br />

Severe financial crisis<br />

(possible bankruptcy)<br />

None of the conditions is met DCC 9 DCC 6<br />

The analysis of the capital structure of the DCCs in<br />

Varna with the support of the table 1 for determination of<br />

the financial sustainability degree of the company reveals<br />

that for year 2013 and year 2014 DCC 3, 4, 5 and 8 have<br />

met all conditions, according to which these hospitals have<br />

very high financial stability. DCC 7 has an average financial<br />

stability, DCC 1 and 2 are in a financial crisis and DCC<br />

6 and 9 are facing bankruptcy.<br />


The capital structure analysis, carried out on the basis<br />

of an overall analysis of the absolute indicators for financial<br />

sustainability of the DCCs in Varna, concludes that<br />

almost half (DCC 1, 2, 6 and 9) of the studied hospitals need<br />

urgent intervention by the owners regarding the preparation<br />

of remedial measures and programs, revaluation of assets,<br />

reduction of capital, reorganization, restructuring and<br />

others. Regarding the Municipal DCC’s that have the same<br />

owner - Varna Municipality, an individual approach for each<br />

hospital should be applied, depending on the different nature<br />

and specifics of the activity. A strict monitoring of the<br />

financial performance and discipline is necessary.<br />

It is importantly that the health care managers continuously<br />

monitor, analyze and forecast the degree of financial<br />

stability of their hospitals. This enables timely implementation<br />

of various anti-crisis measures and procedures.<br />

In addition, the capital structure analysis allows to<br />

all interested external users of information to evaluate the<br />

financial sustainability of the diagnostic-consultative<br />

centers, as well as their ability for debts repayment in the<br />

future. It should be noted that the violations of economic<br />

sustainability of the organization leads to a crisis which<br />

extreme degree is the bankruptcy or termination of the organization.<br />


1. Registry Agency, Ministry of Justice,<br />

Commercial register, last: 11. 05.<br />

<strong>2016</strong>. [in Bulgarian] [Internet]<br />

2. Todorov L. [Assessment of financial<br />

sustainability - part of anti-crisis<br />

business management]. [in Bulgarian]<br />

16. 05. 2012. [Internet]<br />

3. Timchev M. [Financial - economic<br />

analysis]. [in Bulgarian] Nova Zvezda.<br />

2011; p. 200- 270.<br />

4. Trifonov T, Trifonova S. [Financial<br />

analysis of the company]. [in Bulgarian]<br />

Siela, Sofia. 2001; p. 30- 50<br />

5. Kostova N. [Financial Accounting<br />

Analysis]. [in Bulgarian] Activ-K Ltd,<br />

Varna. 2010; p.190-200<br />

6. Todorov G. [Financial Accounting<br />

Analysis]. [in Bulgarian] Steno, Varna.<br />

2003; p. 60- 70<br />

7. Koeva-Dimitrova L. [Analysis of<br />

the Financial Condition of Diagnostic<br />

Consultative Centers – Theoretical and<br />

applied aspects]. [in Bulgarian] MU-<br />

Varna, Steno, Varna. <strong>2016</strong>.<br />

Please cite this article as: Koeva-Dimitrova L. Capital structure analysis of the medical diagnostic-consultative centers in<br />

Varna (absolute indicators). J of IMAB. <strong>2016</strong> Jul-Sep;22(2):1261-1264.<br />

DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1261<br />

Received: 15/05/<strong>2016</strong>; Published online: 11/08/<strong>2016</strong><br />

Address for correspondence:<br />

Lyubomira Koeva-Dimitrova,<br />

Department of Health Economics and Management, Medical University-Varna<br />

55, Marin Drinov Str., 9000 Varna, Bulgaria;<br />

E-mail: lubomira@yahoo.com; lubomiradimitrova@gmail.com<br />

1264 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1265<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />




Ivan Gerdzhikov 1 , Mariana Dimova 2 , Tihomir Georgiev 3<br />

1) Department of Prosthetic dentistry, Faculty of Dental Medicine, Medical<br />

University -Sofia, Bulgaria<br />

2) Department of Prosthetic dentistry, Faculty of Dental Medicine, Medical<br />

University-Sofia, Bulgaria<br />

3) Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine,<br />

Medical University-Varna, Bulgaria<br />


Aim: The aim of this study is to track the effectiveness<br />

of prosthetic treatment with post resection dentures<br />

with solid substitute part and their role in the restoration<br />

of damaged functions.<br />

Materials and methods: The study included 14 patients<br />

(9 men and 5 women) with different size and location<br />

of defects in the upper jaw treated in the period 2010-<br />

<strong>2016</strong> with post resection prostheses with a solid substitute<br />

part.<br />

The impressions were taken with irreversible hydrocolloid<br />

impression material. The prostheses were completed<br />

by heat-curing acrylic with low quantity residual<br />

monomer.<br />

The effectiveness of prosthetics was evaluated by<br />

the method of Mihaylov for both oral-nasal examination<br />

of the pressure with the device “Oronasopneumotest.”<br />

For objectifying and assess the occlusal-articulation<br />

ratios was held computerized occlusal analysis with the system<br />

T-SCAN 8.<br />

Results: The results showed successful obturation<br />

and sealing of defects in all patients.<br />

It was found satisfactory recovery of the speaking<br />

function and normalization of occlusal-articulation ratios.<br />

Conclusion: The prosthetic treatment with post resection<br />

prostheses with a solid substitute part allows successful<br />

recovery of the lost speech and chewing functions,<br />

helping to restore self esteem and social rehabilitation of<br />

patients.<br />

Key words: palatal defects, maxillary resection, obturator,<br />

post resection prostheses.<br />

Damage in the maxillofacial area, occurring after<br />

maxillary resection, inflicts serious aesthetical changes,<br />

mental problems and functional disabilities in respect of<br />

impaired mastication, swallowing, speech and breathing [1,<br />

2]. A common opinion [3, 4, 5, 6] is that the degree of functional<br />

damage depends on the size and location of the defect.<br />

This is also confirmed by a research of Usui et al. [7, 8],<br />

who discovered lesser functional impairment in patients<br />

with smaller defects, a greater number of intact teeth and<br />

mouth opening greater than 20mm. Analogous is Devlin et<br />

Barker [9] position, who found that the localization of the<br />

defect, it’s size, and the condition of the remaining dentition<br />

are crucial for determining the degree of functional<br />

damage and for the prognosis the treatment.<br />

Prosthetic methods of treatment are of prime importance<br />

in complex treatment and rehabilitation in patients<br />

with maxillary resection (10, 11). According to the volume<br />

of the maxillofacial area engaged, treatment has its specifics,<br />

with respect to the degree of disability [12].<br />

Scientific literature describes a multitude of methods<br />

and modifications for treatment of patients with maxillary<br />

resection [13, 14, 15]. Some of these advocate treatment<br />

with closed obturators and others prefer hollow bulb<br />

obturators [16, 17]. Whatever the clinical approach, the main<br />

point of the treatment is to restore the masticatory function<br />

[18, 19]. For its improvement and for heightening of the<br />

masticatory function Umino et al. [20] suggest restoring of<br />

the occlusal contacts of first and second molars. Through<br />

videofluoroscopic analysis Yonthcev et al. [5] visualize the<br />

leading role of these molars in the masticatory cycle along<br />

with the negligible contribution of incisors and the teeth on<br />

the side of the defect. In a similar research before and after<br />

prosthetic treatment of patients with single-sided defects<br />

Xing et al. [21] found a 59,98% raise in masticatory effectiveness<br />

one month after the end of treatment. Similar results<br />

were obtained by Vergo et Chapman [4], who improve<br />

nutrition by distributing the masticatory stress.<br />


With the method applied, a prosthetic rehabilitation<br />

of 14 patients (9 men and 5 women) with oncologic operations<br />

of the maxilla, treated between 2011 and <strong>2016</strong> with<br />

closed post resection prostheses was carried out. The passageway<br />

defects which occurred, were unilateral and engaged<br />

only the hard palate and the alveolar crest, with the<br />

natural teeth preserved (Fig. 1).<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1265

