Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Official Journal of HP University, Shimla

Editorial Board Patron in Chief : Prof. A. D. N. Bajpai Editor in Chief : Dr. Vikas Jindal Vice Chancellor-HP University, Shimla Director-Principal, Department of Periodontics Himachal Dental College, SunderNagar, HP, India

Co-Editors Dr. Rajan Gupta Dr. Anil Singla Dr. R.P. Luthra Principal, Prof.and Head,Deptt of Director, Prof and Head, Deptt of Principal, Prof.and Head,Deptt of Periodontics HIDS, Paonta Sahib, HP Orthodontics, HDC, Sundernagar, HP, India Prosthodontics Govt. Dental College, Shimla, HP Dr. Ajay Chabra Dr. Bharat Bhushan Dr. Gaurav Gupta Principal, Prof and Head, Deptt of Conservative Principal, Prof and Head, Deptt of Director,Prof and Head,Deptt of Prosthodontics Dentistry & Endodontics, Bhojia Dental College, Baddi Pedodontics DAV Dental College, Solan HIDS,Paonta Sahib,HP

Editorial Board

Prof. T C Bhalla Prof. Rajinder Chauhan Dr (Ms) Jaishree Sharma Dean of Studies, Dean, College Development Council Director, Medical Education & Research, Himachal Pradesh University Himachal Pradesh University Himachal Pradesh Dr. Mahesh Verma Dr. K.S.Nagesh Dr. S G Damle Director-Principal, Maulana Azad Principal, D.A.Pandu Memorial Vice Chancellor Institute of Dental Sciences, New Delhi R.V.Dental College, Bangalore MM Mullana Dental College, Ambala Dr A S Gill Dr. Usha. H.L Dr. D K Gautam Director-Principal, Genesis Institute of Principal, Prof and Head, Deptt Dental Sciences and Research, V. S. Dental College, Bangalore of Periodontics, HDC, Sundernagar, HP. India Ferozepur Punjab Dr. Sumeet Sandhu Dr. Eswar Nagraj Dr. Satheesh Reddy Prof and Head, Prof and Head, Deptt of , Professor, Department of Orthodontics & Deptt of Oral surgery, SRM Dental College, Chennai, TN, India Dentofacial Orthopaedics, Sri Sai College SGRD, Sri Amritsar, PB, India Dr. Himanshu Aeran of and Research, Vikarabad. Dr. SC Gupta Director PG Studies, Seema Dental Dr. Vimil Sikri Prof and Head, Deptt of College, Rishikesh, Uttranchal Principal, Prof and Head Community dentistry, Dr. Sameer Kaura Endodontics, Govt. Dental HDC, Sundernagar, HP, India Associate Prof, BJS Dental College, Amritsar, PB, India Dr. Kundabala College, Ludhiana, PB, India Dr. C S Bal Prof and Head, Manipal College Dr. Navneet Grewal Principal, Prof and Head of dental Surgery, Mangalore, Karnataka, India Prof and Head, Deptt of Endodontics, Sri Guru Ram Dass Dr. D S Kalsi Pedodontics, GDC, Amritsar, PB,India Dental College, Sri Amritsar, PB, India Principal, Prof and Head, Deptt Dr. Kapil Dua Dr. Abi Thomas of Periodontics, BJS Dental Prof and Head, Deptt of Principal, Prof and Head, Deptt of College, Ludhiana, PB, India Endodontics, CDC, CMC, Ludhiana, PB,India Pedodontics CDC, CMC, Ludhiana, PB, India

International Editorial Board

Dr. DEEPAK G K, DDS Dr. Manish Valiathan Dr. RAJESH GUTTA, MS Oral and Maxillofacial Surgeon Assistant Professor, Department of Oral and Maxillofacial Surgeon Assistant Professor of Surgery Orthodontics School of Dental Assistant Professor of Surgery University of Cincinnati, Medicine Case Western Reserve University of Cincinnati, Ohio, USA Ohio, USA University, Cleveland, Ohio

Advisors

Dr. I K Pandit Dr. Ashwani Dhobal Dr. Vijay Wadhwan Dr. Ashu Bhardwaj Dr. A K Dubey Col (Dr.) B R Cheetal Dr. Rajinder Singh Dr. S K Khindria Dr. Vinod Kapoor Dr. N C Rao Dr. Sanjay Tiwari Dr. Jaidev S Dhillon Dr. T P Singh Dr. Bhupinder Padda Dr. Malkiat Singh Dr. Rajiv Aggarwal Dr. Ashu Gupta Dr. Pradeep Shukla Dr. Kalwa Pavankumar Dr. Abhiney Puri Dr. S.P.S. Sodhi Dr. Mukesh Singhal AJ)

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. b Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Official Journal of HP University, Shimla

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. c Guest Editorial

Digitisation In Dentistry…..

In the last decade, digital technology has progressed at lightening speed and shows no sign of abating. Talk of technology is nothing new in dentistry. For years, lectures have focused on the next great digital invention and what it will mean to the dental practice and the dentist's bottom line. However, integration and the effect on the practitioner's psyche has rarely been touched upon. Does a dentist truly need to be "digital" to be a "good dentist"? Can digital technology really improve the quality of dental treatments? These are the questions that need serious thought.

Digitisation in dentistry can make it easier and quicker to achieve accurate outcomes that meet and exceed expectations where dentists can make a real difference to the lives of their patients. Dental professionals should think of the digitisation of dentistry as the utilisation of new technology to complement the old established systems. This allows the profession to use progressive technologies, bringing apparent advantages to every day dental practice.

There are clinicians who argue that new streamlined, integrated processes are unnecessary as they have been practising quite happily without them for so many years. But dentistry itself is reaching great heights and digitization is quickly becoming part of the mainstream.

The paradigm shift from analogue to digital is fast catching up. It is important to educate and inform the dental professionals understand the advantages of digitisation, both to themselves and their patients and then to provide the means by which every practice can reap the multitude of benefits that come from imbibing it appropriately.

Most of the dental procedures are being based on the digital techniques. Starting from X-rays or photographs, making impressions, recording jaw movements or fabricating prosthesis, educating and training new dentists or patient motivation for practice build up, all has become digital. CAD- CAM has revolutionized not just the ceramic technology but has also been used for the CAD-CAM implant surgeries, maxillofacial prosthesis and diagnostic splints. Today a practicing dentist needs to be abreast with the latest but with the technology changing so fast, this poses a great challenge. There is endless scope of digitisation and technology in dentistry- let it be in the clinical and lab procedures like use of CAD-CAM technology, rapid prototyping, use of virtual articulators and digital face bows, digital radiographs, fighting caries without drilling - detecting earlier Dr. Vikas Jindal or in the field of training, education and research, dental softwares, digital instron machine, Editor in Chief audiovisual aids,… the list will remain endless. Use of implantology is becoming more and more Indian Journal of Dental Sciences simple thanks to digital diagnostics and navigation software for treatment planning. The dental laboratory comes strongly into play in this regard – in particular with the production of precise drilling templates. The dental technician prepares, the dentist adapts and finally fits the restoration in place.

The day is not far when remote sensing robotic devices would be performing the restorations under the command and surveillance of the master—the dentist without his immediate presence. Is it possible to make a real difference to the day-to-day delivery of dentistry by embracing rather than shunning the opportunities that digitisation offers? As it is said we should not only keep ourselves abreast of the developments but also utilize these in our day to day treatment. That will be real advancement..

Dr. Vikas Jindal Editor in Chief Indian Journal of Dental Sciences

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. d Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Knowledge Of Emergency Management Of 1 Reshma Meka 2 K.V.N.R. Pratap Orofacial Trauma Among Physical Education 3 C. Madhavi Padma 4 V. Siva Kalyan Students In South India 5 A.S.K. Bhargav 6 Surya Chandra Varma Abstract 1 Post Graduate Student Background: Orofacial trauma is the most commonly encountered problem among both children 2 Professor And Hod and adults, which can result in negative impact on quality of life. As great numbers of traumatic 3 Professor dental injuries occur at school during sports activities, physical education teachers and students 4 Reader should be prepared to provide emergency management of . Hence this study was 5 Sr. Lecturer aimed to assess the knowledge of emergency management of orofacial trauma among the 6 Sr. Lecturer physical education students in south India. Public Health Dentistry, Mamata Dental College Methodology: A cross sectional survey was conducted on all the physical education under Address For Correspondence: graduate students from the university college of Physical education located in Khammam, South Dr. Reshma Meka, Post Graduate Student India. A standard questionnaire was used which consisted of 21 questions regarding the Department Of Public Health Dentistry Mamata Dental College Khammam- 507002, A.P. knowledge of emergency management of orofacial trauma. Descriptive statistics were E-mail: [email protected] calculated to know the frequencies of responses. Tel : 91 9966737579 Results: A total of 92 subjects were participated in the study. 55.43% had received first-aid Submission : 20th February 2014 training and 84.31% of the study population reported that their training had covered management Accepted : 19th January 2015 of Dental injury. Half of the students (50%) have identified the tooth correctly. Regarding the medium for storage and transport of avulsed tooth, majority of students (53.61%) opted for anti- septic lotion. Quick Response Code Conclusion: Physical education students have relatively less awareness about management of orofacial trauma when compared to first aid treatment for general injuries. So, there is a need to update their knowledge by upgrading their existing curriculum by incorporating dental first aid component in undergraduate level. Key Words Emergency, Knowledge, Oro-facial Trauma, Physical Education. Introduction in Brazil. The most recent Israeli study Orofacial trauma is one of the most has reported a prevalence of dental trauma[16]. important oral health problems among trauma of 13.5% among fifth and sixth Since sports have been implicated in the children and adolescents throughout the grade Jerusalem school children[2]. etiology of dental trauma and high world[1],[2]. These injuries can vary The prognosis of injured tooth depends proportions of dental trauma at schools from a minor enamel chip to largely on prompt and appropriate occur during physical education classes, displacement or avulsion of teeth to emergency treatment which is frequently the concerned physical education teacher extensive maxillofacial damage which provided by the lay people, including and students should be capable of may result in pain, disfigurement, poor parents and school teachers who are managing the traumatized teeth on time esthetics and speech defects. Among present at the site of accident. A study for the ultimate success of treatment. dentofacial injuries, avulsion of the tooth conducted regarding the awareness of As a matter of an honest observation was most common and large numbers of emergency management among parents physical education students are very studies have reported that these traumas in Australia revealed that 90% of often encountered with trauma of the oral largely affect the upper central incisors respondents have little knowledge on cavity and teeth. Observations demand a leading to loss of function, esthetic correct procedures[13]. Despite a high necessity to carry on ongoing education disturbances as well as negative impact incidence of dental trauma in New system as an instrument to enhance the o n q u a l i t y o f l i f e p r o d u c i n g Zealand, sports coaches generally have opportunities of a good prognosis in these psychological and social discomfort[3]. an inadequate knowledge for managing types of traumas. Hence this study has Falls[4], [5], sports[6], collisions[7], [8], such conditions[14]. Newman and been conducted with an aim to assess the physical leisure activities[9], being stuck Crawford investigated the first aid knowledge of emergency management of by an object[10] and traffic accidents[9] knowledge of teachers of physical orofacial trauma among physical are the major causes of dental traumatic education in UK and concluded that this education undergraduates in south India. injuries. Among them fall is the main group should receive further training in cause[10],[11]. It was reported that sports the management of dental injuries[15]. Methodology: and school injuries accounted for 60% of Panzarini et al conducted a study on It was a cross sectional questionnaire dental trauma[12]. Up-to-date studies physical education undergraduates and based study. All the physical education have demonstrated prevalence levels reported that only 9.7% of the students under graduate students from the ranging from 1.8% in Norway to 18.9% had some knowledge regarding dental university college of Physical education

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 001 located in khammam, South India were old boy breaking his front tooth, only Out of 92 students, 97.83 % (n= 90) felt taken in to the study. Ethical clearance 44.57% of the respondents identified the that this information on emergency was obtained from the institutional tooth correctly as a permanent tooth. In management was necessary and ethical committee, Mamata Dental the appropriate management of the same important, and 95.65 % (n=88) expressed College and informed consent was case, majority of the participants the desire for further training in such obtained from each participant prior to (80.43%) chose the correct option of cases (Table 4). the start of the survey. contacting the parents and advise them to Individuals who were willing to take the child to a dentist. More number Discussion: participate and those were present on the of the respondents, 84.78 % chose to look Major cause of morbidity in both day of survey were included and who for the dental practitioner in case of a developed and developing countries were not willing to participate and those dental injury (Table 2). around the world are injuries. Traumatic were not present on the day of survey In case of avulsion injury with dental injuries are caused by a complex were excluded. Data was collected using emergency action to be taken only array of social and environmental factors. a standard questionnaire consisted of 21 16.30% of them chose correct option i.e. Contact sports, violence, falls, traffic closed ended questions regarding the to look for avulsed tooth immediately and accidents and poor environments have all knowledge of students in the emergency reaching the dentist where as 88.70% been implicated in injuries. management of orofacial trauma. opted for first-aid. When asked about the Fractured teeth or its loss as a result of The investigator approached the students cleaning of the soiled avulsed tooth trauma may cause negative impact on the during their college hours. After majority of the respondents would rinse it physical appearance of individuals and explaining the purpose of the study, under tap water gently (51.01%) society. According to American instructions were given to the students followed by cleaning with a tooth brush organization for prevention of sports regarding the completion of the (36.96%). Regarding the medium to related trauma, there are 10% chances of questionnaire and at last the carry the tooth to a dentist, majority suffering an orofacial injury and 18.9% questionnaire was collected by the (53.61%) of them chose anti-septic of 12 year old children have suffered investigator immediately after solution. In case of a broken jaw majority traumatic dental injury during leisure and completion. The collected data was (65.22%) of the students reported that entered in to the excel sheet for analysis. they will take the injured person to an Table 3: Responses Of The Study Population To Various Descriptive statistics were computed to emergency room in hospital and 33.70% Questions demonstrate the frequency of responses. of students reported that they will try to Questions Number of % of keep the jaw from moving by a three tier respondents respondents Results: bandage (Table 3). During school hours, a 12 year old boy fell from stairs, and was hit in the A total of 92 (75 males and 17 females) . His upper front tooth is found to be missing. What would you do? subjects were participated in the study. Table 2: Responses Of The Study Population To Various Among them 55.43% had received first- Questions a) Look for tooth immediately and take him 15 16.30 aid training and 44.57% had not received Questions Number of % of to a dentist first-aid training. 84.31% of the study respondents respondents b) Give first aid to the boy 77 83.70 population reported that their training A nine year old girl fell and her is bleeding, If you decide to take the tooth and the boy to the dentist but the tooth had had covered management of Dental fallen to the ground and covered in dirt. What would you do? injury. 60.87 % had witnessed injury to what would you do? a) Rinse it under tap water gently 47 51.09 teeth and jaws and 57.61% had seen the a)Clean area and apply pressure with a sterile 47 51.09 management of such injuries (Table 1). gauze b) Clean it with a tooth brush 34 36.96 In an imaginary case of injury with lip b)Take him to a nearby clinic for treatment 45 48.91 c) Don't know 11 11.96 bleeding in a 9 year old girl, 51.09% of c)I don't know 0 0.00 If you used a liquid to take the tooth. What liquid you would use? the respondents chose the appropriate A 11 year old boy fell down and broke his front a) water 3 3.26 option i.e. cleaning with sterile wet gauze tooth. He was otherwise unhurt and didn't lose b) Milk 36 39.13 and apply pressure and 48.91% chose to consciousness. What do you think the broken c) Antiseptic solution 53 57.61 take the girl to a nearby clinic for In a case of a broken jaw in an injury and the patient is conscious, treatment. In the second case of a 11 year tooth is? a)A permanent tooth 41 44.57 what would you do? Table 1: Responses Of The Study Population To Various Questions b)A baby tooth 51 55.43 a) Try to keep the jaw from moving by a three 31 33.70 Questions YES NO In the above case which of the following actions tier bandage n % n % would you consider as the most appropriate? b) Take him to an emergency room in hospital 60 65.22 Have you received first aid training? 51 55.43 41 44.57 a)Give the child a drink and pacify him 14 15.22 c) I don’t know 1 1.08 If yes, did it cover management of dental 43 84.31 8 15.69 b)Contact parents and advice them to send the 74 80.43 Table 4: Responses Of The Study Population To Various injury? child to dentist Questions Have you seen any accidents with injury 60 65.22 32 34.78 c)Not sure what to do 4 4.35 Questions Yes No on the face? If a boy came to you with a knocked out tooth n % n % Have you witnessed any accidents with 56 60.87 36 39.13 in the hand after an injury, whom would Do you consider this information 90 97.83 2 2.17 injury to the teeth or jaws? you contact first and seek treatment? important and necessary? Have you ever seen the management 53 57.61 39 42.39 a)A medical practitioner 14 15.22 Do you think that you need further training 88 95.65 4 4.35 of such injuries? b)A dental practitioner 78 84.78 to manage such cases during school hours?

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 002 sports activities. Traebert reported that Only one-thirds (25%) of the study which is in agreement with Chan et majority of the accidents occurred at population were aware of the al[12]. The cooperative actions between home (60.4%) followed by school management of an avulsed tooth and the dental and physical education (18.6%) and outside in street (18.6%) rest (75%) of the study population were professionals are needed in order to [16]. not aware of the management of an d e v e l o p c o n t i n u e d e d u c a t i o n The future course of an injured tooth will avulsed teeth. This strongly reflects the programmes, since physical education extremely rely on a sufficient urgent lack of knowledge about emergency undergraduate students are not administration of treatment. Physical management of avulsed teeth among adequately prepared to provide education undergraduates were selected physical education undergraduates as emergency care to dental trauma victims. as the study group because a great deal of well as their teachers or could be due to From here to abstain this it is inevitable to dental trauma may occur during sports their lack of prior experience or invest on preventive educational practices. Among the 92 respondents, information from other sources. strategies to promote oral health, aiming only slightly more than half of the In situation of handling a separated or to qualify these future professionals so respondents (55.43%) underwent first aid avulsed tooth, majority of the study that they are aware of their leading role training during the course. In the study population (83.75%) has opted for first when dealing with dental trauma. The conducted by Alencar AHG et al[17] this aid rather than searching for tooth results suggests that almost all of the percentage was slightly lower (46.5%) quickly because the perception of blood physical education colleges have no than the present study. initiates an overwhelming response to contents regarding dental trauma in their The permanent teeth should be replanted control the bleeding. Similarly, focusing curriculum, as is evident from their or placed in milk, physiological saline or on controlling bleeding was observed in inadequate knowledge and attitude saliva if immediate replantation is not the study conducted by Chan et al[12]. towards the matter which coincides with possible and the deciduous teeth should This may be also a reflection of the basic the results of the study conducted by not be replanted. Therefore, to carry out life support provided in first aid training. Alencar AHG et al[17]. t h e m o s t s u i t a b l e e m e rg e n c y Unluckily the child would not have management it is important to distinguish advantage from this maneuver because Recommendations: between the permanent and primary delayed re-planting the tooth will Revision of physical education training teeth[18], [19]. In the present study only endanger its prognosis. curriculum should be considered. To 44.57% of respondents were capable of Milk is a practical storage and transport advise course coordinators of the correctly identifying the tooth which is medium which is easily available and institutions to add dental first-aid similar to the results of the study by Chan relatively free from bacteria, and its component in undergraduate level. et al[12] conducted in Hong Kong osmolality is not harmful to the Educational campaigns and regular (46.8%) and Uma SR et al[20] in periodontal ligament cells. The choice of reinforcement is recommended with the Bangalore (45.1%). This might be due to an adequate transport medium is essential involvement of local dentists and the lack of awareness regarding the time to prevent damage to periodontal institutions. of eruption of teeth among the ligament cells and thus increase the undergraduates and also the lack of chances of a successful treatment[21]. In Limitations: dental topics in their curriculum. the present study only a small percentage The present study was conducted on a When a question was asked regarding of students (39.13%) have reported milk smaller sample; a larger sample can give action to be taken in case of fractured as the best storage and transport medium a better insight. Surveys with closed- tooth, 80.43% stated rightly by opting to of choice and majority of the students ended questions may have a lower communicate with the parents instantly (57.61%) reported that antiseptic validity rate. Qualitative type of studies and recommend them to send the child to solution as the storage and transport can provide detailed information about a dentist. The reason for the correct medium for the avulsed tooth which is in their knowledge regarding the decision may be due to the fact that most favor with the study conducted by chan et emergency management of orofacial people known that dentists treat the tooth al[12] and Claudia Londero et al[21]. The trauma. problems which is comparable to the intention of the students was to kill the study conducted in England by Newman germs on the root surface of the tooth but Conclusion: L, Crawford PJM[15]. they do not realize that the viable cells of From the current study it is familiar that With regard to the dental injury, majority the tooth will also be damaged severely at the majority of the respondents have well of the respondents out of 92 (84.78%) the same time[12]. and adequate knowledge concerning first reported that they would contact dental Majority of the subjects (97.83%) aid measures for managing general practitioner first and seek treatment and considered this information as important; injuries but are found to have noticeably only 15.22% of respondents opted for it is also surprising to know that 95.65% insufficient knowledge regarding the medical practitioner which was in of the study population expressed a desire management of orofacial trauma and accordance with Chan et al[12] (48.8%) for further training in managing such more precisely the management of an and panzarini et al[16] (50%). This could injuries which is similar to study avulsed tooth. Awareness campaigns on be explained by the abundant availability conducted by panzarini et al[16]. The dental traumatic injuries and their of private dental facilities and their idea reason might be due to their high degree consequences must be targeted at t h a t d e n t a l p r o f e s s i o n h a s a of dissatisfaction. physical education students and also to comparatively well knowledge of correct Based on this, it is of prime importance to the public community including health activities taken in case of tooth separation introduce dental trauma management in care professionals, so that they can be than medical profession. physical education trainees’ curriculum, able to provide emergency care to dental

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 003 trauma victims, or to minimize its effects environment of dental injuries in 12- 1991; 7:255-8. during sports practice. to 14-year-old Ontario school 16. Panzarini SR, Pedrini D, Brandini c h i l d r e n . D e n t T r a u m a t o l DA, Poi WR, Santos MF, Correa JP, et References: 2008;24:305-8. a l . P h y s i c a l e d u c a t i o n 1. Jorge KO, Ramos-Jorge ML, de 8. Glendor U. Aetiology and risk factors undergraduates and sental trauma Toledo FF, Alves LC, Paiva SM, related to traumatic dental injuries—a knowledge. Dent Traumatol. 2005 Zarza PM. Knowledge of teachers review of the literature. Dent Dec; 22(6):324-8. and students in physical education’s Traumatol 2009;25:19-31. 17. Auna Helena Goncalves de Alencar, faculties regarding first-aid measures 9. Huang B, Marcenes W, Croucher R, Kely Firmino Bruno,Maria do Carmo for tooth avulsion and replanation. Hector M. Activities related to the matias Freire, Marino Rodrigues de Dent traumatol. 2009 Oct; 25(5):494- occurrence of traumatic dental Moraes, Luana Braz de Queiroz. 9. injuries in 15 to 18 year-olds. Dent Knowledge and attitudes of physical 2. Holan G, Cohenca N, Brin I, Sgan- Traumatol 2009;25:64-8. education undergraduates regarding Cohen H. An oral health promotion 10. Naidoo S, Sheiham A, Tsakos G. dental trauma. Dental press Endod. program for the prevention of Traumatic dental injuries of 2012 Jan-Mar; 2 (1):74-9. complications following avulsion: permanent incisors in 11- to 13-year- 18. Flores MT. Information to the public, the effect of knowledge of physical old South African schoolchildren. patients and emergency services on education teachers. Dent Traumatol. Dent Traumatol 2009;25:224-8. traumatic dental injuries. Textbook 2006; 22(6): 324-8. 11. Noori AJ, Al-Obaidi WA. Traumatic and colour atlas of traumatic injuries 3. Cortes MI, Marcenes W, Sheiham A. dental injuries among primary school to the teeth. 4th ed.Oxford: Blackwell Impact of traumatic injuries to the children in Sulaimani city, Iraq. Dent Munksgaard; 2007: 872. permanent teeth on the oral health- Traumatol 2009;25:442-6. 19. Flores MT, Malmgren B, Andersson related quality of life in 12–14-year- 12. Chan AWK, Wong TKS, Cheung L, et al. Guidelines for the old children. Community Dent Oral GSP. Lay knowledge of physical management of traumatic dental Epidemiol 2002; 30:193–8. education teachers about the injuries. III. Primary teeth. Dent 4. Faus-Damia M, Alegre-Domingo T, emergency management of dental Traumatol 2007;23:196-202. Faus-Matoses I, Faus-Matoses V, trauma in Hong Kong. Dental 20. Dr Uma.S.R, Dr.M.R.Shankar Faus-Llacer VJ. Traumatic dental Traumatol. 2001 APV; 17(2): 77-85. aradhya. Knowledge of emergency injuries among schoolchildren in 13. Raphael SL, Gregory PJ. Parental management of orofacial trauma Valencia, Spain. Med Oral Patol Oral awareness of the emergency among physical education students. Cir Bucal 2011;16:e292-5. management of avulsed teeth in Journal of the Indian association of 5. Wilson S, Smith GA, Preisch J, children. Aust Dent J, 1990, 35:130- public health dentistry. Vol:2011 Casamassimo PS. Epidemiology of 3. Issue 18 Suppl 1: 646-653. dental trauma treated in an urban 14. Stokes AN, Anderson HK, Cowan 21. Claudis Londero pagliarin,Clacir paediatric emergency department. TM. Lay and professional knowledge Londero Zenker, Fernando Branco Pediatr Emerg Care 1997;13:12-5. o f m e t h o d s f o r e m e rg e n c y Barletta. Knowledge of physical 6. Thelen DS, Bardsen A. Traumatic management of avulsed teeth. Endod education teachers about emergency dental injuries in an urban adolescent Dent Traumatol, 1992; 8:160-2. management of tooth avulsion. population in Tirana, Albania. Dent 15. Newman L, Crawford PJM. Dental Stomatos, Vol.17, num.33,2011. PP. Traumatol 2010;26:376-82. injuries: “first-aid” knowledge of 32-42. 7. Fakhruddin KS, Lawrence HP, Southampton teachers of physical Kenny DJ, Locker D. Etiology and education. Endod Dent Traumatol,

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 004 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Prevalence Of Traumatic Dental Injuries And 1 Sudhir Mittal 2 Mrigank Dogra Its Correlates Among School Going Children 3 Kavita Mittal 4 Vasundhara Pathania Between 8-12 Years Of Age In Sundernager, 5 Jasneet Kaur 1 Professor Himachal Pradesh – A Short Study 2 P.G. Student Dept. Of Pedodontics And Preventive Dentistry Himachal Dental College, Sundernagar. Abstract 3 Introduction : Trauma to the teeth is a common reason for emergency room visit among Professor, Department Of Pedodontics Guru Nanak Dev Dental College Sunam. children. Dental trauma has become an important aspect of public health. The consequences of 4 Sr.Lecturer dental trauma include disfigurement, speech defects and psychological effects. The primary 5 P.G. Student requirement before dealing with such a problem is to describe the extent, distribution and the Dept. Of Pedodontics And Preventive Dentistry factors associated with the problem. Himachal Dental College, Sundernagar Aim and objective : A short study was designed to target the age group of 8-12 years to ascertain Address For Correspondence: the prevalence and the factors responsible for trauma in school children. Dr. Sudhir Mittal Material and method : A total of 1130 school going children were examined. Parameters like Professor age, sex distribution, etiological factors and cause of injury were taken into consideration. Dept. Of Pedodontics And Preventive Dentistry Results : Out of 1130 children examined, prevalence of TDI was 27.8%, with males showing a Himachal Dental College, Sundernagar th slightly higher incidence compared to females. Ellis class II fractures were the most common and Submission : 20 February 2014 sports was the major cause of trauma. Accepted : 19th January 2015 Conclusion : TDI is a serious health problem among children and there is a need for collection of data, in order to prevent and manage it efficiently. Quick Response Code Key Words Prevalence, Traumatic Dental Injuries, School Going Children.

Introduction because of increased outdoor activities Traumatic dental injuries are the most by girls[6],[7],[8]. unanticipated events frequently Since most of the dental injuries can be associated with childhood. The incidence prevented, so understanding the factors of these injuries has markedly increased that predispose to trauma is essential for 10yrs, 11yrs and 12yrs age groups among during the last 10 to 20 years, which developing a concept for the prevention. boys and girls respectively.The study was suggests its incidence will soon exceed Although, there are a number of studies conducted in 6 randomly selected schools dental caries and periodontal diseases that have determined the incidence and of the area, enrolling approximately 300 due to high level of violence, road traffic prevalence of dental trauma in various students per school with roughly equal accidents and greater participation in parts of India, but lack of such data has number of boys and girls. Formal sports[1]. been found in the hills of Himachal approval was taken from the principal. These injuries not only compromise Pradesh, which has a different Ethical clearance was obtained by the dental health, but can also lead to geographical terrain. Hence the study ethical committee of the institute. aesthetic, psychological, social and was undertaken with the aim and therapeutic problems. Hamilton et al[2] objective of determining the prevalence Inclusion criteria and Burton et al[3] stated that 6-34% of dental trauma and its correlating -Children willing to participate with individuals respectively suffer from factors in District Mandi, Himachal consent from duly signed by the parents traumatic dental injuries during their life. Pradesh. This study gives a more detailed or guardians. The 7- 12 year age group is considered to insight into the context and factors be most prone to any form of dental associated with the traumatic dental Exclusion criteria trauma because children of this age are injuries in the children of Himachal -Uncooperative children engaged in lots of outdoor activities. Pradesh. -Medically compromised children. According to the earlier literature, boys -Children showing clinical evidence of sustained dental trauma almost twice as Material and method trauma but without any relevant history, much as girls, exhibiting significant Selection of Sample as the study was based on self-report of gender difference with regard to dental A cross sectional study was carried out on children. trauma experience[1], [4]. According to a total of 1130 school going children Equipment-Mouth mirrors, tweezers, Nik-Hussein[5], males experienced 5.5% between the age range of 8 to 12 years periodontal probes, disposable trauma whereas females experienced who were permanent residents of District depressors and cotton gauge pieces only 2.8%. But recent studies have shown Mandi, Himachal Pradesh. The children a reduction in this gender difference were further categorized into 8 yrs, 9yrs, Clinical Examination

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 005 Before examination the teeth were cleaned. Clinical examination was carried out in the school under natural day light. The examination was carried out by trained examiner and assistant. While examining the patient, the trained assistant was made to sit close to the patient, to record the data on specially designed proforma.

Examination was performed in a uniform fashion starting from the maxillary right quadrant to the mandibular right quadrant in a clockwise direction. The examination consisted of recording of age, gender, type of injury, cause of injury and place of injury. Injuries to the permanent teeth were categorized according to Ellis and Davey’s classification (1960) of tooth fracture. Only three criteria’s were included to classify the tooth fractures they were fracture of enamel/ enamel chipping Fig 2 : Most Common Type Of Traumatic Dental Injury In The Examined Children (Percentage) (Ellis class I tooth fracture), fracture of In the present study,out of the 1130 Table 1 : Percentage Among Males And Females Of Different enamel with involvement of dentine children (571 males and 559 females), Variables. (Ellis class II tooth fracture) & fracture of males showed higher percentage of TDI Males Females Chi-square P-value enamel involving dentine and (Ellis than females i.e (29.4%) as compared to (percentage) (percentage) value class III tooth fracture). (28.4%) (Figure1). Males had greater Age : 8years 05.3 06.1 Repeated sessions of calibrations were prevalence of trauma in 9 years (13%) 9 years 13.0 09.3 performed by examiner and a supervisor while females had greater trauma in to standardize recording procedure. 10 years 06.1 12.9 42.70 0.04 10years (12.9%) age group and the 11 years 01.4 00.0 Chronological age was the criteria for difference was statically significant deciding the age of the patient.The data (p<0.05) (Table 1). 12 years 03.0 00.0 obtained was subsequently processed There was maximum incidence of Ellis Place : School 14.7 05.3 and analyzed using SPSS statistical classIII fractures in males while in Playfied 75.3 24.7 software Program. The Chi-square test females Ellis Class II type of tooth Road 55.4 44.1 109.71 0.03 was employed to evaluate the results. The fractured dominated (Figure2). On house 76.9 23.1 P-value < 0.05 was considered as analyzing the place where maximum statistically significant. Cause : Falls 10.3 09.4 injuries occurred, males suffered Collisions 01.8 05.7 maximum amount of TDI at home Accidents 04.2 05.5 42.23 0.04 Results followed by playfields, road and schools Sports 14.0 07.1 Violence 01.2 04.5

whereas in females maximum trauma was seen in playfield (Table1). Fall was found to be the major causative factors of trauma in females and sports was the main factor in case of males (Table 1).

Discussion Dental trauma refers to injury of the teeth or the and the nearby soft tissues such as , tongue etc. These injuries tend to occur more at a young age when growth and development is taking place[9].Trauma has great impact on the quality of life of the child.On an average, children with an untreated TDI were 20 times more likely to report an impact on quality of life when compared to children

Fig 1 : Prevalence Of Traumatic Dental Injuries According To Gender without a TDI[10], [11].

