Letter to Editor

Is There any Commitment for Oral and Dental Health Promotion in Iran?

Mohammad H. Khoshnevisan

Journal of Dental School, Shahid Beheshti University of Medical Sciences, Vol. 41 No. 4 (2023), 7 May 2024,

Despite oral health reform introduced by the Ministry of Health and Medical Education, not much oral health improvement has been reported so far. The dmft index in 6 year old children has been steadily increasing since 1998 when the first national oral health survey was conducted in Iran. The dmft index for primary dentition was 4.8 in 1377 (1998); 5 in 1383 (2004); 5.16 in 1391 (2012) and 5.84 in 1395 (2016) national survey. Without timely attention to primary dentition, permanent teeth will be affected during the mixed dentition period and if not attended early enough, tooth loss would be the inevitable consequence. Local national data shows that over 52 percent of our elderly population are completely edentulous. Aside from these local effects in the oral cavity, there are ample evidence on the association of oral and systemic conditions. Meaning that, oral diseases may cause or intensify systemic diseases such as stroke, cardiovascular, respiratory, urinary, and digestive system; as well as low birth weight and premature birth in pregnant ladies. The good news is that all these problems are preventable because oral diseases are preventable.  

Based on 2012 national data, only 12% of 5-6 year old children were caries-free meaning that dental caries is a silent epidemy in Iran. According to this data 27.4% of the 12 year old children were caries-free. However, after laps of 3 years when these children are 15, only 0.4% of them are caries-free! New caries development in this 27% of children, clearly shows our collective failure in oral health promotion strategies. But why and for how long more we should witness such a tragedy despite having all the necessary means to tackle this problem.

When comparing our country to many other developing countries, we are very happy to have an oral health system in Iran, but unfortunately this system doesn’t work properly, because it does not have a proper leadership and structure. There are dental and oral health units in different departments, working independently like isolated islands without any coordination with each other. For the same reason there is no coordination between prevention, treatment, education, research and dental equipment departments. That’s why we do not implement a nationwide policy for oral health promotion and we do not have a leadership to plan, coordinate and improve the oral health of the nation according to appropriate evidence-based strategies.

Although, we are living under resistive economy, many decision makers do not pay any attention to low cost preventive dentistry for improving the nation’s oral health, rather follow the costly and wrong remedy suggestions. Increasing the number of dental schools, increasing the number of dental students without considering the current shortcomings of dental schools are just a few to mention. There is no report of oral health improvement by increasing the number of dentist or dental schools. While, spending the cost of one dental school on prevention, promotion and maintenance of community oral health could help a lot.

Based on local investigations, developing an oral health structure at the national level is the first priority (1-3) in order to unify all dental and oral health related units located in different departments, in order to follow a single national oral health policy and strategy. Another important priority is manpower development plan with special attention to national prevention activities. If called on local Dental Public Health experts, they can provide a well-defined comprehensive national oral health plan.  

Although, under current situation we are going to miss the 2025 (1404) health system national objectives, but we can plan for definitely having caries-free generation in a 12-year period if proper oral structure is approved by the Ministry of Health and Medical Education in Iran. Although, a single country is the focus of discussion in this commentary, sharing of the information may be useful for other developing nations as well.   

Original Article

Comparison of Apical debris Extrusion of ProTaper Universal rotary and SafeSiders reciprocal Systems

Zohreh Ahangari, Mandana Naseri, Arash Soleimani, Atoosa Yazdani, Mahgol Mehrabani

Journal of Dental School, Shahid Beheshti University of Medical Sciences, Vol. 41 No. 4 (2023), 7 May 2024, Page 128-132

Objectives During root canal preparation, dentinal chips, irrigants, and pulp remnants are extruded into the pre-radicular space. This phenomenon may lead to post-endodontic flare-ups. Furthermore, different preparation systems may be associated with varying amounts of apically extruded debris. This study aimed to compare the amount of debris extrusion using two endodontic preparation systems: ProTaper Universal and SafeSiders.