Fig. 1. Intraoral view of a patient with unilateral maxillary<br />

defect.<br />

The prosthetic rehabilitation was carried out in 4<br />

clinical stages. In the first one we took impressions of both<br />

jaws with irreversible hydrocolloid impression material and<br />

to avoid it’s free entry we tamponed the defects with gauze.<br />

In the second clinical stage we determined the vertical dimension<br />

of occlusion and fixed the centric position with<br />

wax rims and light curing baseplates. After a successful clinical<br />

trial of the teeth in wax, the prostheses were finished in<br />

heat curing acrylic plastic with a low level of residual<br />

monomer. The cleaned and polished closed obturators with<br />

solid substitute part (Fig. 2a) were adjusted and articulated<br />

in the last clinical stage (Fig. 2b).<br />

Through Mihailov’s method of simultaneous oral and<br />

nasal cavity pressure measuring, we checked the effectiveness<br />

of the reached hermetization with the<br />

“Oronasopneumotest” gauge (Fig. 3) With one of the ducts<br />

the air pressure in the mouth was gauged by the oral light<br />

indicator and the other was fixed to the patient’s nostrils by<br />

a dough consistency silicone mass to affect the nasal light<br />

indicator. With each of the patients a triple examination was<br />

conducted, where a flashing of the respective indicator read<br />

presence or lack of hermetization between the oral and the<br />

nasal cavity.<br />

Fig. 3. “Oronasopneumotest” gauge<br />

Fig. 2. Closed obturator with solid substitute part (a),<br />

adjusted in the patient’s mouth (b).<br />

To objectify the obtained occlusal reflections, a computerized<br />

occlusal analysis with the T-SCAN 8 system was<br />

conducted.<br />


The obtained results indicated an optimal degree of<br />

hermetization in all treated patients. The “Oronasopneumotest”<br />

examination found a successfully created barrier between<br />

the oral and nasal cavity. The achieved effectiveness<br />

was a result of the implemented treatment method in which<br />

forming of a closed substitute part provided good retention<br />

and sufficient stability of the prostheses. Vital for the good<br />

clinical results were the comparatively small diameter and<br />

1266 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

the unilateral location of the defects, as well as the presence<br />

of natural teeth.<br />

Hermetization of postresection defects gave the opportunity<br />

to normalize the speech, mastication and swallowing<br />

in all of the patients. To the extent possible, occlusal<br />

relations were restored and documented by a computerized<br />

occlusion analysis with the T-SCAN 8 system (Fig. 4).<br />

The effect of the conducted prosthetic rehabilitation was<br />

restored self-confidence and social activity of the patients.<br />

Fig. 4. Computerized occlusal analysis with the T-<br />

SCAN 8 system<br />

support, but also to relieve pain and result in ease of use<br />

[11]. One of the most crucial parts in the application of obturator<br />

prostheses is retention. [4]. The volume and configuration<br />

of the defect, positioning of the remaining soft<br />

and hard tissues, and weight of the prosthesis are the major<br />

factors influencing the retention and stability of the<br />

prosthesis [8, 9].<br />

In literature there is a multitude of methods for production<br />

of obturators, in which different materials and techniques<br />

are used [15]. Most authors recommend treatment<br />

with hollow bulb obturators, which reduces the volume and<br />

weight of the prostheses and aids their placement in the<br />

defect. Their main disadvantages have to do with worsened<br />

hygiene and risk of developing a bacterial infection. To<br />

overcome this, we applied prosthetic treatment with post<br />

resection prostheses with solid substitute part. The obtained<br />

results indicated good retention and stability of the prostheses,<br />

which ensured optimal hermetisation of the defects.<br />

The positive results were due to the comparatively small<br />

defects, taking up only the hard palate and the alveolar<br />

crest, with remaining natural teeth of the upper jaw. The<br />

applied prosthetic treatment confirmed the statement, that<br />

post resection prostheses ensure the successful restoration<br />

of speech and masticatory function. The computerized occlusal<br />

analysis with the T-SCAN 8 system indicated normal<br />

occluso-articulatory relations and confirmed the statement<br />

of Vergo et Chapman [4], that the even distribution<br />

of masticatory pressure significantly improves nutrition.<br />


Prosthetic treatment with post resection prostheses<br />

is the most commonly used treatment method in patients<br />

with maxillary resection [1, 2, 3]. Well-designed post resection<br />

prostheses for maxillary defects were applied not<br />

only to maintain durable and good retention, stability, and<br />


The most challenging part in rehabilitating the patient<br />

with maxillectomy is achieving adequate retention<br />

and stability of the prosthesis. The prosthetic treatment<br />

with post resection prostheses with a solid substitute part<br />

allows successful recovery of the lost speech and chewing<br />

functions, helping to restore self esteem and social rehabilitation<br />

of patients.<br />


1. Depprich R, Naujoks C, Lind D,<br />

Ommerborn M, Meyer U, Kübler N, et<br />

al. Evaluation of the quality of life of<br />

patients with maxillofacial defects after<br />

prosthodontic therapy with obturator<br />

prostheses. Int J Oral Maxillofac<br />

Surg. 2011 Jan;40(1):71-79. [PubMed]<br />

2. Lethaus B, Lie N, Beer F, Kessler<br />

P, Baat C, Verdonck H. Surgical and<br />

prosthetic reconsiderations in patients<br />

with maxillectomy. J Oral Rehabil.<br />

2010 Feb;37(2):138-142. [PubMed]<br />

3. Keyf F. Obturator prostheses for<br />

hemimaxillectomy patients. J Oral<br />

Rehabil. 2001 Sep;28(9):821-829.<br />

[PubMed]<br />

4. Vergo TJ Jr, Chapman R. Maximizing<br />

support for maxillary defects.<br />

J Prosthet Dent. 1981 Feb;45(2):179-<br />

182. [PubMed]<br />

5. Yontchev E, Karlsson S, Lith A,<br />

Almqvist S, Lindblad P, Engström B.<br />

Orofacial functions in patients with<br />

congenital and acquired maxillary defects:<br />

a fluoroscopic study. J Oral<br />

Rehabil. 1991 Nov;18(6):483-489.<br />

[PubMed]<br />

6. Aramany MA. Basic principles of<br />

obturator design for partially edentulous<br />

patients. Part I: Classification.<br />

1978 [classical article]. J Prosthet<br />

Dent. 2001 Dec;86(6):559-561.<br />

[PubMed]<br />

7. Usui H. [Evaluation of maxillary<br />

prosthesis for better QOL]. [in Japanese]<br />

Nihon Jibiinkoka Gakkai Kaiho.<br />

1994 Sep;97(9):1643-56. [PubMed]<br />

8. Usui H, Sakakura Y, Shimozato<br />

K. [Maxillary prosthesis for better QOL<br />

- analysis of maxillary prosthesis stability].<br />

[in Japanese] Nihon Jibiinkoka<br />

Gakkai Kaiho. 1993 Apr;96(4):632-6.<br />

[PubMed]<br />

9. Devlin H., Barker GR. Prosthetic<br />

rehabilitation of the edentulous patient<br />

requiring a partial maxillectomy. J<br />

Prosthet Dent. 1992 Feb;67(2):223-<br />

227. [PubMed]<br />

10. Chigurupati R, Aloor N, Salas<br />

R, Schmidt B. Quality of life after<br />

maxillectomy and prosthetic obturator<br />

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ehabilitation. J Oral Maxillofac Surg.<br />

2013 Aug;71(8):1471-1478. [PubMed]<br />

11. Chen C, Ren W, Gao L, Cheng<br />

Z, Zhang L, Li S, et al. Function of obturator<br />

prosthesis after maxillectomy<br />

and prosthetic obturator rehabilitation.<br />

Braz J Otorhinolaryngol. <strong>2016</strong> Mar-<br />

Apr;82(2):177-183. [PubMed]<br />

12. Borlase G. Use of obturators in<br />

rehabilitation of maxillectomy defects.<br />

Ann R Australas Coll Dent Surg. 2000<br />

Oct;15:75-79. [PubMed]<br />

13. Anandakrishna GN, Sivaranjani<br />

G. Management of Velopharyngeal<br />

Disorders. A Case Series. J Prosthodont.<br />

2010 Jul;19(5):397-402.<br />

[PubMed]<br />

14. Patil PG. New technique to fabricate<br />

an immediate surgical obturator<br />

restoring the defect in original anatomical<br />

form. J Prosthodont. 2011<br />

Aug;20(6):494-498. [PubMed]<br />

15. Ariani N, Visser A, van Oort RP,<br />

Kusdhany L, Rahardjo TB, Krom BP,<br />

et al. Current state of craniofacial prosthetic<br />

rehabilitation. Int J Prosthodont.<br />

2013 Jan-Feb;26(1):57- 67.<br />

[PubMed]<br />

16. Cotert HS, Cura C, Kesercioglu<br />

A. Modified flasking technique for<br />

processing a maxillary resection obturator<br />

with continuous pressure injection.<br />

J Prosthet Dent. 2001 Oct;86(4):<br />

438-440. [PubMed]<br />

17. Elangovan S, Loibi E. Twopiece<br />

hollow bulb obturator. Indian J<br />

Dent Res. 2011 May-Jun;22(3):486-<br />

488. [PubMed]<br />

18. El Fattah H, Zaghloul A,<br />

Pedemonte E, Escuin T. Pre-prosthetic<br />

surgical alterations in maxillectomy to<br />

enhance the prosthetic prognoses as<br />

part of rehabilitation of oral cancer pa-<br />

tient. Med Oral Patol Oral Cir Bucal.<br />

2012 Mar;17(2):262-70. [PubMed]<br />

19. Kreeft AM, Krap M, Wismeijer<br />

D, Speksnijder CM, Smeele LE, Bosch<br />

SD, et al. Oral function after maxillectomy<br />

and reconstruction with an obturator.<br />

Int J Oral Maxillofac Surg.<br />

2012 Nov;41(11):1387-1392.<br />

[PubMed]<br />

20. Umino S, Masuda G, Fujita K.<br />

Masticatory performance with a prosthesis<br />

following maxillectomy: an<br />

analysis of 43 cases. J Oral Rehabil.<br />

2003 Jun;30(6):642-645. [PubMed]<br />

21. Xing GF, Jiao T, Sun J, Jiang<br />

YL. [The analysis of masticatory efficiency<br />

after maxillofacial prosthetic<br />

treatment for unilateral maxillary defect].<br />

[in Chinese] Shanghai Kou<br />

Qiang Yi Xue. 2003 Dec;12(6):422-<br />

423. [PubMed].<br />

Please cite this article as: Gerdzhikov I, Dimova M, Georgiev T. Efficiency of prosthetic treatment with post resection<br />

prostheses with solid substitute part. J of IMAB. <strong>2016</strong> Jul-Sep;22(3):1265-1268.<br />

DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1265<br />

Received: 21/05/<strong>2016</strong>; Published online: 12/08/<strong>2016</strong><br />

Address for correspondence:<br />

Dr. Ivan Gerdzhikov<br />

Department of Prosthetic dentistry, Faculty of Dental Medicine, Medical<br />

University - Sofia<br />

1, St. George Sofiyski blvd., 1431 Sofia, Bulgaria.<br />

E-mail: ivan_ger1971@abv.bg<br />

1268 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1269<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />




Elitsa Deliverska<br />

Department of Oral and Maxillofacial surgery, Faculty of Dental medicine,<br />

Medical University - Sofia, Bulgaria<br />


Background Hypochlorite solution is widely used<br />

in dental practice during root canal treatment. Although it<br />

is generally regarded as being very safe, potentially severe<br />

complications can occur when it comes into contact with<br />

soft tissue especially due to its cytotoxic features.<br />

Objective The aim of our paper is to present a case of<br />

damage of oral mucosa because of leakage of 3% hypochlorite<br />

through rubber dam during endodontic treatment.<br />

Material and methods We present a 31 years old female<br />

with necrosis of buccal mucosa during the endodontic<br />

treatment of 46.<br />

Results Three days after the procedure the patient<br />

was referred to our department for consultation and treatment.<br />

Antiseptic lavage was performed and oral antibiotic<br />

was administrated. After 5 days intraoral examination<br />

showed signs of almost full recovery.<br />

Conclusion The need for proper tooth isolation during<br />

restorative procedures is obvious. Anything that obscures<br />

the operative field negatively impacts operator efficiency<br />

and effectiveness. Visibility, patient/operator safety,<br />

infection control and the physical properties of dental materials<br />

are all compromised when proper isolation is lacking.<br />

Key words: sodium hypochlorite, mucosa damage,<br />

rubber dam<br />


Sodium hypochlorite (NaOCl) is the most commonly<br />

used solution in root canal treatments, as it is a low-cost<br />

method that displays a very effective antimicrobial activity<br />

against microbiota of infected root canals [1]. Furthermore,<br />

the ability to oxidize and hydrolize cell proteins and its<br />

tissue solvent capacity, increases its value as an irrigant solution<br />

[2]. Root canal treatment aims at the complete removal<br />

of the connective tissue and the destruction of residual<br />

microorganisms found in infected root canals. In addition,<br />

it seeks an effective seal in order to prevent<br />

recolonization of the root canal system with bacteria. However,<br />

this solution can cause complications especially due<br />

to its cytotoxic features.[3, 4] The clinical efficacy of NaOCl<br />

relates to its nonspecific ability to oxidize, hydrolize, and<br />

osmotically draw fluids out of tissues. Thus, this chemical<br />

agent reaches and cleans new areas within infected root canals,<br />

dissolving necrotic-purulent tissues. However, the cytotoxic<br />

effects are directly proportional to the concentration<br />

of the NaOCl [3, 4]. When this solution is injected into<br />

the adjacent tissues, the patient usually experiences intense<br />

pain, and an urgent treatment should be implemented in<br />

order to prevent a long-term sequelae. [5, 6, 7]<br />

The purpose of this paper is to discuss the use of<br />

sodium hypochlorite in dental treatment, reviews the current<br />

literature regarding hypochlorite complications, and<br />

considers the appropriate management for a dental practitioner<br />

when faced with a potentially adverse incident with<br />

this agent.<br />

Complications causing severe tissue reactions associated<br />

with the accidental extrusion of NaOCl into periapical<br />

tissues have been described in the literature. Some authors<br />

have mentioned clinical situations where sodium hypochlorite<br />

was inadvertently injected into the maxillary sinus<br />

[6, 7], or was unintentionally injected into the oral mucosa<br />

[5] causing adverse tissue reactions and life-threatening<br />

allergic responses [8, 9].<br />

With today’s heightened awareness of infection control,<br />

patient safety, and technique sensitive dental materials,<br />

meticulous operative field isolation is mandatory. Barrier<br />

isolation (rubber dam) is the most reliable method. If<br />

isolation is so important, why do so many clinicians resist<br />

using the rubber dam? Perhaps they never really learned<br />

to use it effectively. Today the rubber dam is the “Standard<br />

of Care” for isolation during restorative procedures and<br />

should be employed whenever possible.<br />

Rubber Dam Benefits<br />

· Dry, clean operating field<br />

· Improved access and visibility<br />

· Improved properties of dental materials<br />

· Patient protection<br />

· Improved infection control<br />

· Increased operating efficiency<br />

Sodium hypochlorite is a commonly used irrigant in<br />

endodontic practice. It has many potential complications<br />

ranging from permanent bleaching of clothes to severe soft<br />

tissue damage. NaOCl is highly irritant when extruded into<br />

vital tissues. [10 - 14] The well-perfused tissues of the oral<br />

cavity yet have considerable healing ability. The most<br />

common complication are described in Table 1.<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1269

Table 1.<br />

Complication<br />

Extrusion Of<br />

Irrigant<br />

Damage to<br />

eye<br />

Damage to<br />

oral mucosa<br />

Allergic<br />

reactions<br />

Author<br />

Bosch-Aranda ML, Canalda-Sahli C,<br />

Figueiredo R, Gay-Escoda C. [15]<br />

Motta MV, Chaves-Mendonca MA,<br />

Stirton CG, Cardozo HF. [16]<br />

Gatot A, Arbelle J, Leiberman A, Yanai-<br />

Inbar I. [17]<br />

Ingram TA 3rd. [18]<br />

Becking AG. [19]<br />

Khodabukus R, Tallouzi M. [20]<br />

Markose G, Cotter CJ, Hislop WS. [21]<br />

De Sermeno RF, da Silva LA, Herrera<br />

H, Herrera H, Silva RA, Leonardo ML.<br />

[22]<br />

Linn JL, Messer HH. [23]<br />

Witton R, Brennan PA. [24]<br />

Tosti A, Piraccini BM, Pazzaglia M,<br />

Ghedini G, Papadia F. [25]<br />

Baumgartner JC, Ibay AC. [26]<br />

Study<br />

Response of the human eye to accidental exposure to<br />

sodium hypochlorite.<br />

Complications in the use of sodium hypochlorite during<br />

endodontic treatment. Report of three cases.<br />

Chemical eye injuries 1: presentation, clinical features,<br />

treatment and prognosis.<br />

Response of the human eye to accidental exposure to<br />

sodium hypochlorite.<br />

Complications in the use of sodium hypochlorite during<br />

endodontic treatment. Report of three cases.<br />

Chemical eye injuries 1: presentation, clinical features,<br />

treatment and prognosis<br />

Facial atrophy following accidental subcutaneous extrusion<br />

of sodium hypochlorite.<br />

Tissue damage after sodium hypochlorite extrusion during<br />

root canal treatment.<br />

Hypochlorite injury to the lip following injection via a<br />

labial perforation. Case report<br />

Severe tissue damage and neurological deficit following<br />

extravasation of sodium hypochlorite solution during routine<br />

endodontic treatment.<br />

Severe facial edema following root canal treatment.<br />

The chemical reactions of irrigants used for root canal<br />

debridement.<br />

We describe a case of buccal mucosa necrosis because<br />

of leakage of rubber dam during the root canal treatment<br />

procedure of 46 and irrigation with 3% sodium hypochlorite.<br />

During the rubber dam technique for operative<br />

field isolation of the tooth there occured a leakage of sodium<br />

hypochlorite and caused necrosis of the mucosa.<br />

Fig. 1. Necrosis of buccal mucosa because of sodium<br />

hypochlorite exposure<br />

severe pain started some hours after the procedure. Clinical<br />

examination showed extraorally swelling and intraoral<br />

exam revealed necrosis of mucosa 1/ 2 cm in vestibular fold<br />

of 46, 47 and inflammatory reaction of surrounding tissue.<br />

Treatment consisted of a combination of amoxicillin<br />

and clavulanic acid 875/125 mg (Augmentine® 875/125<br />

mg)1 tablet every 12 hours for 5 days; prednisolone- cortico<br />

(60-40-20) taper dose over a 3 day-period using a decreasing<br />

dosage; paracetamol (0,500g) 1 tablet every 8 hours;<br />

vit C 1,0g twice daily.<br />

Fig. 2. Healing process five days after treatment<br />

Three days after the procedure the patient was referred<br />

to our department for consultation and treatment.<br />

(fig.1) Thirty one years’ old female patient complained of<br />

1270 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Five days after treatment clinical examination revealed<br />