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 006 In various studies, a wide range of In the present study, prevalence of Ellis effective management and adoption of prevalence levels of TDI have been seen class II fractures was most common health policies will help reducing the because they have different diagnostic (10.3%) followed by Ellis class III type of increasing traumatic dental injuries. criterias, methodologies and populations. tooth fracture (8.8%). This was Prevalence refers to all the cases of TDI consistent with the findings in the United References new or old, in a population at a given time Kingdom survey[27] and with the reports 1. Andreason JO, Andreason FM [12]. The present study showed a of several other authors [28], [29], Textbook and color atlas of traumatic prevalence of 27.8%, showing increased [30].These complicated types of dental i n j u r i e s t o t e e t h , risk of TDI in Himachal population .The fractures require immediate dental care ed3.Copenhagen.Munksgaard results were similar to the study with close review and adherence to publishers,1994. conducted by Prabhu et al [13] in which follow up appointments, to reduce the 2. Hamilton FA, Hill FJ, Holloway PJ. the prevalence of TDI was 23.8%. complications associated with delayed An investigation of dentoalveolar Studies done by Ravishankar [14] in treatment. trauma and its treatment in an South India and Sharma and Dua[15] in Our study showed schools to be the most adolescent population. Part I:the Punjab showed comparatively less common place of injury followed by prevalence and incidence of injuries prevalence of 15.7% and 14.5% playfields.This is due to the fact that and the extent and adequacy of respectively.This can be attributed to the children spend around 60% of their time treatment. Br Dent J 1997;182:91-95 difficult and mountainous terrain lacking at their homes under the care and 3. Burton J, Pryke L, Rob M, Lawson playgrounds for children in Himachal supervision of their parents, thus the JS. Traumatized anterior teeth Pradesh.According to Ravn[16], prevalence of trauma at home was less. amongst high school students in however, one study cannot be compared The only time children lack supervision Northern Sydney. Aust Dent J 1985; with another study of dental trauma. was at school, this was validated by 30:346-348 Greater amount of trauma was observed Gupta et al[31] in their study in South 4. Gutmann JL, Gutmann MS. Cause, in boys (29.4%) than in girls (28.4%), but Kanara. The schools, thus, act as an ideal incidence and prevention of trauma to the difference was marginal. A similar setting where children meet their peer teeth. Dent Clin North Am study carried out by Garcia - Godoy et groups and get involved in physical 1995;39:1-13. al[17] also showed a small difference activities unattended. 5. Noriah N, Hussein Nik. Traumatic between trauma prevalence in boys and Due to increased participation in sports injuries to anterior teeth among girls.This can be due to the increased and other vigorous activities by children, schoolchildren in Malaysia. Dental participation of girls in sports and other sports account for the prime cause of TDI Traumatology2001; 17:149-152 vigorous activities. Traebert et al[18] also with a prevalence of 10.6%, followed by 6. Burden DJ.An investigation of the explained in his study that girls can be falls with an incidence of 9.4% in the association between overjetsize. Lip exposed to the same TDI risk factors as present study. Similar result was found by coverage, and traumatic injury to boys, which is characteristic of modern Prabhu A, et al [13] in a study conducted maxillary incisors. Eur J orthod western society.Thus, it is probably the on 458 children of sainik school, where 1995:17:513-7 activities of a person and the environment TDI due to sports was seen to have a 7. Rocha MJ, Cardoso M. Traumatized in which he resides which act as the prevalence of 62%.The present study permanent teeth in Brazilian children determining factors of TDI than the also reported an increase in sports related assisted at the Federal University of gender. injuries (7.1%) amongst females, due to Santa Catarina, Brazil. Dent Age is another well known risk variable. the increased participation of females in traumatology 2001; 17:245-9 School children and teenagers are the sports [6],[7],[8] as a result of increased 8. Traebert J, Peres MA, Blank V, Boell target groups, but less has been awareness.This corroborates the results RD, Pietruza JA. Prevalance of documented about very young children. of studies conducted by Marcenes et al traumatic dental injury and Results from many studies [19], [20], [25] and Nicolau et al [32]. Thus, societal associated factors among 12-years- [21], [22] affirmed that the majority of changes account for this increased old school children in Florianopolis, TDI’s occur in children and adolescents. incidence of trauma among females. Brazil.Dent Traumatol2003;19:15-8. It is estimated that about 71-92% of all 9. Andreason J, Andreason F and TDI’s sustained in a lifetime occur before Conclusion Andersson L. Textbook and colour the age of 19 years. Other studies [23], The increasing incidence of TDI, which Atlas of traumatic injuries to teeth [24] reported a decrease in TDI after the has become a social health problem, fourth edition age of 24-30 years. In the present study, needs immediate intervention. 10. Soriano EP, CaldosJr AF, Carvalloh 13% of TDI was seen in 9 year males and I m p r o v e m e n t i n t h e p h y s i c a l M V, A m o r i u m F i l h o H A . 12.9% of TDI was observed in 10 year environment of children, along with R32;Prevalence and risk factors females, which was similar to the study close supervision when they are involved related to traumatic dental injuries done by Marcenes et al [25] in 9-12 year in physical activities is likely to have a R32;in Brazilian school children. old Syrian children.This is due to the fact positive impact in reduction of TDI. Dent Traumatol 2007;23:232-40. that children are more active during this Screening camps can be conducted at 11. Cortes MIS, Marcenes W, Sheiham age and they lack motoric coordination. schools to identify children at high A. Impact of traumatic injuries to the For this reason they are unable to anatomic and behavioural risk of trauma, permanent teeth on the oral health- precisely evaluate the danger associated followed by appropriate intervention related quality of life in 12-14 yeae with velocity. As they grow, their risk through orthodontic treatment. Also, old children. Community Dent Oral towards TDI is reduced.[26] increasing awareness about TDI and its Epidemiol 2002:30:193-8.

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 007 12. Glendor Ulf. Epidemiology of Traumatol 2006;22:173-8 Dental Clinic. Dent Traumatol 2009; traumatic dental injuries- a 12 year 19. Glendor U, Haling A, Andersson L, 25:84-7 r e v i e w o f t h e l i t e r a t u r e . Eilert-Petersson E. Incidence of 27. O’Brien M. children’s dental health DentTraumatology 2008;24:603-61. traumatic tooth injuries in children in the United Kingdom 1993. OPCS. 13. Prabhu A, Rao AP, Govindarajan M, and adolescents in the county of London: HMSO; 1997. Reddy V, Krishnakumar R, Våstnanland, Sweden. Swed Dent J 28. O’Mullane DM. Some factors Kaliyamoorthy S. Attributes of dental 1996;20:15-28. predisposing to injuries of permanent Trauma in a school population with 20. Davis GT, Knott SC. Dental trauma in incisors in school children. BR Dent J Active sports involvement. Asian J Australia. Aust Dent J 1984;29:217- 1973;134:328-32. Sports Med 2013;4(3):190-194 21 29. Macko, DJ, Grasso JE, Powell EA, 14. Ravishankar TI, Kumar MA, Ramesh 21. Ianetti G, Maggiore C, Ripari M, Doherty NJ. A study of fractured N,Chaitra TR. Prevalence of Grassi P. Studio statistic sulle anterior teeth in a school poplation. Traumatic Dental Injuries to traumatichedeidenti. Minerva ASDC J Dent Child 1979;46:130-3 permanent Incisors among 12-year Stomatol 1984;33:933-43. In Italian 30. Hamdan MA, Rock WP. A study old school children in Davangere, 22. R e d f o r s Å , O l s s o n B . comparing the prevalence and South India.The Chinese Journal of Ta n d s k a d o r i n o r r a Å l v s b o r g distribution of traumatic dental Dental Research 2010;13(1). 94020195013: en delstudie I injuries among 10-12 years –old 15. Dua R, Sharama S. Prevalence, cause “ S k a d e r e g i s t r e r i n g e n I children in an urban area of Jordan. and correlates of traumatic dental NorraAlvsborg”. Vånersborg: Int J paediatrDent 1995;5:237-41 injuries among seven to twelve year LandstingetiÅlvsborg: 1996. In 31. Gupta K, Tandon S, Prabhu D. old school children in Dera Swedish Traumatic injuries to the incisors in Bassi.www.ncbi.nlm.nih.gov/pmc/ar 23. Shulman JD, Peterson J. The children of South Kanara district. A ticles/ PMC3341757 association between incisor trauma p r e v a l e n c e s t u d y. J I n d i a n 16. Ravn JJ. Dental injuries in and occlusal characteristics in SocPedodPrev Dent 2002;20:107-13 Copenhagen school children, school individual 8-50 years of age. Dent 32. N i c o l a u B , M a r c e n e s W, years 1967-1972. Community Dent Traumatol 2004;20:67-74 SheihamA.Prevalence, causes and Oral Epidemiol 1974; 2:231-45. 24. Holland TJ, O’Mullane DM, Whelton correlates of traumatic dental injuries 17. Garcia-Godoy F, Morban-Laucer F, HP. Accidental damage to incisor among 13-year-olds in Brazil. Dent Crominas I.R, Franjul RA, Noyola M. amongst irish adults. Endod Dent Traumatol 2000;17:17-21 Traumatic dental injuries in school Traumatol 1994;10:191-4 children from Santo Domingo. 25. Marcenes W, Al Beiruti N, Tayfour D, Community Dent Oral Epidemiol Issa S. Epidemiology of traumatic 1985;13:177-9 injuries to the permanent incisors of 18. Traebert J, Bittencourt DD, Peres 9-12- year-old schoolchildren in KG, Peres MA, De Lacerda JT, Damascus, Syria. Endod Dent Marcenes W. Aetiology and rates of Traumatol 1999;15:117-123 treatment of traumatic dental injuries 26. IvancicJokic N, Bakarcic D, Fagosic among 12-year-old school children in V, et al. Dental trauma in children and a town in southern Brazil. Dent young adults visiting a University

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 008 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Relative Additional Mechanical Plaque 1 D S Kalsi 2 Anchal Sood Removing Effect Of Fibrous Food (Apple) On 3 Vikrant Sharma 1 Prof & Head Different Sites Of Selected Teeth 2 Reader 3 Senior Lecturer Abstract Department Of The aim of this study was to evaluate the relative additional mechanical plaque Bjs Dental College Ludhiana controlling/removing effect of fibrous food (apple) over and above the already being practiced Address For Correspondence: Dr. D S Kalsi routine measures by the patient. Specific teeth were selected: 11, 15, 25, 41, 35, 45 Prof & Head, Department Of Periodontology (FDI notation) and their labial surfaces were divided into three virtual zone i.e. mesiobuccal 1/3rd, Baba Jaswant Singh Dental College midbuccal 1/3rd and distobuccal 1/3rd for assessment of plaque deposits. It was seen that Hospital & Research Institute. Sector 40. ongoing plaque control mehods practiced by the patients were not completely effective in Chandigarh Road Ludhiana removing all the plaque from the selected teeth and that some surfaces (virtual zones) showed Submission : 27th March 2014 more plaque deposits than others after routinely performed oral hygiene measures. It was also Accepted : 25th February 2015 seen that fibrous food was variably effective in physically removing plaque from these zones and that the mesiobuccal zone was the most and midbuccal zone was the least amenable to cleaning Quick Response Code by fibrous food. It was concluded that fibrous food though offers additional plaque removing effect, but is still not 100% effective and that its plaque removing effect is not the same on different sites of different teeth. Key Words gingival health, , plaque control measures, fibrous food, Introduction of fibrous food on plaque deposits on Dental plaque is regarded as the main teeth are available[8],[11],[22],[23], the etiologic factor of . authors could not find any data on plaque in the study. In all the cases teeth number: The role of dental plaque in the controlling effect of fibrous food at 11, 15, 25, 35, 41 & 45 (FDI notation) development of plaque-induced different sites of teeth. This study was were selected for assessment of plaque. and is therefore designed to study the relative Labial surface of the selected teeth was well established[14],[21],[23],[27]. It is a d d i t i o n a l m e c h a n i c a l p l a q u e divided into three virtual vertical zones believed that the best approach to manage controlling/removing effect of fibrous i.e. mesiobuccal 1/3rd, mid buccal 1/3rd periodontal disease is prevention food (apple) as a plaque controlling agent and distobuccal 1/3rd for assessment of followed by early detection and at different sites (i.e. different selected plaque deposits (Diagram 1). All the treatment. The prevention of periodontal teeth and different zones on the labial subjects were asked to continue any and disease is targeted at the control of dental surface of these selected teeth) over and all plaque control measures (physical p l a q u e . B o t h m e c h a n i c a l a n d above the routine tooth brushing and/or and/or chemical) already being practiced chemicomechanical concepts have been other physical and chemical plaque by them. Within one hour of developed to reduce or prevent the control measures already being practiced toothbrushing, an apple of almost equal d e v e l o p m e n t o f p e r i o d o n t a l by the individual. size and weight was distributed to each diseases.[8],[17] student and the plaque scoring was done Oral health is related to diet in many Materials And Methods for each student before (Prescore) and ways, associations have been suggested Materials after they ate an apple after staining the between nutritional in@258;uences and Fibrous food (Apple), Two tone plaque teeth(Post score) using ‘Alpha Plac’ two craniofacial development, oral cancer disclosing solution (Dye ‘Alpha Plac’ tone disclosing dye solution. The extent and oral infectious diseases[1]. The Dental products of India, The Bombay of plaque on the selected surfaces of each consumption of fibrous food has been Burmah trading corporation ltd.), Mouth tooth was calibrated using the following positively correlated with the prevention mirror, Cheek retractor, Tweezers, criteria (Diagram 2). Score 0 was for no of periodontal diseases by reducing the Cotton rolls. plaque on the selected particular tooth amount of dental plaque[8],[11]. Of these hard foods, apples have been the most Method commonly recommended. Apples have A total of 100 healthy subjects which commonly featured in dental health included 4th year students and interns of programmes and have become, to some Baba Jaswant Singh Dental College and e x t e n t , a s y m b o l o f d e n t a l hospital, Ludhiana, were selected for the health.[8],[11],[22],[23] study. A written informed consent was While many studies correlating the effect taken from all the subjects participating Diagram 1

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 009 (Table1) [it must be mentioned here that some sites did not show any / remarkable change i.e., reduction in post plaque scores]. The distobuccal zones of all the selected teeth showed the maximum remaining plaque [pre score] inspite of regular plaque control measures being practiced by the individual selected for the study, followed by the mesiobuccal zones and the midbuccal zones (Table3). Of all the selected zones, distobuccal zone of the tooth no.41 showed the maximum prescore plaque deposit (0.96) and the midbuccal zone of tooth no. 45 showed the minimum prescore plaque deposit (0.18) (Table4). Comparison in the changes in plaque among the three vertical zones showed maximum reduction on the mesiobuccal surface Diagram 2 (0.42) and the minimum on the surface. Score 1 was assigned to separate tooth surface from CEJ in that particular midbuccal surface (0.27) in all the discontinuous flecks of plaque not selected zone. Score 4 was assigned to selected tooth surfaces/zones (Table 3). exceeding 2mm in diameter in that vertical streaks of plaque covering > Out of all the selected teeth the mid particular selected zones. Score 2 was 2/3rdof the tooth surface from CEJ in that buccal zone of tooth no.41 showed the assigned to vertical streaks of plaque particular selected zone (Diagram 2). maximum percentage change (71.8%) covering < 1/3rd of the tooth surface from and distobuccal zone of tooth no.11 CEJ in that particular selected zone. Results showed the minimum percentage change Score 3 was assigned to vertical streaks The data thus collected was tabulated (43.2%) in the plaque scores after of plaque covering 1/3rd to 2/3rd of the (Table 1,2,3 and 4) and put to statistical consumption of fibrous food, although analysis. Paired t test was used to the total [all three zones combined] inter Table 1. Change In Plaque Scores In All The Evaluated Teeth. compare the change in the total mean tooth difference in plaque score was non- Total Score Prescore Post Score Difference plaque scores in all the teeth. For significant (Table 4). All Teeth 2.17 1.06 1.11 comparing the change in plaque between different teeth and also between 3 Discussion Table 2. Change In Plaque Scores In Individual Teeth. It is proved beyond doubt that the Tooth Pre Post Difference Percentage different tooth surfaces ANOVA was used. presence of dental plaque is absolutely score score difference As is evident from the data collected, the essential for development of periodontal Max. Right 2nd premolar 2.42 1.32 1.1 45.45 results of the above study show that diseases[14]. The bacterial plaque Max. Right central incisor 2.46 1.24 1.22 49.59 ongoing plaque control methods initiates inflammatory process in the Max. Left 2nd premolar 2.16 1.02 1.14 52.77 practiced by the subjects were not supporting structures of the tooth and if Mand. Left 2nd premolar 1.34 0.56 0.8 59.7 completely effective in removing all the allowed to continue, will ultimately lead Mand. Right central incisor 2.68 1.16 1.52 56.71 plaque from the selected teeth (as the to the loss of teeth. For this reason intra- oral cleansing devices have been a part of Mand. Right 2nd premolar 1.8 0.9 0.9 50 plaque deposits were seen on all selected tooth surfaces/zones). The mean plaque the human civilization since ages. Table 3. Change In Mean Plaque Scores On The Three Intra- pre score of all the three surfaces in the 6 Mechanical supragingival plaque control tooth Vertical Zones selected teeth of the 100 cases was 2.17 is the most rational and efficient method Tooth Surface Pre Score Post Score Difference and the mean plaque post score value for the prevention of periodontal Mesiobuccal 0.75 0.33 0.42 after chewing the apple was 1.06 with a diseases.[9] Daily removal of plaque by Buccal 0.49 0.22 0.27 highly significant difference of 1.11 the patient is also of concern for a Distobuccal 0.79 0.38 0.41 beneficial long-term treatment outcome. The effective use of mechanical devices Table 4. Percentage Changes In The Pre-scores [Pre Fibrous Food] And Post-scores [Post Fibrous Food] On The Three Surfaces Of Evaluated Teeth. to reduce dental plaque, in fact, is highly dependent on patient compliance with Tooth no. Mesiobuccal Midbuccal Distobuccal oral hygiene instructions given by dental Pre score Post score change % change Pre score Post score change % change Pre score Post score change % change professionals. A majority of individuals 15 0.90 0.44 0.46 51.1 0.54 0.3 0.24 44.4 0.88 0.46 0.42 47.4 find it difficult or even impossible to 11 0.82 0.40 0.42 51.2 0.72 0.38 0.34 47.2 0.88 0.50 0.38 43.2 comply with a proper oral hygiene 25 0.72 0.36 0.36 50 0.52 0.22 0.30 57.6 0.90 0.42 0.48 53.3 regimen. Moreover, even in those 45 0.60 0.24 0.36 60 0.18 0.08 0.10 55.5 0.58 0.24 0.34 58.6 patients who do achieve high levels of 41 0.94 0.34 0.60 63.5 0.78 0.32 0.56 71.8 0.96 0.48 0.48 50 oral cleanliness after instructions, plaque 35 0.54 0.24 0.30 55.5 0.24 0.10 0.14 58.3 0.60 0.18 0.42 70 control deteriorates over time.[16],[17]

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 010 of the adjacent tooth zones when the fibrous food being masticated rubs past them through these embrasures. This is also clear from the results where the distobuccal and mesiobuccal zones show higher plaque prescores in general than the midbuccal zones. Graph 2. Percentage Changes (Reductions) In The Pre- Graph 1. Changes (Reductions) In Plaque Score In The Six fibrous And Post-fibrous Scores On The Three Surfaces Of Conclusion Selected Teeth After Eating Fibrous Food (Apple) Evaluated Teeth. There is a strong correlation between Reasons for non-compliance are many ongoing and already being practiced brushing frequency and the reduction in and may include level of education, plaque control measures and the plaque/gingivitis on the buccal surfaces. domestic circumstances, disposable distobuccal and the midbuccal zone of The vast majority of self-taught income, beliefs and attitudes regarding tooth no.35 had the minimum. These toothbrushers begin by scrubbing the personal and oral care, stressful life results show that the regular plaque buccal surfaces, especially at the frontal events, psychomotor skills, frequency of control measures practiced by the region, and rarely proceed to the lingual dental visit, and age.[18],[20] Thus, individual are not sufficient to achieve surfaces. Interproximal cleaning is adjunctive methods of mechanical the desired reduction in plaque deposit. simply non-existent in the self-taught. plaque removal are essential and These results are in accordance with the The basic principle for preventive beneficial. epidemiological studies in the past which dentistry is that the preventive measures Fibrous food eating fits in here and it has have shown clearly that there are certain will give the most significant effect if we been encouraged in the past due to many key-risk-teeth (molars and premolars) concentrate them on "key-risk age reasons. It is an age old belief that apple and key risk- surfaces (the proximal groups," "key-risk individuals," "key- eating after meals cleaned the surfaces of the molars and premolars).[3] risk teeth" and "key-risk surfaces." Thus teeth[8],[11] and it removed food there is a need of suggesting and residues and plaque[22],[23]. This In our study after the consumption of incorporating adjunctive plaque control favourable effect of chewing apples apple, the midbuccal zone and measures in the patient’s oral hygiene though is seen across all age groups, but mesiobuccal zone of tooth no. 41 showed regimen. The following conclusion can may not be same in all individuals and all the maximum percentage change be drawn from this study: routinely areas of oral cavity. (reductions) in plaque score and the practiced oral cleansing/plaque control is The present study was therefore midbuccal zone and distobuccal zone of not 100% effective. The mandibular conducted with an objective of assessing tooth no. 15 showed the minimum incisors are the least amenable to the additional plaque removing effect of percentage reduction in plaque scores. cleansing by tooth brushing whereas the fibrous food (apples) on different teeth Although it was found that some teeth mandibular premolars are most amenable and different individual zones on labial surfaces did not show any change to cleansing by tooth brushing. Fibrous teeth surfaces. Results of this study show (reduction) in the pre and post plaque food helps to reduce the plaque scores in that the mean plaque prescore of all the scores after consumption of fibrous food all the teeth. Chewing of apples causes a three selected surfaces in the 6 selected but when analysed as a whole, the above significant reduction in supra-gingival teeth of 100 subjects was 2.17 and the observations suggest a considerable plaque levels. The mandibular teeth are mean plaque post score value after cleansing action of fibrous foods (apples) more amenable to tooth cleansing by the chewing the apple was 1.06. There is a on the supragingival plaque. It can also be use of fibrous food than the maxillary highly significant difference in the inferred that of all the teeth lower teeth particularly the midbuccal zone of prescore and post score plaque levels anteriors are less amenable to plaque mandibular incisors and distobuccal zone [1.11]. When the comparison was made control/removal by routinely practiced of premolars, whereas the maxillary between the 6 selected teeth for the oral hygiene measures alone as they premolars are the least affected teeth in change in plaque scores, maximum showed highest plaque pre plaque scores. relation to the cleansing action by the use percentage reductions were seen in tooth The lower anterior teeth also showed the of fibrous foods. The results of the study no.35 and minimum in tooth no.15, maximum percentage reduction in encourage the use of the fibrous foods in although the intertooth difference in plaque scores after chewing fibrous food. the diet due to their favourable effects on plaque score reduction was non- (Table4, Graph2). Greater reductions in the gingival health. Within the limits of significant when all sites on six teeth plaque scores in the mandibular anterior the study it may be safe to suggest that as were evaluated together. On comparing teeth may be related to the more relative plaque control is relatively more difficult the changes in plaque score among the 3 usage of these teeth as compared to at various sites i.e., distobuccal and vertical zones of all selected teeth, maxillary teeth especially during initial mesiobuccal zones. These sites must be maximum reduction in plaque scores was biting of apples. The greater reduction on carefully monitored by the dental seen on the mesiobuccal surface (0.42) the mesiobuccal and distobuccal zones as surgeons during maintenance visits as and minimum on the midbuccal surface compared to midbuccal zone can be they may be the first sites where (0.27). When changes in the individual related to the presence of embrasures periodontal disease might show up again. teeth surfaces were analysed, it was adjacent to these zones. These Patients must also be educated and observed that distobuccal zone and embrasures probably make tooth cautioned about maintaining good oral mesiobuccal zone of the tooth no. 41 had brushing more cumbersome but allow hygiene at these sites. the highest deposit of plaque even after comparatively greater effective cleansing

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 011 References 10. Lance L.S.: oral carbohydrate Periodontics, 5:217, 1967. 1. Anderson J and Barbara Deskins MS. clearance.: nutrition and caries 20. Schou L. Behavioral aspects of dental "The Nutrition Bible"; RD; 1997 prevention. Almquist & Wiksell, plaque control measures: An oral 2. Axelsson P, Nystrom B, Lindhe J. The Upsala 1965:53-59. health promotion perspective. In: long term effect of a plaque control 11. Lindhe, J &Wicen, PO.: The effects Lang NP, Attstrom R, Loe H, editors. program on tooth mortality, caries on the gingivae of chewing fibrous Proceedings of the European and periodontal disease in adults. foods. J. Periodontal Res. 1969: 4: workshop on mechanical plaque R e s u l t s a f t e r 3 0 y e a r s o f 193-201. control. Berlin: Quintessenz Verlag; maintenance. Journal of Clinical 12. Lindhe, J., Hamp, S. E. and Loe, H.: 1998. pp. 287–99. Periodontology. 2003;30 (Suppl Plaque-induced periodontal disease 21. Silness, J. &LoE, H.: Periodontal 5):4–6. in beagle dogs, JPeriodont Rex, disease in pregnancy. II. Correlation 3. Axelsson P.: The effect of plaque 10:243, 1975. between oral hygiene and periodontal control procedures on gingivitis, 13. Listgarten, M. A.: Structure of the condition. AetaOdontol. Scand. periodontitis and dental caries, microbial flora associated with 1964: 22:121-135. Thesis, 1978. periodontal health and disease in 22. Slack, G. L. &Martin, W. J.: Apples 4. Birkeland J.M. & Jorkjend L: the man, J Periodont, 47:1,1976. and dental health. Br. Dent. J. 1958: effect of chewing apples on dental 14. Loe H., Theilade E. &Jensen SB.: 105: 366-371 plaque and food debris. Community Experimental gingivitis in man. J. 23. Socransky SS and Haffajee AD. The dent. Oral Epidemiol.1974:2:161- Periodontol. 1965: 36: 177-187. Bacterial Etiology of Destructive 162. 15. periodontal disease and caries, Oral Periodontal Disease: Current 5. Bjorn, A. L.: Dental health in relation Sciences Rev, 9:23, 1976. C o n c e p t s . J o u r n a l o f to age and dental care, Odont Re,z, 16. Renvert S, Glavind L. Individualized Periodontology1992;63:332-331 25: suppl. 29, 1974. instruction and compliance in oral 24. Theilade, E. and Theilade, J.: Role of 6. Ciancio S. Improving oral health: hygiene practices: Recommendations plaque in the etiology of Current considerations. J Clin and means of delivery. In: Lang NP, 25. van der Weijden GA, Hioe KP. Periodontol. 2003;30 (Suppl 5):4–6. Attstrom R, Loe H, editors. A s y s t e m a t i c r e v i e w o f t h e 7. Garmyn P, van Steennberghe D, Proceedings of the European effectiveness of self performed Quirynen M. Efficacy of plaque workshop on mechanical plaque mechanical plaque removal in adults control in the maintenance of gingival contro. Berlin: Quintessenz Verlag; with gingivitis using a manual health: Plaque control in primary and 1998. pp. 300–309. . J Clin Periodontol. secondary prevention. In: Lang NP, 17. Sangnes, G., Zaghrisson, B. 2005;32(Suppl 6):214–228. Attstrom R, Loe H, editors. &Gjermo, P.: Effectiveness of 26. Wade, A. B.: Effect on dental plaque Proceedings of the European vertical and horizontal brushing of chewing apples. Dent. Praet. Dent. workshop on mechanical plaque techniques in plaque removal. J. Rec. 1971: 21: 1974-196. control. Berlin: Quintessenz Verla; Dent. Child. 1972: 39: 94-97. 27. Wallace, J S, The Physiology of Oral 1998. pp. 107–20. 18. Sanz M, Herrera D. Role of oral Hygiene and Recent Research, 2nd 8. Knighton H.T. : effect of various hygiene during the healing phase of edn. foods and cleansing agents on the periodontal therapy. In: Lang NP, 28. Zaki, H. A. and Bandt, C. L.: The elimination of artificially inoculated Attstrom R, Loe H, editors. effective use of a self-teaching oral yeast from the mouth. Journal of Proceedings of the European hygiene manual, Journal of American dental association. workshop on mechanical plaque Periodontology 1974.45:491 1942:29:2012-2018. control.Berlin: Quintessenz Verlag; 9. Lang, N. P., Cumming, B. R. and Lee 1998. pp. 248–67. H.: Tooth brushing frequency as it 19. Saxe, S. R., Greene, J. C., Bohannan, relates to plaque development and H. M. and Vermilion, J. R.: Oral gingival health, J Periodontal, 7:396, debris, and periodontal 1973. disease in the beagle dog,

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 012 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Relationship Between Periodontitis And 1 Gayatri 2 Maima Rani Ishwary Anemia - Does It Exist? 3 Anirban Chaterjee 4 Ahad M Hussain Abstract 5 Praveen J Aims: To evaluate the relationship between periodontitis and anemia. 6 Methods and material: 30 patients, 15 with gingivitis and 15 with chronic periodontitis Deepika J 1 Professor participated in this study. Plaque index, , pocket depth were recorded for the 2 patients. A complete hemogram including Hb%, RBC count, ESR, PVC, MCHC, MCV, etc. were Post Graduate Student 3 Professor And Head Of Department recorded. The patients were subjected to scaling and root planning. The clinical parameters were 4 Reader compared to the hematologic parameters in both the groups. 5 Reader Results: The clinical parameters did not correlate with the haematological parameters in both 6 Senior Lecturer the groups. Dept. of Periodontics, The Oxford Dental College Conclusions: This study shows that periodontal disease and anaemia may not be related, and Address For Correspondence: the occurrence of them may be independent of each other. Dr. Gayatri Gundannavar The Oxford Dental College And Hospital Key Words 10th Mile, Bommanahalli Anaemia and periodontitis. Hosur Road, Bangalore 5600068 Submission : 1st February 2014 Introduction: interferone. All the process involved in Accepted : 21st January 2015 Periodontitis is an inflammatory disease the development of ACD can be Quick Response Code of the supporting tissues of the tooth attributed to these cytokines including w h i c h i s c a u s e d b y s p e c i f i c shortened RBC survival, blunted microorganisms in a susceptible host. erythropoietic response to anaemia, The bacteria and their product provoke an impaired erythroid colony formation and inflammatory reaction to the host tissues. a b n o r m a l m o b i l i z a t i o n o f The ulcerated pocket around reticuloendothelial iron stores.[10] the affected teeth form a ‘porte d entre’ These cytokines are also released by for bacteria and their products such as periodontitis tissues in response to Group B patients (n=15) which includes endotoxins.[1] Bacteraemia in bacterial infection which suggests that patients with chronic periodontitis. periodontitis has been demonstrated and periodontitis like other chronic diseases the extent is directly related to the may cause ACD. Inclusion criteria: severity of the of the Therefore the aim of the present study Group A: comprised of 15 systemically periodontal disease. Subgingival was to investigate the association healthy adult patients aged 20 to 55 years microflora in patients with periodontitis between haematological parameters and showing clinical signs of gingivitis causes a significant and persistent clinical parameters in patients with (reddening, loss of , bleeding on bacterial challenge to the host. Several chronic gingivitis and periodontitis. probing) with no signs of periodontitis. research group have demonstrated that Group B: was comprised of 15 periodontitis is associated with elevated Materials and methods: systemically healthy adult patients aged number of WBC[2],[3], C-reactive Source of data: Subjects visiting the 20 to 55 years diagnosed clinically and protein[4], IL6[5], eryththrocytes[6] etc. Department of Periodontics The Oxford radiographically as chronic periodontitis It has therefore been speculated that Dental College and Hospital, with gingival inflammation, pocket periodontitis results in a low grade Bommanahalli, Hosur road Bangalore, depths greater than 5 mm, clinical systemic infection. The purpose of the study was explained attachment loss of more than 3mm in Anaemia of Chronic Disease (ACD) is to the subjects and an informed consent more than 20 teeth with moderate to defined as anaemia occurring in chronic was obtained from all the subjects prior to severe bone loss. Chronic periodontitis infection, chronic inflammatory process the study. will be diagnosed based on the criteria of or tumour formation that is not due to American Academy of Periodontology dysfunction of bone marrow cells or Method of collection of data: classification of periodontal diseases other disease, and occurring despite of Sample size: total 30 subjects (both male 1999. a d e q u a t e i r o n s t o r e s a n d and female) were included in the study. vitamins.[7],[8],[9] A Characteristic Exclusion criteria: finding of the disorder associated with Subjects were divided into 2 groups 1. Patients with history of systemic ACD is increased production of Group A patients (n=15) which includes disorders. cytokines that mediate inflammatory patients with chronic generalised 2. Patients on antibiotics in the past 6 response such as TNF, IL1 and gingivitis. months.