Methods In this in vitro study, 30 single-rooted human mandibular premolars with fully developed apices and curvatures of 0-10 degrees were randomly assigned to two groups (N=15). The root canals were prepared with the ProTaper Universal and the SafeSiders system according to the manufacturer’s instructions. Extruded debris was collected into pre-weighed tubes by washing the apical foramen area with 1cc of distilled water. After incubating tubes for ten days to evaporate the remaining irrigants, the amount of apically extruded debris was calculated by subtracting each tube's initial and final weight. Data were analyzed by Student t-test at P<0.05.

Results The mean values for the amount of apically extruded debris using ProTaper Universal and SafeSiders system were 0.0018±0.0004 g and 0.0023±0.0006 g, respectively. The two groups had a statistically significant difference regarding the amount of the apically extruded debris. The SafeSiders system caused significantly more debris extrusion than the ProTaper Universal system (p<0.01).

Conclusion Both the ProTaper Universal rotary system and the SafeSiders reciprocating system caused apical debris extrusion; However, ProTaper Universal was associated with less debris extrusion.

Exploring Factors Shaping Dental Insurance Utilization: Insights from an Investigation in Iran

Michael Aryan Kya, Tayebe Rojhanian, Fatemeh Sayar Irani

Journal of Dental School, Shahid Beheshti University of Medical Sciences, Vol. 41 No. 4 (2023), 7 May 2024, Page 133-139

Objectives One of the key indicators of the effectiveness of a country's healthcare system is the delivery of accessible and impactful health services, particularly in the field of oral and dental healthcare. Among the barriers to the utilization of oral and dental healthcare services within healthcare systems, the most prominent obstacles are a lack of awareness and insufficient financial resources. The objective of this research is to investigate the factors that influence the extent to which individuals in Iran make use of dental insurance services.

Methods The research employed a linear probability model to evaluate how eight independent variables influence the utilization of dental insurance services. These variables included possession of supplementary dental insurance, age, parenthood, marital status, gender, level of education, DMFT index, and accessibility. The study encompassed data from 384 policyholders who participated across 20 dental clinics located in Tehran. Sampling was conducted using a stratified random sampling method, covering individuals with dental insurance from mid-2022 to mid-2023. The Kolmogorov-Smirnov test ensured data normality. One-sample examined hypotheses, while Pearson's Chi-Square tested relationships. The Gamma coefficient assessed relationship strength, and the Friedman test ranked factors influencing dental service utilization.

Results Possessing supplementary dental insurance with an average rank of 5.2 is the most influential factor in the extent of utilization of dental services. The DMFT index, ranking on average at 2.5, is identified as the third factor (following accessibility to dental services as the second factor) in the utilization of dental services.

Conclusion Possessing insurance emerges as a crucial factor compared to the DMFT index when it comes to dental visits. In other words, Iranians with a DMFT index but lacking insurance coverage show a lower likelihood of seeking dental treatment. This observation holds true even in the more affluent northern areas of Tehran, contrasting with regions spanning from center to lower Tehran.

Comparison of Fluoride Uptake into Tooth Enamel Using Four Different Fluoride Varnishes

Masumeh Moslemi, Samira Asghari Moghaddam, parastoo iranparvar, Fahimeh Kooshki, Solmaz Eskandarion

Journal of Dental School, Shahid Beheshti University of Medical Sciences, Vol. 41 No. 4 (2023), 7 May 2024, Page 140-144

Objectives The efficacy of fluoride varnish in preventing dental caries has been well documented. The objective of this study was to compare the impact of four different fluoride varnish brands containing 5% sodium fluoride on the sound enamel of permanent teeth.