almost full recovery and epitelization of the lesion.<br />

(fig. 2)<br />

Based on the presented case reports, special attention<br />

must be drawn to the potential risks associated with<br />

the use of NaOCl as an irrigant for root canal therapy. Thus,<br />

it is important to carry out an effective technique (isolation<br />

of operative field with rubber dam)) in order to avoid<br />

complications. In the event of accidental extrusion of<br />

NaOCl, treatment guidelines should be applied according<br />

to the magnitude of each individual case.<br />


Although a safe root canal irrigating solution, the<br />

use of NaOCL may also lead to life-threatening complications<br />

[27-33]. So, to ensure best safe, long lasting clinical<br />

practice, it is essential to recognize and manage these complications.<br />

Acute inflammation followed by necrosis results<br />

when NaOCl comes into contact with vital tissues. It causes<br />

severe inflammation and cellular destruction in all tissues.<br />

Sodium hypochlorite when comes in contact with tissue<br />

proteins, forms nitrogen, formaldehyde and acetaldehyde<br />

in short time and peptide links are broken resulting<br />

in dissolution of proteins. During the process, hydrogen in<br />

the amino groups is replaced by chlorine thereby forming<br />

chloramines which plays an important role in antimicrobial<br />

effectiveness. Necrotic tissues are thus dissolved and<br />

antimicrobial agent can reach and clean the infected areas<br />

better. Pashley et al. [3] demonstrated the cytotoxicity of<br />

Sodium hypochlorite using three independent biological<br />

models. They found that a concentration as low as 1:1000<br />

(v/v) of Sodium hypochlorite in saline caused complete<br />

haemolysis of red blood cells in vitro. As the solution used<br />

in this study was isotonic and thus excluded an osmotic<br />

pressure gradient, the observed haemolysis and loss of cellular<br />

protein was due to the oxidizing effects of Sodium<br />

hypochlorite on the cell membrane. Undiluted and 1:10 (v/<br />

v) dilutions produced moderate to severe irritation of rabbit<br />

eyes whilst intradermal injections of undiluted, 1:2, 1:4<br />

and 1:10 (v/v) dilutions of Sodium hypochlorite caused<br />

skin ulcers. Kozol et al. [34] proved Dakin’s solution to be<br />

detrimental to neutrophil chemotaxis and toxic to fibroblasts<br />

and endothelial cells.<br />

Sodium hypochlorite reacts with the protiens and fats<br />

of oral mucosa which might lead to secondary infections.<br />

The patient must be monitored with immediate treatment<br />

if swallowed.<br />

NaOCl is the most widespread irrigant used on root<br />

canal debridement. Used solutions may vary from 0.5% to<br />

5.25% and its biocompatibility is inversely proportional<br />

to its concentration [1, 2, 4]. When it comes in contact with<br />

vital tissues, NaOCl may cause haemolysis, skin ulceration,<br />

marked cell injury in endothelial cells and fibroblasts, and<br />

inhibition of neutrophil migration [3]. Thus, several studies<br />

have been carried out in order to compare the cytotoxic<br />

effects with those of other irrigant solutions. Regarding this<br />

aspect, Navarro-Escobar et al. [35] compared the cytotoxicity<br />

of 15% citric acid, 5% phosphoric acid and 2.5%<br />

NaOCl. They concluded that the irrigating solution with<br />

the highest percentage of cell viability was 2.5% NaOCl<br />

at both 0.1% and 0.5% dilutions. Therefore chlorhexidine<br />

gluconate is recommended as an alternative irrigating solution<br />

to NaOCl, especially in cases of open apex, suspected<br />

allergies to NaOCl or in the event of accidental extrusion<br />

[1, 2, 4].<br />

Author Year Findings<br />

Veeresh et al. [29] 2011 A patient with continuous , severe pain, oedema on left side of face, managed by antibiotics,<br />

analgesics, cold compress and on 10th day all symptoms suppressed.<br />

Loverty PD. [30] 2014 Patient with NaOCl extrusion followed endodontic treatment in maxillary first molar with<br />

excruciating pain, with blood stained fluid from left nostril; all managed by first ENT<br />

consultant for nasoscopy and then later root canal treatment completed.<br />

Jonathan et al. [31] 2015 A patient with NaOCl extrusion followed perforation during root canal treatmentin maxillary<br />

first premolar with swelling, bruising; pain was managed by i.v antibiotics, analgesics,<br />

steroids and then surgical intervention and finally full recovery was observed.<br />

Bernardo et al. [32] 2014 A patient with NaOCl apical extrusion followed root canal treatment returned in 24 hours<br />

with extreme pain, burning sensation in maxillary region with oedema and was managed<br />

by amoxicillin 500mg orally for 7 days then dexamethasone 4mg I.M. for 3days. Symptoms<br />

subsided after 8 months.<br />

If accident occurs treatment protocol should be followed<br />

[36].<br />

Immediate irrigation of canal or damaged soft tissue<br />

with normal saline to dilute the sodium hypochlorite.<br />

- Let the bleeding response continue to flush the irritant<br />

out.<br />

- Advice ice pack compression for 24 hours (15 minutes<br />

interval) to minimize the swelling.<br />

- Recommend warm, moist compress after 24 hours<br />

(15 minutes interval).<br />

- Prescribe non steroid anti-inflammatory drugs and<br />

pain killers for 7 days. Analgesics and antibiotics must be<br />

prescribed to reduce secondary infection. Refer to emergency<br />

on inhalation or injection<br />

- Prophylactic antibiotic coverage for 10 days to prevent<br />

secondary infection. Amoxicillin 1,0 g (2x1) with/<br />

without Metronidazole 500mg(3x1). In penicillin allergic<br />

patients prescribed Clindamycin (2x0,600).<br />

- Steroid therapy for 2-3 days to control inflammatory<br />

reaction.<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1271

- Reassure the patient and provide with both verbal<br />

and written homecare instructions.<br />

- Monitor the patient periodically.<br />


Sodium hypochlorite is an effective antibacterial<br />

agent but, when in contact with vital tissues it becomes a<br />

19. Becking AG. Complications in<br />

the use of sodium hypochlorite during<br />

endodontic treatment. Report of three<br />

cases. Oral Surg Oral Med Oral<br />

Pathol. 1991 Mar;71(3):346-348.<br />

20. Khodabukus R, Tallouzi M.<br />

Chemical eye injuries 1: presentation,<br />

clinical features, treatment and prognosis.<br />

Nurs Times. 2009 Jun;105(22):<br />

28-29. [PubMed]<br />

21. Markose G, Cotter CJ, Hislop<br />

WS. Facial atrophy following accidental<br />

subcutaneous extrusion of sodium<br />

hypochlorite. Br Dent J. 2009 Mar;<br />

206(5):263-264. [PubMed]<br />

22. De SermenÞo RF, da Silva LA,<br />

Herrera H, Herrera H, Silva RA,<br />

Leonardo ML. Tissue damage after sodium<br />

hypochlorite extrusion during<br />

root canal treatment. Oral Surg Oral<br />

Med Oral Pathol Oral Radiol Endod.<br />

2009 Jul;108(1):e46-49. [PubMed]<br />

23. Linn JL, Messer HH. Hypochlorite<br />

injury to the lip following<br />

injection via a labial perforation: Case<br />

report. Aust Dent J. 1993 Aug;38(4):<br />

280-282. [PubMed]<br />

24. Witton R, Brennan PA. Severe<br />

tissue damage and neurological deficit<br />

following extravasation of sodium<br />

hypochlorite solution during routine<br />

endodontic treatment. Br Dent J. 2005<br />

Jun;198(12):749-750. [PubMed]<br />

25. Tosti A, Piraccini BM,<br />

Pazzaglia M, Ghedini G, Papadia F.<br />

Severe facial edema following root canal<br />

treatment. Arch Dermatol. 1996<br />

Feb;132(2):231-233. [PubMed]<br />

26. Baumgartner JC, Ibay AC. The<br />

chemical reactions of irrigants used for<br />

root canal debridement. J Endod. 1987<br />

Feb;13(2):47-51. [PubMed]<br />

27. Marx JA, Hockberger RS, Walls<br />

RM. Rosen’s Emergency Medicine:<br />

Concepts and Clinical Practice. Mosby<br />

Elsevier. 6th edition. 2006; 931-933.<br />

28. Kavanagh CP, Taylor J. Inadvertent<br />

injection of sodium hypochlopotential<br />

irritant causing tissue destruction. So, to prevent<br />

this, injudicious use should be avoided by the use of a<br />

sealed rubber dam isolation during treatment, use of a Leur<br />

lock needle for irrigation, maintain a minimum of 2 mm<br />

reduction from the working length, avoid wedging of needle<br />

into the canal and most importantly avoid excessive<br />

pressure during irrigation.<br />


1. Garberoglio R, Becce C. Smear<br />

layer removal by root canal irrigants.<br />

A comparative scanning electron microscopic<br />

study. Oral Surg Oral Med<br />

Oral Pathol. 1994 Sep;78(3):359-67.<br />

[PubMed]<br />

2. Perez-Heredia M, Ferrer-Luque<br />

CM, González-Rodríguez MP. The effectiveness<br />

of different acid irrigating<br />

solutions in root canal cleaning after<br />

hand and rotatory instrumentation. J<br />

Endod. 2006 Oct;32(10):993-7.<br />

[CrossRef]<br />

3. Pashley EL, Birdsong NL, Bowman<br />

K, Pashley DH. Cytotoxic effects<br />

of NaOCl on vital tissue. J Endod.<br />

1985 Dec;11(12):525-8. [PubMed]<br />

4. Carson KR, Goodell GG,<br />

McClanahan SB, Comparison of the<br />

Antimicrobial Activity of Six Irrigants<br />

on Primary Endodontic Pathogens. J<br />

Endod. 2005 Jun;31(6):471-473.<br />

[CrossRef]<br />

5. Motta MV, Chaves-Mendonça<br />

MA, Stirton CG, Cardozo HF. Accidental<br />

injection with sodium hypochlorite:<br />

Report of a case. Int Endod J.<br />

2009 Feb;42(2):175-82. [PubMed]<br />

6. Kavanagh CP, Taylor J. Inadvertent<br />

injection of sodium hypochlorite<br />

into the maxillary sinus.Br Dent J.<br />

1998 Oct;185(7):336-7. [PubMed]<br />

7. Ehrich DG, Brian JD Jr, Walker<br />

WA. Sodium hypochlorite accident:<br />

Inadvertent injection into the maxillary<br />

sinus. J Endod. 1993 Apr;19(4):<br />

180-2. [CrossRef]<br />

8. Kaufman AY, Keila S. Hypersensitivity<br />

to sodium hypochlorite. J<br />

Endod. 1989 May;15(5):224-6.<br />

[CrossRef]<br />

9. Çaliskan MK, Türküm M, Alper<br />

S. Allergy to sodium hypochlorite during<br />

root canal therapy: A case report.<br />

Int Endod J. 1994 May;27(3):163-7.<br />

[PubMed]<br />

10. Gatot A, Arbelle J, Leinberman<br />

A, Yani-Inbar I. Effects of sodium hy-<br />

pochlorite on soft tissues after its inadvertent<br />

injection beyond the root<br />

apex. J Endod. 1991 Nov;17(11):573-<br />

4. [PubMed]<br />

11. Navarro-Escobar E, González-<br />

Rodríguez MP, Ferrer-Luque CM. Cytotoxic<br />

effects of two acid solutions<br />

and 2.5% sodium hypochlorite used in<br />

endodontic therapy. Med Oral Patol<br />

Oral Cir Bucal. 2010 Jan;15(1):e90-4.<br />

[PubMed]<br />

12. Hülsmann M, Hahn W. Complications<br />

during root canal irrigation:<br />

Literature review and case reports. Int<br />

Endod J. 2000 May;33(3):186-93.<br />

[PubMed]<br />

13. Witton R, Kenthorn M,<br />

Ethunandan M, Harmer S, Brennan PA.<br />

Neurological complications following<br />

extrusion of sodium hypochlorite solution<br />

during root canal treatment. Int<br />

Endod J. 2005 Nov;38(11):843–8.<br />

[PubMed]<br />

14. Kothari P, Hanson N, Cannell<br />

H. Bilateral mandibular nerve damage<br />

following root canal therapy. Br Dent<br />

J. 1996 Mar;180(5):189-90. [PubMed]<br />

15. Bosch-Aranda ML, Canalda-<br />

Sahli C, Figueiredo R, Gay-Escoda C.<br />

Complications following an accidental<br />

sodium hypochlorite extrusion: A<br />

report of two cases. J Clin Exp Dent.<br />

2012 Jul;4(3):e194-8. [PubMed]<br />

16. Motta MV, Chaves-Mendonca<br />

MA, Stirton CG, Cardozo HF. Accidental<br />

injection with sodium hypochlorite:<br />

Report of a case. Int Endod J.<br />

2009 Feb;42(2):175-182. [PubMed]<br />

17. Gatot A, Arbelle J, Leiberman<br />

A, Yanai-Inbar I. Effects of sodium hypochlorite<br />

on soft tissues after its inadvertent<br />

injection beyond the root<br />

apex. J Endod. 1991 Nov;17(11):573-<br />

4. [PubMed]<br />

18. Ingram TA 3rd. Response of the<br />

human eye to accidental exposure to<br />

sodium hypochlorite. J Endod. 1990<br />

May;16(5):235-8. [PubMed]<br />

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ite into the maxillary sinus. Br Dent<br />