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 013 3. Patient with current or past habit of Table 1 - Comparison Of Hb Between The Groups (Mann- Table 10 - Pi Comparison Between The Two Groups tobacco smoking or chewing. Whitney test) Group Mean Std SE of Mean t P-Value Group Mean Std SE of Mean Z P-Value 4. Patients with history of periodontal Dev Mean Difference Dev Mean Difference disease in the previous 6 months. Group A 0.64 0.40 0.10 -0.673 -3.356 0.002* Group A 13.02 3.53 0.91 -0.427 -0.416 0.678 Group B 1.31 0.66 0.17 Clinical Parameters recorded: Group B 13.45 1.55 0.40 *denotes significant difference 1. Plaque index.[11] to group B and the difference between 2. Bleeding on probing. Table 2 - Comparison Of Rbc Between The Groups (t- test) them was not statistically significant 3. Probing pocket depth. Group Mean Std SE of Mean t P-Value (Table 5) and slightly higher MCHC 4. Clinical attachment level. Dev Mean Difference value was recorded for group B when compared to group A and the difference Study Design: Group A 4.64 0.55 0.14 0.051 0.265 0.793 Group B 4.59 0.51 0.13 between them was not statistically A detailed case history and the above significant (Table 6). Bleeding on mentioned clinical parameters were probing was present in both the groups, recorded for each patient. Venous blood Table 3 - Comparison Of Pcv Between The Groups (t- test) the probing depths and the plaque index samples were obtained by veini puncture Group Mean Std SE of Mean t P-Value were slightly higher in group B as in the antecubital fossa. The blood Dev Mean Difference compared to group A but this was not samples were collected in EDTA bulband Group A 42.53 5.37 1.39 1.587 0.842 0.407 statistically significant (Table 7). Group and processed within 4 hours of Group B 40.95 4.94 1.28 B had a higher plaque index score which collection in an automated haematology was of statistical significance (Table 10). analyser. The laboratory blood The clinical attachment level was only investigations included haemoglobin Table 4 - Comparison Of Esr Between The Groups (Mann- recorded in group B, the mean of which (Hb %), total number of erythrocytes, Whitney test) Group Mean Std SE of Mean Z P-Value was 3.25 mm suggesting that Group B pack cell volume, erythrocyte had a moderate form of periodontitis sedimentation rate, mean corpuscular Dev Mean Difference (Table 8). There was a slight negative volume of erythrocytes and mean Group A 9.87 2.53 0.65 -1.067 -0.942 0.346 correlation of haemoglobin and MCV to corpuscular haemoglobin concentration. Group B 10.93 7.93 2.05 probing depth in group A. There was a slight positive correlation of MCHC to Statistical Analysis Table 5 - Comparison Of Mcv Between The Groups (t- test) probing depth in group A. The Statistical test used: t- test/Mann- haemoglobin and the MCV positively Whitney test Group Mean Std SE of Mean t P-Value Dev Mean Difference correlated to the plaque index in group A Decision Criterion: We compare the P- and whereas the MCHC negatively Group A 85.73 6.47 1.67 0.213 0.106 0.916 Value with the level of significance. If correlated with the plaque index in group P<0.05, we reject the null hypothesis and Group B 85.52 4.33 1.12 A. All these correlations were not of any accept the alternate hypothesis. If statistical significance (Table 11,Graph P>0.05, we accept the null hypothesis. Table 6 - Comparison Of Mchc Between The Groups (t- test) 1). For group B the haemoglobin %, pack Group Mean Std SE of Mean t P-Value cell volume and MCV had a negative Results: Dev Mean Difference correlation to probing depth whereas the The study sample consisted of 18 males MCHC had a positive correlation to and 12 females. The mean age for the Group A 33.29 0.89 0.23 -0.333 -1.097 0.282 Group B 33.63 0.77 0.20 probing depth. The haemoglobin, PCV gingivitis group was 34.27 years and for and MCV had a positive correlation to the periodontitis group was 41.40 years. plaque index and MCHC had a negative Slightly higher mean haemoglobin Table 7 - Bop In The Two Groups correlation to plaque index in group B percentage was recorded in group B BOP Group A Group B x2 P-Value and all these correlations were not of (13.45%) as compared to group A N % N % statistical significance (Table 12,Graph (13.02%), but the difference between Present 13 87% 15 100% 2.143 0.143 2). them was not statistically significant (Table 1). The RBC count in group A was Absent 2 13% 0 0% Total 15 100% 15 100% Discussion: 4.64 million/dl, this was slightly higher The aim of the present study was to than the RBC count of group B (4.59 investigate the haematological status of million/dl). The difference between the Table 8 - Cal Comparison Between The Two Groups patients with gingivitis and periodontitis. two groups was not statistically Group Mean Std SE of Mean t P-Value The concept of periodontal disease as a significant (Table 2). The pack cell Dev Mean Difference localised entity affecting only the teeth volume recorded in group A was slightly Group A 0.00 0.00 0.00 ------and the supporting apparatus has been higher when compared to group B but the Group B 3.25 1.06 0.30 revised as it has been seen that rather than difference between them was not being confined to the periodontium statistically significant (Table 3). Higher periodontal disease has a wide range of Table 9 - Pd Comparison Between The Two Groups mean ESR was recorded in group B systemic effects. Periodontal disease has Group Mean Std SE of Mean t P-Value compared to group A and the difference a proven relationship with several between them was not statistically Dev Mean Difference systemic conditions like cardio vascular significant (Table 4). Higher MCV value Group A 2.67 0.49 0.13 -0.267 -1.023 0.315 disease, diabetes mellitus, adverse was recorded for group A when compared Group B 2.93 0.88 0.23 pregnancy outcome, obesity and

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 014 Table 11 - Correlation Between Different Parameters In Group A Correlations (Group A) Hb RBC PCV ESR MCV MCHC PD PI Hb r 1 0.306 -0.166 -0.124 0.203 -0.418 -0.183 0.313 P-Value --- 0.267 0.554 0.660 0.469 0.121 0.515 0.257 RBC r 0.306 1 0.373 0.362 -0.083 0.302 0.186 -0.020 P-Value 0.267 --- 0.170 0.184 0.769 0.275 0.507 0.942 PCV r -0.166 0.373 1 0.147 -0.125 0.305 -0.200 -0.300 P-Value 0.554 0.170 --- 0.600 0.657 0.269 0.475 0.278 ESR r -0.124 0.362 0.147 1 -0.177 0.143 0.193 -0.378 P-Value 0.660 0.184 0.600 --- 0.529 0.612 0.491 0.165 MCV r 0.203 -0.083 -0.125 -0.177 1 -0.559 -0.279 0.492 P-Value 0.469 0.769 0.657 0.529 --- 0.030* 0.314 0.062 MCHC r -0.418 0.302 0.305 0.143 -0.559 1 0.655 -0.542 P-Value 0.121 0.275 0.269 0.612 0.030* --- 0.008* 0.037* Graph 2 - Scatter Plot – Group B: (Correlation Graph) PD r -0.183 0.186 -0.200 0.193 -0.279 0.655 1 -0.615 stroke.[12],[13],[14],[15],[16] One of the P-Value 0.515 0.507 0.475 0.491 0.314 0.008* --- 0.015* lesser documented associations has been PI r 0.313 -0.020 -0.300 -0.378 0.492 -0.542 -0.615 1 interrelationship between periodontal P-Value 0.257 0.942 0.278 0.165 0.062 0.037* 0.015* --- disease and anaemia. *denotes significant difference Anaemia of chronic disease is an immune Table 12 - Correlation Between Different Parameters In Group B driven process in which cytokines result Correlations (Group B) Hb RBC PCV ESR MCV MCHC PD PI in decreased erythropoietin production, Hb r 1 0.306 -0.166 -0.124 0.203 -0.418 -0.183 0.313 impaired proliferation of erythroid P-Value --- 0.267 0.554 0.660 0.469 0.121 0.515 0.257 progenitor cells and disturbed iron RBC r 0.306 1 0.373 0.362 -0.083 0.302 0.186 -0.020 haemostasis. This normocytic and normochromic anaemia has been P-Value 0.267 --- 0.170 0.184 0.769 0.275 0.507 0.942 described in many chronic diseases like PCV r -0.166 0.373 1 0.147 -0.125 0.305 -0.200 -0.300 rheumatoid arthritis, renal failure, P-Value 0.554 0.170 --- 0.600 0.657 0.269 0.475 0.278 bacterial and parasitic infections ESR r -0.124 0.362 0.147 1 -0.177 0.143 0.193 -0.378 etc.[17],[18] P-Value 0.660 0.184 0.600 --- 0.529 0.612 0.491 0.165 The association of anaemia and MCV r 0.203 -0.083 -0.125 -0.177 1 -0.559 -0.279 0.492 periodontitis has been explored since the P-Value 0.469 0.769 0.657 0.529 --- 0.030* 0.314 0.062 early 20th century. Earlier reports have suggested anaemia to be a cause and not a MCHC r -0.418 0.302 0.305 0.143 -0.559 1 0.655 -0.542 consequence of destructive periodontitis. P-Value 0.121 0.275 0.269 0.612 0.030* --- 0.008* 0.037* Lainson et al.[19] was one of the first PD r -0.183 0.186 -0.200 0.193 -0.279 0.655 1 -0.615 authors to implicate anaemia as a P-Value 0.515 0.507 0.475 0.491 0.314 0.008* --- 0.015* systemic cause of periodontitis. Hutter et PI r 0.313 -0.020 -0.300 -0.378 0.492 -0.542 -0.615 1 al.[20] and Thomas et al.[21] found that P-Value 0.257 0.942 0.278 0.165 0.062 0.037* 0.015* --- periodontitis patients had lower *denotes significant difference hematocrit, lower erythrocytes, lower haemoglobin % and higher ESR when compared to healthy controls. In our study the periodontitis group had a higher haemoglobin %, MCHC and ESR as compared to the gingivitis group. On the other hand PCV, MCV and RBC Table 13 - Reference Values For Laboratory Tests count was found to be higher in the Si no. HEMAOLOGICAL PARAMETER NORMAL RANGE gingivitis group as compared to the 1. HEMOGLOBIN MALE-13.3 TO 16.2 gm/dl periodontitis group. The difference FEMALE-12 TO 15.8 gm/dl between the two groups was not of 2. ESR MALE -0 TO 15 mm/hr statistical significance. Also the values FEMALE- 0 TO 20 m/hr for all the haematological parameters were well within the normal range.[22] 3. RBC count MALE- 4.3 TO 5.6 million/mm3 The probing depth, plaque index and FEMALE- 4 to 5.2 million/mm3 bleeding on probing were higher in the 4. PCV MALE- 42-52 % periodontitis group as expected. Since FEMALE-37-47% was absent in the 5. MCV 79-93.3µm3 pg gingivitis group no statistical comparison 6. MCH 26.7-31.9 pg/cell was possible. But the average clinical attachment level for the periodontitis 7. MCHC 32.3-35.9 gm/dl Graph 1 - Scatter Plot – Group A: (Correlation Graph)

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 015 group was 3.25 mm indicating it to be Grossi S, Zambon J J, De Nardin E. 17. Yamamato T, Tsuneishi M, Furuta M. moderate periodontitis. Periodontal infections contribute to Relationship between disease of The increase haemoglobin % found in elevated systemic C reactive protein erythrocyte count and progression of our study has also been reported by level. J Periodontol 2001;72(9):1221- periodontal disease in rural Japanese Wakai et al.[23] who found higher 1227. population. 2011;82(1):106-113. haemoglobin % levels in patients with 5. Mengel R, Bacher M, Flores De 18. Nissenson AR, Goodnough LT, higher CPITN scores. Aljohani H [24] Jacob L. Interactions between stress, Dubois RW. Anemia : Not just an and Havemose Paulsen A[25] also have interleukin 1 β, interleukin 6 and innocent bystander? Arch Inter Med. reported increased heamoglobin % with cortisol in periodontally diseased 163 (12):1400-1404. increased severity of periodontitis. The patients. J Clin Periodontol 19. Lainson PA, Brady PP, Fraleigh CM. periodontitis group in our study was of a 2002;29(4):1012-1022. Anemia a systemic cause of mild to moderate nature whereas most of 6. Salvi G E, Lawrence H P, periodontal disease? J Periodontal the studies which showed correlation Offenbacher S, Beck J D. Influence of 1968;39:35-38. between anaemia and periodontitis had risk factors on pathogenesis of 20. Hutter JW, van der Velden U, patients with severe periodontitis. In periodontitis. Periodontol 2000 Varoufaki A, Huffels RA, Hoek FJ, another study by Enhos S et al.[26] found 1997;14:173-201. Loos BG. Lower number of no correlation between anaemia and 7. Lee G R. The anaemia of chronic erythrocytes and lower levels of periodontitis. d i s e a s e . S e m i n H e m a t o l haemoglobin in periodontitis patients Chronic periodontitis is a milder 1983;20(2):61-80. compared to control subjects. J Clin inflammatory condition compared to 8. Beutter E. The common anaemias. Periontol 2001;28(10):930-936. other systemic infections or conditions JAMA 1988;259(16):2433-2437. 21. Thomas B, Ramesh A, Ritesh k. like rheumatoid arthritis, neoplastic 9. Means R T, Jr., Krantz S B. Progess in Relationship between Periodontitis conditions and fungal or parasitic understanding the pathogenesis of the and erythrocyte count. JISP infections. Hence it may not be enough to anaemia of chronic disease. Blood 2006;10:288-291. show drastic haematological status in 1992;80(7):1639-1647. 22. Harrison’s principles of internal periodontitis patients.[27] 10. Means R T, Jr. Advances in anaemia medicine. 17th ed./editors, Anthony of chronic disease. Int J Hematol S. Fauci,et al. Conclusion: 1999;70(1):7-12. 23. Wakai K, Kawamura T, Umemura O, Based on the results obtained from the 11. Sillness.J,Loe.H Periodontal disease Hara Y,Machida J, Anno J. et al: study we can conclude that there is no in pregnancy (II). Corelation between Association of medical status and correlation between anaemia and oral hygiene and periodontal physical fitness with periodontal periodontitis. The occurrence of the two condition. Acta Odontologica disease. J Clin Periodontol may be independent of each other. These Scandinavica 1964;24:747-759 1999;26:664-672. results could have been different if our 12. Soskoline W, Kingler A. The 24. Aljohani HA. Association between study had a larger sample size and relationship between periodontal haemoglobin level and severity of recruited patients with severe disease and diabetes. An overreview. chronic periodontitis. JKAU: Med periodontitis. Ann Periodontol 2001;6:91-98. Sci, Vol 17 No. 1,53-64. 13. Beck J, Offenbacher S. Association 25. Havemose-Poulsen A, Westergaard References: between periodontal diseases and J,Stoltze K, Skjodt H, Danneskiod – 1. Scannapicco F A, Bush R B, Paju S. cardiovascular diseases: A state of Sameose B, Locht H, Beneltzen K. Associations between periodontal science review. Ann Periodontl Periodontol and haematological disease and risk factors for 2000;6:9-15. charecteristics associated with atherosclerosis, cardiovascular 14. Montebugnoli L, Servidio D, Miaton , juvenile diseases and stroke. A systematic RA, et al. Poor oral health is idiopathic arthritis and Rhematoid review. Ann Periodontal 200;8:38- associated with coronary heart a r t h r i t i s . J P e r i o d o n t o l . 53. disease and elevated systemic 2006;77(2):280-288. 2. Kweider M, Lowe G D, Murray G D, inflammatory and haemostatic 26. Enhos S, Duran J, Erden S, Buyukbas Kinane D F, McGowan B A. Dental factors. J Clin Periodontol. S. Relationship between Iron disease, fibrinogen and white cell 2004;31:25-29. deficiency anemia and periodontal count links with myocardial 15. Joshipura KJ, Wand HC, Merchant status in female patient. J Periodontol i n f a r c t i o n ? S c o t t M e d J TA, Rimm AB. Periodontal disease 2009;80:1750-1754. 1993;38(3):73-74. a n d b i o m a r k e r s r e l a t e d 27. Gokhale SR, Surmanth S, Pandhay 3. Christan C, Dietrich T, Hagewald S, cardiovascular disease. J Dent Res. AM. Evaluation of blood parameters Kage A, Berniemoutin J P. white 2004;83(2):151-155. in patients with chronic periodontitis blood cell count in generalised 16. Aqueda A, Manace C, Guerrero A, for signs of anaemia. J Periodontol aggressive periodontitis after non Echevemia J. Periodontal disease as a 2010;81:1202-1206. surgical periodontal therapy. J Clin risk factor for adverse pregnancy Periodontol 2002:29(3):201-206. outcomes; a prospective cohort study. 4. Noack B, Jenco R J, Trevisan M, J Clin Periodontol. 2008;35:16-22.

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 016 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

A Community Based Study On Hiv / Aids 1 Sunayana Manipal 1 Senior Lecturer, Dept. Of Public Health Dentistry Knowledge Among Dental Students Srm Dental College Address For Correspondence: Dr. Sunayana Manipal Abstract Senior Lecturer, Objective : The aim of the study was to determine the current status of knowledge regarding Department of Public Health Dentisty, HIV/AIDS among dental students. SRM Dental college, No. 69, Harris road Materials and method : A study was conducted taking 130 clinical students of age group 20-25 C/o Milap Stickers Pudupet, Chennai – 600002 years for a period of 1 month.Data was gathered through a pre tested questionnaire. Tamil nadu, India. Results : After the study was done, it was observed that majority of the students had moderately Contact number : 044 28410223, 098400 39576 Email address : [email protected] adequate knowledge regarding HIV/AIDS.Third year and final year students showed highest Submission : 5th March 2013 adequate attitude among the group in terms of social interaction.More than 90% of the subjects in th the study felt that AIDS education must be provided in schools/colleges and in the community. Accepted : 19 January 2015 Discussion and conclusion : These findings highlight the importance of teaching the dental Quick Response Code students the various aspects of the disease. Universal Work Precautions implementation should be emphasized at an early level of their curriculum and reinforced from time to time. Key Words HIV/AIDS, Dental students, awareness, knowledge, Chennai.

Introduction: implementation of practices and The AIDS epidemic is continuing to grow equipment to protect the health care [1]; global estimates indicated that over workers whenever the potential exists for 40 million people are infected by the exposure to blood. Every patient is pre tested questionnaire, comprising of disease [2].The fact that the number of considered to be infected with a blood- 31 questions was issued to each HIV-infected patients under dental care is borne pathogen regardless of the known participant. The questions fell in six main expected to increase[3] ,highlights the sero-status [10]. categories. First the respondents were importance of providing dental treatment Dentists have a responsibility to provide asked about their general awareness to all individuals indiscriminately[4].The treatment for HIV infected patients, about HIV / AIDS. Second they were reports indicated that about 90% of the particularly because oral are questioned on the knowledge of subjects HIV infections among healthcare common among these patients. It is regarding the modes of transmission. The workers occur in developing countries obvious that having adequate knowledge third group of questions was about the where occupational safety is a neglected about HIV / AIDS enhances confidence belief in communicability. The fourth issue [5],[6],[7]. in student’s ability to manage infected group of questions was regarding the Chennai has low HIV/AIDS prevalence. patients. Hence this study aims to know knowledge about safe sex. The fifth Although figures are low compared to the current status of knowledge regarding group of questions pertained to the office southern Africa or Asia, they are still a HIV/AIDS among dental students. g o e r s ’ r e l a t i o n s h i p s , g e n e r a l cause for alarm, particularly since they practitioners, dentists and school/ college are rising rapidly, especially among high- Materials and Method: students and last they were asked about risk groups [8]. Study Area: The study area comprised of the knowledge of high risk groups. The The human immunodeficiency virus dental students from Chennai. The respondents took approximately 10-15 (HIV) is the virus that causes AIDS. HIV number of dental colleges in Chennai is minutes to complete the questionnaire. attacks the by destroying 11. From the list one college was chosen The questionnaire was distributed in CD4 positive (Cd4+) T cells. The at random and all the subjects from across person and collected on the same day. acquired immunodeficiency syndrome various grades were included in the study. Calibration:-The questionnaire was (AIDS) is the end stage of HIV infection. Study Population: A total of 130 clinical pretested before starting the study on a A person infected with HIV is diagnosed students of age group 22-25years of a group of ten students. Based on the with AIDS when he or she has one or r a n d o m l y s e l e c t e d u n i v e r s i t y difficulties faced by the students the more opportunistic infections, such as participated in the survey during April q u e s t i o n n a i r e w a s m o d i f i e d pneumonia or tuberculosis, and has a 2011.The subjects included were the subsequently. dangerously low number of CD4+ T cells undergraduates and post graduates. The less than 200 cells per cubic millimeter of subjects present on the day of Statistical Analysis: The statistical blood [9]. All dental students should have examination were only included. analysis was done using SPSS version 10 complete knowledge about the universal Methods: Ethical clearance was software Chi square tests was used to precautions which is an administrative obtained from Ethical Committee of check for statistical significance. control measure that calls for the Department of Public Health Dentistry. A

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 017 Table 1: General awareness about HIV / AIDS Results: Table 3: Beliefs about communicability Categories Male Female Total P Value Categories Male Female Total P Value N(%) N(%) N(%) Table I shows General awareness about N(%) N(%) N(%) Heard of HIV/AIDS HIV / AIDS. The survey has revealed that Mosquito Yes 47 83 130 100% of the subjects have heard about Yes 1 8 9 HIV / AIDS. Similarly 99% of the (100%) (100%) (100%) 0.00* (2.1%) (9.6%) (6.9%) 0.105+ subjects reported AIDS being an No 0 0 0 important problem in India only 58% of No 46 75 121 AIDS important problem in India the male subjects and 62% of the female (97.8%) (90.3%) (93%) Yes 47 82 (98.7%) 129 subjects reported that there is treatment Sharing Clothes (100%) (99.2%) available for AIDS. Likewise only 28% Yes 3 13 16 No 0 1 1 0.450+ of male subjects and 35% of female (6.3%) (15.6%) (12.3%) 0.122+ (1.2%) (0.7%) subjects believed that there is an effective No 44 70 114 Treatment for AIDS cure for AIDS. (93.6%) (84.3%) (87.6%) Yes 27 45 72 Table 2 shows knowledge of subjects Social Contact with infected person (57.4%) (61.6%) (55.3%) regarding the modes of transmission. Yes 8 15 23 No 20 28 48 0.647+ This table contains questions regarding (17%) (18%) (17.6%) 0.880+ (12.5%) (38.3%) (36.9%) the mode of transmission of HIV/AIDS. No 39 68 107 Effective cure for AIDS After the survey it was observed that (82.9%) (81.9%) (82.3%) Yes 13 29 42 majority of the dental students had Kissing (27.6%) (39.7%) (32.3%) knowledge about mode of transmission Yes 8 40 48 of HIV like sexual inter course No 34 54 88 0.394+ (17%) (48.1%) (36.9%) 0.000* 100%.Likewise 95.7% male and 98.7% (78.7%) (65%) (67.6%) female,97.8% male and 100% No 39 43 82 female,82.9% male and 59% female (82.9%) (51.8%) (63%) Table 2: Knowledge of subjects regarding the modes of Sneezing transmission reported needle /syringes, transfusion of Categories Male N(%) Female Total P Value blood, mother to child transmission were Yes 22 40 62 different modes of transmission of N(%) N(%) (46.8%) (48.1%) (47.6%) 0.897+ HIV/AIDS. Sexual Intercourse No 25 43 68 (53.1%) (51.8%) (52.3%) Yes 47 (100%) 83 130 Ta b l e 3 s h o w s b e l i e f s a b o u t (100%) (100%) 0.00* communicability. This table revealed the Sharing drinking glass, utensils, toilet No 0 0 0 knowledge of dental students on beliefs Yes 9 9 18 Transmission of Blood about communicability. Here 68% of the (19.1%) (10.8%) (13.8%) 0.188+ Yes 46 83 129 subjects have correct knowledge No 38 74 112 (97.8%) (100%) (99.2%) regarding modes of transmission by (80.8%) (89.1%) (86.1%) mosquito, sharing clothes, utensils or No 1 0 1 0.182+ Body contact in public place shaking hands with HIV infected Yes 9 6 15 (2.12%) (0.7%) persons. 87% of the study subjects have Needle Syringes correct knowledge about body contact in (19.1%) (7.2%) (11.5%) 0.022+ Yes 45 82 127 public places or sharing a pool not being No 38 77 115 (95.7%) (98.7%) (97.6%) modes of transmission. (80.8%) (92.7%) (88.4%) No 2 1 3 0.266+ Sharing a pool (4.2%) (1.2%) (2.3%) Table 4 shows knowledge about safe sex. Yes 11 8 19 After the survey was done, it was Tattooing / Ear piercing (23.4%) (9.6%) (14.6%) 0.033+ observed that majority of the study No 36 75 111 Yes 25 48 73 participants (90%) of both genders (76.5%) (90.3%) (85.3%) (53.1%) (57.8%) (56.1%) consider sex without condom to be of No 22 35 57 0.608+ high risk. The level of knowledge was Eating food cooked by an infected person (46.8%) (42.1%) (43.8%) lower regarding faithful couples(79.2%) Yes 3 5 8 BrestFeeding and sex with condom being at the lowest (6.3%) (6%) (6.1%) 0.935+ Yes 26 51 77 risk. No 44 78 122 (55.3%) (61.4%) (59.2%) (93.6%) (93.9%) (93.8%) Table 5 shows knowledge about risk No 21 32 53 0.495+ perception. The survey has revealed that Table 6 shows knowledge about risk (44.6%) (38.5%) (40.7%) 80% of the dental students are aware that Mother to Child Transmission (in the womb) group. We observed that 80% of the office goers were not a high risk group. subjects have correct knowledge that Yes 39 49 88 29%, 30%, 50% were perceived by truck drivers, commercial sex workers (82.9%) (59%) (67.6%) general practitioners / surgeons, dentists, and intravenous drug users are at high No 8 34 42 0.005+ school / college going students risk. Whereas level of knowledge was respectively to be low risk group. (17%) (40.9%) (32.3%) lower in correctly identifying

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 018 Table 4 : Knowledge about Safe Sex Table 5: Knowledge about risk Perception Table 6 : Knowledge about high risk group Categories Male Female Total P Value Categories Male Female Total P Value Categories Male Female Total P Value N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) Faithful coupes Office goers Truckers High Risk 1 1 2 High Risk 1 1 2 High Risk 29 50 79 (2.1%) (1.2%) (1.5%) (2.1%) (1.2%) (1.5%) (61.7%) (60.2%) (60.7%) Low Risk 39 64 103 1.017+ Low Risk 40 64 104 1.700+ Low Risk 10 20 30 0.148+ (82.9%) ( 77.1%) (79.2%) (85.1%) (77.1%) (80%) (21.2%) (24%) (23%) Don’t know 7 18 25 Don’t know 6 18 24 Don’t know 8 13 21 (16.2%) ( 21.6%) (19.2%) (12.7%) (21.6%) (18.4%) (17%) (15.6%) (16.1%) Sex without condom General Practitioners / Surgeons Commercial Sex Workers High Risk 43 74 117 High Risk 25 60 85 High Risk 44 76 120 (9.4%) (89.1%) (90%) (53.1%) (72.2%) (65.3%) (93.6%) (91.5%) (92.3%) Low Risk 2 1 3 2.359+ Low Risk 16 15 31 5.156+ Low Risk 2 3 5 0.611+ (4.2%) (1.2%) (2.3%) (34%) (18%) (23.8%) (4.2%) (3.6%) (3.8%) Don’t Know 2 8 10 Don’t Know 6 8 14 Don’t Know 1 4 5 (4.2%) (9.6%) (7.6%) (12.7%) (9.6%) (10.7%) (2.1%) (4.8%) (3.8%) Sex with Condom Dentist Professional Blood Donors High Risk 1 8 9 High Risk 22 55 75 High Risk 24 42 66 (2.1%) (9.6%) (6.9%) (46.8%) (66.2%) (57.6%) (51%) (50.6%) (50.7%) Low Risk 41 67 114 3.183+ Low Risk 18 21 39 4.770+ Low Risk 19 29 48 1.108+ (87.2%) (80.9%) (83%) (38.2%) (25.3%) (30%) (40.4%) (34.9%) (36.9%) Don’t Know 5 8 13 Don’t Know 7 7 14 Don’t Know 4 12 16 (10.6%) (9.6%) (10%) (14.8%) (8.4%) (10%) (8.5%) (14.4%) (12.3%) professional blood donors (51%) and School / College Students IV drug users homosexual (79%) to be at high risk. High Risk 18 26 44 High Risk 42 72 114 (38.2%) (31.3%) (33.8%) (89.3%) (86.7%) (87.6%) Discussion: Low Risk 24 41 65 38.365+ Low Risk 4 7 11 0.589+ A significant number of students did not (51.0%) (49.3%) (50%) (8.5%) (8.4%) (8.4%) know when it is possible to confirm the Don’t Know 5 16 21 Don’t Know 1 4 5 HIV infection. The inadequate (10.6%) (19.2%) (16.1%) (2.1%) (4.8%) (3.8%) knowledge of HIV virology was also reported by Nigerian and Sudanese been estimated as less than 0.5% per Homosexuals dental students. accident. Using IV drugs is a possible High Risk 37 65 102 Since oral lesions are common in HIV / transmission route and has been (78.7%) (78.3%) (78.4%) AIDS patients, oral health care is an considered by the vast majority of Low Risk 8 5 13 7.014+ important component of their treatment students. (17%) (6%) (10%) plan. Although many dentists used to Clinical dental students in particular may Don’t Know 2 13 15 encounter a number of incidents where reject providing dental treatment to AIDS (4.2%) (15.6%) (11.5%) patients, dentists attitude toward the infections, including AIDS, from treatment of these patients have patient's body fluids may occur. In attitude about HIV. The sample was improved in recent years. comparison to other infectious diseases, homogenous. There were no ethnic or A study conducted in Jordan few years dental students were found to be more religious variations, future studies are ago to investigate willingness of working willing to treat HBV- and HCV-infected encouraged to study the influence of dentists to treat HIV infected patients has patients than those with HIV infection other factors, which were not studied here show that, when a fake AIDS patient [11]. Male students were reported to have such as the social class, the income, contacted dental practices by phone for significantly stronger negative attitudes education of parents and the area of treatment of pain of dental origin, there towards patients at risk for or with HIV residency on the student’s attitude was fear of the HIV illness and only15% infections/AIDS than female students towards HIV patients, as this is a of dentists accepted to provide such [12]. Dental students were reported to limitation of this study. Also future treatment. favour the inclusion in their tutored studies are encouraged to hold this study The fear of treating HIV infected patients programs a more comprehensive among dental students of the other dental was further revealed by the inadequate material about patients with HIV faculty in Chennai and among other knowledge of HIV transmission reported infections/AIDS, such materials as case health care workers. by the students participated in this study. studies, discussion groups and closely Evidence indicated a low occupational supervised clinical experiences[12]. Conclusion: risk for HIV infection among health care In this study, survey was made between Although a large number of these professionals. The highest risk was under graduate and post graduate dental students claim to be knowledgeable following a needle prick injury and has students regarding their knowledge and about HIV/AIDS, it is obvious that a true

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 019 understanding of the disease is lacking. A exposure to the risk of HIV infection k n o w l e d g e o f h u m a n concerted effort should be made to among health care workers in immunodeficiency virus. J Dent change the uninformed perception Mwanza Region, United Republic of 2008, 36:374-378. a m o n g s t d e n t a l s t u d e n t s b y Tanzania. Bull World Health Organ 16. Nasir EF, Astrøm AN, David J, Ali implementing curriculums that will 1997, 75:133-40. RW: HIV and AIDS related enhance their knowledge of HIV/AIDS 8. Epidemiological fact sheet on HIV knowledge, sources of information, starting from preclinical stage which will and AIDS. Geneva: WHO/ UNAIDS / and reported need for further be sustained in the clinical level. U N I C E F education among dental students in [http://apps.who.int/globalatlas/pred Sudan--a cross sectional study. BMC References: e f i n e d R e p o r t s / Public Health 2008, 8:286. 1. Cohen LA, Romberg E, Grace EG, EFS2008/full/EFS2008_JO.pdf] 17. Samaranayake LP: Oral care of the Barnes DM: Attitudes of advanced 9. HIV Infection and AIDS, An HIV patient. Dent Update 1992, dental education students toward Overview, NIAID Fact Sheet: NIAID 19:56-58. individuals with AIDS. J Dent Educ [http://www.wrongdiagnosis.com/art 18. Senna MI, Guimarães MD, Pordeus 2005, 69:896-900. ic/hiv_infection_and_aids_an_overv IA: Factors associated with dentists' 2. Ogunbodede EO, Rudolf MJ: iew_niaid_fact_sheet_niaid.htm] willingness to treat HIV/AIDS Policies and protocol for preventing 10. Centers for Disease Control, patients in the National Health transmission of HIV infection in oral Prevention: Guidelines for infection System in Belo Horizonte, Minas health care in South Africa.S Afr Dent control in health care personnel. Gerais, Brazil. Cad Saude Publica J 2002, 57:469-474. Infect Control Hosp. Epidemiol 2005, 21:217-25. 3. Patton LL: HIV disease. Dent Clin 1998, 19:445. 19. Erasmus S, Luiters S, Brijlal P: Oral North Am 2003, 47:467-492. 11. Hu SW, Lai HR, Liao PH: Comparing Hygiene and dental student's 4. Lohrmann C, Valimaki M, Suominen dental students' knowledge of and knowledge, attitude and behaviour in T, Muinonen U, Dassen T, Peate I: attitudes toward hepatitis B virus-, managing HIV/AIDS patients. Int J German nursing students' knowledge hepatitis C virus-, and HIV-infected Dent Hyg 2005, 3:213-217. of and attitudes to HIV and AIDS: two patients in Taiwan. AIDS Patient Care 20. El-Maaytah M, Al Kayed A, Al decades after the first AIDS cases. J STDS 2004, 18:587-593. Qudah M, Al Ahmad H, Moutasim K, Adv Nurs 2000, 31:696-703. 12. Seacat JP, Inglehart MR: Education Jerjes W, Al Khawalde M, Abu 5. Kermode M, Holmes W, Langkham about treating patients with HIV Hammad O, Dar Odeh N, El-Maaytah B, Thomas MS, Gifford S: infections/AIDS: the student K, Al Shmailan Y, Porter S, Scully C: Occupational exposure to blood and perspective. J Dent Educ 2003, Willingness of dentists in Jordan to risk of bloodborne infection among 67:630-640. treat HIV-infected patients. Oral Dis health care workers in rural north 13. Gilbert AD, Nuttall NM: Knowledge 2005, 11:318-322. Indian healthy care settings. Am J of the human immunodeficiency 21. Cusini M: Transmission of HIV Infect Control 2005, 33:34-41. virus among final year dental infection. Semin Dermatol 1995, 6. Ansa VO, UdAnsa VO, Udoma EJ, students. J Dent 1994, 22:229-235. 14:202-204. Umoh MS, Anah MU: Occupational 14. Centres for disease control: 22. Blignaut E: The role of the dental risk of infection by human Recommendations for preventing profession in the AIDS epidemic. immunodeficiency and hepatitis B t r a n s m i s s i o n o f h u m a n Practitioners corner. J Dent Assoc S viruses among health workers in immunodeficiency virus and Afr 1994, 49:113-152. south-eastern Nigeria. East AfrMed J Hepatitis B virus to patients during 2002, 79:254-6. exposure prone invasive procedures. 7. Gumodoka B, Favot I, Berege ZA, MMWR Recomm Rep 1991, 40:1-9. Dolmans WM: Occupational 15. Ajayi YO, Ajayi EO: Dental students'

