Analysis of The Mandible Cortical Bone Height in Amlodipine user Patient Using Panoramic Radiograph

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2 Analysis of The Mandible Cortical Bone Height in Amlodipine user Patient Using Panoramic Radiograph 1 Farihah S, 2 Epsilawati L, 2 Suhardjo, 2 AAG Dananjaya 1 Radiology Departement, Faculty of Dentistry, Brawijaya University, Malang, Indonesia 2 Radiology Departement, Faculty of Dentistry, Padjadjaran University, Bandung, Indonesia ABSTRACT INTRODUCTION: Hypertension is a systemic disease that is associated with blood vessels. One consequence of this disease is the sufferer must take anti-hypertensive drugs for a lifetime. There is a miraculous kind of anti-hypertensive drug classes include channel blocker, which is able to block the absorption of calcium into the body, and consequently decreased bone density and quality.measurement of bone density can be performed using a digital panoramic radiograph. Objective : To analysis the height of the cortical mandibula bone in amlodinine user patient using panoramic radiograph. Material and Method: This study using descriptive research design. Analysis was performed on 30 patients using panoramic radiographs amlodipine, where measurements were taken at the mandibular cortical bone. Assessment is done by three index measurement: Antegonion Index (AI), Gonion Index (GI) and Mental Index (MI). Result : based on research results, the value of GI and AI had a similar range between 1.75 to 1.76 mm, while MI ranges from 1.8 to 1.9 mm. When Viewed with the normal value indicates it turns out the only difference seen in MI.. Conclusion: The conclusion that can be drawn from this study, the height of the mandibular cortical bone in patients taking amlodipine, index AI andgh GI not seen any difference, whereas in MI seen there is a decreasevisible compare than normal patient, but the three of them is quite normal its mean that there is no osteoporosis or osteopenia. Keyword: Cortical Mandibula Height, Mental Index, Gonion Index, Antegonion Index, Amlodipine INTRODUCTION Hypertension or high blood pressure is a vascular disorder that cause in the supply of oxygen and nutrients carried by the blood to the tissues of the body is inhibited. 1 Prevalence of hypertension according to the American Heart Association (AHA) in American in patients aged over 20 years reached numbers 74.5 million people, while in Indonesia in 2007 was 31.7% are cases

3 To treat a hypertension commonly doctor using oral medication. Hypertension drug, such as amlodipine, is a Calcium Channel Blocker class. Amlodipine as peripheral arterial vasodilator, and causes a decrease in vascular resistance, which in turn lowers blood pressure. Several studies have described about the effects of drug use Calcium Chanel Blockers, suspected that these drugs can affect the quality of the calcium in the bones, This is evidenced by Rejnmark et al in 2006 which found that the risk of fracture increased by 6% in the Calcium channel blocker or amlodipine, while Takaoka et al in 2013 reported the same about Calcium channel blockers, but until now research will be it is still very rare. 2,3 Panoramic radiography is one of the conventional radiographs of the most common and frequently used in dentistry. A panoramic radiograph provides thorough information we can continuously. Many examinations can be made include bone density measurement. Sign of the reduction in density can be seen with some indicators on panoramic radiographs, one technique to assess is the height of the cortical bone of the mandible with five index measurements, namely Panoramic Mndibular Index (PMI), Mndibular Cortical Index (MCI), Mental Index (MI), Gonion Index (GI) and Antegonion Index (AI). 4 Hypertention patients who consume amlodipine is suspected decreased in bone density. which can use panoramic radiographs, through multiple indices of measurement, this is the basic of this research. MATERIAL AND METHOD This research is descriptive research design, which will see a comparison of mandibular bone height in patients in amlodipine user and non-amlodipine user patients used three different measurement index. Population and sample in this research is all panoramic radiography data of hypertension patient users amlodipine totaled 30 panoramic radiographs were in accordance with the criteria of the study, namely: taking amlodipine for 1-3 years, aged years, patients do not have a history of fracture of the condyle and systemic disease bone metabolism such as hyperparathyroidism, hypoparathyroidism, pagets disease, osteomalaysia, renal osteodystrophy, osteoporosis and osteogenesis Figure 1. A. Measurement of height of mandibular cortex on the mental foramen. Line: (A) the outer line of mandibular cortex, (B) Outline of the mental foramen drawn perpendicular to A and (d) The mandibular cortex height by the mental foramen / Mental Index.(B) Measurement Index Gonion altitude. Line: (A) a line that of mandibular rami to point gonion, (B) line of mandibular outer cortex (e) The height of the mandibular cortex by Gonion / Gonion Index PROCEEDING