J. 1998; 185: 336-337.<br />

29. Tegginmani VS, Chawla VL,<br />

Kahate MM, Jain VS. Hypochlorite accident<br />

– A case report. Endodontology.<br />

2011; 23:89–94<br />

30. Loverty PD. A case report of accidental<br />

extrusion of sodium hypochlorite<br />

into the maxillary sinus during<br />

endodontic retreatment and review<br />

of current prevention and management.<br />

J Res Dent. 2014; 2(2):96-100.<br />

[CrossRef]<br />

31. Hatton J, Walsh S, Wilson A.<br />

Management of the sodium hypochlorite<br />

accident: a rare but significant<br />

complication of root canal treatment.<br />

BMJ Case Rep. 2015 Mar 25;2015.<br />

pii: bcr2014207480. [PubMed]<br />

32. Almeida AB, Gomes FA,<br />

Ferretra CM, de Sousa BC, Costa<br />

FWG. Hypochlorite-induced severe<br />

cellulitis during endodontic treatment:<br />

Case report. RSBO. 2014 Apr-<br />

Jun;11(2):199-203<br />

33. Al Sebaei MO, Halabi OA, El-<br />

Hakim IE. Sodium hypochlorite accident<br />

resulting in life-threatening airway<br />

obstruction during root canal<br />

treatment: a case report. Clin Cosmet<br />

Investig Dent. 2015 Mar;7:41-44.<br />

[PubMed] [CrossRef]<br />

34. Kozol RA, Gillies C, Elgebaly<br />

SA. Effects of sodium hypochlorite<br />

(Dakin’s solution) on cells of the<br />

wound module. Arch Surg. 1988<br />

Apr;123(4):420-423. [PubMed]<br />

35. Navarro-Escobar E, Baca P,<br />

González-Rodríguez MP, Arias-Moliz<br />

MT, Ruiz M, Ferrer-Luque CM. Ex<br />

vivo microbial leakage after using different<br />

final irrigation regimens with<br />

chlorhexidine. J Appl Oral Sci. 2013<br />

Jan-Feb;21(1):74-9. [PubMed]<br />

36. Shibu TM. Risks and Management<br />

of Sodium Hypochlorite in Endodontics.<br />

Oral Hyg Health. 2015<br />

Jul;3(3):178. [CrossRef]<br />

Please cite this article as: Deliverska E. Oral mucosa damage because of hypochlorite accident – a Case report and literature<br />

review. J of IMAB. <strong>2016</strong> Jul-Sep;22(3):1269-1273. DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1269<br />

Received: 18/05/<strong>2016</strong>; Published online: 12/08/<strong>2016</strong><br />

Corresponding author:<br />

Associate prof. Elitsa Deliverska, PhD<br />

Department of Oral and Maxillofacial surgery, Faculty of Dental medicine,<br />

Medical University Sofia<br />

1, St. Georgi Sofiiski Str., 1431 Sofia, Bulgaria.<br />

E-mail: elitsadeliverska@yahoo.com<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1273

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1274<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />



Elitsa Deliverska<br />

Department of Oral and Maxillofacial surgery, Faculty of Dental medicine,<br />

Medical University - Sofia, Bulgaria.<br />


Background Osteoma is a benign osteogenic tumor<br />

arising from the proliferation of cancellous or compact bone.<br />

The osteoma can be central, peripheral or of an extraskeletal<br />

type.<br />

Objective: The purpose of our paper is to present a<br />

case of peripheral osteoma of the mandible and to evaluate<br />

the diagnosis and management of osteoma of the<br />

maxillofacial region with an analysis of the literature.<br />

Material and Methods: We present a 68 years old<br />

female patient with a hard, well defined swelling on the left<br />

side of the mandible in vestibular aspect near to the lower<br />

margin and medial to the angle.<br />

Results: Clinical evaluation (extraoral and intraoral)<br />

of patient and radiological findings directs for a diagnosisperipheral<br />

osteoma of left side of mandible and the patient<br />

was scheduled for surgical treatment.<br />

Conclusion: Peripheral osteoma of the jaw bones is<br />

uncommon. The post surgical follow-up should include<br />

periodic clinical and radiographic studies. Patients with<br />

osteoma associated with impacted or supernumerary teeth<br />

should be evaluated for possible Gardner’s syndrome.<br />

Key words: neoplasm, osteoma, mandible<br />

fibrofatty marrow enclosing osteoblasts with an architecture<br />

resembling mature bone [10, 11] “Recommended treatment<br />

is surgery, recurrence is rare and there are no reports of<br />

malignant transformation” [10, 12]. Most osteomas are small;<br />

however, in rare cases they may become large enough to<br />

cause displacement and damage to adjacent structures.<br />

Although osteomas may occur at any age, they are most<br />

frequently found in people over 40 years of age [1, 10].<br />

Clinically, the PO is usually an asymptomatic slow<br />

growing lesion which can produce swelling and asymmetry.<br />

The pathogenesis of PO is unclear. Some investigators<br />

consider it a true neoplasm, while others classify it as a<br />

developmental anomaly [8]. The possibility of a reactive<br />

mechanism, triggered by trauma or infection has also been<br />

suggested [6]. The association between maxillofacial<br />

osteomas, cutaneous sebaceous cysts, multiple<br />

supernumerary teeth and colorectal polyposis is known as<br />

Gardner’s syndrome [8].<br />

The purpose of this paper is to present the clinical<br />

and radiographic features of a case of huge osteoma of the<br />

mandible, its diagnosis and management.<br />

Fig. 1. Facial asymmetry because of osteoma of left<br />

side of mandible with no local sensitivity.<br />


Osteoma is a benign osteogenic tumour arising from<br />

the proliferation of cancellous or compact bone. Biological<br />

behavior includes slow expansive growth. It is a rare<br />

encapsulated bone neoplasm located in the bone tissue of<br />

the skull and the face [1, 2]. The osteoma can be central,<br />

peripheral or of an extraskeletal type. The central osteoma<br />

arises from the endosteum, the peripheral osteoma (PO) from<br />

the periosteum and the extraskeletal soft tissue osteoma<br />

usually develops within muscle [1, 2]. Peripheral osteomas<br />

in maxillofacial region are uncommon.<br />

It may occur as a solitary or multiple lesions on a<br />

single or numerous sections of the bone. The tumour may<br />

arise from cartilage or embryonal periosteum. “It may arise<br />

from the endosteal or periosteal surface” [3, 4, 5, 6]. One of<br />

the major differences of osteoma from other bony exostoses<br />

is the ability of this lesion to continue its growth during<br />

adulthood [3, 5, 7]. This is more common in men [1].<br />

Histologically, osteoma may be of two types:<br />

1) Compact or “ivory” and 2) Cancellous, trabecular<br />

or spongy [1, 8, 9]. The compact osteoma comprises dense<br />

bone with few marrow spaces and only a few osteons. The<br />

cancellous osteoma is characterized by bony trabeculae and<br />

1274 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

A 68-year-old woman came to the department of Oral<br />

and Maxillofacial Surgery of Faculty of Dental medicine,<br />

Medical University- Sofia for evaluation of a swelling in the<br />

left side of mandible which she found by chance a couple<br />

of months prior to examination and had grown slowly the<br />

last few months. A mild facial asymmetry was observed.<br />

(figure 1). Clinical examination revealed a non painful firm<br />

well-circumscribed palpable mass in the buccal vestibule<br />

aspect of the left side of the mandible near to the lower<br />

margin of the angle. The lesion was covered by normal skin.<br />

The patient had no paresthesia. The patient was in good<br />

health generally and with negative history of trauma in this<br />

region prior to the onset.<br />

Fig. 2. Peripheral osteoma affecting the body of the<br />

left mandible- panoramic radiograph showing a radiopaque<br />

mass attached to the body of the lower margin of the<br />

mandible.<br />

On panoramic radiography, a moderately well-defined<br />

radiopaque lesion was seen adjacent to the inferior border<br />

of the left side of the mandible extending from the lower<br />

border of mandible and with some degree of extension to<br />

the angle of the mandible. (figure 2).<br />

CT revealed a 4 × 4.3 cm well-defined, unilateral,<br />

pedunculated mushroom-like mass. The radiodense lesion<br />

is arising from the left buccal aspect of the inferior border<br />

of mandible, (figure 3). A working diagnosis of osteoma<br />

was established based on the clinical and radiographic<br />

findings. The lesion was scheduled for surgical removal<br />

under general anesthesia with extraoral approach.<br />


Osteomas, which are benign, slow-growing and welldefined<br />

neoplasms, may originate from membranous<br />

maxillofacial bones. [1, 12, 19] The tumours are often<br />

asymptomatic and are usually detected as an incidental<br />

finding on radiographic examinations, “revealed in roughly<br />

1% of routine scans” [13, 14, 15, 16]. “Headache [15],<br />

epistaxis [18], visual changes, pain and proptosis” are the<br />

most common symptoms of unusual tumours inside the<br />

paranasal sinuses [14]. Osteomas are frequently<br />

accompanied by chronic inflammation of the adjacent<br />

mucous membranes lining the sinuses and by mucoceles<br />

[12, 14].<br />

In the frontal sinus, an osteoma can cause erosion<br />

of the posterior wall, resulting in spontaneous<br />

pneumocephalus and cerebrospinal fluid (CSF) rhinorrhea<br />

[18, 20]. Obstruction of the draining ducts can facilitate<br />

the development of sinusitis or formation of a mucocele<br />

[20]. “Lesions larger than 3 cm in diameter are considered<br />

giant tumours” [20].<br />

The mandible is more commonly involved than the<br />

maxilla. They usually occur in the posterior region of the<br />

mandible on the lingual side of the ramus or on the inferior<br />

mandibular border below the molars [1, 19, 13, 17, 21].<br />

Other locations include the condylar and coronoid region.<br />

Structurally, osteomas are divided into three types: those<br />

composed of compact bone (ivory), those composed of<br />

Fig. 3. Bucco-lingual reconstruction of an axial CBCT scan of the<br />

mandible showing a radiopaque mass attached to the lower border of the<br />

mandible extending towards the buccal aspect.<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1275