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 020 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Evaluation Of Efficacy Of A Dentifrice 1 D S Kalsi 2 Kulmeet Kaur Containing A Combination Of Arginine And 3 Vikrant Sharma 1 Professor Calcium Carbonate In Reducing 2 Reader 3 Senior Lecturer, Dept. Of Perioontology Hypersensitivity Bjs Dental College, Ludhiana Address For Correspondence: Dr. D S Kalsi Abstract Department Of Periodontology Objectives : The aim of this study was to evaluate the efficacy of the desensitizing dentifrice BJS Dental college, Ludhiana “Colgate® Sensitive Pro-relief™” containing arginine and calcium carbonate on reduction of Submission : 2nd March 2014 dentinal hypersensitivity instantly after application as a single in-office application as claimed by Accepted : 21st February 2015 manufacturing company. The study population consisted of 61 subjects between the ages of 18- 70 years and in good general health. They were required to possess a minimum of two Quick Response Code hypersensitive teeth with no clinical evidence of mobility, ongoing periodontal disease or dental restorations and cavities. Clinical procedure involved scoring baseline using tactile exploration, air blast and cold water and then reevaluation of scores after 5 min of paste application. Statistical analysis was performed using paired t-test for comparison of baseline versus final sensitivity scores. Results and Conclusions : The results were statistically analyzed and it was found that the dentrifice containing Arginine-Calcium carbonate (Colgate® Sensitive Pro-relief™) was effective in reducing Dentin hypersensitivity as all the parameters i.e., tactile exploration, air blast stimulation and cold water test showed a highly statistically significant reduction from baseline scores. claimed by the manufacturing company. Key Words Dentin/Dentinal hypersensitivity (DHS), Arginine, Calcium carbonate Material And Methods This clinical study was conducted at Introduction the or by formation of smear B.J.S. Dental College, Ludhiana to Dentin/Dentinal hypersensitivity (DHS) layer during brushing or act as protein clinically evaluate the efficacy of a newly may be defined as short, sharp pain precipitants[8],[9]. Many of these available dentifrice “Colgate® Sensitive arising from exposed dentine typically in formulations have been shown to provide Pro-Relief™” on dentin hypersensitivity response to chemical, thermal or osmotic measurable reductions in dentin in providing instant relief from dentin stimuli that cannot be explained as hypersensitivity after two to four weeks hypersensitivity after a single arising from any other form of dental of twice daily use and generally several professional application of the product defect or pathology[1]. The two most weeks or more to demonstrate maximum for 5 minutes. The desensitizing paste common pathways that lead to dentin effectiveness and achieve maximum contains 8% Arginine and Calcium exposure and dentin hypersensitivity are levels of pain relief [10],[11],[12]. Their carbonate as active desensitizing agents. [2] and enamel loss effects are sustained for as long as daily Inclusion criteria - Eligible study subjects due to abrasion, erosion, and use of the desensitizing toothpaste is had to be between the ages of 18-70 years . A variety of products for continued but may rapidly wear off and in good general health. They were home use and professional treatments for thereafter. Recently a new dentifrice required to possess a minimum of two dentin hypersensitivity are available e.g., “Colgate® Sensitive Pro-Relief™” hypersensitive teeth with mild - moderate desensitizing toothpastes, mouth rinses containing Arginine and Calcium recession as assessed with a blast of air, with high fluoride content, varnishes and carbonate claiming instant and long stream of cold water at 5-10°C restorative materials etc. Many lasting relief from dental hypersensitivity temperature and with exploration with an desensitizing toothpastes contain a has become available. explorer. None of the teeth under potassium salt which is believed to work The objective of this clinical study evaluation showed mobility, ongoing by penetrating the length of the dentinal conducted in a group of patients with periodontal disease, pathological tubule and depolarizing the pulpal nerves known dentin hypersensitivity, was to migration or had dental restorations or thus interrupting the neural response to determine the efficacy of Colgate® cavities. Subjects with reported history of pain stimuli[3],[4],[5],[6],[7]. Various Sensitive Pro-Relief™ and test the claim allergy to any dentifrice were excluded other available dentifrices contain of manufacturing company in reducing from the study. desensitizing agents like calcium dentin hypersensitivity of this Clinical procedure - 61 subjects who met carbonate, aluminium, calcium desensitizing paste containing Arginine the selection criteria received a baseline phosphate, silicates, strontium chloride, and Calcium carbonate, instantly after evaluation to assess and grade dentin sodium fluoride and zinc chloride which application as a single in-office hypersensitivity by air blast, cold water act either by blocking dentinal tubules by application on the affected teeth as and tactile exploration tests. A trained

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 021 dental professional applied a pea sized Table 1 Intragroup comparisons of the mean pre-scores and tubules thereby effectively blocking the amount of dentifrice being evaluated to post-scores of tactile, air blast and cold water tests. flow of dentinal fluid through dentinal the sensitive surfaces of the teeth being Group Pre score Post score Difference in P Significance tubules which is essential for causing tested with a cotton pellet after isolation (Mean± Sd) (Mean± Sd) percentage value DHS as per the widely accepted with cotton rolls. Patients were refrained Tactile test 0.75±0.92 0.30±0.50 60.0% <0.001 HS hydrodynamic theory by Brannstrom. from rinsing for 4 minutes. After the Air blast test 1.16±0.79 0.63±0.55 45.6% <0.001 HS [20],[21] holding time of 4 minutes, patients were Cold water test 2.02±0.88 1.10±0.94 45.5% <0.001 HS The purpose of this study was to evaluate asked to rinse thoroughly with tap water the efficacy of the commercially and tactile, cold water and air blast Tactile, air blast and cold water available desensitizing product based on hypersensitivity scoring was repeated. sensitivity scores were recorded before Pro-Argin™ technology “Colgate® product application and after product Sensitive Pro-relief™” on dentin Clinical Scoring Procedures application and the comparison was done hypersensitivity. It is demonstrated in Verbal rating scale was used for scoring between the mean pre-operative and this study that as claimed by the DHS and patients were told to score post-operative scores. company, the effective use of the test degree of hypersensitivity on the For tactile hypersenstivity, the mean product requires less than 1 minute of following scale. baseline pre scores were 0.75±0.92 and application time, is very easy to use, and 0 - No hypersensitivity post-scores were 0.30±0.50. The has the advantage of pre-treating 1 - Mild hypersensitivity percentage changes from baseline were suspected hypersensitive areas. 2 - Moderate hypersensitivity 60.0% which is highly significant. An adult population with history of 3 - Severe hypersensitivity For air blast hypersensitivity, the mean dentin hypersensitivity was enrolled for Tactile hypersensitivity was assessed baseline pre-scores were 1.16±0.79 and participation in this study and tactile, using a sharp explorer. For this the tip of a post-scores were 0.63±0.55. The cold water and air blast scores were d e n t a l e x p l o r e r w a s m o v e d percentage changes from baseline were recorded as baseline hyper-sensitivity approximately at right angle over the 45.6% which is highly significant. values and then after 5 minutes (1 minute tooth being tested using light force For cold water hypersensitivity, the mean dentrifice application and 4 minutes of similar to the one used for probing and the baseline pre scores were 2.02±0.88 and dentrifice holding time) dentin patients were then asked to grade the pain post-scores were 1.10±0.94. The hypersensitivity was re-evaluated. of hypersensitivity if any. percentage changes from baseline were Significant reductions in dentin F o r e v a l u a t i o n o f a i r b l a s t 45.5% which is highly significant. hypersensitivity scores i.e., 60.0% hypersensitivity, a blast of air was reduction in tactile hypersensitivity, directed from a standard dental unit air Discussion 4 5 . 6 % r e d u c t i o n i n a i r- b l a s t syringe on the tooth being evaluated for 1 Dentin/Dentinal hypersensitivity is hypersensitivity and 45.5% reduction in sec from a distance of 1 cm after covering characterized by short sharp pain arising cold water hypersensitivity instantly adjacent tooth surfaces with operator’s from exposed dentine typically in after product application were observed. fingers. response to thermal, evaporative, tactile, These results were comparable to the For assessing cold water sensitivity 5ml osmotic or chemical stimuli which work conducted by Kleinberg et al[19] cold water at 5-100C was taken in a cannot be ascribed to any other form of who reported statistically significant syringe and slowly flowed in 10 seconds dental defect or pathology[13],[14],[15]. reductions of 58.8% in air blast from a distance of 1cm on the tooth being It is a painful clinical condition that stimulated hypersensitivity and 64.6% in evaluated. The adjacent tooth surfaces affects 8 to 57% of adult population and is tactile hypersensitivity for Arginine were covered by operator’s fingers. associated with dentin exposure to the dentrifice group following a single post- oral environment.[16],[17] A recent scaling application of the 8% Arginine- Statistical Methods novel approach for the treatment of DHS Calcium carbonate desensitizing Data was collected and tabulated and is a technology based on Arginine, a dentrifice. They subsequently conducted statistical analysis was performed natural product, and Calcium carbonate. a monadic design study to establish separately for tactile hypersensitivity, air In 2002, Kleinberg et al. reported the duration of the hypersensitivity relief blast hypersensitivity and cold water development of this novel desensitizing b e n e f i t a n d r e p o r t e d i n s t a n t hypersensitivity scores. Within treatment technology based on the role that saliva hypersensitivity improvements of 71.7% groups, comparisons of the baseline plays in naturally reducing dentinal (air blast) and 84.2% (tactile) that were versus final hypersensitivity scores were hypersensitivity. Saliva provides calcium maintained for 28 days after a single analysed using paired t-test. and phosphate, which over time occlude application of the product thus validating and block open dentinal tubules from its use as home application too. A similar Results external stimuli known to cause dentinal clinical study conducted on 390 patients Sixty one subjects participated in the h y p e r s e n s i t i v i t y. [ 1 8 ] , [ 1 9 ] T h e found professional application of study. Throughout the study, there were technology is proposed to block dentinal Arginine and Calcium carbonate by no adverse effects on the oral soft or hard hypersensitivity pain by occluding dentists and dental hygienists in Hong tissues of the oral cavity as observed by dentinal tubules by using Arginine, Kong significantly reduced severity of the examiner or reported by the subjects which is positively charged at pain in patients with dentine when questioned. The mean pre and post physiologic pH of 6.5-7.5, to bind to the hypersensitivity.[22] tactile, air blast and cold water negatively charged dentin surface, which In clinical trials, this product has been hypersensitivity scores are shown in helps attracts a calcium-rich layer from found to provide immediate and lasting Table 1. saliva, and infiltrates and blocks dentinal relief of dentin hypersensitivity for four

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 022 weeks when it is applied in patients al. Hypersensitive Dentin: Testingof t h e U K . J C l i n immediately after dental scaling, as a procedures for mechanical and Periodontol.2000;27:860-5 final polishing step during a professional chemical obliteration of dentinal 16. Markowitz K, Pashley DH (2007) cleaning procedure[23]. Another study tubuli. J Periodontol 1993;64:366- Personal reflections on a sensitive demonstrated its effectiveness in 373. subject. J Dent Res86,292-295 relieving dentinal hypersensitivity when 5. Poulsen S, Errboe M, Hovgaard O, et 17. A d d y M ( 2 0 0 0 ) D e n t i n e applied prior to dental prophylaxis, with al. Potassium nitrate toothpaste for h y p e r s e n s i t i v i t y : d e f i n i t i o n , a significant reduction in dentinal dentine hypersensitivity(Review). prevalence, distribution and hypersensitivity postprocedurally[24]. A The Cochrane Collaboration 2004, aetiology. In: and range of state-of-the-art measurement Issue 4, Wiley Publisher.1-11. sensitivity; clinical advances in techniques have been used to establish 6. Nagata T, Ishida H, Shinohara H, et restorative dentistry ,Addy M, the mechanism of action of this product al. Clinical evaluation of a potassium Embery G, Edgar WM, Orchardson R e.g., confocal laser scanning microscopy nitrate dentifrice for the treatment of eds, Martin Dunitz,London,239-248l (CLSM) studies etc. These have dentinal hypersensitivity. J Clin 18. Panakos F, Schiff T,Guigon A. Dentin demonstrated its effectiveness in Peridontol 1994;21 (3):217-21. hypersensitivity: Effective treatment occluding open dentin tubules[23]. In 7. Schiff T, Dotson M, Cohen S, et al. with an in-office desensitizing paste addition, it was determined through Efficacy of a dentifrice containing containing 8% arginine and calcium hydraulic conductance testing that these p o t a s s i u m n i t r a t e , s o l u b l e c a r b o n a t e . A m J D e n t . deposits significantly reduced the flow of p y r o p h o s p h a t e , P V M / M A 2009;22(Special Issue):3A-7A dentinal fluid in the tubules[25]. copolymer, and sodium fluoride on 19. Kleinberg I.Sensitat: A new saliva- dentinal hypersensitivity: a twelve- based composition for simple and Conclusions week clinical study. J Clin Dent effective treatment of dentinal The results of this clinical study support 1994;5 Spec No: 87-92 hypersensitivity pain. Dent the conclusions that – single professional 8. Prati C, Venturi L, ValdrèG, Today.2002;21:42-7 application of the dentrifice containing Mongiorgi R (2002) Dentin 20. Brannstrom M. Dentin sensitivity and Arginine and Calcium carbonate morphology and permeability after aspiration of odontoblasts. J Am Dent (Colgate® sensitive pro-relief™) brushing with different toothpastes in Assoc.1963;66:366-70 provides a highly significant instant presence and absence of smear layer. 21. Cummins D. Dentin hypersensitivity: reduction in dentin hypersensitivity as J Periodontol 73, 183-190. From diagnosis to a breakthrough evaluated with tactile test, air blast test 9. Prati C, Montebugnoli L, Suppa P, therapy for everyday sensitive relief. and cold water tests. ValdrèG, Mongiorgi R (2003) J Clin Dent. 2009;20(Special The results from this study demonstrate Permeability and morphologyof Issue):1-9 that this desensitizing paste can be used dentin after erosion induced by acidic 22. Chu CH, Lui KS ,Lau KP, Kwok CM, as an in-office modality to provide relief drinks. J Periodontol 74, 428-436. Huang T. Effects of 8% arginine from pre-existing or anticipated dentin 10. Cummins D: Dentin Hypersenstivity: desensitizing paste on teeth with hypersenstivity when applied in advance From diagnosis to breakthrough hypersensitivity .J Dent Res of dental procedures, such as scaling and therapy for everyday sensitive relief. 2010,89(Spec Issue A)(Submitted on root planning etc. It seems that this J Clin Dent 20(Spec Iss):1-9, 2009 Feb 5,2010) product has the potential to be of great 11. Millers, Truong T, Heu R, Stranick M. 23. Schiff T, Delgado E ,Zhang YP, et al. assistance to clinicians in dealing with Bouchard D, Gaffar A: Recent Clinical evaluation of the efficacy of dentin hypersensitivity as an in office advances in stannous fluoride an in –office desensitizing paste dentinal hypersensitivity controlling technology: Antibacterial efficacy containing 8% arginine and calcium agent and home use agent, especially and mechanism of action towards carbonate in providing instant and when used prior to pre-existing or hypersensitivity. Int Dent J l a s t i n g r e l i e f o f d e n t i n anticipated post operative dentinal 44(suppl):83-98,1994 h y p e r s e n s i t i v i t y . A m J hypersensitivity. 12. Walters PA: Dentin hypersensitivity: Dent.2009;22(Spec Issue): 8A-15A A review. J Contemp Dent Pract 24. Hamlin D, Phlean Williams E, References 6:107-117,2005 Delgado E, et al. Clinical evaluation 1. Addy M, Urquart E. Dentine 13. Canadian Advisory Board on Dentine of the efficacy of a desensitizing paste hypersensitivity: its prevalence, Hypersensitivity. Consensus-based containing 8% arginine and calcium aetiology and clinical management. recommendations for the diagnosis carbonate for the in-office relief of D e n t a l U p d a t e 1 9 9 2 ; and management of dentine dentin hypersensitivity associated 19:407,408,410-412. hypersensitivity. J Can Dent with dental prophylaxis. Am JDent. 2. Addy M. Dentine hypersensitivity: Assoc.2003;69:221-6 2009;22:16A-20A New perspectives on an old problem. 14. Que K, Ruan J, Fan X, Liang X, Hu D. 25. Petrou I, Heu R, Stranick M, et al. Int Dent J 2002; 52:375-6. A multi-centre and cross-sectional Abreakthough therapy for dentin 3. Tarbet WJ, Buckner A, Stark MM, et study of dentine hypersensitivity in hypersensitivity:dental products al. The pulpal effects of brushing with C h i n a . J C l i n containing 8% arginine and calcium a 5 percent potassium nitrate paste Periodontol.2010;37:631-7 carbonate work to deliver effective used for desensitization. Oral 15. Rees JS. The prevalence of dentine relief of sensitive teeth.J Clin Surg1981;600-602. hypersensitivity in general practice in Dent.2009;(Spec Iss);23-31 4. Knight NN, Tryggve L, Clark SM, et Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 023 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Knowledge, Attitudes And Practices 1 Rohit Sharma 2 Ajay Sharma Regarding Controversies In Infective 1 Consultant, Dept. of Oral and Maxillofacial Surgery Yamuna Nagar 2 Professor and Head , Department of Medicine Endocarditis Prophylaxis In Dentistry – A D.A.V. (C) Dental College and Hospital Address For Correspondence: Survey Dr. Rohit Sharma, Senior Lecturer Department of Oral and Maxillofacial Surgery Abstract Gian Sagar Dental College and Hospital Dental procedures have been regarded as a predisposing causative factor for Infective Ram Nagar, Teh. Rajpura, Distt. Patiala (Punjab) Endocarditis. A lot of emphasis has been laid on making the dental professionals at various levels Phone No.: +919915607043 E-mail: [email protected] aware. This double blind, randomized study was conducted to gauge the awareness of dental th surgeons regarding Infective Endocarditis prophylaxis in dentistry, their attitudes towards the Submission : 22 April 2013 th controversial issues surrounding antibiotic prophylaxis and current practices regarding dental Accepted : 9 October 2014 treatment in patients with pre-existing heart diseases Quick Response Code Key Words Endocarditis Prophylaxis, Dentistry, Controversy Introduction Materials And Methods Infective Endocarditis is a serious, The survey was conducted on 60 dental potentially life threatening disease surgeons working in the departments of i n v o l v i n g p r o l i f e r a t i o n o f Oral and Maxillofacial surgery, microorganisms on the endothelium of Endodontics, Pedodontics and heart secondary to bacteremia, usually in Periodontics of the D.A.V. Centenary very low. patients already suffering from a Dental College, Yamuna Nagar, which is structural heart disease. Dental a post-graduate teaching institute. As many as 25% of the surveyed dental procedures, especially extractions are Interns, post graduate students and surgeons were not aware of the frequently blamed as the cause of faculty members were included in the commonest organisms causing Infective bacteremia[1], and a lot of emphasis is study. They were asked to fill a Endocarditis after dental procedures. laid on antimicrobial prophylaxis before questionnaire containing 12 questions of 20% were not clear which kind of such procedures in cardiac patients. objective and subjective nature. The procedures required endocarditis However, analysis of available data answers were analysed to evaluate the prophylaxis, although the majority had indicate that the proportion of cases of level of knowledge regarding Infective the concept clear that procedures causing endocarditis which result from a dental Endocarditis Prophylaxis, their attitudes gingival or mucosal bleeding warranted procedure is exceedingly small [2], [3]. towards the recent controversies and the prophylactic administration of Although 40% of Infective Endocarditis current practices regarding dental antibiotics. cases of native valve endocarditis which procedures in cardiac patients Only 20 out of 60 (33.3%) surveyed are positive for Streptococci originate dentists were aware of the cardiac lesions from the mouth, the emphasis for in which antibiotic prophylaxis was Observations And Analyses required. The maximum confusion was Infective Endocarditis causation has 75% of dental surgeons were of the shifted from procedure related regarding risk of infective carditis in opinion that dental extraction is the most patients with stents, coronary artery b a c t e r e m i a [ 4 ] t o c u m u l a t i v e common predisposing factor for causing bacteremia[5]. Some authorities have bypass graft, surgically corrected bacteremia leading to Infective congenital heart disease and cardiac gone to the extent of recommending that Endocarditis whereas 17% thought that routine administration of prophylactic pacemakers. other procedures like scaling or root As many as 25% were not clear about the antibiotics is neither necessary nor cost canal treatment were the leading factors. effective and may even be hazardous [3]. dosing and timing of antibiotic Only 3% appeared to be aware that in prophylaxis. Majority (66.6%) thought fact, intra venous drug abuse is the most that a second dose of half the initial dose Aims And Objectives common cause of bacteremia leading to of antibiotic is recommended in all cases, A double blind, randomized study was Infective Endocarditis. whereas 17% were of the opinion that a conducted to gauge the awareness of Half (50%) of the dentists surveyed had second dose is not required. Only 16% dental surgeons regarding Infective the impression that the risk of a patient were aware of the current consensus that Endocarditis prophylaxis in dentistry, with valvular heart disease developing a second dose should only be given in their attitudes towards the controversial infective endocarditis after dental high risk cases. issues surrounding antibiotic prophylaxis extraction without antibiotic prophylaxis Only 25% were of the opinion that a and current practices regarding dental was very high (75%-100%). Nearly 45% thorough cardiovascular examination treatment in patients with pre-existing thought that the risk was moderately high should be done in all cases before dental heart diseases. (25%-50). Only one faculty member was procedures involving bleeding, whereas aware of the fact that the risk was actually

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 024 the majority (75%) thought that a prior history of Infective Endocarditis regarding prophylaxis of Infective cardiovascular check up is required only should receive prophylaxis [6]. Endocarditis in dentistry. The level of where history is suggestive of Nevertheless, an expert committee of the awareness may even be lower in those cardiovascular disease. American Heart Association along with doing private practice. The recent 40 out of 60 (66.6%) thought that the similar advisory groups in other controversies and raging debates benefits of antibiotic prophylaxis is developing countries has identified regarding efficacy and desirability of established beyond doubt, whereas 10 procedures that may precipitate antibiotic prophylaxis notwithstanding, (16.6%) said they could not say. Only 10 bacteremia and patients who should the standard practice of giving were aware of the recent controversy receive prophylaxis [7]. prophylaxis to high risk cases must be regarding efficacy of antibiotic An overwhelming majority of dental followed, even if only for medico-legal prophylaxis. surgeons appeared to be unaware of the purposes. All patients undergoing ongoing controversy regarding the invasive dental procedures must be Discussion efficacy and desirability of prophylactic screened for pre-existing cardiac The survey revealed a paucity of antibiotic administration. A Dutch study problems, even if that entails some information regarding prophylaxis [8] assessed 427 patients with Infective amount of inconvenience to the patient against Infective Endocarditis in a Endocarditis and concluded that even if and increased cost factor. In vulnerable significant number of dental surgeons, antibiotic prophylaxis was 100% patients, the importance of maintaining even in a post graduate teaching institute. effective and was provided to all cases at good oral hygiene and aggressive Not only were there lacunae in the risk, only a small fraction of cases (5.3%) treatment of local infections is of knowledge, there was also a lack of could be potentially prevented. Some paramount importance for preventing awareness regarding the current authorities have gone to the extent of Infective Endocarditis. controversies prevailing, and a certain suggesting that the standard practice of casual attitude towards the need for antibiotic prophylaxis before dental References preventive measures. extractions may be more for medico- 1. Bayliss R. et al, Whitfield AGW. The The most common cause of bacteremia legal purposes than scientific norms. teeth and Infective Endocarditis. causing Infective Endocarditis is intra R e s e a r c h e r s a t U n i v e r s i t y o f British Heart Journal 1983; 50: 506- venous drug addiction whereas majority Pennsylvania School of Medicine have 512. thought that it was dental extraction. determined that dental procedures are 2. Roberts GJ. Dentists are innocent. Even where the source of bacteremia is NOT a risk factor for endocarditis even in Everyday bacteremia is the real the mouth, it is the cumulative bacteremia patients with underlying cardiovascular culprit. A review and assessment of [2] rather than procedure related abnormalities. In view of high rate of evidence that dental surgical bacteremia [4] which is responsible for failures for prophylaxis, low incidence of procedures are a principal cause of Infective Endocarditis. The seminal the disease and risk of adverse reactions Bacterial Endocarditis in children. paper of Guntheroth [5] showed that to drugs, the guidelines regarding Paediatric Cardiology 1999; 20: 317- cumulative bacteremia in the mouth prior antibiotic prophylaxis should be revised. 325 to a single extraction is 5000 times The cost effectiveness also appears to be 3. Tanbert K. Review of causation of greater than the bacteremia immediately a deterrent- some Western studies have Infective Endocarditis. American following extraction of a single tooth. concluded that Clarithromycin may be Heart Association, May 2005. more cost effective than Amoxycillin, The emerging view is that patients with 4. Van der Mecr JTM et al. Distribution, cardiac defects are more likely to develop though this may not hold true in developing countries like India. antibiotic susceptibility and tolerance Infective Endocarditis from everyday to bacterial isolates in culture positive bacteremia rather than from dental These are dissenting views which cases of bacterial endocarditis in the procedures. Most cases of Infective emphasise that dental causes are still the Netherlands. European Journal of Endocarditis are caused by bad oral predominant etiology in causation of Clinical Microbiology and Infectious hygiene, inflamed and bleeding gingivae. Infective Endocarditis. A recent study has diseases 1991; 10: 728-734 Contrary to the popular belief among shown that the frequency of positive blood culture was significantly lower in 5. Guntheroth WG. How important are dental surgeons that the risk of Infective dental procedures as a cause of Endocarditis is very high after dental patients who received antibiotic prophylaxis than who did not. Infective Endocarditis? American extractions, the risk is actually quite low. Journal of Cardiology 1984; 54: 797- The awareness regarding high risk The importance of a thorough cardiac 807 examination of patients undergoing cardiac cases requiring antibiotic 6. Duracle DT. Antibiotics for prophylaxis was quite low in the present traumatic dental procedures cannot be over emphasised. A majority of dental prevention of Endocarditis during study. The areas of doubt were especially dentistry: time to scale back? Annual coronary artery bypass graft, stents and surgeons surveyed were of the opinion that a cardiac check up is essential only in Internal Medicine 1998; 129: 829- pacemakers- all of these are extremely 831 low risk cases and do not require patients giving history suggestive of heart disease. As many as 50% of patients 7. AS Dajani et al. JAMA 1997; 277: antibiotic prophylaxis before dental 1799 procedures. Another misconception was with Infective Endocarditis were not aware of a pre existing cardiac lesion pre- 8. v a n d e r M e c r J T M e t a l . regarding surgically corrected congenital E p i d e m i o l o g y o f I n f e c t i v e heart diseases. Surgical repair can disposing to infections in different studies. Endocarditis in Netherlands. Arch eliminate risk of Infective Endocarditis if Internal Medicine 1998; 129: 761- no residual lesion is present [1]. However 769 corrective surgery is not always Conclusion protective and may itself create potential The survey revealed that majority of the targets for infection. dental surgeons, even those practising in A suggestion has been made that only a post graduate dental institute, were patients with prosthetic cardiac valves or having a lacuna in the knowledge

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 025 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Dental Students’ Attitude Towards Tobacco 1 KoppulaYadav Rao 2 M. Monica Cessation In Oxford Dental College Hospital 3 Deepika Reddy 1 Senior Lecturer And Research Centre, India. 2 Senior Lecturer Department of public health dentistry Sri Sai College of Dental Surgery, vikarabad Abstract 3 Signature Smiles Dental Hospital, Dentist can play an important role in helping patients quit using tobacco. The aim of this study General Dentist New Jersey, USA. was to investigate dental students’ attitude towards tobacco cessation promotion in the dental Address For Correspondence: setting. Methodology:A cross-sectional study was conducted on 370 students in Oxford dental Dr. Koppula Yadav Rao college, hospital and research centre. A fourteen item questionnaire was administered to dental Department of Public Health Dentistry, students which focused on dental professional responsibility and scope of practice in promotion Sri Sai College Of Dental Surgery, of tobacco cessation. Results: 98.6% agreed that it is the dental professional’s responsibility to Opp. Shiv Sagar, kothrepally, Vikarabad-501101, Andhra Pradesh. educate patients about the oral health risks of tobacco use. 98% of respondents agreed that it is Email-Id: [email protected] within the scope of dental practice to ask patients if they use tobacco, to advise patients to quit Contact no: +91-9553164309 using tobacco (98% in total), to discuss the health hazards of tobacco use (98% in total), and to Submission : 5th December 2012 discuss the benefits of stopping (99% in total), and to discuss the specific strategies for stopping th (93.9% in total). Conclusion: Dental student’s attitude towards tobacco cessation counseling in Accepted : 9 August 2014 the dental setting represents a promising baseline for future tobacco cessation program Quick Response Code development. Key Words Dental students, attitude, tobacco cessation, counseling Introduction children whose mother smokers during The epidemic of tobacco use is one of the pregnancy. Tobacco use suppresses the greatest threats to global health today. immune system’s response to oral Approximately one third of the adult infection, retards healing following oral population in the world use tobacco in surgical and accidental wounding, reported in countries such as Germany, some form and nearly half will die promotes periodontal degeneration in Denmark, Scotland, Central and Eastern prematurely. According to the most diabetics and adversely affects the Europe and rates are on the increases in recent estimate by the World Health cardiovascular system. These risks Japan, Australia, New Zealand and in the Organization (WHO), 4.9 million people increase when tobacco is used in USA among non-whites. worldwide died in 2000 as a result of their combination with alcohol or areca nut. Dental students in USA appear to be addiction to nicotine (WHO, World Most oral consequences of tobacco use positive regarding their responsibility to Health Report, 2002). This huge death impair quality of life be they as simple as educate patients about the risks of toll is rising rapidly, especially in low and halitosis, as complex as oral birth defects, tobacco use, there was a general middle-income countries where most of as common as periodontal diseases or as agreement that their educational the world’s 1.2 billion tobacco users troublesome as complications during programme adequately prepared them to live.[2] healing. help smokers quit [7],[8],[9]. The Tobacco prevalence in India is influenced Tobacco induced oral diseases contribute majority of Australian dental students by the popular habit of tobacco (bidi) significantly to the global oral diseases planned to advise patients about tobacco smoking, but the relative risk of burden. In some industrialized countries use, although their perception of the betel/tobacco quid chewing has been studies show that smoking is responsible effectiveness of smoking cessation shown to be at least twice as great as the for more than half of the periodontics counseling seems to be low[10]. The risk of bidi smoking [6]. The combination cases among adults (Tomar and Asthma, same trend was observed in Europe of the two habits increases the risk even 2000). Oral and pharyngeal cancers pose where Greek students considered more. Approximately 30% of oral a special challenge to oral health tobacco cessation counseling a duty for cancers in India are attributed to programmes particularly in developing every dentist, although an important part betel/tobacco chewing alone and an countries. Cancer of oral cavity is high (32%) believed it to be ineffective. On the additional 50% to the combined habits of among men, where oral cavity is the eight other hand, students showed significant chewing and smoking [5]. most common cancers in the world. knowledge on tobacco health effects According to Reibel 2003, Johnson and Incidence rates of oral cancer are high in [11]. Bain 2000 tobacco use is a primary cause developing countries, particularly in The effectiveness of training health of many oral diseases and adverse oral areas of South Central Asia where cancer professionals to deliver smoking conditions. Tobacco is a risk factor for of the oral cavity is among the three most cessation interventions to their patients oral cancer, oral cancer recurrence, adult frequent types of cancer. Meanwhile, has been reviewed recently by Lancaster periodontal diseases, and congenital dramatic increases in incidence rates of T, Silagy C, Fowler G and reported in the defects such as cleft lip and in oral pharyngeal cancer have been Cochrane database 2003. They concluded that training health