Methods In this experimental study, 40 sound human premolar teeth were randomly assigned to four groups (Fluorilaq®, FluoroDose®, Preventa®, Kimia®; N=10). Each tooth was sectioned into buccal and lingual halves, corresponding to the control and the experimental subgroups, respectively. In the experimental halves, a semi-circular shaped area of the enamel was treated with the designated fluoride varnish. All specimens underwent Acid Etch Enamel Biopsy. Fluoride and Calcium concentrations were measured using a Potentiometer and Inductively Coupled Plasma optical emission spectrometer, respectively. The collected data were analyzed using paired t-test and one-way ANOVA at P<0.05.

Results There was a significant difference between the enamel fluoride content of experimental and control halves in all groups (P<0.05). Preventa® Fluoride varnish caused the highest Fluoride uptake, followed by FluoroDose®, Fluorilaq®, and Kimia®. All pair comparisons were statistically significant (P<0.05), except for Preventa® vs. FluoroDose® (P=0.36).

Conclusion Since all examined Fluoride varnishes increased the Fluoride content of the tooth enamel, they potentially qualify for caries prevention. Furthermore, Preventa® could be considered a good domestic alternative for other brands investigated in this research, in terms of enamel fluoride uptake.

Psychological Status of Orthodontic Patients During Covid-19 Pandemic and its Impact on their Treatment Process

Soodeh Tahmasbi, Mahshid Namdari, Kazem Dalaie, Mohammad Behnaz, Aminhesam Seif Zargar , Reyhaneh Nilgaran

Journal of Dental School, Shahid Beheshti University of Medical Sciences, Vol. 41 No. 4 (2023), 7 May 2024, Page 145-149

Objectives The present study aimed to investigate the patients’ psychological status, level of awareness, and attitude toward the coronavirus disease 2019 (COVID-19) pandemic and its effects on the process of orthodontic treatment in patients at the School of Dentistry, Shahid Beheshti University of Medical Sciences, and three private clinics in the city of Tehran in 2021-2022.

Methods A questionnaire with four parts was designed. The participant’s general information and the information regarding orthodontic treatments were collected in the first part, and the patient’s knowledge and attitude in confronting COVID-19 were collected in the next two parts. In the last part, the patient’s psychological status was assessed using Kessler’s Psychological Distress Scale (K10). A total of 300 questionnaires were distributed among the patients in four clinics. Spearman’s correlation coefficients, the t-test, and U Mann-Whitney statistical test were used at a significance level of 0.05.

Results A total of 209 patients undergoing fixed orthodontic treatment participated in the present study. The mean score of the K10 questionnaire among the participants was 11.93. 30.14% of the participants could not attend their orthodontic appointments at least once during 6 months. 59.8% of the participants reported much concern about going to the dental office and contracting a disease. 25.8% of patients were worried about falling brackets, loosening bands, and breaking wires during the outbreak. On the other hand, 69.8% had no problem in contacting their orthodontist.

Conclusion Most patients had no missed orthodontic appointments during 6 months, and more than a quarter believed that COVID-19 had affected their orthodontic treatments. The patients’ psychological status was not suitable especially in women. In general, with higher educational level, the awareness of COVID-19 increased, and the psychological status worsened.

In Vitro Evaluation of Antimicrobial, Antioxidant, and Cytotoxic Effects of Sumac (Rhus coriaria L.)/Rose Water Mouthwash

Maryam Torshabi, Razieh Shahbazi, Maryam Nikoosokhan

Journal of Dental School, Shahid Beheshti University of Medical Sciences, Vol. 41 No. 4 (2023), 7 May 2024, Page 150-156

Objectives Mouthwashes are one of the most effective non-mechanical methods for removing bacteria from the mouth. This study aimed to assess the cytocompatibility, antimicrobial effects (compared to chlorhexidine mouthwash), and antioxidant activity of an experimental herbal mouthwash made from sumac (Rhus coriaria L.) and rose water.