cancellous bone and those composed of a combination of<br />

compact and cancellous bone. Osteomas may have<br />

osteoblastoma-like areas and distinguishing it from true<br />

osteoblastoma may be challenging. Some believe osteomas<br />

with osteoblastoma-like features behave more aggressively.<br />

Cortical-type osteomas develop more often in men, while<br />

women have the highest incidence of the cancellous type<br />

[1].<br />

As noted in previous reports in the literature, PO of<br />

the jaw bones is quite rare. These lesions usually appear<br />

as unilateral, pedunculated mushroom-like masses. In the<br />

mandible, the most common sites are the angle and lower<br />

border of the body, locations that are more susceptible to<br />

trauma. Also, the location of PO of the jaws is usually in<br />

close proximity to areas of muscle attachment, suggesting<br />

that muscle traction may play a role in its development [6,<br />

8, 16, 17]. Though the exact etiology and pathogenesis of<br />

PO is still unclear, traumatic, congenital, inflammatory and<br />

endocrine causes have been considered as possible<br />

etiologic factors [21]. There is evidence for some authors<br />

to suggest that the peripheral osteoma of the mandible is a<br />

traumatically induced reactive lesion and that muscle<br />

traction plays a role in its initiation. In view of this<br />

possibility, the term “perosteal osseous hyperplasia” may<br />

be more appropriate for those lesions in which a positive<br />

history of trauma preceded the onset. [6]<br />

Most cases of PO appear to have a very slow growth<br />

rate, without significant symptoms. In many cases, the<br />

discovery of the PO is an incidental finding. In some of<br />

the cases, however, depending on the location, the size of<br />

the tumour may cause facial deformity, deviation of the<br />

mandible on opening, headache or exophthalmos.<br />

Imaging of PO can be achieved by traditional<br />

radiography (i.e.: panoramic radiograph, Water’s view) or<br />

by CT scan. The use of CT scanning with 3-D<br />

reconstruction makes it possible to achieve a better<br />

resolution and more precise localization [6]. Bone scan was<br />

not performed routinely in all our patients, but when used,<br />

it was able to disclose the physiologic activity of the PO,<br />

enabling to determine whether it is a long standing, mature<br />

lesion with no further growth, or a relatively young lesion<br />

that is actively growing.<br />

CT, particularly three-dimensional CT scans, is so<br />

useful in defining the exact extension of the tumour and<br />

to determine the position of the lesion in relation with<br />

adjacent anatomical structures, when removal of the lesion<br />

is considered [14, 16, 17, 18]. CT scans, particularly CT<br />

scan in bone window and magnetic resonance imaging<br />

(MRI) give very good diagnostic possibilities, but plain<br />

radiography is also sufficient for the purpose of post<br />

operative follow-up. “Scan should be performed at least in<br />

six-month intervals during the first few years after surgery”<br />

[22]. Recurrence after surgical procedure is rare.<br />

The differential diagnosis includes exostoses–bony<br />

excrescences considered as hamartomas that stop growing<br />

after puberty, while osteomas may continue growth after<br />

puberty; peripheral ossifying fibroma – a reactive focal<br />

lesion; periosteal osteoblastoma; osteoid osteoma – those<br />

occur in young patients and are rare in the maxillofacial<br />

region and parosteal osteosarcoma–that present as painful<br />

destructive masses with rapid growth [1]. The appearance<br />

and homogeneity of osteoma is not difficult to characterize<br />

and diagnose.<br />

Osteomas involving the condylar head may be<br />

difficult to differentiate from osteochondromas,<br />

osteophytes or condylar hyperplasia and those involving<br />

the coronoid process may be similar to osteochondromas.<br />

A person who manifests with multiple intraoral or<br />

head and neck osteomas requires further radiographic work<br />

up to rule out Gardner’s syndrome. This syndrome,<br />

consisting of multiple epidermoid or sebaceous cysts,<br />

supernumerary teeth, retinal pigmentation and intestinal<br />

polyposis, necessitates a gastrointestinal radiographic<br />

evaluation because the polyps involved are premalignant<br />

[20]. The treatment for osteoma is surgical excision,<br />

particularly if there is a painful or active lesion growth [22,<br />

23].<br />

Removal of PO is not generally necessary. Surgery<br />

is indicated only when the lesion is symptomatic or<br />

actively growing. The surgical approach should be case<br />

specific. For the mandible there are intraoral or extraoral<br />

approaches. The intraoral approach is preferable when<br />

possible, mainly for cosmetic reasons. For the maxillary<br />

antrum, the sub-labial gingivo-buccal (Caldwell-Luc)<br />

approach is convenient. Endoscopic techniques have been<br />

advocated in selected cases [24]. For the temporal, frontal<br />

and fronto-orbito-ethmoidal lesions the coronal or bicoronal<br />

approaches have been classically used. However,<br />

these require an extensive amount of dissection, and carry<br />

the potential for significant morbidity, especially<br />

considering that the lesion to be resected is benign. There<br />

have been recent reports of use of the endoscopic nasal<br />

approach for the resection of ethmoidal and frontal<br />

osteomas [12, 14, 18, 24, 25].<br />

Recurrence of PO after surgical excision is extremely<br />

rare. There are no reports of malignant transformation of<br />

PO in the literature. There is very little understanding about<br />

the nature of PO, and three theories have been proposed:<br />

developmental, neoplastic and reactive [26]. It is unlikely<br />

that PO is a developmental anomaly, as most cases occur<br />

in adults and not during childhood or adolescence. It is<br />

also unlikely that PO is of a neoplastic nature, because of<br />

its very slow growth rate. The possibility that PO may be a<br />

reactive lesion, possibly to local trauma, is based on the<br />

history of trauma prior to the development of the lesion in<br />

some cases. However, this can be considered only in sites<br />

that are more susceptible to trauma, such as the angle or<br />

lower border of the mandible, but not in most of the cases.<br />

As many of the PO lesions are located in close proximity<br />

to muscle attachment (i.e.: masseter, medial pterygoid,<br />

temporalis), it is possible that muscle traction may play a<br />

role in the development of the PO. The combination of<br />

trauma and muscle traction was also suggested as a possible<br />

mechanism of the pathogenesis of PO. Patients with PO and<br />

supernumerary or impacted teeth should undergo a workup<br />

for Gardner’s syndrome [27, 28, 29, 30]. The triad of<br />

colorectal polyposis, skeletal abnormalities and multiple<br />

impacted or supernumerary teeth is consistent with this<br />

syndrome. The skeletal involvement includes peripheral<br />

and endosteal osteomas, which are found more frequently<br />

1276 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

in the skull, ethmoid sinuses, mandible and maxilla.[26]<br />

Because the osteomas often develop before the colorectal<br />

polyposis, early recognition of the syndrome may be in<br />

some cases, a life saving event. Mandibular osteomas may<br />

be a genetic marker for the development of colorectal<br />

carcinoma [27, 28, 29, 30]. Therefore the patient with a<br />

diagnosis of mandibular osteoma, suspected to have<br />

Gardner’s syndrome, should be further examined to rule out<br />

colorectal carcinoma.<br />


The peripheral type of osteoma is most common in<br />

the lower jaw, occurs at the surface of the cortical bone and<br />

is sessile or pedicled. The treatment for osteoma is surgical<br />

excision, particularly if there is painful or active lesion<br />

growth, or in order to correct asymmetry or other secondary<br />

problems, such as blockage of cavities, nerve foramina and<br />

vital organ compression. Recurrence after surgical<br />

procedure is rare.<br />


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Gunhan O. Peripheral osteoma of the<br />

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S, Shiba R. Unusual peripheral osteoma<br />

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11. Bosshardt L, Gordon RC,<br />

Westerberg M, Morgan A. Recurrent peripheral<br />

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446–50. [PubMed]<br />

12. Strek P, Zagolski O, Skladzien<br />

J, Kurzynski M, Dyduch G. Osteomas<br />

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Kumar SP. Solitary osteoma of body of<br />

the mandible. Journal of Orofacial Sciences.<br />

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Vincent C, Pertuzon B, Assaker R. [Frontal<br />

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1):104-8. [PubMed]<br />

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16. Chattopadhyay CP, Chander<br />

MG Peripheral osteoma of the maxillofacial<br />

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Gunbey PH, Celik A. Peripheral osteoma<br />

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18. Summers LE, Mascott CR,<br />

Tompkins JR, Richardson DE. Frontal<br />

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Castro JF, Catunda I, Leão JC, da Cruz<br />

Perez DE. Solitary peripheral osteomas<br />

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Hartman KS, Langlais RP. Diagnostic<br />

imaging of the salivary glands and<br />

periglandular regions. In: DelBalso AM,<br />

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Saunders; 1990. pp. 198–201.<br />

21. Lucas RB. Pathology of tumors<br />

of the Oral Tissues. 4th ed. Edinburgh,<br />

Scotland: Churchill Livingstone; 1984.<br />

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22. Rao VM, Sharma D, Madan A.<br />

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23. Woldenberg Y, Nash M, Bodner<br />

L. Peripheral osteoma of the maxillofacial<br />

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Lazar A, Kimmelman CP, Soletic I.<br />

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[CrossRef]<br />

27. Wesley RK, Cullen CL, Bloom<br />

WS. Gardner’s syndrome with bilateral<br />

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Mar;9(1):53-7. [PubMed]<br />

28. Sondergaard JO, Rusmussen<br />

MS, Videbak H, Bernstein IT, Myrhoj T,<br />

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1993;28:23-4.<br />

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MI, Rocha A, Tardin Torrezan G, Alves<br />

FA. Oral and maxillofacial considerations<br />

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Please cite this article as: Deliverska E. Peripheral Osteoma of Mandible - a case report and analysis of literature. J of<br />

IMAB. <strong>2016</strong> Jul-Sep;22(3):1274-1278. DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1274<br />

Received: 18/05/<strong>2016</strong>; Published online: 01/09/<strong>2016</strong><br />

Corresponding author:<br />

Associate prof. Elitsa Deliverska, PhD<br />

Department of Oral and Maxillofacial surgery, Faculty of Dental medicine,<br />

Medical University Sofia<br />

1, St. Georgi Sofiiski Str., 1431 Sofia, Bulgaria.<br />

E-mail: elitsadeliverska@yahoo.com<br />

1278 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1279<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />




REPORT<br />

Rosen Borisov,<br />

Department of Oral and diagnostic imaging, Faculty of Dental Medicine, Medical<br />

University – Sofia, Bulgaria<br />

Summary:<br />

The use of surgical guides in implant treatment increases<br />

the accuracy of the dental implant positioning compared<br />

with manual methods. Regardless of how they are<br />

made, deviations of implants from their intended position<br />

are established in all kinds of surgical guides. This article<br />

considers the use of plastic material and new scanning technique<br />

for the production of CAD/CAM surgical guides that<br />

aim to overcome the deficiencies of the currently applied<br />

technologies in the production of surgical guides.<br />

Materials and methods: The study shows the techniques<br />

used to overcome degraded by metal artifacts CBCT<br />

images in implant treatment of patients with partial<br />

edentulism, and located medially to the defect metal-ceramic<br />

crowns. When planning implant treatment, a triple<br />

scan method has been implied. At the beginning, CBCT<br />

scan of the patient with a silicone impression material is<br />

made in the zone of interest. Secondly, CBCT scan only of<br />

the silicon impression is made, and thirdly - intraoral scanning<br />

of the patient with an intraoral scanner. Virtual analogues<br />

have been created of images from the three scans<br />

and have been repositioned one over another; as thereby<br />

an intraoral image have been accurately positioned over<br />

the CBCT image of the patient. Virtual planning of the implant<br />

positioning has been performed, and a model of surgical<br />

guide has been made for their placement. The guide<br />

has been printed with an SLA 3D printer technology of<br />

photopolymer with dualistic characteristics-rigid in the<br />

working part and plastic in the fixing part. Through it, implants<br />

have been placed to the treatment planning. Postoperative<br />

CBCT has been done on the patient to measure<br />

the implant deviation to their position in the treatment<br />

planning.<br />

Results: Axes angular deviation of the planned and<br />

placed implants has not been established. Average linear<br />

displacement of 240 µ (+/- 40 µ) has been found.<br />

Conclusions: Using the triple scan method is possible<br />

to overcome the poor image quality of the metal (metalceramic)<br />

structures artifacts in CBTC scan of patients for<br />

implant treatment. Using semi-plastic material for printing<br />

of the surgical guide allows its good fixation intraoperative<br />

and the accurate guidance of the implant drill that provides<br />

the implant placement with clinically negligible deviation<br />

from their intended position.<br />

Keywords: CAD/CAM surgical guides, CBCT, dental<br />

implant, intraoral scanner,<br />


With the increasingly widespread use of implant<br />

treatment, the expectations of its results increase. Its planning<br />

takes substantial part of it and largely determines the<br />

final result [1]. Modern digital technology allows this process<br />

to be performed entirely in the digital environment<br />

without the need for physical models. Future prosthetic<br />

constructions are generated with software, and the position<br />

of the future implants is planned according to them, and<br />

the available bone tissue. Their position is translated<br />

intraoperative with surgical guides, as with virtual 3D printing,<br />

their virtual model becomes a physical one. The use<br />

of surgical guides when inserting the dental implants leads<br />

to their more accurate positioning in comparison with<br />

manual methods [2, 3, 4].<br />

The production of these CAD/CAM surgical guides<br />

include the use of so called double scan method [5], its<br />

virtual creation based on CBCT images of the patient, its<br />

plastic model and its printing. Although this approach is a<br />

qualitatively new level compared to laboratory methods of<br />

surgical guides’ production, it has several drawbacks:<br />

Detail of CBCT images is low - they are used to create<br />

a virtual anatomical model for planning the implant positioning<br />

and a contact surface of the surgical guide is carried<br />

out on them (Fig.1)<br />

Detail of the CBCT depends on the scan resolution<br />

and varies between 150 and 600 µ. The uneven absorption<br />

of X-rays from different hard tissue (bone, enamel, and dentin)<br />

is an additional complication. Therefore, virtual models,<br />

created directly from X-ray images of patients, have uneven<br />

surface and guides created on them could not be adjusted<br />

exactly on their real anatomical analogue. This is<br />

compensated by the double scan technique whereby a gypsum<br />

cast from the patient is scanned, and positioned on<br />

the X-ray images of the patient. Spatial variations that<br />

could occur from possible deformation of the patient’s impression<br />

and its cast can not be avoided.<br />

An alternative to casts could be the use of intraoral<br />

scanners whose images are superimposed on the CBCT<br />

study. Scientific data on the use of this approach are scarce.<br />

In fact, only 3 articles have been found describing individual<br />

cases [6, 7, 8]. Here again two scans are performed,<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1279