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 026 professionals to provide smoking cessation training, with 14 closed ended strongly agreed that it is the dental cessation interventions had a measurable questions focusing on professional professional’s responsibility to educate effect on professional performance but responsibility, scope of dental practice patients about the oral health risks of that there was no strong evidence that it and effectiveness was prepared to tobacco use. A total of 69.4% of changed smoking behaviour[12]. At least determine students’ attitude using four respondents strongly agreed or 29.2% there is an agreement that students’ point likert scale ranging from strongly agreed that it is dental professional’s attitude will be influenced by peers, a g r e e s t o s t r o n g l y d i s a g r e e . responsibility to encourage patients to teachers and curriculum content. The Questionnaire was distributed to the quit using tobacco. educational system's movement towards students, sufficient time was given to Majority of respondents strongly agreed prevention and holism is a trend that complete and collected back personally. that it is within the scope of dental deals with the relevant themes in our practice to counsel patients regarding changing society and that can contribute The questionnaire focused on: tobacco usage and to discuss the specific to the development of students’ attitudes. 1. Professional responsibility: Three strategies for stopping (93.9% in total). The dental team can play an important items focused on students attitudes Fewer respondents strongly agreed or role in tobacco control programmes, towards the dental professional agreed to prescribe tobacco chewing gum both, directed towards the community as responsibility to promote tobacco or transdermal patch to their patients a whole or towards the individual patient. cessation. (29.4%). Through participation in community and 2. Scope of dental practice: Eight items Effectiveness of tobacco cessation political action and in counseling their focused on student’s attitude regarding activities in the dental setting is 93%, patients to quit, the health professional, in the extent to which the tobacco cessation respondents strongly agreed or agreed particular the dentist and his/her team, services recommended in the public that tobacco counseling offered in the can contribute to a more tobacco free health Service guidelines are within the dental office can have an impact on society. Besides the important impact of scope of dental practice. These guidelines patients quitting. 65% disagreed or national and international legislation, for brief tobacco cessation interventions strongly disagreed with the statement “It there is ample evidence that general are organized around the 5As or five steps is not worth discussing tobacco use with medical practitioner advice to quit in delivering a brief tobacco cessation patients since most people already know tobacco use is respected by the majority intervention. they should quit”. Finally 71% strongly of patients, and several recent studies 3. Effectiveness: Three items focused on disagreed or disagreed that dental show that the efforts of dentists can be student’s attitudes regarding the professional’s time can be much better equally effective [13],[14],[15]. This effectiveness of tobacco cessation spent doing things other than trying to study is conducted to know the dental promotion in the dental setting in helping reduce tobacco use in patients. students knowledge and attitude towards patients quit tobacco use. Respondents interested in receiving tobacco cessation. The Statistical package for social training in tobacco cessation counseling sciences software (SPSS Inc., version15, were 62.6% and 37.4% were not Methodology Chicago, IL, USA) was used for data A cross-sectional study was conducted by processing and data analysis. Microsoft the department of public health dentistry, Table 1: Description according to gender, age, class of word and Excel have been used to studying, smoking status, tobacco cessation training and Oxford dental college, hospital and generate graphs, tables.[16], [17]. interested in receiving training in tobacco cessation research centre. This study was carried Analysis of variance (ANOVA) and counseling out over a period of two months to Student t test have been used to find the Variable n (%) Total (n=353) Mean ± SD P-value investigate dental student’s attitude significance of attitude between the Gender towards tobacco cessation. students. After receiving the approval from the Male 120(34.0) 44.97±4.16 institutional ethical committee of Oxford Results Female 233(66.0) 45.54±4.04 P=0.211 dental college hospital and research A Cross-sectional study of 353 students, Age centre, Bangalore, India pilot study was which includes third year BDS, Final £20 years 39(11.0) 47.23±2.92 conducted on 20 students to assess the years, Interns and PG students attending 21-25 years 218(61.8) 45.43±3.96 validity of the questionnaire. clinics was undertaken to assess the 26-30 years 88(24.9) 44.28±4.58 A total of 370 students (comprising all the dental student attitude towards the third BDS, fourth BDS, house surgeon Tobacco cessation. Response rate was 31-35 years 8(2.3) 45.63±3.25 P=0.002 and post graduate students attending 95% (353/370). Respondents were 66% Class of studying clinics) in Oxford dental college, hospital females and 34% males, with mean age Third year 73(20.7) 45.59±4.22 and research centre were invited to 23.5±3.0 years. 89% of respondents Final year 90(25.5) 46.11±3.28 participate in the study of which 353 reported that they had never used House surgeons 97(27.5) 44.63±4.01 students participated, 17 students tobacco, 4.2% reported that they has declined due to various reasons. The aim experimented with or used tobacco PG 93(26.3) 45.16±4.64 P=0.085 of the study was explained to dental regularly in the past, 5.9% reported they Smoking status students who participated in the study. are moderate social smoker, and 0.8% Never 314(89.0) 45.60±3.98 Dental students attending clinics during reported they are current smokers. The In the past 15(4.2) 43.33±4.69 the period of the study were included, majority of the respondents (91%) had Moderate social smoker 21(5.9) 43.19±4.54 first and second BDS were excluded as not received prior training in tobacco they are still in pre clinical. cessation promotion (Table 1). Heavy smoker 3(0.8) 44.33±3.22 P=0.012 The structured questionnaire included Responses to items related to Tobacco cessation training demographic data (age, gender), year of professional responsibility are shown in Yes 30(8.5) 45.93±4.93 study, smoking status and tobacco Table 2. Majority of respondents No 323(91.5) 45.29±4.01 P=0.411

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 027 Table 2: cessation reveals that majority of the discussion of specific strategies for Response students (97.7%) have moderately stopping and 11% for prescription of Attitude (n=353) Strongly Agree Disagree Strongly adequate attitude towards tobacco tobacco chewing gum. It may be that the agree Disagree cessation counseling. students do not view active involvement in an individual quitting efforts as a part A. Responses /professional responsibility Discussion of dentist role – they are content with a 1. Educate patients about the risks 277 71 5 0 The present investigation was to explore more hands–off approach, providing to tobacco use related to overall (78.4%) (20.1%) (1.4%) the opinion and attitudes of students general information and education but health and well-being towards tobacco cessation in Oxford not becoming more actively involved. 2. Educate patients about the risks of 276 72 5 0 dental college hospital and research Assisting patients with prescription of nicotine replacement therapy was not a tobacco use related to oral health (78.2%) (20.4%) (1.4%) centre Bangalore, India. The study was conducted on 370 under graduates (III, part of usual and customary practice for 3. Encourage patients to quit using 245 103 5 0 IV BDS), house surgeons and post the responding dentists, with 30-35% tobacco (69.4%) (29.2%) (1.4%) graduates students out of which 353 reporting that giving advice about the B. Scope of Dental practice students responded. nicotine transdermal patch was not a part 4. Ask patients if they use tobacco 209 140 4 0 The result of this study reveals important of their tobacco cessation activities and (59.2%) (39.6%) (1.1%) information about dental student’s fewer than 10% reporting that it was a attitudes towards tobacco cessation regular part of their activities. These 207 141 5 0 5. Advise patients to quit using promotion in a dental setting. The study findings are in accordance to the study tobacco (58.6%) (39.9%) (1.4%) states that demographic data, neither of conducted by Albert et al. 2002 where in 6. Discuss health hazards of 194 154 5 0 the gender is interested in receiving 40% to 50% reported that giving advice tobacco use (54.9%) (43.6%) (1.4%) training regarding the tobacco about the nicotine transdermal patch was 7. Discuss benefits of stopping 213 137 1 2 counseling but on increasing in age of the not a part of their tobacco cessation students the interest towards the training activities and fewer than 10% reported (60.3%) (38.8%) (0.3%) (0.6%) programmes were more significant. that it was a regular part of their activities. 8. Discuss specific strategies for 161 171 19 2 The interest towards the tobacco training Third, some students may be skeptical stopping (45.6%) (48.4%) (5.4%) (0.6%) programme was not much significant about the extent to which tobacco 9. Prescribe tobacco chewing gum 38 166 17 32 with different class of the studying cessation promotion is effective in (10.8%) (47.0%) (4.8%) (9.1%) groups and there was no significance helping patients to quit when asked about the impact of tobacco cessation 10. Prescribe tobacco transdermal 12 202 112 27 among the smoking status and tobacco cessation training among various groups counselling in patients quitting; only patch (3.4%) (57.2%) (31.7%) (7.6%) of students. 25% of students strongly agreed that 11. Refer to cessation clinic or other 91 228 27 7 First, nearly all students (98%) agreed counselling can have an impact. This is health care professional (25.8%) (64.6%) (7.6%) (1.9%) that it is dental professional similar to the findings of study done by C. Effectiveness responsibility to educate patients about Victoroff et al[9] in 2004 where 20 % strongly agreed that counselling can have 12. Tobacco use cessation 88 242 22 1 risks of tobacco use. These findings were consistent with results of the previous an impact. counseling offered in the dental (24.9%) (68.6%) (6.2%) (0.3%) studies conducted by Victorrof et al[9] in 29% of dental students agreed that dental office can have an impact on 2004 in which 99% dental students in U.S professional’s time can be better spent patients quitting agreed, and also in accordance to the doing other things. These responses 13. The dental professional’s time 16 86 225 26 Indian study conducted in Bangalore by suggest that the majority of students are positive about the extent to which can be much better spent doing (4.5%) (24.4%) (63.7%) (7.4%) Ajwani et al. in 2001. Also, in this study most agreed (98%) that it is part of dental tobacco cessation promotion is effective things other than trying to educate professional’s role to ask patients if they in helping patients to quit, but that some to reduce tobacco use in patients. use tobacco, to discuss the benefits of students may have reservations about 14. It is not worth discussing 20 103 187 43 stopping and to advice tobacco users to effectiveness. tobacco use with patients since (5.7%) (29.2%) (52.9%) (12.2%) quit. These results are almost similar to When asked about the statement “It is not most people already know they previous studies done by Fried et al[20] worth discussing tobacco use with in 2003 where in 90% agreed that it is patients since most people already know should quit. professional responsibility to advice they should quit”. 65% of students Table 3: patient to quit tobacco. A similar finding disagreed or strongly disagreed with it. Interested in receiving training in tobacco cessation counseling n (%) was revealed in a study conducted by This is similar with Victoroff et al . Yes 221(62.6) Rikard-Bell[23] in 2003 on Australian Nearly, two-third of respondents was No 132(37.4) dental students in Sydney were in 91% interested in receiving tobacco cessation advice patients to quit. training this shows positive attitude of interested in receiving training. Table 3. Second, despite their overall high level of dental students towards reception of There is significant association of agreement that dental professionals have tobacco cessation training. attitude with age in years, respondents a responsibility to educate patients, some It is noteworthy to find that students below the age of 20 had better attitude students are not certain that all activities below the age of 20 years have more when compared with other age groups. within each of five categories fall within positive attitude and as the age increased Moderately significant attitude was scope of dental practice. The proportion there was decrease in the level of attitude observed with association of attitude with of students, who strongly agreed that the towards tobacco cessation. smoking status. specified activity is within the scope of Finally, qualitative assessment of dental Finally, qualitative assessment of dental dental practice, fell to 58% for advising student’s attitude towards tobacco student’s attitude towards tobacco the patient to quit using tobacco, 45% for cessation reveals that only 0.8% have

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 028 adequate attitude and 97.7% have W H O G l o b a l O r a l H e a l t h 1087. moderately adequate attitude. These Programme. Community Dent Oral 14. Johnson NW. The role of the dental findings are consistent with results of Epidemiology 2003:31 (suppl.1):3- team in tobacco cessation. Eur J Dnet Vanobbergen et al[18]. This result 23. Educ 2004:8(suppl 4):18-24. suggests that there is room for 2. Petersen PE. Tobacco and oral health- 15. Carr AB, Ebbert JO. Interventions for improvement in their attitude towards the role of the World Health tobacco cessation in the dental tobacco cessation Organization. Oral Health Preventive setting. Cochrane Database Syst Rev The findings of this study suggest that Dent 2003:1:309-315. 2006:1:CD005084. there is variation in dental students’ 3. Reibel J. Tobacco and oral diseases. 16. B e r n a r d R o s n e r ( 2 0 0 0 ) , attitudes toward tobacco cessation Update on the evidence, with Fundamentals of Biostatistics, 5th promotion. If the goal of tobacco recommendations. Med Princ Pract Edition, Duxbury. cessation curricula is to influence 2003:12(suppl.1) 22-32. 17. M.Venkataswamy Reddy (2002), students’ future clinical practice 4. Little J, Cardy A, Munger RG. Statistics for Mental Health Care behaviors—to produce practitioners who Tobacco smoking and oral clefts: a Research, NIMHANS publication, incorporate tobacco cessation promotion meta-analysis. Bull World Health INDIA. as a routine component of dental Organ 2004:82:213-218. 18. Vanobbergen.j et al Dental student’s practice—then instructors must 5. Murti PR, Gupta PC, Bhonsle RB, et attitude towards anti-smoking understand where students are starting al. Smokeless tobacco use in India: programmes: a study in Flanders, from, Attitudes, concerns, and effects on . In: Stotts RC, Belgium. Eur J Dent Educ 2007; 11: reservations must be acknowledged and Schroeder KL, Burns DM (editors). 177-183. addressed. It may be tempting to ignore Smokeless tobacco or health. 19. D r . M i h i r N . S h a h H e a l t h student resistance to a topic and simply Bethesda, Maryland: National Professionals in Tobacco Control: present the facts to be memorized. Institutes of Health (NCI), NIH Evidence from Global Health However, if tobacco cessation curricula Publication No. 92-3461, 1992: 51- Professional Survey (GHPS) of are presented without acknowledgment 65. Dental students in India, 2005. A of students’ attitudes, beliefs, 6. Jayant K, Notani P. Epidemiology of reportprepared for World Health reservations, and concerns, it is likely oral cancer. In: Rao RS, Desai PB Organization (WHO) South-East that students will listen quietly but then (eds). Oral cancer. Bombay, India: Asia Region Office (SEARO) New fail to incorporate tobacco cessation Tata Memorial Centre, 1991. Delhi, India. promotion as a part of their future clinical 7. Yip JK, Hay JL, OstrofffJS, Stewart 20. Fried JL, Reid BC, DeVore LE. A practice behaviors. RK, Cruz GD, Dental student’s comparison of health professions As suggested in the literature one may attitudes towards smoking cessation student attitudes regarding tobacco need more alternate teaching methods guidelines. JDent Educ 2000:64: 641- curricula and interventionist roles. J such as problem based discussion, 650. Dent Educ. 2004 Mar;68(3):370-7 tutorials, small group discussion and skill 8. Fried JL, Reid BC, DeVore LE. A 21. Victoroff Kristin.Z et al Attitude of laboratories to improve the awareness, comparison of health professions incoming dental students towards belief and skills of dental students, students attitudes regarding tobacco tobacco cessation promotion in the especially in this matter, in which attitude curricula and interventionist roles.J dental setting. Journal of Dental play a significant role. In this way, Dent Educ 2004:68:370-377. Education. May 2004. opportunities for developing awareness 9. Victoroff KZ, Dankulich- huryn T, 22. Nuytens P, Vanobbergen Jet al Dental of one’s own beliefs and attitudes, as well Haque S. Attitudes of incoming student’s attitude towards anti- as opportunities to hear other points of dental students toward tobacco smoking programmes: a study in view and approaches through discussion cessation promotion in the dental Flanders, Belgium. Eur J Dent Educ with peers and faculty, can be provided. setting. J Dent Educ 2004:68:563- 2007; 11: 177-183. A formal evaluation of the curriculum is 568. 23. Rikard-Bell G, Groenlund C, Ward J. necessary so that a comprehensive 10. Rikard-Bell G, Groenlund C, Ward J. Australian dental students' views tobacco prevention and cessation Australian dental student’s views about smoking cessation counseling program can be developed and about smoking cessation counselling and their skills as counselors. J Public implemented. Horowitz and Ogwell[25] and their skills as counselors. J Public H e a l t h D e n t . 2 0 0 3 have identified a research agenda that Health Dent 2003:63:200-206. Summer;63(3):200-6. incorporates both didactic instruction on 11. Polychonopoulou A, Gatou T, 24. Polychonopoulou A, Gatou T, how tobacco use influences oral health, Athanassouli T, Greek dental Athanassouli T. Greek dental and clinical training in tobacco use student’s attitude toward tobacco students' attitudes toward tobacco interventions. This approach, combined control programmes. Int Dent J control programmes.Int Dent J. 2004 with a dental school requirement that all 2004:54; 119-125. Jun;54(3):119 25. students must provide cessation advice 12. Lancaster T, Silagy C, Fowler G. 25. Horowitz AM, Ogwell EO. Where to for tobacco users and that all students Training health professionals in from here? Journal Dental Education must be competent in doing so, would smoking cessation. Cochran 2002; 66: 1099-01. likely enhance these practices. Database Syst Rev 2003: 3: 26. Furukawa sayaka, Tokunaga ryo et al Cd000214. Dental students' smoking behavior References 13. Warnakulasuriya S. Effectiveness of and their attitude towards smoking. 1. Peterson PE. The world oral health tobacco counselling in the dental Journal of the Stomatological r e p o r t 2 0 0 3 : C o n t i n u o u s office. J Dent Educ 2002: 66:1079- Society, Japan 2005.72;(3);201-208. improvement of oral Health in the 21st century- The approach of the Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 029 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

A Comparative Evaluation Of Shear Bond 1 Sonia Arora 2 Suman Yadav Strengths Of Composite To Dentin, Using 3 Harish Yadav 4 Sumeet Sharma Total Etch And Self Etch Dentin Bonding 1 Senior Lecturer 2 Professor & Hod Agents - An In Vitro Study Dept. Of Conservative Dentistry & Endodontics 3 Principal & Hod, Dept. Of Prosthodontics S.G.T. Dental College, Abstract Hospital & Research Institute, Gurgaon, Haryana Objectives: The purpose of this in-vitro study was to comparatively evaluate the shear bond 4 Professor & Hod, strength of newer dentin bonding agents i.e. two-step etch & rinse adhesives i.e. Prime & Bond Dept. Of Conservative Dentistry & Endodontics NT and one-step self etching agents i.e. G Bond, Xeno V & two step self-etching adhesive i.e. Idst Modinagar Adper SE Plus. Address For Correspondence: Materials and Methods: Eighty freshly extracted non-carious intact human molars were ground Dr. Sonia Arora B-503, Swami Dayanand Apartments, flat, exposing the dentin surface. They were randomly divided into four groups according to Plot No. 5, Sector 6, Dwarka, New Delhi-110075 adhesive system used (n=10/group), namely group I-prime & bond NT, group II-Xeno V, group III- Submission : 19th January 2013 Adper SE Plus and group IV-G Bond. Each group was treated with its respective bonding agents, Accepted : 9th August 2014 as per the manufacturers’ instructions. Cylinders of composite resin were built up using Teflon mould and cured. Specimens were stored in distilled water (37I0;C, 24 hours) and then Quick Response Code thermocycling was carried out. Shear bond strengths were tested using Instron machine (cross- head speed of 1 mm/min) and recorded in MPa. The results were statistically analyzed using One-way Anova and Tukeys HSD Test. Results: The Mean Shear bond strength values (MPa) for the groups I, II, III and IV were 23.48; 22.08; 19.97 and 17.35 respectively. Group I (Total etch adhesive) exhibited a significantly higher value than all other groups (Self etch adhesives) (p<0.005), whereas Group IV had the lowest value. Conclusions: Within the limitations of this in vitro study, it can be concluded that all the adhesives agents evaluated showed optimal shear bond strength of 17-20 MPa. However, the tooth substrate are accomplished or results demonstrated the capacity of traditional etch & rinse adhesive to outperform the self-etch adhesives. simplified. Two step systems are sub- Key Words divided into the self priming adhesives Dental students, attitude, tobacco cessation, counseling that require a separate etching step, and the self etching primers that require an Introduction whereas bonding to dentin represents a additional bonding step. The recently Restorative Dentistry has irrevocably greater challenge and has proved to be introduced all in one adhesives further entered a revolutionary era of aesthetic more difficult and less predictable. combined these three bonding restorative materials. Patients’ demand Difficulties in bonding to dentin are a procedures into a single step for aesthetic restorations & the search for result of inherent characteristics of this application[5]. filling materials that can provide long- substrate (Perdiago, 2002; Lopes et al, The current concept has proved itself term stability are leading to development 2002; Perdiago, Lopes, 1999)[4]. While both scientifically and clinically .The of new products in adhesive dentistry at enamel is 92% inorganic hydroxyapatite concept reduces the clinical steps, can be an unprecedented rate[1]. by volume, dentin is about 45% inorganic placed inexpensively, provides adequate The foundation of modern adhesive & the rest being organic & water. bonding to enamel and dentin and most dentistry was laid in 1955 when To counteract these problems constant importantly, ensures the patients post Buonocore reported that acids could be active research in the field of adhesive operative comfort[6]. used to alter the surface of enamel to dentistry has resulted in the rapid The purpose of this in-vitro study was to render it more receptive to adhesion[2]. evolution of dental adhesive systems comparatively evaluate the shear bond Acid etching of the enamel with through several generations with changes strength of these newer dentin bonding phosphoric acid produced micro in chemistry, mechanisms, number of agents i.e. two-step etch & rinse porosities in the enamel allowing resin bottles, application techniques & clinical adhesives i.e. Prime & Bond NT and one- bonding via micro-mechanical effectiveness. step self etching agents i.e. G Bond, Xeno retention[3]. Adhesive dentistry involves two V & two step self-etching adhesive i.e. Acid etching of the enamel gave way to methods: the total-etch bonding Adper SE Plus. total etch techniques, in which both the technique & Self-etching systems[4]. enamel and dentin surfaces are acid Dentin Adhesives are currently available Materials and Method conditioned to allow for resin adherence as two step, and single step systems Materials used in the study: (Figure 1) to both enamel and dentin surfaces[3]. depending on how the three cardinal Dentin Bonding Agents used: Bonding to enamel is more reliable steps of etching, priming and bonding to

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 030 Materials used in the study: (Figure 1) Dentin Bonding Agents used: Bonding Agent Manufacturer Type Composition Di- and Trimethacrylate resins PENTA (dipentaerythritol penta acrylate monophosphate) Nanofillers-Amorphous Silicon Dioxide Prime & Bond NT Dentsply Caulk Total-etch Photoinitiators Stabilizers Cetylamine hydrofluoride Acetone Bifunctional acrylate Acidic acrylate Figure 1: Materials used for specimen preparation Functionalized phosphoric acid ester Bonding Agents A : 37% phosphoric acid and Prime & Bond NT Xeno V Dentsply Caulk One-step self-etch Acrylic acid B : Xeno V Water C : Adper SE Plus D : G-Bond Tertiary butanol Composite Material Initiator E : Filtek Z350 XT Stabilizer Liquid A: Water HEMA Surfactant Pink colorant

Adper SE Plus 3M ESPE Two-step self-etch Liquid B: UDMA TEGDMA Figure 2: Chrome Plated Steel mould for mounting of tooth specimen TMPTMA (hydrophobic trimethacrylate) resin was poured in the moulds to embed HEMA phosphates the prepared tooth, exposing the crown MHP (methacrylated phosphates) portion of the tooth (Figure 2). The Bonded zirconia nanofiller prepared specimens were then randomly divided into four groups, based on dentin Initiator system based on camphorquinone. bonding agent used, with twenty Acetone, specimens in each group, namely: 4-META Group I – for Prime & Bond NT (4-Methacryloxyethyltrimellitate anhydride), Group II – for Xeno V UDMA (Urethane dimethacrylate), Group III – for Adper SE Plus G Bond GC One-step self-etch Phosphate monomer, Group IV – for G Bond TEGDMA (Triethyleneglycol dimethacrylate), The mounted teeth were then stored in normal saline at room temperature. Water, Fumed silica fillers, Application of bonding agent and Photoinitiator. composite build up:- Operative Procedure specimen teeth were utilized for this Bonding agent (Prime&Bond NT, G Sample collection, cleaning and storage: study within six months of extraction as Bond, Xeno V, and Adper SE Plus) was Eighty freshly extracted non-carious per ISO standards (G. Oilo, 1993). applied on the flat dentinal surface of intact human molars were selected for Preparation and grouping of the each mounted tooth of all the four groups this study. Teeth with restorations, specimens for shear bond strength: according to the manufacturers’ cracks, attrition and other structural To standardize depth of cavity, depth instructions. defects were excluded. After extraction holes were drilled in the deepest part of The split-teflon mould was placed over all the teeth collected were cleaned of central fossa of each tooth. The occlusal the bonded surface at the pre-designed blood and saliva in running water. surfaces of all the teeth were ground on location in the mould holder. Filtek Z350 Calculus was removed with the help of a water-cooled orthodontic trimmer to XT (3M ESPE) was placed in increments scaler followed by thorough cleaning obtain a flat dentinal surface. into the circular punch hole measuring 3 with pumice slurry and rubber Steel moulds of dimension 2.1 x 2.1 cm mm × 3 mm in a Teflon sheet and cured prophylaxis cup. The teeth were then were placed in position over the teeth. A layer by layer for 20 seconds with stored in normal saline solution. These thin mix of auto-polymerizing acrylic SmartLite PS (Dentsply) (intensity >500 mW/cm2) (Figure 3 a and b).

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 031 Table 1. Shear Bond Strength in Megapascals (Mpa) adapted in them, were adjusted vertically No Of Samples Group I Group II Group III Group IV in the inferior (static) jaw of the 1 23.451 20.988 19.56 16.543 Universal Testing Machine. The 2 24.82 21.84 20.564 16.78 placement of the specimen in the steel 3 22.495 21.302 20.86 17.432 mould was such that the composite build up stood parallel to the floor. A key with 4 21.224 22.754 19.53 17.34 dimensions same as that of the composite 5 20.95 22.75 15.534 17.783 cylinder (3 mm x 3 mm), gripped in the 6 24.56 24.657 20.34 18.534 superior jaw of the Instron machine, was 7 22.875 23.785 20.763 16.32 adapted on to the composite build up. The Figure 3 a: Chrome plated steel mold holder and Split Teflon 8 23.65 22.95 20.546 19.76 shear force was then applied at the resin- mould used in shear bond strength study 9 23.657 22.454 21.56 17.65 dentin interface until the dislodgement of 10 24.886 20.77 20.432 16.432 the composite cylinder from the dentinal 11 26.785 24.758 17.765 17.543 surface occurred (Figure 4). The results of all four groups were then 12 27.544 21.65 20.645 18.543 statistically analysed using SPSS 10 13 23.896 20.836 21.556 17.324 software for one-way ANOVA tests 14 22.876 21.67 23.56 18.34 followed by Tukeys HSD test to 15 21.757 22.67 16.9 17.324 determine if significant differences 16 23.864 21.849 20.34 16.742 existed between the groups. 17 24.1 20.64 19.564 19.43 18 21.85 21.784 20.61 17.542 Results Figure 3 b: Chrome plated steel mold holder and Split Teflon Shear bond strengths (MPa) of each 19 22.675 22.39 18.56 15.5 mould with tooth specimen in place for composite build-up specimen of all four groups were 20 24.3 20.76 19.654 14.762 obtained (Table 1), and then put to AVG (MPa) 23.47943 22.0799 19.9709 17.35071 statistical analysis. SD 1.692879 1.217825 1.666203 1.155526 The results revealed that samples of Table 2: Mean and standard deviation values for shear bond Group I (Prime & Bond NT) had the strength maximum shear bond strength (23.479 Value N Mean Std. deviation Minimum Maximum MPa). Group I 20 23.479 1.692 20.853 24.886 Strength decreasing order: Group I > Group II 20 22.079 1.217 20.421 24.758 Group II > Group III > Group IV Group III 20 19.970 1.666 17.765 23.56 When a comparison of the shear bond Group IV 20 17.350 1.155 14.762 19.76 strength of total etch and newer self etch F = 8.1968, P < 0.005 vhs adhesives was made using one-way Table 3: Intergroup comparison of shear bond strength ANOVA, it showed high statistically values significant results. (Table 2) Groups Mean difference t p p < 0.005. So our experimental results Group I Group II 1.399 3.609 .005 vhs will give 0.05% error or 95% confident Group I Group III 3.508 8.673 .005 vhs level at significance level. Hence, multigroup comparison was done using Group I Group IV 6.128 12.452 .005 vhs Tukeys HSD Test. Group II Group III 2.109 4.927 .005 vhs The shear bond strength values of the Group II Group IV 4.729 10.451 .005 vhs control group Prime & Bond NT (Group Group III Group IV 2.620 5.748 .005 vhs I) showed the highest mean bond strength values compared to the experimental Shear bond strength testing:- Figure 4: Specimens positioned in INSTRON for shear groups of self etch adhesives (Group II, Specimens were then mounted on a testing. Group III and Group IV). Intergroup Universal Testing Machine in the Once the composite was cured, the split comparison was done between the Department of Textile Engineering, teflon mould was gently lifted out and adhesives using Tukey HSD test. The Indian Institute of Technology (IIT), specimens were obtained. shear bond strength values of Group I Delhi and loaded until resin-dentin (Prime & Bond NT) versus Group II interface fractured. The machine was Thermocycling of the specimens:- (Xeno V), Group III (Adper SE Plus), adjusted to operate on a load of 100 Kgs. Specimens were then stored in distilled Group IV (G-Bond), and showed high A cross-head speed of 1 mm/minute was water at 37I0;C for 24 hours. The significance level. This indicated that the used and the breaking load was measured thermocycling of specimens of each total etch adhesives have better bonding by recording the reading on the display group was carried out in accordance with ability as compared to the newer self panel of the machine. The breaking load the ISO standards that are 500 cycles at etching adhesives. (Table 3) in kilograms was then converted into 5ºC and 55ºC, dwell time of 30 seconds Intercomparison was done between the bond strength in megapascals. and transfer time of 15 seconds (G.Oilo, self etch adhesives using Tukeys HSD For shear bond strength testing, the steel 1993). test. Comparison between Group II moulds with the prepared specimens (Xeno V) and Group III (Adper SE Plus)

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 032 to modify and infiltrate the smear layer III) and one-step self-etch adhesive with resin, while the other is based on a systems Xeno V (Group II) and G-Bond so-called hybridization process in which (Group IV), achieved the optimal bond complete removal of the smear layer and strength values for dentin. However, the concurrent demineralization of the dentin total etch system Prime & Bond NT surface layer, followed by resin showed better bond strength compared to interdiffusion into the microporosities of the self etching adhesives - Xeno V, the exposed dentinal collagen matrix [9]. Adper SE Plus and G-Bond. Shear type of test is the most commonly This result was in accordance with used methods as described by the ISO Bouillaguet et al, Chuang et al, Kerby et Standards [10]. Barkmeier and Cooley al who concluded that self etching Figure 5. Bar Diagram Showing Comparison of Mean Shear (1992) said that the shear bond strength adhesives have lower bond strength as Bond Strengths in MPa of various Study Groups test is a simple evaluation procedure used compared to total etch bonding systems also showed statistical significant to test the adhesion of dental adhesives. [18], [19], [20]. Senawongse et al also difference (p<0.05) indicating that one- In vitro bond strength tests are useful and demonstrated that 2 self etching systems, step self etch adhesive Xeno V is a better essential for predicting the performance One – up bond and Clearfil SE bond, had dentin bonding agent than two-step self of adhesive systems and have a lower bond strength than did the total etch adhesive Adper SE Plus. correlation with clinical issues [4],[11]. etch system Single bond.[14] According Comparison of Group II (Xeno V) with The present in-vitro study compared in to Hashimato et al, self etch adhesives Group IV (G-Bond), which are both one- vitro shear bond strength of the 5th produced thinner and shorter resin tags step self-etch adhesives, showed high generation total-etch dentin adhesive than those produced by phosphoric acid statistically significant difference Prime and Bond NT with newer self-etch etching and thus resulted in inferior bond inferring that Xeno V had comparatively bonding systems Adper SE Plus, Xeno V, strength as compared to total etch higher bond strength to dentin. and G bond. adhesive systems.[20], [21] When intergroup comparison was done Thermal cycling allows bonded The highest shear bond strength of Prime between Group III and Group IV using specimens to be subjected to extreme & Bond NT (Group I) when compared Tukeys HSD test, the results proved to be temperatures, which mimic intraoral with the various other dentin bonding significant statistically, showing that temperature variations (M Miya Zaki et agents used (Group II, Group III & Group Adper SE Plus had better bond strength al, 2000)[12]. So in the present study, IV) can be explained by the fact that than G bond. thermocycling of specimens of each PENTA in Prime & Bond NT is a Conclusion: Among these four groups, group was carried out in accordance with molecule of mild acidity that behaves as a Group I had highest shear bond strength the ISO standards i.e. 500 cycles at 5ºC conditioning agent (Perdigao et al, (Avg 23.48 MPa), and Group IV had and 55ºC, dwell time of 30 seconds and 1994)[22]. PENTA is claimed to bond minimum shear bond strength (Avg transfer time of 15 seconds[13]. ionically to dentinal calcium [22] and is 17.35 MPa) (Figure 5). Shear bond strength testing was done an adhesion promoter that facilitates the with a Universal Testing Machine, penetration of resin monomer into the Discussion Instron, (Instron - UTM, Model 4202). dentin for micromechanical bonding. Ever since the introduction of dental Instron machine is conventionally UDMA in Prime & Bond NT is a composite resins by Bowen (1962) and popular for evaluating the adhesive hydrophobic monomer for proper the concept of retention using acid ability of adhesive /restorative materials. polymerization and cross linking and etching by Buonocore (1955), there has With the simple technique and relevant bonds to surface-bound hydroxyl groups been extensive addition to their plethora results it is considered a benefit for through its urethane groups (Andre V. of applications. Dental composites with ranking and marketing purposes[14], Ritter et al, 2000)[23]. This could have dentine adhesive systems are currently [15]. So in the present study, the machine resulted in better penetration through the most popular materials for was adjusted to operate on a load range of smear layer and improved contact of restorations. 0-100 kilograms. ISO recommended monomer within the exposed collagen Over the last three decades, numerous values of cross-head speed i.e. 0.45-1.05 fibres, resulting in a homogenous dentin adhesive systems have been m m / m i n u t e w e r e t a k e n i n t o interface with no voids and hence, better released in the market, all claiming their consideration and 1 mm/minute cross bonding. own specific adhesion strategy. head speed was used. According to the present study self etch Clinicians are faced with many Kiremitci A. et al (2004) postulated that adhesives showed lower bond strength as challenges when selecting a dental minimum bond strength of 17-20 MPA to compared to total etch bonding systems. adhesive system to bond resin-based enamel and dentin is needed to resist Self etching adhesives provide lower materials to mineralized tooth structure. contraction forces of resin composite bond strength than total etch systems The current trend in adhesive dentistry is materials [16]. Clinical experiences because of their semi permeability, focused on using systems that are simple confirm this bond strength is sufficient incorporation of smear layer, shorter to use and have minimal chair-side for successful retention of resin resin tag formation, residual acidity and time[7]. restoration.[17] h y d r o l y t i c i n s t a b i l i t y [ 2 4 ] . T h e Modern dentin adhesive systems All adhesive systems used in this present phosphoric acid etching and water generally use one of two adhesion study - total etch adhesive Prime & Bond rinsing in total-etch to remove dissolved strategies based on method of dealing NT (Group I); two-step self-etch calcium phosphate would prevent with the smear layer [8]. One strategy is adhesive system Adper SE Plus (Group entrapment of this residue within the