Methods The sensitivity of Streptococcus mutans, S. sanguinis, Staphylococcus aureus, Candida albicans, and Aggregatibacter actinomycetemcomitans to the experimental mouthwash was estimated by measuring the diameter of the inhibition zones. Additionally, the minimum inhibitory concentrations (MICs) were determined using the redox dye resazurin, as well as the minimum bactericidal/fungicidal concentrations (MBCs/MFCs) using the standard spot inoculation method. Cytotoxicity was evaluated using the methyl thiazolyl tetrazolium (MTT) assay, while antioxidant activity was assessed using the 2,2-diphenyl-1-picrylhydrazyl (DPPH) assay.

Results The MIC and MBC of the sumac mouthwash for the bacteria under study (except S. mutans) ranged from 0.13 to 16.65 mg/mL. For the yeast C. albicans, the MIC and MFC of the sumac mouthwash were determined to be 0.52 mg/mL. Furthermore, the sumac mouthwash showed no cytotoxicity and demonstrated significant antioxidant effects at various concentrations.

Conclusion Sumac/rose water mouthwash, which is a safe, natural, biocompatible, and antioxidant product, may serve as a viable alternative to chemical antibacterial mouthwashes like chlorhexidine. This is particularly true when it is used in conjunction with regular oral hygiene practices over extended time periods.

Comparison of Cytotoxic and Antibacterial Effects of Elettaria cardamomum Extract and Essential Oil

Surena Vahabi, Maryam Torshabi, Seyede Zahra Mirsharif

Journal of Dental School, Shahid Beheshti University of Medical Sciences, Vol. 41 No. 4 (2023), 7 May 2024, Page 157-161

Objectives This study aimed to investigate the cytotoxic and antibacterial properties of essential oils and hydroalcoholic extracts from Elettaria cardamomum fruit (E. cardamomum).

Methods Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans) was used as the test subject for the agar diffusion test in this in-vitro investigation to determine the antibacterial effect of the extract and essential oil. The broth microdilution method was used to calculate their minimum bactericidal concentration (MBC) and minimum inhibitory concentration (MIC). The methyl thiazolyl tetrazolium (MTT) assay was used to assess their cytotoxicity against human gingival fibroblasts. Tukey's test (alpha=0.05) and ANOVA were used to evaluate the data.

Results The E. cardamomum hydroalcoholic extracts and essential oil demonstrated strong antibacterial activity on A. actinomycetemcomitans. E. cardamomum essential oil (91.5±1.1 mm) and E. cardamomum extract (9.5±0.4 mm) had the highest and lowest growth inhibition zones, respectively. For E. cardamomum essential oil, the MIC and MBC were 1.45%, and for E. cardamomum extract, they were 11.5% (v/v). The essential oil exhibited appreciable cytotoxicity at low doses, while the extract did not.

Conclusion Because of its antibacterial properties and low cytotoxicity at low concentrations, the hydroalcoholic extract of E. cardamomum, one of the compounds examined, may have applications as an organic mouthwash.

Case Report

COVID-19-Associated Maxillary Osteomyelitis: A Case Report

Saede Atarbashi-Moghadam, Ali Lotfi, Fazele Atarbashi-Moghadam, Parsa Eftekhari-Moghadam

Journal of Dental School, Shahid Beheshti University of Medical Sciences, Vol. 41 No. 4 (2023), 7 May 2024, Page 162-163

Objectives Mucormycosis, a lethal opportunistic infection, is associated with high rates of morbidity and mortality. The pathogenesis of this disease appears to be multifactorial, with numerous factors contributing to its onset and progression, particularly in relation to COVID-19 infection.

Case The presented case was a 41-year-old male who had a history of COVID-19 infection and had received high-dose corticosteroid therapy. He presented with a painless, extensive necrotic lesion on the right maxilla.

Conclusion A biopsy confirmed the diagnosis of maxillary mucormycotic osteomyelitis associated with COVID-19. Overall, understanding this severe infection is crucial for accurate diagnosis and prompt treatment.