Fig. 1 a, b. CBCT image and its virtual analogue; c, d. Virtual surgical guide created in the images of a and b.<br />

but the second one is not a CBCT of the plastic model,<br />

but an intraoral scanner.<br />

2. The classical approach is difficult or impossible<br />

for application where metal artifacts mask the X-ray<br />

anatomy in which to be repositioned the image of the impression<br />

model (Fig.2). The reason is that anatomical markers<br />

are lost, according to which are adjusted to fit the virtual<br />

images of the model, and the X-ray image of the patient.<br />

There is a very big risk both models not to be fully<br />

compliant and hence to obtain an implant variation.<br />

Fig. 2. Crown contours, which are the anatomic<br />

markers, are invisible due to so called “scattering” caused<br />

by the presence of metal-ceramic constructions.<br />

attempt to overcome these shortcomings in the planning<br />

and use of surgical guides for dental implant treatment.<br />


Implant treatment has been conducted on a 52-yearold<br />

male, nonsmoker, in good general health with distal<br />

unlimited partial edentulism in the field from 46 and 47.<br />

The patient had no contraindications to treatment (radioor<br />

chemotherapy, chronic systemic diseases or bruxism).<br />

After the initial view and discuss, we proceeded to treatment<br />

planning.<br />

Since from the clinical view, it has been found that<br />

medially located to the edentulous area teeth have metalceramic<br />

constructions, it has been decided to apply the<br />

method of triple scan to overcome artifacts that these<br />

crowns would cause scan of the patient in CBCT.<br />

The first scan is CBCT of the patient (ProMax 3D<br />

Mid, Planmeca). The special feature of this scan is that it is<br />

made with C-silicone impression material (Zetaplus,<br />

Zhermack®) in the patient’s mouth (Fig. 3).<br />

Fig. 3. CBCT of patient. Despite artifacts of metalceramic<br />

crowns, the outlines of silicone impression material<br />

are seen clearly.<br />

3. The printed surgical guide is hard (rigid). Because<br />

of the absence of any plasticity, its fixing part is arranged<br />

above the equatorial area (in tooth-supporting guides) and<br />

this leads to micro movement of the guide, and deviation<br />

respectively in its use.<br />

We believe that the above three issues are the main<br />

reason for registered by researchers many deviations in the<br />

use of surgical guides to the planned ones in the implant<br />

positioning [9, 10, 11, 12, 13, 14].<br />

The study offers if not a decision, then at least an<br />

The second scan is on the impression itself, and it<br />

has been made with the same CBCT system. It is used to<br />

make a virtual model of the impression in a STL format<br />

(Fig. 4)<br />

1280 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Fig. 4. CBCT of the silicone impression and its virtual<br />

analogue in a STL format.<br />

As the silicon impression contours of the first scanner<br />

are clearly visible, its virtual replica of the second scanner<br />

is easily positioned on it (Fig. 6)<br />

Fig. 6. STL model contours of the silicon impression<br />

are visible with green color positioned on its shadow<br />

of the first CBCT. Crown contours are already well defined<br />

thanks to that reposition.<br />

The third scan has been made with a precise<br />

intraoral scanner (TRIOS® 3, 3SHAPE). It serves as a highquality<br />

digital impression from the zone of interest. It also<br />

creates a virtual model in a STL format (Fig. 5).<br />

Fig. 5 a. Image of intraoral scanner of the two jaws<br />

in the zone of interest; b. Image of the lower jaw; c. STL<br />

model of the same jaw.<br />

The intraoral scanner STL model is positioned on<br />

the crown contours of the repositioned already silicone impression<br />

(Fig.7).<br />

Fig. 7. Intraoral scanner STL model contour is<br />

marked with red.<br />

The intraoral scanner image has high resolution<br />

(about 20 µ in this case), this is the reason it recreates the<br />

actual anatomy very accurately in the zone of interest. It<br />

gives the opportunity to build up virtual wax-up, digitalup<br />

(dig-up) (Fig.8)<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1281

Fig. 8. Dig-up<br />

sleeves for drill guidance are) it is rigid and allows stable<br />

movement of the osteotomy drill (Fig.10).<br />

Fig. 10 a. Digital design of the guide; b. Printed<br />

guide; c. Finished guide over the dental cast<br />

This dig–up allows us to define the best of prosthetic<br />

and osseointegration view to future implants. Their size,<br />

angle and depth of positioning (Fig.9)<br />

Fig. 9. Digital view of the future position of the implants.<br />

The guide has been used for the pilot drill. Osteotomy<br />

has been transgingival as the extension of the bone<br />

bed has been carried out manually.<br />

Postoperative period has passed without complications<br />

and a control CBCT has been made a week after the<br />

intervention.<br />

To compare the implant positioning with the<br />

planned one, a bone STL model has been made with<br />

preoperative scan. This model along with the guide have<br />

been superimposed on the bone outlines from the second<br />

scanner. For starting point for measurements of deviations<br />

has been used a central axis of the guide’s working part, as<br />

they have been made along the planned implants axes. The<br />

angular deviation and linear deviation of the central axis<br />

guide to the implant axis have been measured (Fig. 11).<br />

In the case we chose in the zone of 46, an implant<br />

with sizes 4,2 x10 mm to be placed, and in the zone of 47<br />

- implant with sizes 4,2 x 8 mm (Legacy 3, Implant Direct).<br />

In CAD software, based on this implant positioning,<br />

a guide, which has been created and printed with semi plastic<br />

material SLA technology (DentalXlab Guide, Dentalxlab).<br />

This guide of printing depth from 0,8 to 1 mm is<br />

semi plastic and its fixing part tightly cover the retention,<br />

under equatorial areas of crowns. Meanwhile in thickness<br />

more than 1 mm, such as its working areas are (areas where<br />

1282 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Fig. 11 a. STL model of the jaw in the implant zone<br />

with a guide’s model; b. Blue contour shows the positioning<br />

model of the jaw from the first CBCT on the bone outlines<br />

in the second CBCT. Guide’s outlines are marked with<br />

the red contour.<br />

Fig. 12 a, b. Distance between outlines of the<br />

planned implant (green) and placed implant (radiopacity)<br />

is measured .<br />


In the implant in the area of 46, no angulation has<br />

been established, linear displacement in the vestibular direction<br />

of approximately 280 µ has been reported (Fig.12a).<br />

An implant in the area of 47 hasn’t been also angulated to<br />

the intended position. Linear displacement of 200 µ has<br />

been also measured in the vestibular direction. (Fig.12b)<br />


Using the triple scan technique, inaccuracies caused<br />

by metal artifacts are overcome in the creation of digital<br />

models when planning implant treatment. This technique<br />

allows the integration of high-quality images of intraoral<br />

scanners in the planning process. Since they are with high<br />

detail, the created on these surfaces surgical guides show<br />

very good agreement with the actual anatomical structures<br />

on which they are fixed intraoperative.<br />

Semi plastic materials used in the surgical guide<br />

printing are fixed many stably on teeth as they cover under<br />

equatorial areas. However, in the working areas of the<br />

guide (where the leading sleeves are located), they are rigid<br />

and do not allow deformation and deviation in drill guidance<br />

in osteotomy.<br />

Registered deviations can be explained by the fact<br />

that the surgical guide has been used for keeping only the<br />

pilot drill, and the expansion of the osteotomy bed has been<br />

completed manually.<br />

The method described shows that although registered<br />

deviations, they could be reported as clinically negligible<br />

as they are below 500 µ and in horizontal direction,<br />

as deviations of angulation and depth have not been<br />

registered. Described approach would be a decision of the<br />

‘extremely difficult’ in the words of Van Assche [15] task<br />

to reduce the accuracy of surgical guides below 500 µ.<br />

Of course, we need further research to confirm the<br />

clinical relevance of the described approach.<br />


1. Misch CE. Contemporary Implant<br />

Dentistry. 3rd ed. St. Louis:<br />

Mosby. 2007.<br />

2. Scherer U, Stoetzer M, Ruecker<br />

M, Gellrich NC, von See C. Templateguided<br />

vs. non-guided drilling in site<br />

preparation of dental implants. Clin<br />

Oral Investig. 2015 Jul;19(6):1339-46.<br />

[PubMed] [CrossRef]<br />

3.Noharet R, Pettersson A, Bourgeois<br />

D Accuracy of implant placement<br />

in the posterior maxilla as related to 2<br />

types of surgical guides: a pilot study<br />

in the human cadaver. J Prosthet<br />

Dent. 2014 Sep;112(3):526-32.<br />

[PubMed] [CrossRef]<br />

4. Arisan V, Karabuda CZ, Mumcu E,<br />

Özdemir T. Implant positioning errors<br />

in freehand and computer-aided placement<br />

methods: a single-blind clinical<br />

comparative study. Int J Oral<br />

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Maxillofac Implants. 2013 Jan-Feb;<br />

28(1):190-204. [PubMed] [CrossRef]<br />

5. Vercruyssen M, Jacobs R, Van<br />

Assche N, van Steenberghe D. The use<br />

of CT scan based planning for oral rehabilitation<br />

by Means of implants and<br />

its transfer to the surgicalfield: acritical<br />

review on accuracy. J Oral Rehabil.<br />

2008 Jun;35(6):454-74. [PubMed]<br />

6. Lanis A, Alvarez Del Canto O.<br />

The combination of digital surface<br />

scanners and cone beam computed tomography<br />

technology for guided implant<br />

surgery using 3Shape implant studio<br />

software: a case history report. Int<br />

J Prosthodont. 2015 Mar-Apr;28(2):<br />

169-78. [PubMed] [CrossRef]<br />

7. Flügge TV, Nelson K, Schmelzeisen<br />

R, Metzger MC. Three-dimensional<br />

plotting and printing of an implant<br />

drilling guide: simplifying<br />

guided implant surgery. J Oral<br />

Maxillofac Surg. 2013 Aug;71(8):<br />

1340-6. [PubMed] [CrossRef]<br />

8. Lee CY, Ganz SD, Wong N,<br />

Suzuki JB. Use of cone beam computed<br />

tomography and a laser intraoral scanner<br />

in virtual dental implant surgery:<br />

part 1. Implant Dent. 2012 Aug;21(4):<br />

265-71. [PubMed] [CrossRef]<br />

9. Yatzkair G, Cheng A, Brodie S,<br />

Raviv E, Boyan BD, Schwartz Z . Accuracy<br />

of computer-guided implantation<br />

in a human cadaver model. Clin<br />

Oral Implants Res. 2015 Oct;26(10):<br />

1143-9. [PubMed] [CrossRef]<br />

10. Cassetta M, Giansanti M, Di<br />

Mambro A, Stefanelli LV.Accuracy of<br />

positioning of implants inserted using<br />

a mucosa-supported stereolithographic<br />

surgical guide in the edentulous maxilla<br />

and mandible. Int J Oral Maxillofac<br />

Implants. 2014 Sep-Oct;29(5):1071-8.<br />

[PubMed] [CrossRef]<br />

11. Vieira DM, Sotto-Maior BS,<br />

Barros CA, Reis ES, Francischone<br />

CE.Clinical accuracy of flapless computer-guided<br />

surgery for implant placement<br />

in edentulous arches. Int J Oral<br />

Maxillofac Implants. 2013 Sep-Oct;<br />

28(5):1347-51. [PubMed] [CrossRef]<br />

12. Turbush SK, Turkyilmaz I. Accuracy<br />

of three different types of stereolithographic<br />

surgical guide in implant<br />

placement: an in vitro study. J Prosthet<br />

Dent. 2012 Sep;108(3):181-8.<br />

[PubMed]<br />

13. Soares MM, Harari ND, Cardoso<br />

ES, Manso MC, Conz MB, Vidigal GM<br />

Jr.An in vitro model to evaluate the accuracy<br />

of guided surgery systems. Int J<br />

Oral Maxillofac Implants. 2012 Jul-<br />

Aug;27(4):824-31. [PubMed]<br />

14. Giordano M, Ausiello P,<br />

Martorelli M.Accuracy evaluation of<br />

surgical guides in implant dentistry by<br />

non-contact reverse engineering techniques.<br />

Dent Mater. 2012 Sep;28(9):<br />

e178-85. [PubMed]<br />

15. Van Assche N, Vercruyssen M,<br />

Coucke W, Teughels W, Jacobs R,<br />

Quirynen M. Accuracy of computeraided<br />

implant placement. Clin Oral Implants<br />

Res. 2012 Oct;23 Suppl 6:112-<br />

23. [PubMed] [CrossRef]<br />

Please cite this article as: Borisov R. Use of plastic material and triple scan in the preparation of surgical guides for the<br />

dental implant treatment - case report. J of IMAB. <strong>2016</strong> Jul-Sep;22(3):1279-1284.<br />