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 033 bonding resin layer which might provide strong adhesion. It is also separation[33] that is, it helps to mix otherwise interfere with resin penetration s u g g e s t e d t h a t t h e r e s i d u a l h y d r o p h o b i c a n d h y d r o p h i l i c as seen in self etching adhesives[25]. hydroxyapatite at the hybrid layer base components into one single solution, as Self etching adhesive systems rely on may still allow for chemical well as it serves as a co-solvent to acidic monomers to simultaneously intermolecular interaction.[29] dissolve the diverse active ingredients demineralize and infiltrate enamel and The self etching systems which were into water . Self-etch adhesives need dentin. This acidity must be neutralized tested in different studies showed water for providing an ionization by the mineral content of the tooth significant differences in performance in medium to enable self-etching [33]. On s t r u c t u r e t o a l l o w c o m p l e t e terms of bond strength. These differences the other hand, HEMA lowers the vapor polymerization of the adhesive film [26]. could be attributed to the efficiency of pressure of water when added to a water With total-etch adhesive, smear layer and their respective monomers at infiltrating mixture, making it more difficult to dissolved mineral are removed during the the smear layers and producing resin remove water from the adhesive and rinsing step. But because of some tags.[18], [31] retaining water within the adhesive questions regarding residual acidity of Two-step self-etch system, showed a layer[34]. So, HEMA being hydrophilic the self-etch adhesives, and the fact that superior in vitro performance in holds water within the adhesive layer, the smear layer is not removed, the issue comparison with one-step self-etch thereby hindering the polymerization of long term hydrolytic stability of the systems [2]. Adper SE Plus (Group III) process and thus be detrimental to the self etching adhesive systems still which is two step self etching adhesive bond on the long term. It promotes water remains unresolved [3], [27]. Further the resulted in higher shear bond strength to be bonded in unstable soft hydrogels presence of smear layer in self-etch than other self etch adhesive i.e. G-Bond prone to hydrolytic degradation [33]. It adhesives could have inhibited the (Group IV), even though it showed low even enhances water uptake from the penetration of the primer/resin into bond strength compared to Xeno V tooth as well as the outer oral collagen fibres[28]. (Group II) (p<0.05). Achievement of environment, rendering the bond more However, Kiremitci et al (2004) strong micromechanical bonding prone to degradation with time [5], [27] concluded that self etching adhesive depends on the depth of monomer Hence, HEMA free single step self etch system produced higher bond strength penetration into demineralized dentin adhesives were developed (G-Bond). than conventional total etch systems, (Erikson, 1992). The superior bonding of In accordance with the results of the especially all in one system which Adper SE Plus can be attributed to this present study, the lowest shear bond produced the highest bond strength.[17] two-step procedure for dentin bonding strength was obtained by the self etching Whereas, Sensi et al (2005) have asserted wherein first step prepares and conditions HEMA free adhesive G-bond (Group that self etch and total etch primer the tooth surface leading to more depth of IV). The consequence of the HEMA-free showed comparable dentin bond penetration and in a way mimics total formulation of G-Bondis that upon strength.[4] etch technique but with a different evaporation of the acetone solvent (once Among the self etching adhesive systems mechanism. The second step produces supplied within the cavity), the adhesive tested, Xeno V (Group II) showed the identical depths of etching and monomers separate from the water highest bond strength compared to all penetration of the adhesive. Nanoleakage content (Van Landuyt et al., 2005). other experimental groups i.e. G-Bond resulting from an insufficient penetration Following this phase separation, water (Group IV) and Adper SE Plus (Group depth of the adhesive can be minimized droplets are formed within the adhesive III) and the results came out to be by this mechanism. In addition, this layer. The convergence of small blisters statistically significant (p<0.05). keeps the collagen fibers from collapsing into larger ones tends to produce “Strong” self-etch adhesives usually and eliminates dependence on “moist honeycomb structures that may have a pH of 1 or below. This high acidity bonding” characteristic of the 5th jeopardize the bonded interface [27], results in rather deep demineralization generation systems. The adhesive part of [33].This could be the probable reason effects. At enamel, the resulting acid etch Adper SE Plus Self-Etch Adhesive for the lowest shear bond strength of G- pattern resembles a phosphoric-acid contains phosphoric acid esters, which Bond in the present study. Moreover, G- treatment following an etch & rinse under aqueous conditions will etch the Bond contains 4-methacryloxyethyl approach. At dentin, collagen is exposed surfaces of dentin and enamel to allow for trimellitic acid (4-META) which has a and nearly all hydroxyapatite crystals are the micromechanical bonding to the weaker bonding potential (Yoshida Y. et dissolved (B. Van Meerbeek et al, tooth. Adper™ SE Plus Self-Etch al, 2004) [35]. 2003).[24], [29] Adhesive contains a bonded zirconia Of all the adhesive system tested, the The good bond strength values obtained nanofiller which helps to develop a total-etch Prime & Bond NT provided a with Xeno V, which is an intermediately uniform film, which in turn can lead to highest shear bond strength and among strong self etch adhesive, has been higher bond strengths [32]. the self etching adhesives Xeno V attributed to its acidic pH of 1.4. This Single bottle adhesives are complex showed the highest bond strength acidic nature results in better mixtures of hydrophilic and hydrophobic compared to all other experimental micromechanical interlocking to enamel resin monomers dissolved in water / groups. and dentin compared to mild self etch solvent combinations. Most single step Within the limitations of this in-vitro adhesives [30]. Low pH ensures etching self etch adhesives contain hydroxyethyl study it can be concluded that all the through thick smear layers to engage methacrylate (HEMA), hydrophilic adhesive agents evaluated showed underlying intact dentin to form thin primer, and the presence of HEMA is optimal shear bond strength. However, zones of demineralization that are advisable for maintaining resins in total etch adhesives recorded a higher simultaneously infiltrated by resinsto solution and preventing phase shear bond strength than the newer self

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 034 etching bonding agents. But the existing 262. 17. Kiremitci A, Yalcin F, Gokalp S self-etch adhesives are popular because 4. Sensi LG, Lopes GC, Monterio S, (2004) Bonding to enamel and dentin they are easy to handle, convenient, and Baratieri Jr. LN, Vieira LCC (2005) using self–etching adhesive systems. less confusing for the clinician than the Dentin bond strength of self-etching Quint Int. 35: 367-370. multistep adhesive systems and also as primers/adhesives. Oper Dent. 30-1: 18. Bouillaguet S, Gysi P, Wataha J.C, their bond strength lies in the optimal 63-68. Ciucchi B, Cattani M, Godin C, range for clinical success [36]. 5. Tay F, Pashley D, Suh B, Carvalho R, Meyer J.M (2001) Bond Strength of Even though dental adhesives have been Itthagarun A (2002) Single step composite to dentine using available over several generations with adhesives are Permeable membranes. conventional, one step, and self an array of new materials being launched J Dent. 30: 371-382. etching adhesive systems. J Dent. 29: every year, clinical studies are not 6. Christensen Gordon. J (2001) Self 55-61. abundant in the literature. There has been –etching primers are here. J Am Dent 19. Kerby RE, Knobloch LA, Clelland N, frequent practice among manufacturers Assoc. 132: 1042-1043. L i l l e y H , S e g h i R ( 2 0 0 5 ) to launch a new version of a specific 7. Kimmes NS, Barkmeier WW, Microtensile Bond Strengths of One- adhesive even before the previous one Erickson RL, Latta MA (2010) step and Self–etching Adhesive has been fully tested. As a result of all Adhesive bond strengths to enamel Systems. Oper Dent. 30(2): 195-200. these limitations, clinicians still rely on and dentin using recommended and 20. Chuang S, Chang L, Chang C, Yaman data from laboratory studies to predict the extended treatment times. Oper Dent. P, Liu J (2006) Influence of enamel behaviour of adhesive materials. Hence, 35(1): 112-119. wetness on Composite restorations since the materials that were used in the 8. Meerbeek BV, Inokoshi S, Braem M, using various dentin bonding agents; present study were relatively new, further et al (1992) Morphological aspect of Part 2 – effects on shear bond studies need to be done for further the resin dentin interdiffusion zone strength. J Dent. 34:352-361. clinical evaluation. with different dentin adhesive 21. Ogata M, Okuda M, Nakajima M, systems. J Dent Res 71: 1530 – 1540. Pereira P, Sano H, Tagami J (2001) Conclusion 9. Nakabayashi N, Pashley DH (1998) Influence of the direction of tubules Within the limitations of this in vitro Hybridization of dental hard tissues on bond strength to dentin. Oper study, it can be concluded that all the Quintessence publishers. Tokyo. Dent. 26: 27-35. adhesives agents evaluated showed 10. Oilo G (1993) Bond strength testing – 22. Turgut M.D, Tekcicek M, Olmez S optimal shear bond strength of 17-20 What does it mean? International (2004) Clinical evaluation of a MPa. However, the one bottle total-etch dental Journal 43(5): 492-498. polyacid-modified resin composited adhesive Prime & Bond NT recorded 11. Mason P, Ferrari M, Cagidiaco C, under different conditioning methods higher shear bond strength than the newer Davidson C (1996) Shear bond in primary teeth. Oper Dent. 29(5): self etch bonding agents. In this study, it strength of four dentin bond 515-523. was seen that among the self etch adhesives applied in vivo and in vitro. 23. Ritter A.V, Heymann H.O, Swift Jr adhesives, Xeno V showed the highest J Dent. 24(3): 217-222. E.J, Perdigao J, Rosa B.T (2000) shear bond strength and G-Bond showed 12. Nikaido T, Kunzelmann K.H, Chen Effects of different re-wetting the lowest shear bond strength. H, Ogata M et al (2002) Evaluation of techniques on dentin shear bond Therefore, this in-vitro study concluded thermal cycling and mechanical strengths. J. Esthet Dent. 12: 85-96. that shear bond strengths of dentin loading on bond strength of a self- 24. Norbert Moszner, Ulrich salz, Jorg bonding agents with old concept of two- etching primer system to dentin. Dent zimmermann (2005) Chemical step total-etch technique are superior to Mater. 18(3): 269-275. aspects of self- etching enamel-dentin that of newer self-etch systems, although 13. International Organization for adhesives: A systematic review. their bond strength values also lies within Standardization (1994) ISO TR Dental materials 21: 895-910. the acceptable range of clinical 11405; Dental materials – guidance 25. Tate W.H, You C, Powers J.M (2000) requirements. on testing of adhesion to tooth Bond strength of compomers to structure Geneve: International human enamel. Oper Dent. 25: 283- References Organization for Standardization. 291. 1. Luhrs A-K, Guhr S, Schilke R, 14. Senawongse P, Sattabanasuk V, 26. Riekurokawoa, Werner J, Finger B, Borchers L, Geurtsen W, Gunay H Shinada Y, Otsuki M, Tagami J (2004) Marcus Hoffmann C (2007) (2008) Shear bond strength of self- Bond strengths of current adhesive Interactions of self-etch adhesives etch adhesives to enamel with systems on intact and ground enamel. with resin composites. J Dent. 35: additional phosphoric acid etching. J Esthet Restor Dent. 16(2): 107-116. 923-929. Oper Dent. 33-2: 155-162. 15. Mithra N Hegde, Shruti Bhandary 27. Salz U, Zimmermann J, Zeuner F, 2. Chopra V, Sharma H, Prasad S. Datta ( 2 0 0 8 ) A n e v a l u a t i o n a n d Moszner N (2005) Hydrolytic (2009) A comparative evaluation of comparision of shear bond strength of stability of self-etching adhesive the bonding efficacy of to-step vs all- composite resin to dentin, using systems. J Adhes Dent. 7: 107-16. in-one bonding agents – An in-vitro newer dentin bonding agents. J 28. Pashley DH, Carvalho RM (1997) study. J Conserv Dent 12: 101-104. Conserv Dent 11(2): 71-75. Dentin permeability and dentin 3. Naughton W, Latta M (2005) Bond 16. Retief D, Mandras R, Russell C adhesion. J Dent. 25: 355-372. Strength of Composite to Dentin (1994) Shear bond strength required 29. Meeerbeek Van B, De Munck J, Using Self Etching Adhesive to prevent microleakage at the dentin- Yoshida Y, Inoue S. Vargas M, Vijay Systems .Quintessence Int. 36: 259- resin interface. Am J Dent 7: 43-46. P, Van K. Landuyt, Lambrechts P,

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 035 Vanherle G (2003) Buonocore strengths between resin and dentine. J Nakayama Y, Okazaki M, Shintani H, Memorial Lecture Adhesion to Dent. 27: 265-74. Inoue S, Tagawa Y, Suzuki K, Munck Enamel and Dentin: Current Status 32. 3M ESPE Adper SE Plus Self-etch J. De and Meerbeek B.V (2004) and Future Challenges. Oper Dent. Adhesive. Product Guide. Comparative Study on Adhesive 28(3): 215-235. 33. Monticelli F, Osorio R, Proemca J, P e r f o r m a n c e o f F u n c t i o n a l 30. Meerbeek B V, Conn LJ. Jr, Duke ES, Toledano N (2007) Resistance to Monomers. J Den Res.83(6): 454- Eick JD, Robinson SJ, Gueerero D degradation of resin-dentin bonds 458. (1996) Correlative transmission using a one step HEMA – free 36. Lopes G, Baratieri L, Andrada C, electron microscopy examination of adhesive. J Dent. 35: 181-186. Vieira C (2002) Dental adhesion: non demineralized and demineralized 34. Hiraishi N, Breschi L, Prati C, Ferrai present state of the art and future resin-dentin inferfaces formed by two M, Tagami J, King N (2007) p e r s p e c t i v e s . Q u i n t e s s e n c e dentin adhesive system. J Dent Res. Technique sensitivity Associated International33:213-224. 75: 879 – 888. with air drying of HEMA-Free, single 31. Prukkanon S, Burrow MF, Tyas MJ bottle, once step self etch adhesive. (1999) The effect of dentine location Dent Mater. 23: 498-505. and tubule orientation on the bond 35. Yoshida Y, Nagakane K, Fukuda R,

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 036 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

An In Vitro Comparative Evaluation Of The 1 M.Daneswari 2 B. Nandlal Shear Bond Strength At The Glass Ionomer 3 Shalini Kalia 1 Reader , Department Of Pedodontics Cement And Composite Resin Interface Using Mamata Dental College 2 Principal And H.O.D , Department Of Pedodontics 3 Ex-post Graduate , Department Of Oral Medicine Gold Standard Sandwich Technique And J.S.S.University, J.S.S.Dental College Address For Correspondence: Newer Simultaneous Activation Technique Dr. M. Daneswari, Reader Dept. of Pedodontics & Preventive Dentistry Abstract Mamatha Dental College, Aims: The purpose of this study was to evaluate and compare the shear bond strength at the Khammam,Andhra Pradesh. glass ionomer and composite resin interface of this new technique with that of the gold standard Contact No:9441177888 E-Mail ID : [email protected] sandwich technique using conventional and resin modified glass ionomer cement. Submission : 19th January 2013 Methods and Material: Fifty two standardized cylindrical bonded specimens were prepared with th two-part demountable Teflon mould. Based on composite resin (Z100) bonded to conventional Accepted : 9 August 2014 glass ionomer cement (Fuji IX) and resin-modified glass ionomer cement (Vitremer), they were Quick Response Code randomly assigned to two groups as Fuji IX+Z100 and Vitremer+Z100, which were further divided into two subgroups as Set and Etched and Unset and Non-etched. All bonded specimens were stored in distilled water for 24 hours at 370 C before shear bond strength testing. After debonding, the fracture site was carefully evaluated with Stereomicroscope for failure mode analysis. Statistical analysis used: Independent ‘t’ test,One way ANOVA,Two way ANOVA Results: The Unset and Non-etched subgroup of Fuji IX+Z100 group, had higher mean shear bond strength values (7.37±1.01MPa) followed by Set and Etched subgroup (4.60±0.62 MPa).Higher mean shear bond strength values were observed in Set and Etched subgroup (15.10±1.32 MPa) followed by Unset and Non-etched subgroups (12.20±1.22 MPa) in glass ionomer systems which seemed to Vitremer+Z100 group. One way and Two way ANOVA revealed significant difference in mean overcome most of disadvantages of bond strength among subgroups. The fracture modes of both groups showed cohesive and traditional glass ionomer which might be mixed type. Adhesive failures were observed maximum (23%) in the Set and Etched subgroup of material of choice in laminate Fuji IX +Z100 group. Conclusions: The bond strength values obtained in this present study concludes that resin restorations due to their higher modified glass ionomer cement (Vitremer) offered better bond strength than conventional glass mechanical strength and less technique ionomer cements (Fuji IX). sensitive.[12],[13] Key Words In original sandwich technique, after Bond strength; composite resin; glass ionomer cements. insertion of glass ionomer cement in the Introduction degree of elastic deformation during cavity, it is necessary to wait until the The ongoing search for a biologically early stages of setting and hence glass chemical cure or photoactivation of the acceptable material that not only has i o n o m e r c e m e n t s h a v e b e e n material, and then can the acid etching physico-mechanical properties similar to recommended as base material.[5],[6] ,rinsing, and drying be done followed by those of natural tooth tissues, but is In sandwich or double laminate the application of the bonding agent and economical,substituting presumed technique the glass ionomer cement is insertion of composite resin. The toxicity of amalgam has dramatically used as an “underlay” to bonded resin technique is too complex and long for increased.[1],[2] The expanding use of composite which makes use of adhesive children.[14],[15] composite resin, particularly in relation properties and biocompatibility of the Dr G. Knight introduced the concept of to posterior restorations, is being limited glass ionomer cement and the desirable co-curing when he accidentally cured despite constant improvements, presence surface and esthetic appearance of the specimens of light-activated glass of shrinkage from 2.6-7.1% during composite resin.[7],[8],[9]This ionomer and composite resin located polymerization can cause post operative technique is based on principle of together .This new technique eliminates sensitivity due to rupture of adhesion ‘Biomimesis’ allowing the monolithic the number of clinical steps as involved between restoration and cavity wall. [3] reconstruction of a tooth which is most for Gold standard sandwich technique Several dentin bonding agents are being valuable in conservative dentistry, thus reducing technique sensitivity and marketed, yet there are doubts minimizing some clinical problems increasing the efficacy of placement concerning the longevity of the union related to microleakage and secondary procedure.[16] because of hydrolysis of the resin leading c a r i e s . [ 1 0 ] , [ 11 ] A n i m p o r t a n t However, the usefulness of bonding is to marginal leakage and secondary advancement in glass ionomer clear and the current concerns are caries.[4] These contraction stresses are technology that has influenced dentistry centered around what materials, or relieved by using materials with higher is the introduction of resin-modified combination of materials, best serves the needs of particular restorative

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 037 problem.[17]Hence, this present study ionomer cement followed by adhesive All bonded specimens were stored in was conducted in vitro to evaluate and applied using the applicator tip on the distilled water for 24 hours at 370 C compare the shear bond strength at the primed surface and light cured for 10 before shear bond strength testing. The glass ionomer and composite resin seconds prior to placement of composite glass ionomer component of the interface of this new technique with that resin with similar subsequent steps specimen was engaged into a specially of the gold standard sandwich technique involved as above. designed guiding device with the using conventional and resin modified The bonding procedure for Set and composite resin side protruding from test glass ionomer cement. E t c h e d s u b g r o u p s a m p l e s o f assembly. The cutting edge (4mm) of the Vitremer+Z100 group as the mixed glass knife edge shearing chisel was then Subjects And Methods ionomer cement was placed into the first engaged at the glass ionomer –composite The feasibility of bonding composite Teflon mould with cavity of 6mm´4mm resin interface, force applied resin (Z100) to conventional glass with same spatula, properly condensed; perpendicular to the long axis of ionomer (Fuji IX GP) and resin modified surface covered was covered with glass specimen . The equipment was operated glass ionomer (VitremerTM) was slide, light-activated by placing the wand at cross head speed of 0.5mm/min and evaluated by preparing fifty two of curing lamp directly applied against maximum load to debond the specimen specimens with two-part demountable the glass for 40 seconds. The glass slide was recorded in Newton (N).Shear bond Teflon mould .They were assigned into was carefully removed, the exposed glass strength was calculated in Mega Pascals two groups of twenty six each as Fuji ionomer surface was acid etched with (MPa) by the ratio of maximum load in IX+Z100 and Vitremer +Z100 which etchant for 15 seconds,washed,dried,then Newton to the cross-sectional area of the were further subdivided into two primer was applied on the etched surface bonded interface in mm.After subgroups as Set and Etched and Unset ,dried gently for 5 seconds. Subsequently debonding, the fracture site was carefully and Non-etched each consisting of using the applicator tip, Scotchbond evaluated with Stereomicroscope- thirteen samples. Multipurpose adhesive was applied on LEICA WILD M3Z at 40´magnification In the Set and Etched subgroup of Fuji the primed surface and light cured for 10 and were categorized as follows: IX+Z100, the glass ionomer mix was seconds. The second demountable Teflon Adhesion (A): Failure at the glass placed in the 6mm´4mm cylindrical mould with a cylindrical cavity of ionomer - composite resin interface, cavity drilled in the first Teflon mould, 4mm´4mm was centered on the first Cohesion(C): Complete failure within properly condensed, which was covered mould by slipping through the bolts, glass ionomer cement or composite resin, with glass microscope slide and static Composite resin was added on top of the Mixed (M): Combination of Adhesion- load of 500gms applied during its initial specimen, in two increments, thickness cohesive failure. set of 7 minutes. The glass slide was no greater than 2mm to ensure total light carefully removed ensuring smooth glass polymerization. Each increment Results ionomer surface was not pitted. compressed firmly, photo cured for 40 In FujiIX+Z100,the bond strength of The exposed glass ionomer surface was seconds each with TransluxÒlight, from Unset and Non-etched subgroup had acid etched with Scotchbond etchant (3M two diametrically opposite directions. higher value than the Set and Etched Products) for 15 seconds, washed, dried, The samples preparation for Unset and subgroup whereas in Vitremer+Z100 followed by placement of Scotchbond Non-etched subgroup of Vitremer+Z100 group the Set and Etched subgroup had Multipurpose primer then dried gently group in that the mixed glass ionomer mean values significantly higher than for 5 seconds. Scotchbond Multipurpose cement was placed into the first mould, Unset and Non-etched subgroup with adhesive was applied on the primed condensed, but Vitremer cement was not significant ‘t’ value (P<0.001)[Table surface using the applicator tip and light photo-activated and no etching 1].Intergroup comparison, the mean bond cured for 10 seconds. The second performed, primer was applied strength values were higher for Set and demountable Teflon mould with a cavity immediately with applicator tip, dried E t c h e d s u b g r o u p s 4mm´4mm was centered on the first mold gently for 5 seconds followed by ofVitremer+Z100group than compared by slipping through the bolts, secured application of adhesive on the primed to Set and Etched subgroups of Fuji with help of tightening nuts to stabilize surface and light cured for 10 seconds. IX+Z100group [Table 2]. Both One-way the specimens during its setting phase Afterward, composite resin was added on ANOVA and Two-way ANOVA revealed with screw tightened nuts to maintain top of the specimen in two increments, a significant difference in the mean shear assembly intact. Composite resin was photo cured for 40 second each, from two strength values of different groups (P < added on top of the specimen, in two diametrically opposite directions as 0.001) [Table 3,4]. The debonded increments, thickness no greater than followed for above subgroup. The specimens were examined using 2mm to ensure total light polymerization. specimens were allowed to set for 30 Stereomicroscope at 40x magnification Each increment compressed firmly, minutes, and then the parts of jig were revealed the failure types as shown photo cured with TransluxÒlight held detached to remove bonded specimens. [Table 5]. 1.0mm away from the resin surface for 40 seconds each, from two diametrically Table 1. Shear Bond Strength in Megapascals (Mpa) opposite directions. Group (Cement+Z100) Subgroups N Mean ± S.D* MPa Mean difference ‘t’ value df P Value The samples of Unset and Non-etched Fuji IX +Z100 Set and Etched 13 4.60±0.62 2.78 8.46 24 <0.001 subgroup were prepared as similar to Unset and Non-etched 13 7.37±1.01 above subgroup but for the immediate Vitremer +Z100 Set and Etched 13 15.10±1.32 2.89 5.81 24 <0.001 application of Scotchbond Multipurpose primer on the unset and non-etched glass Unset and Non-etched 13 12.20±1.22 N – Number of samples;*Standard Deviation; df – degrees of freedom; P- Probability

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 038 Table 2: Intergroup comparison of shear bond strength using independent samples‘t’ test matrix of glass ionomer mass dissolves, Group (Cement+Z100) Subgroups N Mean ± S.D MPa Mean difference ‘t’ value df P value resulting in a rough and porous surface. Fuji IX+Z100 Set and Etched 13 4.60±0.62 10.50 26.02 24 <0.001 The bonding agent penetrates into the Vitremer+Z100 Set and Etched 13 15.10±1.32 surface irregularities and hardens Fuji IX +Z100 Unset and Non-etched 13 7.37±1.01 4.83 10.99 24 <0.001 resulting in mechanical attachment.The free phosphate phases may increase the Vitremer+Z100 Unset and Non-etched 13 12.20±1.22 polarity of the ionomer, while the N – Number of samples;*Standard Deviation; df – degrees of freedom; P- Probability monomer-bonded phosphate phases may Table 3: Results of One-way ANOVA wait for the setting of material or etch the Source of variation Sum of squares Df Mean square F Sig.(P) bond primarily or secondarily to the glass ionomer surface, which appeared to substrate which preserves the external Between groups 868.21 3 289.40 250.10 <0.001 enhance physical properties of the core of the ionomer at the critical stress- Within groups 55.54 48 1.16 resulting restoration. Reduction in the bearing interface.[23],[25] Total 923.76 51 number of operative steps, without a In Vitremer +Z100 group,the Set and df – degrees of freedom; F- Fisher’s value; P- Probability consequent decrease in the acceptability Etched subgroup had higher values than Table 4: Results of Two-way ANOVA of clinical outcome, would help reduce Unset and Non-etched subgroup Source Of Variation Sum of squares df Mean Square F Sig.(P) the time of a dental appointment for the probably the increased availability of Between groups 11.67 12 0.97 0.81 0.64 patient and the dentist.[14],[15],[16] unsaturated double bonds, in the air Hence, this present study was conducted Within groups 866.46 3 288.82 240.20 <0.001 inhibited layer of resin-modified glass in vitro to evaluate and compare the shear Error 43.29 36 1.20 ionomer cements, may assist in chemical bond strength at the glass ionomer and bonding to resin bonding agent and resin Total 921.41 51 composite resin interface of this new c o m p o s i t e . U n p o l y m e r i z e d df – degrees of freedom; F- Fisher’s value; P- Probability technique, with that of the gold standard hydroxyethyl methacrylate, Unsaturated Table 5: Percentage Distribution Of Failure Mode Of Fracture sandwich technique using conventional methacrylate pendants and modified Sites In All Subgroups and resin modified glass ionomer polyacrylic acids on the surfaces Group (Cement+Z100) Subgroups Adhesive Cohesive Mixed Total cements. increases the surface wetting capability Fuji IX +Z100 Set and Etched 3 9 1 13 Keeping in view various factors affecting of bonding agent and could increase bond Percentage % 23% 69% 8% 100% the union of glass ionomer cement and strength when polymerized.[26] Unset and Non-etched 2 7 4 13 composite resin like acid etching and The bond strength values of Unset and Percentage % 15% 54% 31% 100% etching times, cement strength, rate of Non-etched subgroup were less than Set set, effect of cement thickness, viscosity Total 5 16 5 26 and Etched subgroup of Vitremer+Z100 and wettability of bonding resin, group attributed to the omission of light Percentage % 19% 62% 19% 100% materials with superior mechanical activation shortly after the powder and Vitremer +Z100 Set and Etched 1 4 8 13 properties had been used .[19] liquid components are mixed, the Percentage % 8% 31% 61% 100% Fifty two cylindrical bonded specimens mobility of polyalkeonate chains Unset and Non-etched 2 6 5 13 of each 10mmx4mm were prepared using gradually decreased as they become more Percentage % 15% 46% 38% 100% a two-part demountable Teflon mould ionically cross-linked.[27] From the Total 3 10 13 26 with aligning jig to confine the cement mean values it is clear that bond strength and resin. This 6mm´4mm specification Percentage % 12% 38% 50% 100% of Unset and Non-etched subgroup of for glass ionomer cement was in Vitremer+Z100 group was higher than a c c o r d a n c e t o n e w I S O D I S Unset and Non-etched subgroup of Fuji Discussion 9917.[20],[21] IX+Z100 group may due to fact that the The adhesion between glass-ionomer and For Set and Etched subgroup, glass resin modified glass ionomer bonded the composite resin restricts the free ionomer cement was allowed to initial set strongly to dental composite due to its surface area of shrinking composite, for 7 minutes, against glass microscopic similarity in chemistry providing a yielding higher polymerization stresses, slide to produce a smooth surface and potential for chemical bonding between which compete with the shrinkage static load was applied to compact the the materials.[28] vectors directed towards the light source. mass and reduce porosity.[22],[23]In Majority of failure pattern in Set and Because the adhesion between the etched Unset and Non-etched subgroup, the time Etched subgroup of Fuji IX+Z100 group glass-ionomer cement and the composite lapse between the end of the mix and are cohesive attributing the fact that acid resin is stronger than the adhesion application of the bonding agent was etching of glass ionomer forms a between the glass-ionomer cement and maintained constant with the stopwatch, weakened zone whichcan be partially dentin, polymerization shrinkage of so that the bonding agent penetrates into r e i n f o r c e d w i t h t h e b o n d i n g composite resin will “pull away” the the surface irregularities and hardens at agent.[29]Set and Etched subgroup of glass ionomer cement from dentinal the initial stages of setting of glass Vitremer+Z100 group have also failed walls .[18] ionomer mass, resulting in mechanical cohesively where all exhibited composite The concept of co-curing is a new attachment for better bond strength.[24] resin tags located at the center of the glass alternative for the union between glass In Fuji IX+Z100 group,the mean bond ionomer surfaces, thus indicating that the ionomer and composite resin. In this, strength value of the Unset and Non- cohesive strength of resin modified after insertion of glass ionomer cement etched subgroup was significantly higher cements is greatly increased compared into the cavity, the bonding agent is than Set and Etched subgroup mostly due with that of conventional cements.[26] immediately applied and light cured prior to fact that low pH bonding agents etch The fracture strength of brittle materials to placement of resin where no need to the glass ionomer cement surface, and the is strongly influenced by surface

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 039 imperfections, which acts as stress London/Philadelphia/ St.Louis: storage in water on the properties of concentrators. The nature of those Mosby International Ltd; 1998. commercial light-cured glass- surface defects is strongly influenced by 9. Mount GJ. Esthetics with glass- ionomer cements. Br Dent J 1992; the pretreatment. The unfilled resin may ionomer cements and the “sandwich” 173: 98-101. help offset the effect of the etch-induced technique. Quintessence Int 1990; 21. Hinoura L, Moore K, Philips RW. surface flaws by wetting the glass- 21(2): 93-101. Tensile bond strength between glass ionomer cement and filling asperities, 10. Mount GJ, Ngo H .Minimal ionomer cements and composite minimizing their potential as crack Intervention: A new concept for resins. J Am Dent Assoc 1987; nucleators. [29] operative dentistry. Quintessence Int 114:167-72. The properties of the tooth in concert 2000; 31: 527-33. 22. Garcia-Godoy F, Draheim RN, Titus with the restorative materials; under 11. Oilo G,Um CM. Bond strength of HW. Shear bond strength of a functional load determine the necessary glass ionomer cement and composite posterior composite resin to glass level of bond strength. The conclusion of resin combinations. Quintessence Int ionomer bases. Quintessence Int this in vitro investigation must be 1992; 23: 633-39. 1988; 19 (5): 357-59. extrapolated to the in clinical situation 12. Mc Lean JW. Evolution of Glass- 23. Rao V, Reddy VV. An In vitro with care, and further trials with these Ionomer Cements: A Personal View. J comparative evaluation of the tensile materials and surface treatments to Esthet Dent 1994; 6 (5):195-205. bond strength at the two interfaces of c o n f i r m v a l i d i t y o f t h e s e 13. Aboush YEY, Torabzadeh H. Clinical the sandwich technique. J Indian Soc recommendations. performance of class II restorations in Pedod Prev Dent 1995; 13: 10-12. which resin composite is laminated 24. Hinoura K, Suzuki H, Onose H. References over resin-modified glass ionomer. Factors influencing bond strength 1. Liebenberg WH. Assuring restorative Oper Dent 2000; 25: 367-73. between unetched glass ionomers and integrity in extensive posterior resin 14. Pinheiro SL, Oda M, Matson E, resins. Oper Dent 1991; 16: 90-95. composite restorations: Pushing the Daurte DA, Guedes-Pinto ACG. 25. Papagiannoulis L, Eliades G, Lekka envelope. Quintessence Int 2000; Simultaneous Activation Technique: M. Etched glass ionomer liners: 31(3): 153-64. An alternative for bonding composite surface properties and interfacial 2. Willems G, Lambrechts P, Braem M, resin to glass ionomer. Pediatr Dent profile with composite resins. J oral Vanherle G. Composite resins in the 2003; 25 (3): 270-74. Rehab 1990; 17: 25-36. 21st century. Quintessence Int 1993; 15. Milicich G. Auto-cure GIC- 26. Farah CS, Orton VG, Collard SM. 24 (9): 641-58. composite co-cure technique. Shear bond strength of chemical and 3. Braga RR, Hilton TJ, Ferracane JL. Famdent 2003; 3: 15-19. light-cured glass ionomer cements Contraction stress of flowable 16. Knight GM. The co-cured, light- bonded to resin composites. Aust composite materials and their activated glass-ionomer cement- Dent J 1998; 43(2): 81-86. efficacy as stress relieving layers. J composite resin restoration. 27. De Gee AJ, Leloup G, Werner A, Am Dent Assoc 2003; 134: 721-28. Quintessence Int 1994; 25 (2): 97- Vreven J, Davidson CL. Structural 4. Mount GJ. The tensile strength of the 100. integrity of resin-modified glass union between various glass ionomer 17. Erickson RL, Glasspoole EA. ionomers as affected by the delay or cements and various composite Bonding to tooth structure: A omission of light activation. J Dent resins. Aust Dent J 1989; 34 (2): 136- comparison of glass-Ionomer and Res 1998; 77 (8): 1658-63. 46. composite –resin systems. J Esthet 28. Li J, Liu Y, Liu Y, Soremark R, 5. Mc Lean JW. Dentinal bonding Dent 1994; 6 (5): 227-42. Sundstrom F. Flexural strength of agents versus glass-ionomer cements. 18. Meyers R, Gracia-Godoy F, Norling resin-modified glass ionomer Quintessence Int 1996; 27: 659-67. BK. Failure mode of posterior cements and their bond strength to 6. Burgess JO, Walker R, Davidson JM. composite resin bonded to a glass dental composites. Acta Odontol Posterior resin-based composite: ionomer cement treated with various Scand 1996; 54: 55-58. review of the literature. Pediatr Dent etching times and with or without a 29. Smith EDK, Martin FE. Acid etching 2002; 24 (5): 465-79. coupling agent. Quintessence Int of a glass ionomer base: SEM study. 7. Croll TP, Nicholson JW. Glass 1990; 21: 501-506. Aust Dent J 1990; 35 (3): 236-40. ionomer cements in pediatric 19. Wilson AD, Mc Lean JW. Glass- dentistry: review of the literature. I o n o m e r C e m e n t . C h i c a g o : Pediatr Dent 2002; 24 (5): 423-29. Quintessence Publishing Co; 1988. 8. Mount GJ, Hume WR. Preservation 20. Nicholson JW, Mc Lean JW. A and restoration of tooth structure. preliminary report on the effect of

