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17Pakistan Oral & Dental Journal Vol 27, No. 1

The Impacts of Amalgam Overhang Removal

INTRODUCTION

Over-hanging (iatrogenic) tooth restorations canbecome a risk factor for periodontal breakdown due tothe production of environmental changes and distur-bance of the balance between beneficial bacteria andperiodontopathogens (Nunn, 2003), (Lang et al. , 1983).

Studies have shown that there is more periodontalattachment loss and inflammation associated withteeth with overhangs than those without. Overhangscause an increase in plaque formation (Kells & Linden,1992; Keszthelyi & Szabo, 1984; Lervik et al. , 1984), anda shift in the microbial composition (Lang et al. , 1983)from healthy flora to one characteristic of periodontaldisease. In addition to their effect on the inflam-matory process, overhangs may also cause damage byimpinging on the interdental embrasure and thebiologic width.

Evidence exists that any restoration with a subgin-gival margin is associated with some degree of inflam-mation both clinically and histologically (Karlsen, 1970;Trivedi & Talim, 1973), and with increased gingivalfluid flow (Mannerberg, 1971; Mormann et al. , 1974).

The effect of an overhanging restoration is to exagger-ate these responses by increasing the plaque retentionpotential. In animal model systems plaque retentionleads to the extension of gingival inflammation into theperiodontal tissues (Lindhe et al. , 1973; Saxe et al. ,1967). Increased plaque retention results

in a greatly increased rate of destruction of the peri-odontal tissues (Schroeder & Lindhe, 1975). A signifi-cantly greater prevalence and degree of severity of periodontal disease are associated with the presence of overhanging restorations. Most studies report an in-creased level of gingival inflammation and significantloss of alveolar bone associated with the overhang(Gilmore & Sheiham, 1971; Rodriguez-Ferrer et al. ,1980).

Therefore, the aim of this study was to compare theshort-term clinical changes occurring in the periodon-tium after the removal of overhanging amalgam, insubgingival restorations. The periodontal status andthe changes in the crevicular fluid volume is assessedand compared before and after the removal of amalgamoverhangs.

P ERIODONTOLOGY

THE IMPACTS OF AMALGAM OVERHANG REMOVAL ON PERIODONTALPARAMETERS AND GINGIVAL CREVICULAR FLUID VOLUME

SAMEER A. MOKEEM, BDS, MS, PhD

ABSTRACT

Research has shown that overhanging dental restorations and subgingival margin placement playan important role in providing an ecologic niche for periodontal pathogens. Periodontal attachmentloss and inflammation associated with overhanging restorations were reported extensively in theliterature. A total of 15 overhanging amalgam restorations were selected and the plaque index (PI),Gingival Index (GI), Probing pocket depth (PPD) and Gingival crevicular fluid (GCF) was analyzed. Theamalgam overhangs were removed and the readings were repeated at the end of one week and 4 weeksto find out the effect on periodontal health. Statistically significant reductions in all parameters wereobserved showing improved periodontal health after the removal of the overhang. These observations

further highlight the importance of removing the overhanging margins of the restorations as an

important part of initial periodontal therapy.

Key words: dental amalgam, periodontal status, periodontal index, marginal overhang .

For Communications: Dr. Sameer A. Mokeem, BDS, MS, PhD, Assistant Professor, Department of PreventiveDental Sciences, College of Dentistry, King Saud University, P.O. Box: 60169, Riyadh 11454, E mail:[email protected]

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18 Pakistan Oral & Dental Journal Vol 27, No. 1


MATERIALS AND METHODS

Fifteen patients (37.46 5.25 years of age) whopresented to the Periodontics Clinics, College of Den-tistry, King Saud University participated in the study.Inclusion criteria required at least 15 teeth and ClassII amalgam restorations with overhang and an inter-proximal subgingival margin on at least one molartooth, excluding third molars. These restorations weretwo surfaces, including the occlusal surface and mesialor distal surfaces. To be considered for the study, therestoration had to have been present in the patientsmouth for exactly18 -24 months. Out of 10 teethrestored mesially and 13 teeth restored distally, a totalof 15 restorations were selected for the study.

Exclusion criteria included the following: cigarettesmoking; diabetes; immunocompromised subjects; preg-

nant and breast-feeding women; subjects with orth-odontic devices; subjects with ongoing dental or peri-odontal treatment 12months prior to the beginning of the study or those who had taken antibiotics within 6months prior to the clinical examination; and anymedication that could lead to decreased salivary flow.Personal information related to the medical and dentalhistory of the subjects was obtained by a questionnaire.

All subjects signed an informed consent.

Periodontal Examination

One trained and calibrated examiner (SM) re-corded plaque index, gingival index and periodontalprobing depth at the overhang dental surface using aperiodontal probe. The reproducibility of these mea-surements using k statistics resulted in k = 0.82. Inaddition, the same calibrated examiner evaluated plaqueand gingival indices at the same dental surfaces.

Assessment of Restoration Quality The quality of the proximal restoration on each tooth was examinedusing radiographs and a clinical exploration. Radio-

graphic films were exposed using the bitewing tech-nique and were viewed under standardized conditionsusing a constant light source without magnification.