DOI: http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1279<br />

Received: 12/04/<strong>2016</strong>; Published online: 30/09/<strong>2016</strong><br />

Address for correspondence<br />

Dr Rosen Borisov<br />

Department of Oral and diagnostic imaging, Faculty of Dental Medicine<br />

1, George Sofiiski str., 1431 Sofia, Bulgaria<br />

Mobile: +359889241512<br />

e-mail: rosenborisov@gmail.com<br />

1284 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Journal of IMAB<br />

ISSN: 1312-773X<br />

http://www.journal-imab-bg.org<br />

http://dx.doi.org/10.5272/jimab.<strong>2016</strong>223.1285<br />

Journal of IMAB - Annual Proceeding (Scientific Papers) <strong>2016</strong>, vol. 22, issue 3<br />


SURGICAL GUIDES. A literature review<br />

Rosen Borisov,<br />

Department of Oral and diagnostic imaging, Faculty of Dental Medicine, Medical<br />

University – Sofia, Bulgaria<br />


Modern digital technologies are changing significantly<br />

the classical approach when planning implant<br />

treatment. Cone-beam computed tomography (CBCT)<br />

and computer-aided design/computer-aided manufacturing<br />

(CAD/CAM) based radiological templates and surgical<br />

guides allow the clinical translation of the<br />

preoperative implant planning. In this review, literary<br />

sources concerning the use of radiological templates and<br />

surgical guides are reviewed in the dental implant treatment.<br />

On comparable bases, modern digital concepts<br />

have been explored in their preparation. The advantages<br />

and problems associated with their use have been<br />

analyzed.<br />

Keywords: CAD/CAM, CBCT, intraoral scanner,<br />

radiological template, surgical guide<br />

Branemark set scientific foundations of the dental<br />

implantology in middle of the last century, and it has<br />

been developed very seriously with the advent of digital<br />

technology. While in the past, as a successful was<br />

considered a treatment, in which the implants in different<br />

periods were fixed; nowadays, the implant treatment<br />

is laden with expectations to be permanently functional<br />

and aesthetic solution for patients with partial and complete<br />

edentulism. Since the oral cavity is relatively limited<br />

space, high precision in implant placement is very<br />

important for successful prosthetic treatment [1]. Misch<br />

added that this fidelity must be sought still in planning,<br />

to avoid iatrogenic damage during the implant treatment<br />

[2]. Poorly positioned or poorly oriented to others implant,<br />

often leads to problems during its placement or<br />

in the stages of prosthetic construction development. This<br />

could jeopardize the aesthetic result or have negative<br />

biological and mechanical effect for long term [3,<br />

4]. Translation of preoperative implant planning in the<br />

intraoperative clinical stage is the critical point that defines<br />

how the results will match expectations. To achieve<br />

this in the most controlled environment, visualization<br />

and navigation tools are used grouped under the conceptual<br />

name of surgical guides.<br />

The progress in imaging and particularly the development<br />

of CBCT technology allow the production of<br />

surgical guides and treatment planning, generally to be<br />

digitized. Thus making surgical guides is transferred<br />

from classical dental laboratory in cyberspace, where the<br />

use of impression materials, plaster casts and polymers –<br />

referred to as materials that undergo geometric changes,<br />

are avoided. The use of classical impression and casts<br />

materials is considered one of the main reasons for the<br />

registered differences in the planned and achieved implant<br />

positioning using guides [5, 6]. Therefore, so many<br />

hopes are pinned on digitization of this process. It is<br />

based on classical CAD/CAM technology, and based on<br />

imaging (Multislice computed tomography (MSCT),<br />

CBCT) implant positioning is defined. Subsequently a<br />

guide’s model is generated with software, which then is<br />

printed with stereo lithography (SLA- stereo lithographic<br />

apparatus) or with selective laser sintering (SLS). The traditional<br />

approach involves several stages:<br />

1. Developing a radiological template.<br />

2. Three-dimensional imaging (MSCT, CBCT).<br />

3. Implant planning with specialized software.<br />

4. Development of a surgical guide.<br />

Implant treatment is directed towards functional<br />

and esthetic restoration of patients with partial or complete<br />

edentulism. The final prosthetic structure is the<br />

starting point in planning this treatment or in other<br />

words, the concept of prosthetic guided implantology is<br />

followed [7], as this process begins with the production<br />

of wax-up laboratory (Fig.3).<br />

Our idea of where the future crowns will be placed<br />

is important as from mechanical - functional perspective<br />

the future implants respectively their abutments should<br />

be located ideally in the center of the future crowns.<br />

This is important not only for maximum resistance to bite<br />

force, but also for the aesthetic result. The substantial deviation<br />

from this ideal position requires compromises in<br />

size and vestibulo-lingual placement for future crowns<br />

(Fig.1).<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1285

Fig. 1 a, b and c - On a digitally reconstructed situation of Figure 1 a and b, it can be seen (c) that the implants are<br />

situated prosthetic incorrectly.<br />

A radiological template is molded on the wax-up. The<br />

template’s purpose is to give a visual representation of the<br />

future implant ideal positioning in imaging. This<br />

is achieved, as in the central areas of the molded in wax-upa<br />

template an x-ray contrast material is placed directed to<br />

the central axis of the crowns. For this purpose, a guttapercha,<br />

metal cannulas, x-ray contrast plastics or varnish<br />

may be used. When using the last ones, crowns contours are<br />

presented with an x-ray as a guide for planning the implants<br />

positioning. Formation process, its variants and radiological<br />

image are represented from figures 2 to 7.<br />

Fig. 4. Thermoforming foil with metal sleeves<br />

Fig. 2. Diagnostic model<br />

Fig. 5. Thermoforming foil with gutta-percha<br />

Fig. 3. Wax-up on a diagnostic model<br />

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Fig. 6. Vacuum-forming foil covered with X-ray contrast<br />

varnish<br />

Fig. 9. The prosthetic axis set by markers (gutta-percha<br />

in this case) matches with the osseointegration appropriate<br />

position of the implant.<br />

Fig. 7. X-ray image of the sleeve, gutta-percha and<br />

varnish cover<br />

1. X-ray image of a metal sleeve 2. X-ray image of<br />

the gutta-percha; 3. - image of X-ray varnished<br />

In this situation, we say that the prosthetic and Osseo<br />

integration implant positioning match. The next steps are<br />

straightforward and clear. We can easily transform the template<br />

in a guide (if we have used cannulas practically the<br />

template is a guide Fig .10) or we just use them for marking<br />

the pilot drill entry point and then, relying on our own<br />

manuality and sufficient bone volume, which allows slight<br />

spatial deviation to put implant.<br />

Fig. 10. Template guide with metal sleeves<br />

Imaging is held with the finished radiological template<br />

(Fig.8).<br />

Fig. 8. The gutta-percha is contrasting central axis of<br />

the X-ray invisible crown.<br />

The second case is when both osseointegration and<br />

prosthetic implant positioning do not match (Fig.11).<br />

Fig. 11. If you follow the axis of the contrast marker<br />

implant would be positioned almost entirely outside the<br />

bone.<br />

At this stage, it is important to ensure immobility of<br />

templates during scanning, so easily deformable materials<br />

(thin vacuum splints or easily breakable plastics) should be<br />

avoided because even minor shifts will compromise the planning.<br />

Since the study is three-dimensional, in combination<br />

with the x-ray template, it gives us a quantitative and qualitative<br />

picture of the bone base in the area of intervention.<br />

The results follow two directions- in one case, under<br />

the ideal implant positioning from prosthetic point<br />

(marked with template) there is sufficient bone substrate for<br />

the implant Osseo integration (Fig. 9).<br />

Unfortunately, in practice this is the most common<br />

variant, and this is easily explained as toothless areas, in<br />

which we implant, are such most often because of the accompanied<br />

with osteolysis pathological processes caused the<br />

tooth extraction. There is angulation (Fig. 11) or linear deviation<br />

in medio-distal or vestibulo-oral direction (Fig.12).<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1287

Fig. 12. Transverse slices show that the position of the implant according to the contrast template allows its osseointegration,<br />

but media-distal inclination of the implant, if put through the template, would be unfavorable to the root of<br />

the medial tooth.<br />

Decisions are two:<br />

Radiological measurement of the deviation and correction<br />

- clinical or laboratory of this deviation. In practice,<br />

the clinical correction is more often and it is expressed in a<br />

very subjective judgment of the operator based solely on its<br />

manuality and its own idea of its magnitude.<br />

The laboratory correction is possible through exotic<br />

devices [8] or sophisticated equipment [9] but there is no scientific<br />

evidence for its practical applicability, unless the<br />

published by the authors of these methods.<br />

A frequent situation where prosthetic ideal implant<br />

positioning and its osseointegration do not match, actually<br />

makes the use of radiological template, non rationalize and<br />

implantologists have to solely rely on their own insight and<br />

knowledge about where, what angle and depth to place the<br />

implant.<br />

The radiological template, may not serve as a complete<br />

surgical guide, but it has intraoperative value by navigating<br />

benchmarks remain the clinical ones for the physician<br />

(crowns and axes of the adjacent teeth, geometry of the<br />

alveolar ridges etc.). The more important is it could be used<br />

as a visual reference to the crown contours intraoperative<br />

and thus the area, in which to strive to place the implants<br />

without it, is “marked” (Fig.13).<br />

Fig. 13. Surgical guide that outlines the contours of<br />

the crowns of Wax-up<br />

Not a rare situation in the absence of such benchmark<br />

are cases where in search of suitable for its osseointegration<br />

position, the implant is positioned so that the aesthetics of<br />

the prosthetic structure is compromised (Fig.1).<br />

The next stage is the analysis of survey of 3D images<br />

and implant treatment planning.<br />

In modern implantology, CBCT is perceived as<br />

the most appropriate three-dimensional method, and this role<br />

is defined by numerous studies [10, 11, 12, 13]. Bone zones<br />

are analyzed qualitatively and quantitatively in the areas of<br />

implantation. Number, size, dimension, type and positioning<br />

of the implants, and possibly augmentation procedures are<br />

planned.<br />

Crucial for making quality planning is the better<br />

knowing the nature of the images, possible artifacts, qualities<br />

and shortcomings of the software through which areas<br />

of interest are visualized gradually. This knowledge ensures<br />

that the implant treatment will be well planned. This means<br />

that we are able, based on analysis of images, to choose the<br />

right size and type of implants, to determine the clinical and<br />

postoperative behavior. Different phases will take place without<br />

complications and it will be unnecessary to adapt to unforeseen<br />

situations as in the course of implantation to choose<br />

the implant’s length, for example.<br />

The last stage of implant treatment planning is software<br />

design and manufacture of surgical guide. Through it,<br />

the planning’s translation is performed. It is the link between<br />

our planned implantology treatment and its immediate<br />

clinical implementation. With its help, the selected implants<br />

are placed exactly in the places that we have identified as<br />

the most suitable during the planning. They allow us to put<br />

them not only in the location but also in the position (inclination<br />

to three planes and depth) that we want.<br />

Surgical guides, as well as their very name suggest are<br />

the tools for surgical navigation. The common among them,<br />

regardless of their diversity, is that they are fixed in the oral<br />

cavity and guide the direction of movement, and some limit<br />

the depth of penetration of the pilot drill or any ones, necessary<br />

to form the bone bed prior to the implant placement.<br />

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Depending on the fixation method, they are tooth-, mucosa<br />

- or bone supporting guides (Fig. 14-16).<br />

Fig. 16. Bone-supported surgical guide<br />

Fig. 14. Tooth -supported guide<br />

Fig. 15. Mucosa - supported guide<br />

They can be made to the already mentioned analogue<br />

manner, based on plaster models (transformation of radiological<br />

template in a surgical guide). Alternatively, they are<br />

manufactured with CAD/CAM technology, by simply using<br />

three-dimensional images of computed tomography study<br />

and 3D printing. For the first time, this method of manufacture<br />

for the purpose of dental implantology is mentioned in<br />

a scientific paper in 2003 [14, 15] and, in essence, is now<br />

used unchanged.<br />

The images from CT are the basis for the generation<br />

of three-dimensional virtual “replica” of the anatomical area<br />

subject to implantation (Fig. 17, 18).<br />

Fig. 17. Native-CBCT images<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1289