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 040 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Evaluation Of Bond Strength Between 1 Rubina 2 Manjit Kumar Modified Ridge Lap Surface Of Acrylic Teeth & 3 Manmohit Singh 4 Amandeep Bhullar Pmma Denture Base Resin - An In Vitro Study 5 Reshim Garg 1 Senior Resident, Abstract Dept. Of Prosthodontics & Crown & Bridge Background: In dentures, acrylic teeth are preferred to porcelain teeth as they unite chemically Genesis Institute of Dental Sciences with denture base resin but their fracture from denture is common. Many researchers have & Research Ferozepur Punjab 2 Professor attempted to improve the bond strength of denture teeth to acrylic resin denture base by chemical 3 or mechanical modification of the ridge lap surface of denture teeth. Reader Department Of Prosthodontics And Crown & Bridge Aim: This study was carried out to determine whether certain modifications of teeth would Bhojia Dental College, Baddi improve the bond strength between the artificial cross-linked acrylic resin teeth and denture 4 Reader base. 5 Senior Resident Materials and Method: A total of 100 artificial cross-linked acrylic resin central incisors were Department Of Prosthodontics And Crown & Bridge divided into 5 groups - Group A (Control group), Group B (Roughened using sandpaper), Group C Genesis Institute of Dental Sciences (Vertical grooves), Group D (Diatoric recess) and Group E (Monomer application). They were & Research Ferozepur Punjab mounted on wax blocks and the blocks acrylized. The bond strength values were obtained by Address For Correspondence: Dr. Rubina subjecting the samples to shear compressive load under Universal Testing Machine. Senior Resident, Department Of Statistical analysis used: Analysis of Variance and Post Hoc Tukey HSD tests (for multiple Prosthodontics And Crown & Bridge comparisons) Genesis Institute of Dental Sciences Results: Significantly improved bond strength values were obtained in modified groups as & Research Ferozepur Punjab compared to the control group. Submission : 5th February 2013 Conclusion: Monomer application provided with the highest bond strength and is recommended Accepted : 19th September 2014 to prevent debonding of the teeth from the denture base. Key Words Quick Response Code Bond strength; Polymethylmethacrylate; Ridge lap surface; Diatoric recess Introduction and denture bases. Teeth are the best measure of individuality of a person. Teeth used in Materials and method the fabrication of dentures should The method used in the study was divided demonstrate optimum physical and into the following steps - mechanical properties to withstand hundred central incisors rigorous demands of masticatory I. Fabrication of triangular wax blocks 100 cross-linked acrylic resin central functions such as chewing, biting, for arranging acrylic resin teeth incisors (Acryrock, Ruthinium Dental shearing of food and simultaneously A triangular wax block having each side Products Pvt. Ltd., Gujarat) of same superior esthetics particularly in the 3.5 cm and length of 4.5 cm with 60o mould were taken and divided into 5 anterior region of the mouth. Acrylic angulation was fabricated using groups, 20 in each group resin (PMMA) and porcelain teeth are the modelling wax (Rolex Modelling Wax Group A: Teeth without any modification most commonly used ones. But the No. 2, Ashoo Sons, Delhi) and checked to the ridge lap surface (control group) fracture of acrylic resin teeth from a using graph paper (Fig. 1). Its impression (Fig. 2). maxillary denture, is not uncommon was made in polyvinyl siloxane putty especially the teeth in the anterior material (3M ESPE AG, Seefeld region[1],[2].Over the years, many Germany) to standardize the size of wax researchers have attempted to improve blocks and similar blocks were fabricated the bond strength of denture teeth to an by pouring molten wax in the polyvinyl acrylic resin denture base, either by siloxane mould. chemical treatment or by mechanical modification of the ridge lap portion of II. Preparation of ridge lap surfaces of the denture tooth. However, the results have been mixed and conflicting. This study was carried out to determine whether certain modifications to the ridge lap surface of the teeth would improve the bond strength between the artificial cross linked acrylic resin teeth Fig. 1 Wax block Fig. 2 Unmodified surface

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 041 Group B: The glazed ridge lap surfaces of teeth were roughened using sandpaper (No. 120 – John Oakey and Mohan Ltd., Ghaziabad) (Fig. 3). 23 cm long and 2cm wide strips of sandpaper were cut and ten strokes along the entire length of strip were given on the ridge lap surface of Fig. 8 Wax block with mounted teeth Fig. 3 Ridge lap surface roughened by sandpapering each tooth. A single strip of sandpaper was used for each tooth. Group C: Teeth modified by preparing two vertical grooves labiopalatally on the ridge lap surfaces. The grooves were prepared using straight fissure bur no. 557 (S.S. White, Inc., New Jersey),which were 1mm in depth and 1mm in width (Fig. 4). Fig. 9 Finished acrylic block after deflasking Group D: Teeth modified by preparing a diatoric recess on the ridge lap surfaces with a round bur no. 6 (S.S. White, Inc., New Jersey),2 mm in diameter (Fig. 5). Group E:Teeth were kept as such and monomer application (Trevalon Heat Cure Polymethyl methacrylate resin, Dentsply India Pvt. Ltd., Gurgaon)was Fig. 4 Ridge lap surface modified by vertical grooves done with a brush just before packing the resin (Fig. 6). Fig. 10 Testing in Universal Testing Machine The position of vertical grooves and V. Measurement of bond strength diatoric recess was standardized using an The acrylic wax blocks were stabilized in acrylic mould on which the teeth could be a fixture so that no movement occurred mounted. The teeth were also stabilized during load application and subjected to in the same mould while modifying the Instron Universal Testing Machine (Fig. ridge lap surfaces. 10). Force was applied by a 1.5 mm diameter stainless steel pin at a crosshead III. Arrangement of teeth on speed of 5 mm/min until detachment of triangular wax blocks teeth occurred. On a graph paper, an equilateral triangle of dimensions 3.5 cm was drawn and Results lines were drawn on both sides of the The readings were subjected to statistical triangle at an angle of 130o (Fig. 7). This analysis by applying Analysis of was done to standardize the position and Variance and Post Hoc Tukey HSD tests angulation of the teeth on the wax blocks. Fig. 5 Ridge lap surface modified by diatoric recess (for multiple comparisons) and graphs Ten teeth were arranged on each block (5 were plotted. The samples modified by on each side) at an angle of 130o with the monomer application showed the highest help of graph paper (Fig. 8). This mean debonding force of 0.8875 KN angulation was chosen to simulate the followed by vertical grooves (0.7035 average angle of contact between KN), diatoric recess (0.6040 KN) and maxillary and mandibular teeth in Class I sandpapered group (0.4940 KN). All the occlusion. Teeth of different groups were mechanical modifications as well as placed on different wax blocks. monomer application showed an Fig. 6 Ridge lap surface modified by monomer application improvement in bond strength over the IV. Processing of wax blocks control group (0.4045 KN) (Table 1 and Triangular wax blocks with teeth were Graph 1). On applying one way Analysis processed in varsity pattern dental flask, following standard procedure according to manufacturer’s instructions about ratio Table 1 : Bond Strength (Mean ± Sd) Values and manipulation of Trevalon Heat Cure Group N Range Mean ± SD Sem Polymethyl methacrylate resin (Dentsply A 20 0.310 - 0.500 0.4045 ± 0.0587 0.0131 India Pvt. Ltd., Gurgaon). Acrylic blocks B 20 0.400 - 0.580 0.4940 ± 0.0546 0.0122 with mounted teeth were then finished, C 20 0.630 - 0.840 0.7035 ± 0.0573 0.0128 rechecked on graph paper and stored in D 20 0.500 – 0.680 0.6040 ± 0.0528 0.0118 water (Fig. 9). E 20 0.770 – 1.030 0.8875 ± 0.0700 0.0156 Fig. 7 Triangle with angulations on graph paper SD: Standard Deviation, SEm: Standard Error of Mean

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 042 Group with diatoric on the ridge lap 8. C a s w e l l C W, N o r l i n g B K . surface showed higher bond strength Comparative study of the bond values as compared to the control group strengths of three abrasion-resistant and surface roughened group. A diatoric plastic denture teeth bonded to a significantly decreased the failure load in cross-linked and a grafted, cross- one type of resin but actually decreased it linked denture base material. J in another resin. The improvement in Prosthet Dent 1986;55:701-708. bond strength by placement of diatorics 9. Amin WL. Improving bonding of w a s a l s o r e p o r t e d b y s o m e acrylic teeth to self-polymerizing others[17],[18]. denture base resins. Saudi Dental Monomer modified group showed Journal 2002;14:15-19. Graph 1 : Mean Shear Compressive Load In Different Groups highest bond strength as compared to 10. Chung KH, Chung CY, Chung CY, Table 2 : One Way Anova (Analysis Of Variance) control group as well as other modified Chan DCN. Effect of pre-processing Source of variance Sum of Squares Df Mean Square F p Value groups. Similar results were also surface treatments of acrylic teeth on Between Groups 2.822 4 0.705 202.544 <0.001* obtained by some authors[19], [20], [21], bonding to the denture base. J Oral Within Groups 0.331 95 0.003 [22]. Rehabil 2008;35:268-275. Total 3.153 99 11. Bragaglia LE, Prates LHM, Calvo * p < 0.001; Significant Conclusion And Summary MCM. The role of surface treatments of Variance, a statistically significant Modification of the ridge lap surface of on the bond between acrylic denture difference was seen between the strength maxillary anterior teeth by monomer base and teeth. Braz J Oral Sci with different ridge lap modifications of application or mechanical modification 2009;20:156-61. the samples within groups and between is hence recommended to enhance their 12. Amarnath GS, Indra Kumar HS, groups i.e. p < 0.001 (Table 2). bond strength to the denture bases. Muddugangadhar BC. Bond strength Monomer application is the easiest and tensile strength of surface treated Discussion method and also provides the highest resin teeth with microwave cured and Harold Vernon first introduced the use of bond strength values without any extra heat cured acrylic resin denture base: methyl methacrylate in the form of a cost and time.Further in vivo studies on An in-vitro study. International powder and liquid to be used as a denture various methods to increase the bond Journal of Clinical Dental Science base in the 1930’s[3].Debonding of strength of teeth and denture bases should 2011;2:27-31. denture teeth from a denture base has be carried out. 13. Cunningham JL, Benington IC. An remained a major problem in investigation of the variables which prosthodontic practice. Studies that have References may affect the bond between plastic evaluated the frequency of various 1. Cardash HS, Liberman R, Helft M. teeth and denture base resin. J Dent denture repairs have found tooth The effect of retention grooves in 1999;27:129-35. debonding/fracture to be the most acrylic resin teeth on tooth denture- 14. Spratley MH. An investigation of the frequentin both complete and partial base bond. J Prosthet Dent adhesion of acrylic teeth to dentures. J dentures followed by the midline fracture 1986;55:526-28. Prosthet Dent 1987;58:389-92. of complete dentures[4], [5]. The lack of 2. Cardash HS, Applebaum B, Baharav 15. Azad AA, Siddiqui A, Jawad A, Jia adequate bonding is believed to be the H, Liberman R. Effect of retention M, Ali T. Effect of mechanical result incompatible surface conditions at grooves on tooth-denture base bond. J modification of acrylic resin denture the tooth/base interface. This Prosthet Dent 1990;64:492-6. teeth bonded to acrylic denture base. incompatibility is brought about by two 3. Kelly EB. Has the advent of plastics Pakistan Oral & Dental Journal factors - contamination of the surfaces in dentistry proved of great scientific 2012;32:149-153. particularly by wax and possibly by value? J Prosthet Dent 1951;1:168- 16. Saavedra G, Neisser MP, Sinhoreti sodium alginate as separating medium 76. MAC, Machado C. Evaluation of and the difference in the structure of the 4. Barpal D, Curtis DA, Finzen F, Perry bond strength of denture teeth bonded two components due to their different J, Gansky SA. Failure load of acrylic to heat polymerized acrylic resin processing[6]. resin denture teeth bonded to high denture bases. Braz J Oral Sci Sandpapered group showed higher bond impact acrylic resins. J Prosthet Dent 2004;3:458-64. strength values as compared to the 1998;80:666-71. 17. MengGK, Chung KH, Fletcher-Stark control group. The improvement in bond 5. Darbar UR, Huggett R, Harrison A. ML,Zhang H. Effect of surface strength on grinding was also reported by Denture fracture – a survey. Br Dent J treatments and cyclicloading on the various authors[7],[8],[9],[10],[11],[12]. 1994;74: 591-4. bond strength of acrylic resin denture Contradictory results were obtained by 6. Cunningham JL, Benington IC. A teeth with autopolymerized repair some authors[13],[14]. s u r v e y o f t h e p r e - b o n d i n g acrylic resin. J Prosthet Dent Vertical grooves showed higher values preparation of denture teeth and the 2010;103:245-52. than control group, surface roughened efficiency of dewaxing methods. J 18. Takahashi Y, Chai J, Takahashi T, group and with diatoric recess. Similar Dent 1997;2:125-8. Habu T. Bond strength of denture results were obtained by some 7. Civjan S, Huget EF, Simon LB. teeth to denture base resins. Int J others[15]. No improvement in bond Modifications of the fluid resin Prosthodont 2000;13:59-65. strength on grooving was obtained in technique. J Am Dent Assoc 19. Geerts GAVM, Jooste CH. A some studies[16]. 1972;85:109-12. comparison of the bond strengths of

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 043 microwave- and water-bath cured acrylic denture base resin. Dent conventional and microwave curve denture material. J Prosthet Dent Mater J 2006;25:75-80. on bond strength between denture 1990;70:406-09. 21. Beuer F, Erdelt KJ, Friedrich R, base resin and acrylic teeth with 20. Nishigawa G, Maruo Y, Okamoto M, Bogai KK, Eichberger M. Retention different surface treatments. Oki K, Kinuta Y, Minagi S, Irie M, and fracture resistance of acrylic International Journal of Dental Suzuki K. Effect of adhesive primer denture teeth on the denture base. Clinics 2010;2:41-45. developed exclusively for heat- Deutsche Zahnarzliche Zeitschrift curing resin on adhesive strength 2006;61:147-50. between plastic artificial tooth and 22. GugwadRS, Nagaral S. Effect of

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 044 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Large Peripheral Giant Cell Granuloma In An 1 Pankaj Kukreja 2 Manu Sharma Edentulous Mandibular Ridge - A Case Report 3 Vidhi Chhabra 4 Sanjeev Kumar Abstract 1 Reader Peripheral giant cell granuloma (PGCG) is an infrequent exophytic lesion of the oral cavity, 2 Senior Lecturer Called variously giant cell reparative granuloma, osteoclastoma, giant cell , and myeloid 3 Post Graduate epulis, this lesion was first reported as fungus flesh in 1848and probably is a reactive response to 4 Professor and Head local irritations and trauma. It usually abuts periodontally compromised teeth. It predominantly Department of Oral and Maxillofacial surgery affects women and occurs most frequently in first 4 decades of life when hormonal changes are I.T.S Centre For Dental Studies & Research, Ghaziabad prominent but the cause is not certainly known. The differential diagnosis of PGCG includes Address For Correspondence: Dr. Pankaj Kukreja lesions with very similar clinical and histological characteristics, such as central giant cell Reader, Department of Oral & Maxillofacial surgery, granuloma, which are located within the jaw itself and exhibit a more aggressive behaviour. Only I.T.S Centre for dental studies and research, radiological evaluation can establish a distinction. In some instances, the giant cell granuloma of Delhi-Meerut Road, Muradnagar, the gingiva is locally invasive and causes destruction of the underlying bone. The early and Ghaziabad, PIN-201206, precise diagnosis of these lesions allows conservative management without risk to the adjacent Uttar Pradesh, India teeth or bone. The aim in publishing this report is to present the clinical, histopathological E-mail: [email protected] Contact no: +91-9999998558 features and treatment of a PGCG case which was seen on the edentulous ridge of a 55 years old nd female patient, with disturbed chewing functions due to its large size. We also review briefly the Submission : 2 April 2013 th current literature regarding the lesion. Accepted : 3 September 2014 Key Words Granuloma, Giant-cell, Peripheral, Central Quick Response Code Introduction Clinical appearance of PGCG can present The peripheral giant cell granuloma as polyploidy or nodular lesion, (PGCG) is a relatively common tumor- Primarily bluish red with a smooth shiny like growth of the oral cavity. It is an or mamillated surface stalky or sessile exophytic lesion of the oral cavity, also base, small and well demarcated. Pain is k n o w n a s g i a n t c e l l e p u l i s , rare and in most cases the lesion is osteoclastoma, giant cell reparative induced by constant trauma.[9] PGCG covered with stratified squamous granuloma, giant-cell hyperplasia, or occurs exclusively on gingiva or epithelium. There are a large number of peripheral giant cell reparative edentulous alveolar ridge1 as variable multinucleated giant cells resembling granuloma.[1] It is a benign hyperplastic sized, sessile or pedunculated lesion foreign body giant cells.[13],[14] It also lesion caused by local or chronic trauma. which is usually bleed easily.[10] They appears as a non-capsulated mass of It originates from the of vary in size, though are rarely reported to tissue containing a large number of t h e p e r i o d o n t a l l i g a m e n t o r exceed 2 cm in diameter.[11] However, young connective tissue cells and mucoperiosteum.[2],[3] Even though it is there have been reports of masses in multinucleated giant cells.[15] a common giant cell lesion found in the excess of 5 cm, where factors such as H e m ¬ o r r h a g e , h e m o s i d e r i n , oral cavity,[4] it is the least commonly deficient oral hygiene or xerostomia inflammatory cells, and newly formed diagnosed lesion among the various appear to play an important role in lesion bone or calcified material may also be hyperplastic gingival lesions e.g. growth.[2] Incipient lesions induce seen throughout the cellular connective , fibrous hyperplasia minor changes in gingival contour but tis-sue.[4],[9],[16] and peripheral ossifying .[4],[5] large ones adversely affect normal oral Treatment consists of local surgical C h r o n i c t r a u m a c a n i n d u c e function.2 In some cases the underlying excision down to the underlying bone,[1] inflammation, produce granulation tissue bone, suffers erosion and cup-shaped for extensive clearing of the base.[10] with endothelial cells, chronic radiolucency occurs.[6] The lesion can Removal of local factors or irritants is inflammatory cells and fibroblasts develop at any age. It is, however, more also required.[17] If resection is only proliferation and manifests as an common in the fifth and sixth decades of superficial, the growth may recur.[5] overgrowth called reactive hyperplasia. life with a slight female predilection. Exposure of all bony walls following [6] PGCG is one of the most frequent [3],[12] thorough surgical resection responds reactive hyperplastic lesions of the jaws. The radiographic findings of PGCG are satisfactorily most of the time.[12] These tumor-like lesions are not neo- generally unremarkable, although tooth Recurrence rate of 5.0-70.6% (average plastic, but they indicate a chronic or osseous resorption may rarely be 9.9%) has been reported in various process in which an exaggerated repair found in an adjacent area. Histologically, epidemiologic studies.[18] A recurrence occurs (granulation tissue and formation PGCGs present with giant cells in a rate of 5% has been reported by Giansanti of scars) following injury.[3],[7],[8] vascular stroma of collagen fibers and are and Waldron (1969)[19] while a study by Eversole and Rovin(1972)[20] showed a

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 045 recurrence of 11%. Recurrences are believed to be related to lack of inclusion of the periosteum or periodontal ligament in the excised specimen.[17] A re- excision must be performed for these cases.[1] Aggressive tendencies[21] or malignant transformation of these lesions has never been reported.[4] PGCG lesions are self-limiting.[21]

Case Report A 55 years old female patient who Figure-1: Pre-operative View Of The Lesion Figure-6: Post-operative View Of The Site At 12 Months. complained about Jaffe first suggested the term “giant cell and pain while chewing was referred to reparative granuloma” for the similar our clinic. Her intraoral examination central lesion of the jaw bones[4] to help revealed a raised, round; sessile, smooth- differentiate them from the giant cell edged mass 3 x 2.5 cm in diameter tumor[12] as he believed the former located on the right mandibular alveolar lesion to represent a local reparative ridge and had no ulcerated surface reaction rather than being a true (Figure-1). The patient's oral hygiene neoplasm.[22],[23] Bernier and Cahn was poor and she was mostly edentulous, proposed the term“peripheral giant cell with a few teeth remaining. There was reparative granuloma” for the lesion.[4] accumulation of plaque and calculus on The latter terminology is currently not those remaining teeth. She was Figure-2: Opg Radiograph being used as the reparative nature of the systemically healthy and was not taking lesion has not been proved.[24] Today, a n y m e d i c a t i o n . R a d i o l o g i c a l the term peripheral giant cell granuloma examination revealed no evidence of is universally accepted.[4] bony involvement (Figure-2). Many studies have been undertaken on Excisional biopsy of the lesion was the demographics and treatment performed, followed by curettage of the modalities of PGCG. It has been reported underlying bone. Biopsy specimen was in unusual places like mandibular preserved in 10% formalin and sent to condyle, nasopharynx, temporal bone department of pathology (Figure-3). and . It has also been Routine histological examination with reported around dental implants (Table- haematoxylin and eosin stain was 1). performed. The specimen showed Li et al (2010)[29] investigated the fibrovascular connective tissue stroma Figure-3: Excised Specimen clinicopathological features, diagnosis comprising of large number of and treatment of giant cell granuloma proliferating plump fibroblasts having outside the jaw. They retrospectively round to ovoid nuclei and numerous analyzed the clinical and pathological multinucleated giant cells of uniform size datas of 3 cases in nasopharynx, temporal having nuclei up to 20 in number. bone and maxillary sinus, and also Numerous blood vessels and foci of reviewed the relevant literatures. The haemorrhage were evident, particularly patients in their study presented with around the periphery of the lesion. Areas local painless mass, part of which were of ossification and chronic inflammatory aggressive. Histopathological feature c e l l i n f i l t r a t e , p r e d o m i n a n t l y was, replacement of the normal bone lymphocytes, were seen. The overlying structure with proliferating fibrous tissue epithelium was parakeratinized stratified Figure-4: Histopathology Of The Lesion (Marker Showing containing numerous giant cells was squamous epithelium with irregular rete Giant Cell At 10x Magnification) shown. The authors concluded that Giant r i d g e s , a n d s h o w e d a r e a s o f cell granuloma outside the jaw was a non- discontinuation. A large number of neoplastic lesion, and extremely rare. It stromal fibroblastic cells and was somewhat difficult to make a correct multinucleated giant cells were seen in diagnosis. Combining the clinical data 10X and 40X magnifications (Figure-4, and pathological feature were more Figure-5). The microscopic features of helpful to the diagnosis. Total surgical the lesion were consistent with PGCG. resection was an effective therapeutic Postoperative healing was uneventful. method. No recurrence of the lesion was found 12 Mighell et al (1995),[18] in their study, months after surgery (Figure-6). had identified the principle clinical features of the peripheral giant cell Discussion Figure-5: Histopathology Of The Lesion (40x Magnification) granuloma (PGCG), and recognised

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 046 Table 1 (4.41%) of recurrence of CGCGs and 8 Year Authors No of patients Site Findings/ treatment cases (1.39%) of recurrence of PGCGs 1988 Katsikeris et al4 224 new > Most characteristic histologic feature - non encapsulated documented during the follow-up period 956 review highly cellular mass with abundant giant cells, (ranging from 1-12 years). interstitial haemorrhage, inflammation, hemosiderin PGCG is more common in the lower jaw rather than the upper jaw. [3], [12], [15], deposits and mature bone or osteoid. [19] The reported proportion is 2.4:1 and 1995 Mighell et al18 62 (77 lesions) Various sites in maxilla and mandible Surgical excision. Recurrence may not follow in most cases, it occurs anterior to molar incomplete excision. region. [6],[16],[19],[30] However, 1997 Bodner et al15 79 Various sites in maxilla and mandible Surgical excision according to Pindborg31 the preferential 2002 Gandara-Rey JM et al11 13 8 in maxilla, 5 in mandible surgical excision and subsequent curettage to remove location is the premolar and the molar the base of the lesion zones. According to Motamedi et al, 2004 Bischof et al25 1 Around mandibular Surgical excision PGCG more frequently involves the 2005 Chaparro-Avendaño AV et al2 5 3 in maxilla, 2 in mandible Resection and biopsy, using a carbon dioxide laser in mandible, commonly in the areas posterior to canines.[12] PGCG affects 2 cases and a cold scalpel in the remaining 3. f e m a l e s m o r e t h a n m a l e s , 2005 Ozcan C et al26 1 Mandibular condyle, presenting as a Surgical excision via blunt disssection [4],[7],[16],[19] with a proportion of Preauricular mass 1:1.5 or 1:2 according to Reichart and 2007 Mootamedi et al12 204 central 575 352 mandible, 223 in maxilla Thorough curettage Philipsen [30] or Giansanti and Waldron peripheral Trauma and poor oral hygiene main etiologic factors. studies[19] respectively. However 2008 Shirani and Arshad 27 20 Maxilla and mandible Effect of sex hormones secondary to local factors Bhaskar et al,[21] Salum et al,[32] Zhang 2009 Shadman et al3 123 64.6% in mandible, 35.3% in maxilla Surgical resection, with extensive clearing of the et al[33] and also Murat et al[34] reported a slight predilection for the male sex. But base of the lesion in some texts and studies, PGCG had an 2010 Etoz OA et al9 3 Edentulous mandible in complete Resection of the lesion and closure of the defect with equal prevalence in both genders.[8],[12] denture users a mucosal graft. Giant cells may develop in normal bone 2010 Lev et al.28 1 Maxillary lateral incisor Surgical excision with sub-epithelial connective tissue graft or in pre-existing lesions, such as fibrous and split thickness pouch technique. dysplasia, hyperparathyroid bone disease 2010 Li et al.29 3 3 Unusual sites (nasopharynx, temporal Total surgical resection or, rarely, Paget’s disease.[35] The bone and maxillary sinus) differential diagnosis of PGCG particularly involves giant cell tumor, clinical features of PGCG that were (CGCGs) in patients treated at their nonossifying fibroma, pyogenic poorly defined. They had reviewed centers. Their 12-year retrospective granuloma, CGCG, chondroblastoma retrospectively 77 cases of PGCG from study was based on existing data from and odontogenic . [35],[36] Because 62 patients with respect to incidence, sex, 1993-2004. In their study, PGCGs GCG is indistinguishable from a brown patient age, race, clinical symptoms and presented in 575 patients, who varied in tumor in microscopic examination, it signs, radiographic features and age from 2 to 85 years with a mean age of must be ruled out from underlying recurrence following excision.Their 31.02 years. Among these, 297 cases hyperparathyroidism using laboratory results was largely in agreement with (51.65%) occurred in females and 278 and radiological methods. Malignant previous reports. They have stated that (48.34%) in males. Four hundred sixty- transformation has not been seen in any there is wide variation in the results seven cases (81.2%) occurred in the first GCG cases.[36] published between series. In addition, five decades of life, and 352 cases Timoscaand Gavrilitã (1976) [37] have some clinical features of PGCG are (61.21%) appeared in the mandible. The studied PGCG in a series of 173 patients poorly defined. Little is known about the authors concluded that PGCG lesions amongst 894 with epulis type tumours. relative incidences of PGCG and central occurred more than 2 times more The highest occurrence rate of PGCG giant cell granuloma. An association frequently than CGCGs. CGCGs was found during the period of mixed between PGCG and may exist, occurred about 2 times more frequently dentition. Whilst in childhood PGCG but is poorly defined, and not all PGCG in females, whereas PGCGs had an equal was commoner in boys than girls, after that involve edentulous areas follow prevalence in both genders (P < .05). The the age of 16 the number of women recent tooth loss. Information about mean age for patients with CGCGs was affected was twice that of men. PGCG PGCG recurrence after excision is less than patients with PGCGs (P < .05). occurs more frequently in the mandible limited, and does not necessarily follow Central GCGs involved the mandible than the maxilla and more often in the incomplete excision. Despite the large approximately 2 times more frequently premolar-molar region than the incisor- number of reported cases of PGCG, than the maxilla (P < .05). However, canine region. Osteolysis of the alveolar clarification of some clinical features is when presenting in the maxilla, CGCGs edge was more marked than in other required, and may help formulation and most frequently presented in the area forms of epulis and in a smaller number interpretation of future laboratory-based anterior to the canines (P < .05). of cases osteogenic forms of PGCG were research into this poorly understood Peripheral GCGs involved the mandible found with the formation of a substantial lesion. approximately 1.5 times more frequently amount of reactive bone. From a Motamedi et al (2007)[12] have assessed than the maxilla (P < .05). Thorough histopathological standpoint, a the demographic characteristics of curettage was the main treatment connective-tissue/vascular stroma with PGCGs and central giant cell granulomas modality used. There were 9 cases giant cells and developing in relation

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 047 with the capillary endothelium, and of 5–70.6%. This wide variation may be lesion in children. Pediatr Dent 2000; similar appearance to CGCG was noted. attributed to the surgical technique used 22: 232. Dayan et al (1990)[38] have analysed in excision. The recurrence rate increases 6. Wood NK, Goaz PW. 5th ed. Mineralized products in a series of 62 in hyperparathyroid cases. Long-term St.Louis: Mosby; 1997. Differential cases of peripheral giant cell granuloma follow-up is mandatory because of the Diagnosis of Oral and Maxillofacial of the gingiva or alveolar ridge of man. possibility of recurrence of the Lesions; pp. 141–2. Histologic sections were examined by PGCG.[11],[41],[42] PGCG is a lesion of 7. Carvalho YR, Loyola AM, Gomez routine light microscopy and under the gingiva mostly localized between the RS, Araujo VC. Peripheral giant cell polarized light to assess the extent and first molars and incisors. granuloma. An immunohisto- composition of mineralized tissues in chemical and ultrastructural study. these lesions. In 35% of the cases, Conclusion Oral Dis. 1995;1(1):20–5. mineralized tissue was identified in the In conclusion, the early and precise 8. Regezi JA, Sciubba JJ, Jordan RCK. form of woven and/or lamellar bone and diagnosis of PGCG, based on the clinical 5th ed. St.Louis: WB. Saunders; dystrophic calcification. The most and radiological findings and 2007. Oral Pathology: Clinical common type was the woven bone which histological study, allows conservative Pathologic Correlations; pp. 112–3. appeared alone or in combination with management with a lesser risk for the 9. Etoz OA, Demirbas AE, Bulbul M, lamellar bone in 82% of the lesions teeth and adjacent bone. The Akay E. The Peripheralgiant cell containing mineralized material. Unlike characteristics and clinical behavior of granuloma in edentulous patients: peripheral ossifying fibroma, no PGCG may vary in different populations report ofthree unique cases. Eu J Dent -like material was identified in and be difficult to predict, reflecting 2010; 4:329-33 peripheral giant cell granuloma. different environmental influences, 10. Kfir Y, Buchner A, Hansen LS. Bartel andPiatowska (1977)[39] have lifestyles, and racial factors, assessment Reactive lesions of the gingiva.A done an Electron microscopic study of of which may help in the diagnosis and clinicopathological study of 741 peripheral giant-cell reparative management. Information regarding cases. J Periodontol 1980;51: 655-61. granuloma. Six giant-cell tumors have gender, age, signs, and symptoms may be 11. Gandara-Rey JM, Pacheco Martins been examined by electron microscopic useful and lead to an early diagnosis and Carneiro JL, Gandara-Vila P, Blanco- methods in order to determine their proper management, preventing further Carrion A, Garcia-Garcia A, histogenesis and to expand knowledge of damage to hard and soft tissues of Madrinan-Grana P, et al. Peripheral cell structures. The examination of giant involved areas. The usual line of giant-cell granuloma. Review of 13 cells revealed an abundance of cell treatment for PGCG is local excision cases. Med Oral. 2002;7(4):254–9 organelles, especially mitochondria. down to the bony base along with 12. Motamedi MH, Eshghyar N, Jafari Apart from typical stromal cells, such as elimination of the local etiological SM, Lassemi E, Navi F, Abbas FM, et fibroblasts, macrophages, and mast cells, factors; failing to do so may result in the al. Peripheral and central giant cell clusters of stromal "light" cells were recurrence of the growth. granulomas of the jaws: a often found with an intimate relation demographic study. Oral Surg Oral between their cell membranes. The role References Med Oral Pathol Oral Radiol Endod. and function of these cells is not well 1. Neville BW, Damm DD, Allen CM, 2007;103(3):e39–e43. known. Between fibroblasts of regular Bouquot JE. Soft Tissue Tumors. In 13. Eronat N, Aktug M, Giinbay T, Unal appearance with a small number of Neville BW, Damm DD, Allen CM, T: Peripheralgiant cell granuloma: cytoplasmic organelles, others were Bouquot JE, eds. Oral and three case reports.J Clin Pediatr Dent found with an incrased number of Maxillofacial Pathology 3rd ed. St. 2000; 24: 245–248. mitochondria. These cells often formed Louis:Saunders; 2009: 507-563. 14. Özalp N, #0;ener E, Songur T. aggregates. This suggests that giant cells 2. Chaparro-Avendano AV, Berini- Peripheral Giant Cell Granuloma and develop through the association of Aytes L, Gay-Escoda C. Peripheral Peripheral Ossifying Fibroma in stroma fibroblast cells. giant cell granuloma. A report of five Children: Two Case Reports. Med The treatment of choice is surgical cases and review of the literature. Princ Pract 2010;19:159–162 excision in cases of PGCG. The Med Oral Patol Oral Cir Bucal. 15. Bodner L, Peist M, Gatot A, Fliss periosteum must be included in the 2005;10(1):53–7. DM:Growth potential of peripheral excision to prevent recurrences. If 3. S h a d m a n N , E b r a h i m i S F , giant cellgranuloma. Oral Surg Oral resection is only superficial, the growth JafariS,EslamiM. Peripheral Giant Med Oral PatholOral Radiol Endod may recur. Most lesions respond Cell Granuloma: A Review of 123 1997; 83: 548–551. satisfactorily to thorough surgical Cases. Dent Res J (Isfahan). 2009 16. Shafer WG, Hine MK, Levy BM. A resection, with exposure of all the bone Spring; 6(1): 47–50 textbook of oral pathol. 4th ed. walls. When the periodontal membrane is 4. K a t s i k e r i s N , K a k a r a n t z a - Philadelphia: WB Saunders affected, extraction of the adjacent teeth Angelopoulou E, Angelopoulos AP. 1983:144-146. may prove necessary to insure full Peripheral giant cell granuloma. 17. Regezi JA, Sciubba JJ, Jordan RCK. resection though this is initially Clinicopathologic study of 224 new Red-Blue lesions. InRegezi JA, contraindicated.[2],[40] cases and review of 956 reported Sciubba JJ, Jordan RCK, eds. Oral Curettage in addition to the excision to cases. Int J Oral Maxillofac Surg Pathology.Clinical Pathologic remove the base of the lesion also has 1988; 17: 94-99. Correlations 5th ed. St. Louis: been suggested. The recurrence rate of 5. Flaitz CM. Peripheral Giant Cell Saunders;2009: 107-25. PGCG has been reported to range from Granuloma: A potentially aggressive 18. Mighell AJ, Robinson PA, Hume WJ.