For clinical exploration, a dental explorer wasmoved coronally across the margin of the restoration.Restorations were considered good when theypre-sented a smooth junctional surface without a ledge.The poor restorations presented a junctional surfacewith an edge, deficiency, or gross roughness. Selected

test teeth presented an edge or overhang raised >0.5mm from the enamel surface. The restorations werealso evaluated using a Cross calculus probe movedcoronally across the tooth-restoration junction. Radio-graphs and all clinical data were obtained at baselineand one week and four weeks after scaling and root

planing and overhang removal.Gingival Crevicular Fluid (GCF)

GCF was collected from the teeth with overhang-ing restorations. The sites to be sampled were isolatedwith cotton rolls and carefully sprayed with water toremove saliva followed the method suggested by themanufacturer (Harco Electronics Limited). Each sitewas gently dried using an air syringe during 10 sec-onds. A paper strip (Periopaper, ProFlow, Amityville,NY, USA) was inserted at the orifice of the gingival

crevice and left there for 30 s. The fluid volume wasdetermined from standard curves using a Periotron6000 (Periotron, Pro Flow, Amityville, NY, USA). Theprocedure was repeated at the end of the first week andfourth week after the removal of the overhangingrestorations.

Periodontal Therapy

After baseline radiographs were taken and clinicalexaminations were performed all subjects receivedstandardized oral hygiene instructions. At the same

visit, amalgam overhangs were removed either bycomplete removal of the filing and replacement of newfilling or by using a specific system with diamond tipsinserted in a hand piece and fine grain diamond-coatedrotary instrument. Rubber cups were used as the finalstep to ensure the smoothness of the surfaces. Bitew-ing radiographs were taken to assure the quality of therestorations. The teeth received scaling and rootplaning. After the amalgam overhang removal, thequality of each proximal restoration was re-examined.The patients were recalled at the end of 1 week and 4week and the measurements were repeated.

Statistical Analysis

The data obtained at the base line, one and fourweeks after the treatment were recorded and analyzedstatistically using Instat Graph Pad software(GraphPad Software, Inc. San Diego, CA ,USA). ANOVA was used to compare the various groups and post hoctesting (Tukey-Kramer Multiplr Comparison Test) was

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Periodontal Pre-treatment One week One weekparameters (Mean + SD) (Mean + SD) (Mean + SD)

Plaque Index 1.73 0.46 0.27 0.46 0.13 0.35

Gingival Index 1.80 0.43 0.2 0.32 0.17 0.27

Probing Pocket Depth (mm) 3.80 1.15 2.93 1.22 2.33 0.9

GCF Volume (l) 0.36 0.06 0.2 0.04 0.14 0.03

Table 1. GI, PI, PPD and GCF Volume before and after the removal of amalgam overhang (one weekand one month)

Fig 1. Plaque Index before and after the removal of amalgam overhang (one week and one month)

performed to explore the differences between anytwo groups. P-Values < 0.05 were considered signifi-cant.

RESULTS

The mean plaque index, Gingival Index, Probingpocket depth and GCF volume is given in Table 1 andFig 1 4. The plaque Index reduced significantly after

removal of the overhanging amalgam restorations.The values were significantly lower at one week andone month (P< 0.001).

The mean Gingival Index showed significant reduc-tion at one week and one month after the overhangremoval (Table 1 and Fig 2). The mean probing pocketdepth was 3.80 (SD - 1.15) in the pre treatment group.This has reduced subsequent to the removal of over-

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Fig 2. Gingival Index before and after the removal of amalgam overhang (one week and one month)

Fig 3. Probing Pocket Depth before and after the removal of amalgam overhang (one week and one month)

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hang to 2.93 (SD -1.22) and 2.33 (SD - 0.9) respectivelyafter one week and one month

The Gingival Crevicular fluid was estimated usingperiopaper (Table 1 and Fig 4) . The mean values werefound to be 0.36 l in the pre-treatment group. Onemonth after the removal of the overhanging amalgamrestoration the GCF volume has reduced to 0.14. Thereduction in GCF values were found to be statisticallysignificantly (P

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bined with good plaque control resulted in a significantdecrease in gingival inflammation.

Gingival inflammation adjacent to overhangingrestorations was studied by assessing the bleedingindex, or gingival crevicular fluid. Most of the studiesreported significantly more inflammation adjacent tooverhanging restorations which is in agreement withthe present study (Eid, 1987; Gorzo et al. , 1979; Lang etal. , 1983; Trott & Sherkat, 1964). The presence of gingivitis during restorative treatment predisposesteeth to ODR placement. Bleeding and edema of thetissues hamper access and visibility for proper place-ment of interproximal restorations. In some instances,therefore, overhangs may result from periodontal dis-ease and then contribute to its progress.

The normal gingival crevicular fluid ( GCF) value

range from 0.24-1.56 l and has been proven to be amore sensitive marker of gingival inflammation, andits measurement has become a method widely em-ployed in clinical studies (Cimasoni, 1983) . In thepresent study significant reduction in GCF was ob-served after the removal of the overhanging amalgam.This observation is in agreement with the other stud-ies reported earlier (Eid, 1986; Eid, 1987; Hadavi et al. ,1986).

A consistent finding in several studies was the

pocket depth adjacent to overhanging restorations.Pocket depth measurements reflect the level of peri-odontal attachment. In the present study a significantreduction in pocket depth was observed after removalof the overhanging restoration (Claman et al. , 1986;Gorzo et al. , 1979; Roman-Torres et al. , 2006).

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