Fig. 18. Virtual analogue of the CT images<br />

For mucosa supporting guides this mucosa is needed<br />

to contrast with X-ray scanning or apply the so called “double-scan<br />

method” [16]. The first scanning is tomographic<br />

(CBCT or MSCT) of the area of interest (the patient). The<br />

second one is also tomographic, but the diagnostic cast of<br />

the patient from the same area. The images of both tomographic<br />

studies superimpose (reposition) on one another,<br />

thereby to visualize all of the information within the area of<br />

interest, even invisible radiological soft tissue (Fig. 20-22).<br />

Fig. 20. CAD image of the scanned with CBCT cast.<br />

Fig. 19. The guide modeled by CAD software. The<br />

blue color marked its fixing part, the orange part is the working<br />

one, through which are guided the implant drills.<br />

Fig. 21. 3D reconstruction of X-ray image of the patient.<br />

This replica is used to design the surgical guide itself<br />

with CAD †software. The guides are composed of two parts<br />

– a fixing one, which is located on appropriate supporting<br />

part, and a working one where there are openings with a diameter<br />

corresponding to the implant drills (Fig.19). The<br />

tooth supporting and bone supporting guides are made in<br />

this way as in the tomography images mucosa is usually invisible.<br />

Fig. 22 a. On both models are marked identical points, by which software superimpose the images. b. The superimposed<br />

images.<br />

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Fig. 23. Stereolithografic printed surgical guide.<br />

Once a surgical guide is modeled in the software, it<br />

is printed on a 3D printer (Fig. 24). It is printed in one of the<br />

two methods stereolithography (SLA) or with laser sintering<br />

(SLS). SLA is more suitable for implant purposes, because it<br />

allows to be made of transparent material (photopolymer),<br />

which further increases intraoperative control and generates<br />

smaller spatial deviation compared with the technique of selective<br />

laser sintering [17]. Thus, made guide is ready for use.<br />

• They allow an osteotomy depth control.<br />

• They allow preoperative preparation of prosthetic<br />

design and its immediate fixation.<br />

This way of working has disadvantages:<br />

• Prototype material is hard, rigid, no plasticity to<br />

overcome the equator of the teeth (in the case of tooth supporting)<br />

or undercuts areas (in bone and mucosa variants). To<br />

be stable they need additional laboratory processing and<br />

intraoperative fixation. (Fig. 25).<br />

Fig. 25 a - angulation between the axes of the implant<br />

planned position (the purple implant) and the placed<br />

one; b - linear displacement in the cervical region; c - linear<br />

displacement in the apical zone.<br />

Fig. 24. Surgical guide with fixing pins<br />

• Many often after the guides attachment, the limited<br />

intraoral (most often molar) space, makes impossible the introduction<br />

of the implant drills into osteotomy area.<br />

• When there are artifacts of prosthetic structures (e.g.<br />

metal-ceramic), determining the contours in the fixation areas<br />

and development of guides (teeth, bone, mucosa) are impossible.<br />

The advantages of these guides relative to the conventional<br />

and manual methods are several:<br />

• They are more precise by free manual procedures and<br />

from conventional guides with respect to the linear deviations<br />

from the intended position, angulation and depth of the<br />

osteotomy [18].<br />

• They eliminate the need for development of radiological<br />

template - a laboratory stage is skipped, which reduces<br />

the time to clinical intervention and overall treatment<br />

time.<br />

• Trans gingival implants are possible through them,<br />

where we want to avoid the flap forming (e.g. preceding augmentation<br />

and possible flap would violate the integrity of<br />

the surface [19], or we want to avoid postoperative pain and<br />

hematoma associated with flap [20, 21]. The latter is especially<br />

true for older patients with compromised health [22].<br />

• They provide accurate implant positioning relative<br />

to one another.<br />

• They allow proper angulation, which is often indispensable<br />

especially in the frontal aesthetic zone.<br />

Surgical guides’ precision<br />

Question with the precision of CAD/CAM guides has<br />

been the subject of many scientific researches [23 - 37]. In<br />

all these studies, different variations of the implant positioning<br />

compared to the planned ones are established. This position<br />

is assessed as linear and angular deviations of the implant<br />

axis to the axis of its virtual analogue (the digital replica<br />

of the actual implant used in treatment planning). Linear<br />

variations are measured in two zones - in the cervical portion<br />

of the implant and its apical area (Fig. 26).<br />

Van Asscheet et al. [38] properly noted that angulation<br />

is important, because the apical deviation in the same<br />

deviation of the axis would be different for implants with<br />

different length. We would add that exactly because of the<br />

same reason coronary deviation is important because no angulation<br />

can be found, but just parallel movement to the axis<br />

in one direction or another, different than the planned one,<br />

and again there will be a deviation. The announced results<br />

for the registered deviations vary widely. Most studies<br />

reported averages, but for the practice the maximum possible<br />

deviation is significant, but very few authors have focused<br />

their attention on this indicator [25, 28, 29, 32,]. There<br />

are cases in these studies in which the angle reaches 8.86 degrees<br />

[30]. Linear deviations in the cervical area reach 3.04<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1291

mm, and in the apical one reach 5.03 [25]. According to<br />

Cassetta et al. [24] the deviation in the maxillary guides is<br />

smaller than those used for implantation in the mandible.<br />

Their study shows that it is important whether the patient is<br />

a smoker or not (it is associated with the more common<br />

hypertrophy of the mucosa in smokers and hence a poor stability<br />

of the guide). Ersoy et al. registered also smaller spatial<br />

variations in maxillary guides [31]. According to Turbush<br />

et al. [26] and Arisan et al. [21], mucosa as compared to the<br />

tooth and bone are of smaller deviation. Micro movements<br />

of the guide during implantation, use of more drills [34, 37],<br />

number and distribution of the remaining teeth, height and<br />

number of the cannula can influence it [35, 36]. Linear variations<br />

in the use of guides and the mentioned conventions<br />

lead to errors associated with adverse effects when they are<br />

used in dental implantology. Reasons for them can be sought<br />

in several directions.<br />

First are the images of CBCT, which serve as a basis<br />

on which the guides are made. In some cases, they are directly<br />

used to generate the guide contact interface. To be<br />

used for these purposes, the primary DICOM files are transformed<br />

with CAD software into usable STL files .The latter<br />

describe only the surface geometry of objects from the<br />

DICOM files. Therefore, if the scanning resolution is low, the<br />

surfaces detail of the generated from them STL objects is<br />

lower (Fig. 26, 27).<br />

Fig. 27. X-ray image when scanning with resolution<br />

of 400 µ and its corresponding STL analogue.<br />

Fig. 26. CBCT with a resolution of 150 µ; b-generated<br />

by X-ray data three-dimensional STL model.<br />

Differences among objects created from images of<br />

varying resolution are well illustrated in Fig. 28. A crosscut<br />

section of the three superimposed resolutions (Fig. 28<br />

c) shows that the less resolution is, the better the contour<br />

of the real object is followed. The picture with pink color<br />

shows the real geometry of the object (scanned with<br />

intraoral camera with high resolution); in the picture with<br />

yellow color is the object with the smallest resolution<br />

(400 µ), and the picture with gray color shows the object<br />

with the largest resolution (150 µ). It is clear that the yellow<br />

contour follows unevenly surface detail of the real<br />

object, as at times it crosses it. If the guide is made according<br />

to this contour, it will not be relevant to the real<br />

surface and it will be fixed in a position, which is not consistent.<br />

The gray contour displays accordance with the actual<br />

surface, but it naturally does not coincide with it.<br />

1292 http://www.journal-imab-bg.org / J of IMAB. <strong>2016</strong>, vol. 22, issue 3/

Fig. 28 a, b. - a software model of a real object taken with intraoral camera with high resolution (about 20 µ), c. The<br />

three image superimposed on the lines of coincidence, d. Crosscut of the three images with different resolution.<br />

Even with double-scan technique, the accuracy under<br />

150 µ can not be achieved (as the limiting resolution<br />

of the best so far CBCT sensors is). Solutions should be<br />

sought in the superimposition of images with bigger than<br />

the above mentioned resolution.<br />

However, which is the limit value, which will provide<br />

enough detailed image for making a precise guide? A<br />

surgical guide should be considered as a prosthetic construction.<br />

Its inner surface must be congruent, to follow the<br />

anatomy of the area, for which it is fixed with the accuracy<br />

of prosthetic construction. Therefore, we can determine,<br />

such as accuracy, the adopted for prosthetic designs accuracy<br />

- 50 µ by Gonzalo et al. [39]. In addition, the closer<br />

we are to the border in the final product geometry accuracy<br />

(the surgical guide), the less deviation from the<br />

planned position of the implants we can expect.<br />

The presence of artifacts in x-ray images, as it was<br />

mentioned, is an additional factor to generate errors. Especially<br />

strong is true that for artifacts of prosthetic appliances,<br />

filling material and the canal filling means. They are<br />

mainly in the crown areas, and in them - the contours, on<br />

which the guide should be generated is difficult or impossible<br />

to find. This explains the reported greater accuracy<br />

of mucosa supporting guides compared to tooth support-<br />

ing guides in some studies [21, 26]. The physical receipt<br />

of the guide is also a potential generator of error, because<br />

end models can be printed with different accuracy. They<br />

can be printed with a resolution of more than 25 µ and it<br />

can be a cause of spatial correspondence between both surfaces<br />

(one of the guide and one of its anatomical analog).<br />

Material from which it is printed is rigid, non-plastic<br />

structure, but must be positioned on non-linear, made<br />

up of different curves surface, such as anatomical areas of<br />

guides’ fixation. In addition, while medio-distal and vestibule-oral<br />

direction is no problem, its vertical adjustment<br />

is impossible because to overcome the equator of the teeth<br />

(or vertical vestibular and lingual/palatal ridges in cases<br />

of bone and mucosa support). These guides should be completed<br />

over the area of the teeth equator, because they lack<br />

plasticity to overcome this relief. This makes them movable<br />

in a vertical direction and creates an opportunity for<br />

different ‘stable’ positions of the guide, which displaces the<br />

position of the planned one of the cannula (Fig. 29 a, b, c,<br />

d).<br />

The additional fixing of the guides with locking pins<br />

does not solve the problem, because they can be wrongly<br />

positioned before fixation. This additional fixation prevents<br />

only its further shift in the use of implant drills.<br />

Fig. 29 a. With green color are visible equator areas for the development of fixing part of the guide; b. Sectional<br />

view of the crown of 15 with the generated of the outline of Fig. 29 a guide; d. If it can be superimposed the occlusal<br />

surface of the guide on the teeth - medial and vestibular, the contact between the two must be released, which creates<br />

conditions for micro-mobility and different “stable” positions of the guide relative to the axis of the tooth.<br />


The information we receive from three-dimensional<br />

imaging is essential when planning implant treatment,<br />

but it is not enough to get a full translation of this planning<br />

in the clinical setting. This is so, because it concerns the<br />

structures that are invisible clinically and intraoperative and<br />

we do not have landmarks, which spatially guide us on the<br />

anatomy of these structures. The purpose of radiological<br />

templates and guides is to help us in this direction. Modern<br />

digital methods of intra and extra oral scanning combined<br />

with CAD/CAM technologies output production and use of<br />

new qualitative level. Despite their proven advantage, compared<br />

to manual methods, their application, however, is associated<br />

with fluctuating results. The registered deviation in<br />

the use of surgical guides sometimes reaches values, which<br />

if security zones, as distance to critical structures are not provided;<br />

it could lead to unintended consequences.<br />

Analysis on the literature data refers theoretically to<br />

three main problems, related to spatial variations in the use<br />

of these guides:<br />

/ J of IMAB. <strong>2016</strong>, vol. 22, issue 3/ http://www.journal-imab-bg.org 1293

1. The low resolution of the scanned images should<br />

be overcome;<br />

2. The influence of metal artifacts, where there<br />

are such, should be neutralized on anatomical structures in<br />

areas of interest;<br />

3. Impression material should be used, which has a<br />

dualistic characteristics - to be flexible enough in areas,<br />

where the vertical relief have to be followed (its fixing part),<br />

and at the same time sufficiently rigid in the zones, in which<br />

implant drills will be used (the working part).<br />

Solution of the first problem is an answer of the issue<br />

with the quality on the base, from which the implant planning<br />

starts. An image with a resolution or surface detail of<br />

the order of 50 microns would be an ideal matrix for software<br />

modeling of the surgical guide, which subsequently<br />

will be fixed on its anatomical analogue with sufficient accuracy.<br />

The second task concerns the universality of surgical<br />

guides’ application. Artifacts in CBCT are very common<br />

problem and overcoming their influence would make surgical<br />

guides reliably applicable to all patients.<br />

The third issue is perhaps the most important, because<br />

in our opinion is the most largely responsible for registered<br />

variations in the use of surgical guides. Its decision will allow<br />

secure intraoperative fixation of the guide and in position,<br />

which will fully coincide with or have minimal deviation<br />

from the planned one.<br />

Aforesaid confirms the finding of a number of authors,<br />

who concluded in their researches, that CAD/CAM based<br />

guides need further improvement and that are necessary further<br />

researches to clarify and resolve problems associated<br />

with their use [8, 17, 21].<br />


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