4 Figure 2. The measurement technique Antegonion Index (AI) (A) Outline the outer cortex of the mandible (B) of antengion straight line, perpendicular from the cortex of the mandible (c) The line perpendicular intersection between the lines A and B / Altitude mandibular cortex by Antegonion. 6 imperfecta, better quality which is clearly visible mandibular cortex, whereas for patients with non ampodipine obtained from the value of previous researchers. It studied were mandibular cortex bone measurement techniques performed on three kinds of scale in millimeters (mm). The selected index for the mesurement is Mental Index (MI), Gonion Index (GI) and Antegonion Index (AI). 1,5,6 RESULT Results of the research that has been done in this study showed: 1. Assessment of the height of the mandibular cortex is: Table 1. The height of the mandible bone cortex in amlodipine user pasient using panoramic radiographs in Gonion Index No Asessment Hight Rate Low Rate Average 1 GI Right GI Left Table 2. The height of the mandible bone cortex in amlodipine user pasient using panoramic radiographs in Antegonion Index No Asessment Hight Rate Low Rate Average 1 AI Right AI Left

5 Table 3. The height of the mandible bone cortex in amlodipine user pasient using panoramic radiographs in Mental Index No Asessment Hight Rate Low Rate Average 1 MI Right MI Left Comparison of Mandible cortex bone between Users and non user amlodipine Patient is: Table 4. Description of mandible cortical bone hight in user and non user amlodipine pasient with Gonion Indeks Mean N Std. Deviation Std. Error Mean Pair 1 Pair 2 GI Normal Right GI measured Right GI Normal Right GI measured Right Tabel 5. Description of mandible cortical bone hight in user and non user amlodipine patient with Antegonion Indeks Mean N Std. Deviation Std. Error Mean Pair 3 Pair 4 AI Normal Right AI measured Right AI Normal Left AI measured Left Table 6. Description of mandible cortical bone hight in user and non user amlodipine pasient with Mental Indeks Mean N Std. Deviation Std. Error Mean Pair 5 MI Normal Right MI measured Right Pair 6 MI Normal Left MI measured Left PROCEEDING

6 DISCUSSION Based on the Annova analysis that has been done shows that the ratio of height of mandibular cortex in normal patients with patients on amlodipine using methods Gonion index (GI), the Antegonion index (AI) and the Mental Index (MI) there is a difference. The value used has significance level α = 0.05 and nilai t table > t meassure. If the comparison between the value of GI with AI in patients with amlodipine not seen a significant difference, as well as on the GI and MI. Things are different, if done at AI value calculation shows that the value AI against GI significantly, while the MI is no difference. In the assessment of the value of MI compared to the value of GI and AI also has a value that is not meaningful. This value shows that, mandibular cortex bone hight in patients with amlodipine on three indexes, have different values. The third value of the index figures show almost identical, but the value of cortex elevation on users and non-users amlodipine pasient, show there was in users amlodipine has lower value. According Gungor et al, that the normal value of mandibular cortical bone height 0.32mm, 0:25 to 0:32 mm at risk of osteopenia and osteoporosis 0:25 mm. Mandibular cortical bone height values in the amlodipine has a value of 0.32 and they can be quite good, although the value is lower than the average value of non-users amlidipine. Osteocytes are adult cells that are involved in the maintenance of bone function, located in the osteon (bone matrix unit) while osteoclasts are multinuclear cells (multinucleated) that have a role in the destruction, resorption and bone remodeling. Osteoblasts found the surface and inner teh bone. Osteoblasts respond to any variety of chemical signals to produce bone matrix. In the first, the bone matrix called osteoid. Within a few days, calcium in the osteoid began to settle and harden for a few weeks or months later. Part of the osteoblast become apart of osteoid and colled true bond. Along with the formation of bone, osteocytes in matrix form protrusions that connect one osteocytes to another osteosyt, to made a form of microscopic channels system in the bone. 7 The Calcium is one of the components that contribute to bone, mostly of calcium ions in the bone which is not crystallized. non-crystalline calcium is calcium ions are capable of move from one matrix to another matrix within the bone through the interstitial fluid, and blood. Bone formation continues over both the direction of the length or thickness. Rate of bone formation is always changing throughout life. Bone formation is determined by hormones, food, and stress on a bone. Amlodipine induced suppression of bone repair by decreasing bone formation and increase bone resorpsi. The latest research shows that the renin-angiotensin system (RAS), which is the main substance in the amlodipine, a role in controlling blood pressure and effect on bone density. Asaba J. et al. RAS conduct research on transgenic mice and the results showed that angiotensin II has the role of causing a decline in bone density. Angiotensin II on cytokines RANKL and vascular endothelial growth factor (VEGF), which is capable of inducing the formation of osteoclasts, and also decrease in bone density

7 The whole system of renin to angiotensin II, known as Renin Angiotensin Aldosterone System (RAAS), which is one of the causes of hypertension, for RAAS is a hormonal system that plays a role in controlling the cardiovascular system, kidneys, glands andrenal and blood pressure regulation. 9 There are 10 residues known as angiotensin I. Angiotensin I is then converted into angiotensin II by the angiotensin converting enzyme (ACE), the residue is then will be found in the pulmonary circulation and the vascular endothelium darah. 10 Angiotensin II serves to enhance the effect of sympathetic nerves including vasoconstriction (narrowing of blood vessels), which can cause increased blood pressure (hypertension), renal efferent arteriolar vasoconstriction leading to an increasing perfusion pressure in the glomeruli. The adrenal cortex function releases the hormone aldosterone, a hormone that works on the renal tubules to retain sodium and excrete potassium and chloride. If sodium reabsorption it will be followed by the entry of water into the blood vessels, which causes an increase in blood volume, and increase the blood pressure. 10 The use of ACE inhibitors, work by suppressing angiotensin II, thereby causing a decrease in cytokines and vascular endothelial growth factor (VEGF), which is able to inhibit osteoclast, so it does not lower the bone density. In contrast to amlodipine, lowering the influx of calcium ions into myocardial cells and blood vessels, but not to angiotensin II, so as not to inhibit the increase in cytokines and vascular endothelial factor (VEGF), whose effects cannot inhibit the increase osteoclast, so the decline in bone density occur. This is what causes the difference in height of the alveolar bone, the user amlodipine with nonamlodipine patient. 11,12,13,14 CONCLUSION The conclusion that can be drawn from this study, the height of the mandibular cortical bone in patients taking amlodipine, index AI andgh GI not seen any difference, whereas in MI seen there is a decreasevisible compare than normal patient, but the three of them is quite normal its mean that there is no osteoporosis or osteopenia REFERENCE 1. Ross C. Brownson, Patrick L. Remington, James R. davis, High Blood Pressure in Chronic Disease Epidemiology and Control. Second Edition, American Public Health Assosiation: Pusat data dan Informasi Kementrian Kesehatan RI. Hipertensi, InfoDATIN; Karinaastheria : Fisiologi Tulang (online), Fakultas Kesehatan Masyarakat UI, diakses 25 Februari Kostova E., Javanoska E., Zafirov D, Jakovski K, Maleva, and Slaninka- Miceska M Dual inhibition of angiotensin converting enzyme and neutral endopeptidase produces effective blood pressure control in spontaneously hypertensive rats. Bratisl 396 PROCEEDING

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