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 048 Peripheral giant cell granuloma: a of the mandibular condyle presenting 34. Muratakgül H, Güngrmü M, Harorli clinical study of 77 cases from 62 as a preauricular mass. Eur Arch A. Peripheral giant cell granuloma. a patients, and literature review. Oral O t o r h i n o l a r y n g o l . 2 0 0 5 clinical and radiological study. Dis. 1995 Mar;1(1):12-9. Mar;262(3):178-81 2004;16(1):59–63 19. Giansanti JS, Waldron CA. 27. Shirani G, Arshad M. Relationship 35. Dorfman HD, Czernıak B (1998) Peripheral giant cell granuloma: between circulating levels of sex Giant cell lesions. In: Bonetumors, review of 720 cases. J Oral Surg 1969 Hormones and peripheral giant cell 1st edn. Mosby, St. Louis, pp Oct; 27: 787-91. granuloma. Acta Medica Iranica 559–605 20. Eversole LR, Rovin S. Reactive 2008; 46(5): 429-433. 36. Kaw YT (1994) Fine-needle lesions of gingiva. J OralPathol 1972; 28. Lev R, Moses O, Holtzclaw D, Tal H. aspiration cytology of central 1: 30-38. Esthetic treatment of peripheral giant giantcell granuloma of the jaw. Acta 21. Bhaskar SN, Cutright DE, Beasley cell granuloma using a subepithelial Cytol 38:475–478 JD, Perez B. Giant cell reparative connective tissue graft and a split- 37. Timosca G, Gavrilitã L.Peripheral granuloma (peripheral): report of 50 thickness pouch technique. J giant cell granuloma of the jaw. Study cases. J OralSurg 1971; 29: 110-15. Periodontol.2010 Jul;81(7):1092-8. of 173 casesRev Stomatol Chir 22. Kruse-L}5;sler B, Diallo R, Gaertner 29. Li S Wang S, Zhu L. Giant cell M a x i l l o f a c . 1 9 7 6 A p r - C, Mischke K-L, Joos U, Kleinheinz granuloma outside the jaw three cases May;77(3):587-97. J. Central giant cell granuloma of the and literature review. Lin Chung Er 38. Dayan D, Buchner A, Spirer S. Bone jaws: A clinical, radiologic and Bi Yan Hou Tou Jing Wai Ke Za formation in peripheral giant cell histopathologic study of 26 cases. Zhi.2010 Nov;24(22):1032-4. granuloma. J Periodontol.1990 Oral Surg Oral Med Oral Pathol Oral 30. Reichart P, Philipsen H P. Peripheral Jul;61(7):444-6. Radiol Endod 2006; 101: 346-54. giant cell granuloma: review of 720 39. Bartel H, Piatowska D. Electron 23. Jaffe HL. Giant cell reparative cases. J Oral Surg. 2000:164. microscopic study of peripheral granuloma, traumatic bone and 31. Pindborg JJ. 5th ed. London: Wiley- giant-cell reparative granuloma. Oral fibrous (fibro-osseous) dysplasia of Blackwell; 1995. Atlas of Diseases of Surg Oral Med Oral Pathol.1977 jaw bones. Oral Surg 1953; 6:159-75. the Oral Mucosa; p. 186 Jan;43(1):82-96. 24. Carranza FA, Hogan EL. Gingival 32. Salum FG, Yurgel LS, Cherubini K, 40. Warrington RD, Reese DJ, Allen G. Enlargements. In Newman MG, De Figueiredo MA, Medeiros IC, The peripheral giant cell granuloma. Takei HH, Klokkevold PR, eds. Nicola FS. Pyogenic granuloma, Gen Dent. 1997;45(6):577–9 Carranza’s ClinicalPeriodontology peripheral giant cell granuloma and 41. Breault LG, Fowler EB, Wolfang MJ, 10th ed. St Louis: Saunders; 2009: peripheral ossifying fibroma: Lewis DW. Peripheral giant cell 373-390. retrospective analysis of 138 cases. granuloma: a case report. Gen Dent 25. Bischof M, Nedir R, Lombardi T. M i n e r v a S t o m a t o l . 2000:716–719 Peripheral giant cell granuloma 2008;57(5):227–32. 42. Junquera LM, Lupi E, Lombardia E, associated with dental implant. Int J 33. Zhang W, Chen Y, An Z, Geng N, Bao Fresno MF. Multiple and syncronous Oral Maxillofac Implants 2004; D. Reactive gingival lesions: a peripheral giant cell granulomas 19(2): 295-299 retrospective study of 2, 439 cases. ofthe . Ann Otol Rhinol 26. Ozcan C, Apaydin FD, Görür K, Apa Q u i n t e s s e n c e I n t . Laryngol 2002;111:751–753 DD. Peripheral giant cell granuloma 2007;38(2):103–10.

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 049 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Reterival Of A Endodontic Fractured 1 Konark 2 Abhash Kumar Instrument: Challenges And Perception 3 Anju Singh 4 D K Singh Abstract 1 Senior Lectures , Conservative & Endodontics An unpleasant and frustrating complication during root canal treatment is instrument fracture Sarjug Dental College & Hospital, Darbhanga, Bihar within the root canal. The present case reports describe the successful removal of a fractured 2 Dental Surgeon , Oral Surgery endodontic instrument in the root canal.Various techniques and treatment modalities are Sadar Hospital , Sheohar 3 available for instrument retrieval form root canal and most of them have brought about Senior Lectures , Peadiatrics & Preventive Dentistry Sarjug Dental College & Hospital, Darbhanga, Bihar unpredictable results causing a lot of damage to the remaining root. Removal of a separated 4 instrument from a root canal must be performed with minimum damage to the tooth and the Professor , Prosthodontics Patna Dental College & Hospital surrounding tissues. Therefore, an alternative technique utilizing cyanoacrylate adhesive was Address For Correspondence: utilized with success. This method is quick, efficient and practically possible to remove the Dr. Konark separated instruments from the canal. C-403, Kauhsalya Estate, Success was defined as complete removal of the fractured instrument from the root canal without Bandar Bagicha,Dakbangala Road, Patna creating a perforation. This is a clinician-derived technical outcome. Submission : 20th February 2014 Key Words Accepted : 17th March 2015 Fractured instrument, instrument removal, separated instrument, ultrasonics, Cyanoacrylate Glue Quick Response Code Introduction Endo Extractor System. Sieraski and The separation of instruments during Zillich (1993) used the ultrasonic scaler endodontic therapy is a troublesome that produces less dentin wear as already incident, and its incidence ranges from reported by Souyave et al. (1985) and 2% to 6% of the cases investigated.[1] Meidinger and Kabes (1985). The Canal Successful endodontic treatment Finder System can also be used depends on a series of sequential successfully according to Hüllsman Varying extents of tooth structure are procedures including cleaning and (1990) in an experimental and clinical removed during this procedure which shaping of the root canal system. study. may potentially cause complications. Procedural errors such as ledging, Fors and Berg (1993) reported a clinical There is no doubt that the degree of zipping, canal perforation and apex case of removal of a broken file in the curvature is one of most important factors transportation can occur during root mesio-buccal canal of a mandibular third influencing the successful management canal instrumentation. However, m o l a r u s i n g a m i c r o - s u rg i c a l of separated instruments[5]. However, separation of endodontic instruments Castroviejos needle holder for fragments present in the root canal can (SEF) is a problematic incident. ophthalmology. Weissman (1993) also hinder proper preparation of root canal Conflicting results have been reported reported the use of a perry pliers for space. A technique as devised by rowe regarding the clinical significance of removal of a silver cone. uses cyanoacrylate glue {permabond or fractured files remaining within treated Many guidelines have been suggested for super glue # 30 } and hypodermic needle root canals.[1] Therefore, when an the prevention of SEF. Most are related to to retrieve silver point. According to it instrument fractures in the root canal, the the operator, including: when a silver point is not protruding into clinician must evaluate carefully the • Instrument should be examined the pulp chamber then select a options of attempting to remove the ,before and after use,to make certain hypodermic needle that fits snugly over instrument, attempting to bypass the that blades are regular aligned silver point remove the bevel of needle instrument, or preparing and filling to the • Instrument should not be used in dry and cement it over the silver point using fractured instrument (Suter et al. canals cyanocarylate glue after 5 minutes of 2005).[2] • Files should be used according to the setting time the needle is grasped the Many techniques, methods and manufacturer’s instruction and hemostat and silver point worried from instruments have been proposed for the excessive forces should be avoided. place. [6] removal of foreign bodies, broken Following case describes the clinical instruments, silver cones and cemented There is a variety of protocol for root scenario of fractured fragment removal posts in root canals, i.e., Canal Finder canal instrument. Experience of file by the use of cyanocarylate glue system, Masseran Kit, Endo Extractor separation was found to differ not only System, Ultrasonics, and several kinds of beween different dental practitioners, but Case Report pliers. Feldman et al. (1974) reported the also at different times for the same This clinical endodontic study was removal of broken instruments from practitioners.[3],[4] performed in an endodontic department single root and multiple roots with the in Mullana, Ambala.

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 050 A 38 year old male patient reported with millimeters of the obstruction begins to the history of pain in lower right back loosen, unwind and then spin. And it was teeth since one month. On examination, revealed that the instrument could be there was a deep dental caries on the partially bypassed and that it was loose lower right first molar. On radiographic within the root canal. examination radiolucency was seen in After Drying The Canal with 20 no k file dentin on the mesial buccal encroaching was taken and the cyanoacrlate adhesive the pulp space. Root canal treatment was was applied onto the file (Figure2). then decided as the treatment for the tooth. taken into the canal that will adhere firmly with the broken instrument Clinical sequence (Figure3). and after not moving the The clinical procedure consists of combination slowly in coronal direction consecutive steps: Figure 1 Will Bring The Broken Instrument Safely The aim is to achieve direct access to the Out Of The Canal. (Figure 4, 5). When fragment while removing as little dentin instrument removal was completed and as possible. Instrument fractures in the before obturation, a radiograph was taken coronal or middle third of the root canal to confirm whether the instrument was are most frequently caused by incorrect absent as in successful cases or in the case preparation of the access cavity or the of failure, the size and location of the presence of a curve in the coronal third of remaining fragment. Success was the canal. The first step is, therefore, defined as complete removal of the dedicated to rectifying the canal access fractured instrument from the root canal and relocating the coronal entrance. This without creating a perforation (Figure 6). requires straightening of the canal wall The canal was then routinely prepared opposite the curve.[7],[8] and all canals filled with lateral • A cylindro-conical bur with non- compaction of gutta-percha and AH26 cutting tip for straightening Figure 2 (Dentsply) sealer (Fig. 7). • the walls of the access cavity • A short Gates Glidden size 4 for Discussion relocation of the canal entrance, Morphological variations in root canal which is moved along the wall system anatomy should always be opposite the coronal curve with considered at the beginning of treatment. vertical back-and-forth movements Each case, independently of the type of • A Gates Glidden size 3 to prepare tooth, should be examined carefully, access to the fragment clinically and radiographically in order to Local anaesthesia was administered d e t e c t p o s s i b l e a n a t o m i c a l (Xylocaine 2% adrenaline). Isolation was aberrations.[9] Intracanal separation of done using rubber dam (Hygenic, Coltene/Whaledent Inc). Access opening was done using endo-access bur. Initial Figure 3 exploration of the canal was done using K file #10. K file #15 was the next instrument used in the canal. K file #15 instrument fracture was observed in the distobuccal canal of the tooth. A radiograph was taken to confirm the instrument separation. In the radiograph, the instrument was seen extending from the apical third to the coronal orifice of the canal (Figure 1). Figure 6 Gates glidden drill was also used for the Figure 4 enlarging root canal. Appropriately sized ULTRASONIC instrument was selected, such that the length will reached to the broken obstruction and its diameter will passively fit into the previously shaped canal. Then the ultrasonic instrument was placed in intimate contact against the obstruction and typically then it was activated within the lower power setting. Ultrasonic action trephines, sands away the dentin and exposes the coronal few Figure 5 Figure 7

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 051 instruments usually prevents access to are removed during this procedure which eliminate the broken instrument the apex, impedes thorough cleaning and may potentially cause complications. procedural accident.[16],[17],[18] shaping of the root canal, and thus may There is no doubt that the degree of compromise the outcome of endodontic curvature is one of most important factors References treatment and reduce the chances of influencing the successful management 1. Arcangelo CM, Varvara G, Fazio PD. successful retreatment. In such cases, of separated instruments [12]. Broken instrument removal two prognosis following an endodontic A technique as devised by rowe uses cases. J Endod. 2000;26:568–70. therapy depends on the condition of the cyanoacrylate glue {permabond or super 2. A. Madarati,1 D. C. Watts2 and A. J. root canal (vital or nonvital), tooth glue # 30 } and hypodermic needle to E. Qualtro. Factors contributing to the (symptomatic or asymptomatic, with or retrieve silver point. According to it when separation of endodontic files. British without periapical pathology), level of a silver point is not protruding into the Dental Journal Volume 204 NO. 5 cleaning and shaping at the time of pulp chamber then select a hypodermic MAR 8 2008. separation, the level of separation in the needle that fits snugly over silver point 3. Ruddle CJ: Ch. 8, Cleaning and canal; and is generally lower than that remove the bevel of needle and cement it shaping root canal systems. In Cohen with normal endodontic treatment.[10] over the silver point using cyanocarylate S, Burns RC, editors: Pathways of the glue after 5 minutes of setting time the Pulp, 8th ed., Mosby, St. Louis, pp. Factors should be considered when needle is grasped the hemostat and silver 231-291, 2001. treatment planning fractured instrument point worried from place.[13] 4. Shikha gulati. Retreatrment of silver case : Although the short term sealability point obturation A case report and an • Preoperative pulpal and periapical success of silver point seemed overview.journal of contemporary diagnosis comparable to that of gutta perch, silver dentistry. Sep- Dec 2012,2(3):114- • Extent of chemo-mechanical point are a poor long term choice as 118. prior to instrument routine obturation materal.[14] 5. M. Rahimi & P. Parashos A novel breakage Factors Influencing Broken Instrument technique for the removal of fractured • Position of fractured instrument, i.e. Removal instruments in the apical third curved direct vision and adequate straight Success of retrieval depends on the canal root canals. International Endodontic line access ? anatomy, what type of metal the piece is Journal, 42, 264–270, 2009. • Length of fragment made out of (stainless steel files tend to be 6. Shen Y, Peng B, Cheung GS. Factors • Anatomy of the root (thickness, easier to remove), the location in the associated with the removal of presence of concavities and curvature canal of the fragment, the plane in which fractured NiTi instruments from root of the root canal) the canal curves, the length of the canal systems. Oral Surg Oral Med • Can the instrument be bypassed? If separated fragment, and the diameter of Oral Pathol Oral Radiol Endod 2004; yes, bypass it and do not actively the canal itself[15]. In general, if one 98: 605–10. attempt removal. [11] third of the overall length of an 7. Ruddle CJ.: Broken Instrument clinical practices in endodontics that the obstruction can be exposed, it can usually R e m o v a l : T h e E n d o d o n t i c use of magnification is considered be removed. Challenge, Dentistry Today, July helpful for the successful completion of Instruments that lie in the straightaway 2002. endodontic treatment. According to portions of a canal can typically be 8. Mandel E, Adib-Yazdi M, Benhamou endodontic literature, the MM canal can removed. More challenging are separated LM, Lachkar T. Rotary Ni-Ti profile be found in 1–15% of the cases . instruments that lie partially around canal systems forpreparing curved canals In most of the cases, this canal is hidden curvatures, but these can often be in resin blocks: influence of operator by a dentinal projection of the mesial removed if straight-line access can be on instrument breakage. Int Endo J aspect of pulp chamber walls. In all cases established to their most coronal extents. 1999;32: 436-443. of mandibular molars, this dentinal If the broken instrument segment is 9. Shikha gulati. Retreatrment of silver growth is usually located between the apical to the curvature of the canal and point obturation A case report and an two main canals and should be removed safe access cannot be accomplished, then overview.journal of contemporary carefully in order to detect the additional removal is usually not possible. dentistry. Sep- Dec 2012,2(3):114- canal or canals. Ultrasound technology is 118. Farhad Faramarzi, DDS, MSD1; a very useful tool for the clinician to clean Conclusion Hamidreza Fakri, DDS2; Homan H such an area efficiently. Conventional Techniques Must Be Tried Javaheri, DDS2.. Removal of the fractured instruments is But If They Prove To Be Unsuccessful, 10. Farhad Faramarzi, DDS, MSD1; more influenced by the anatomy of tooth, Alternative Method - Cyanoacrylate Hamidreza Fakri, DDS2; Homan H degree of root canal curvature and the Glue Helped For Removal Of Broken Javaheri, DDS2. Endodontic location of the fragment than the specific Endodontic Instruments. treatment of a mandibular first molar technique used. Success rate can be quite Method Is Simple, Cost Effective And At with three mesial canals and broken variable because removal of the fractured The Same Time Can Result In instrument removal.Aust Endod J instruments is difficult and time- Predictable Success 2010; 36: 39–41 consuming. A technique utilising The best antidote for a broken file is 11. Arun Kulandaivelu Thirumalai, modified Gates–Glidden burs and prevention. Adhering to proven concepts, Mahalaxmi Sekar, and Sumitha ultrasonic has recently been advocated to integrating best strategies and utilizing Mylswamy. Retrieval of a separated remove fractured instruments from root safe techniques during root canal instrument using Masserann canals. Varying extents of tooth structure preparation procedures will virtually technique J Conserv Dent. 2008 Jan-

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 052 Mar; 11(1): 42–45. clean shape pack, 2-tape video series, Factors influencing defect of rotary 12. Peter Parashos, MDSc, PhDemail, Advanced Endodontics, Santa n i c k e l - t i t a n i u m e n d o d o n t i c Harold H. Messer, MDSc, PhD Barbara, 2002. instruments after clinical use. J Endo Journal of Endodontics 32, 15. Marnding M, Lutz F,Barbakow F. 2004;30:722-725 1 0 3 1 – 4 3 . 2 0 0 6 R o t a r y N i T i Scanning electron microscope 18. Iqbal M K, Kohli M R , Kim J S. A Instrument Fracture and its a p p e a r a n c e s o f l i g h t s p e e d retrospective clinical study of Consequences. instruments used clinically : a pilot incidence of root canal instrument 13. Shen Y, Peng B, Cheung GS. Factors study. Int Endod J 1998; 31:57-62. separation in an endodonticsgraduate associated with the removal of 16. Yared Gm, Dagher F E, Machtou program: a pennEndodata base study. fractured NiTi instruments from root P,Kulkarni G K. Influence of J Endo 2006;32:1048-1052. canal systems. Oral Surg Oral Med rotational speed, torque, and operator Oral Pathol Oral Radiol Endod 2004; proficiency on failure of greater taper 98: 605–10. files. Int Endod J 2002,35: 7-12. 14. Studio 2050, producer: Ruddle on 17. Parashos P,Gordon I, Messer H H.

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Modified Nance Palatal Arch: An Aesthetic 1 Bimal Chandra Kirtaniya 2 Jasneet Kaur Approach To Missing Anterior Teeth - A Case 3 Bakshinder Singh Lyall 4 Vasundhara Pathania Report 1 Head Of The Department 2 Mds Student Abstract 3 Mds Student The maintenance of arch length in the primary, mixed and early permanent dentition is important 4 Senior Lecturer for the normal development of the occlusion. Premature loss of primary teeth can result in the Dept. Of Pedodontics loss of arch length leading to often increasing the need for orthodontic treatment. Himachal Dental College Address For Correspondence: Space maintenance can often prevent space loss and prevent the development of a later Dr. Bimal Chandra Kirtaniya malocclusion or reduce its severity by guiding the eruption of permanent teeth. While missing Dept. Of Pedodontics posterior teeth pose space loss complications, missing anterior teeth result in functional, Himachal Dental College, Sundernagar, HP. psychological and aesthetic disturbances which a have negative impact on the confidence of the Submission : 19th March 2014 child. The following case report presents a new and an innovative technique for the replacement Accepted : 7th March 2015 of maxillary incisors incorporated in the design of conventional Nance Palatal Arch space maintainer. The novel appliance fabricated fully satisfied the demands of the patient for Quick Response Code aesthetics and at the same time maintained the space for posterior teeth. Key Words Nance palatal arch, aesthetics, space maintenance, deleterious habit. Introduction of anterior teeth.[1] It also has impact on There are many morphogenetic and speech development and the ability to environmental influences, which effect articulate certain speech sounds, thus the occlusal development, and a disorder effecting the overall personality of the or deviation in any of these elements may growing child.[3] All these factors the palatal mucosa, provides support influence the occlusion. The permanent necessitate the replacement of the d e r i v e d f r o m t h e h a r d teeth dislocation occurs in the eruptive, anterior teeth by an appliance that palate.[5]However, when there is pre functional and functional periods of satisfies the aesthetics and functional premature loss of multiple posterior teeth the eruption, i.e. within the primary arch needs. occur in one segment, we can use and in the mixed dentition stage. [1] An anterior removable appliance transpalatal arch space maintainer, Premature loss of primary posterior teeth incorporating artificial teeth satisfy because the loss of space in the upper arch leads to mesial migration or tipping of the aesthetic requirements of the young takes place in mesiopalatal direction. adjacent tooth, which can be permanent patients, but when considered the factors In this case report, we present the first molar or deciduous second molar like cooperation in wear, comfort, modification of traditional Nance into the space. This leads to loss of arch appliance loss or damage, such Appliance, where acrylic teeth were length, thus affecting the structural r e m o v a b l e a p p l i a n c e a r e incorporated in the anterior part of the balance and functional efficiency by problematic.Fixed appliances, on the appliance, for a patient with missing causing crowding or ectopic eruption and other hand, if properly designed, are less maxillary incisors and first molars even impaction of permanent teeth[2]. damaging to the oral tissues and less of an bilaterally. The modified design met the This necessitates the preservation of arch annoyance to the paediatric patient patients’ need for a space maintainer in length by means of space maintainers to thereby ensuring compliance and the posterior segment and a fixed prevent the need of complex orthodontic longevity of wear.[4] prosthesis replacing maxillary incisors in treatment at a later stage. Traditionally, the treatment of choice for the anterior segment. Additional Space loss, generally does not occur in premature and bilateral maxillary stabilization of the anterior part of the the anterior segment if primary canines posterior teeth loss is the placement of a appliance was obtained by adding a are present in the occlusion. But loss of Nance appliance. It was first described by framework of stainless steel wire which anterior teeth, on the other hand, acts as a Nance in 1947, and it is very popularly in was acrylized adding the teeth. major setback for the growing patient pediatric dentistry even today. The because of the aesthetic reasons. It can appliance is cemented with bands placed Case Report lead to mocking by peer groups in school, on the molar teeth and a palatal acrylic A 5 year old boy reported to with missing causing psychological trauma to the button placed in the region of the rugae maxillary incisors and both the first growing child. Development of palatinae in the anterior part of the palate. molars (Fig.1). The parents gave a deleterious habits like tongue thrusting, The bands are connected to the button history of caries associated with the teeth forward resting posture of the tongue is using a 0.9 mm round stainless steel wire. for which extractions were performed at a also a concern following premature loss The acrylic button, which is up against private clinic. From the history given by

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 054 parents, it was concluded that the patient primary tooth loss has been estimated to had severe early childhood caries, so the be as high as 28.9%, with a range of 4.3 to dentist performed extractions of the 42.6%. [6] The premature loss of primary involved teeth. The parents wanted the teeth due to caries, trauma, ectopic restoration of the involved teeth and eruption, or other causes may lead to replacement of the anterior teeth. undesirable tooth movements of primary The option of placement of modified and/or permanent teeth including loss of Nance Palatal Arch was discussed and arch length.[7] Jytte Pedersenet al, 2006 consent was obtained from the parents. reported that early loss of primary teeth Figure 1- Intra-oral view of missing primary maxillary central During the first visit, molar bands were would result in an increased frequency of incisors and primary maxillary molars. fabricated on the deciduous right and left sagittal, vertical as well as transversal maxillary second molars. A full mouth malocclusion. Hence, wherever possible, alginate impression with bands in place restoration of the natural primary tooth was made for maxillary arch. Mandibular should be attempted but in case of impression was also made and wax bite extraction or avulsion of the natural registration was done. tooth, maintenance of the space to guide Under laboratory procedures, stone the eruption of permanent tooth is models were cast from the impressions. mandated. With 19 gauge stainless steel wire, a Developmental stage of occlusion, as Nance palatal arch was made and the wire well as differences in maxillary and lay passively against the anteroinferior mandibular arches are important factors aspect of the palate. The distal end of the to be considered while space wire rested in contact with the palatal management. When the loss of primary Figure 2 (a) Fabricated modified nance palatal arch. surface of the maxillary molar bands and tooth occurs close to the physiological was soldered. An additional wire age of exfoliation, premature eruption of framework, made of 21 gauge wire was the permanent successor occurs. soldered on the anterior aspect of the However, when the loss of primary tooth standard Nance framework which occurs when the root has just started extended from mesial of one canine to the forming, bone neoforms over permanent labial surface of the maxillary ridge to the tooth germ which could result in delayed mesial of the other canine. The bite eruption, mandating the need of space registration was done to maintain the maintenance.[6] Radiographs can be vertical and anteroposterior relations of used to detect the amount of bone jaws and teeth. The metal framework was covering the permanent tooth bud and it waxed up with teeth and routine usually takes 4 to 6 months by an erupting procedures were carried out. The tooth to move through 1mm of bone. Figure 2 (b)- Fabricated modified nance palatal arch. appliance was removed after heat curing Moreover, teeth erupting adjacent to the the acrylic followed by finishing and edentulous area have a greater effect on polishing.(Fig. 2a,b). the amount of space lost than do fully On the next appointment, try-in of the erupted teeth.[1] appliance and occlusal adjustments were The loss of space is more in premature done. All the carious teeth were restored. loss of second primary molar than the Finally, the finished appliance was first primary molar, with greater cemented using the Glass Ionomer mesialization of the permanent first Cement. Prior to discharge of the patient, molar occurring during its active eruption instructions were given regarding oral phase. However, in case of loss of Figure 3- Occlusal view of modified nance palatal arch in hygiene maintenance and consumption deciduous first molar, there is greater situ. of soft diet for first few hours.(Fig.3) The distalization of canine into the available patient was recalled after one week to space than mesialization of the adjoining check any impingement of the appliance tooth into the space and extending the and the parents were instructed to report changes to as far as the midline. The loss to the clinic after six months. of space is more in children having Both the patient and the parents were deleterious habits like thumbsucking, satisfied with the treatment and the tongue thrusting, mouth breathing etc.[8] aesthetics.(Fig.4). Most of the space loss occurs during the first 6 months of the loss of deciduous Discussion: tooth, with space closure occurring more Despite of advances in dental sciences, in rapidly in maxillary arch than the methods of caries prevention and mandibular arch. Also, when mandibular promotion of oral health globally, early permanent molars move anteriorly, they primary tooth loss continues to affect show only mesial tipping into the Figure 4- Intraoral view of the appliance after positive many children. The prevalence of early available space leading to loss of space adaptation to the child.

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 055 whereas the permanent maxillary molars teeth, restoration of masticatory function, 8. Dawjee S.M, Khan M.I, Hlongwa P- rotate mesiopalatally around the large prevention of overeruption of The repositioning nance appliance : a palatal root which acts as a pivot causing antagonists, compatibility with soft fixed functional appliance and case rotation as well as bodily movement. tissues and effective hindrance of report. J Maxillofac Oral Surg 8(1): Hence, contributing to greater loss of torquing forces on abutment teeth. But an 68-73. space in maxilla than in the mandible. attempt was made to meet the aesthetic 9. Stivaros N, Lowe C, Dandy N, This makes the use of holding appliance demands while preventing the space loss Doherty B and Mandall N.A- A inevitable to maintain the position of the with this new innovative appliance.[10] randomized clinical trial to compare teeth. In case of unilateral loss of the Goshgarian and nance palatal maxillary first and second molars, Conclusion: a r c h . E u r o p e a n J o u r n a l o f transpalatal arch may be givenas it Early loss of primary teeth continues to Orthodontics 32 (2010) 171-176. reduces anterior molar movement by be highly prevalent in India due to bottle 10. Wilson .B, Joseph .J, Bharadwaj P, coupling the right and left permanent feeding habit, lack of knowledge of Kaushik P.C- Space management in molars together and, thus, preventing any proper oral hygiene maintenance, Paediatric dentistry. The journal of possibility of rotations.[2] Bilateral loss abnormal food habits leading to dental Panacea 2014, oct-nov,Vol of both the primary molars indicate the malocclusion in developing permanent 1(2). use of Nance palatal arch and lingual dentition. A continuous and meticulous 11. Rapp R, Demiroz I – A new design for holding arch in maxilla and mandible treatment planning is essential to monitor space maintainers replacing respectively. space loss and eruption of permanent prematurely lost first primary molars. Anterior dental disharmonies especially teeth to prevent malocclusion. Pediatric dentistry, American interfere with the normal tongue academy of Pedodontics vol.5 (2): placement which then can lead to the References: 131-134. development of maladaptive articulatory 1. Heilborn J.C, Kuchler E.C, Fidalgo 12. Ngan .P, Alkire R.G, Fields. H- habits. Tongue thrust commonly T.K.S, Antines L.A.A, Costa M.C.- Management of space problems in the develops when prematurely lost Early primary tooth loss: prevalence, primary and mixed dentitions. JADA deciduous anterior teeth are not consequence and treatment. Int J ,Sept. 1999 vol 130: 1331-1339. replaced.Yet another consideration is the Dent, Recife, 10(3) 126-130. 13. Kupietzky .A- The treatment and long child’s speech development following 2. Kupietzky .A, Eli Tal- The term management of several multiple extraction of all four incisors. Many transpalatal Arch: An alternative to avulsions of primary teeth in a 19- sounds are made with the tongue the nance appliance for space month old child. AAPD 2001; 25(6): touching the lingual side of the maxillary maintainers. Pediatric dentistry, 517-521. incisors and inappropriate speech May/June 07, Vol. 29(3): 235-238. 14. Guideline on Pediatric restorative compensations can develop if the teeth 3. Turgut M.D, Genc G.A, Basar F, dentistry. AAPD,1991. are missing.[3] Tekcicek M.U- The effect of early 15. Faheemuddin M, Yazdanie N, Nawaz Removable or fixed prosthesis can be loss of anterior primary tooth on M.S- A simple and quick technique of used to replace deciduous anterior teeth speech production in preschool fabricating a space maintainer for in children that have been prematurely children. Turk J. Med Sci 2012; avulsed primary maxillary incisors. lost due to disease.[9] Modification of 42(5): 867-875. Pakistan Oral and Dental journal Nance appliance with acrylic teeth in the 4. Klapper B.J, Sherwin R.S- Esthetic (Aug 2012), vol 32(2). anterior part, meets the need of a anterior space maintenance. Pediatric 16. Prabhakar M, Kaur Mauli Simrit- posterior space maintainer and anterior dentistry, AAPD vol.5(2):121-123. Prosthetic replacement options for fixed prosthesis in a young child. It serves 5. Singh Paramjit and Cox Shirley- premature loss of deciduous anterior as an interim appliance in children with Nance Palatal arch: a cautionary tale. teeth. Indian journal of dental premature loss of anterior teeth.Despite Journal of Orthodontics, 2009; vol.36 sciences, October 2014, vol 6(4). its short-term usage, it aids to improve : 272-276. 17. Willet R.C- Premature loss of speech and esthetics, and prevent 6. Rickman G.A, El-Badrawy H.E- deciduous teeth. Chicago association psychological disturbances and tongue Effect of premature loss of primary of orthodontics, Jan 23, 1933. thrust habits. It is cemented into position maxillary incisors on speech. 18. Dr. Mohammad Khursheed Alam- A and requires minimal post insertion Pediatric dentistry, June 1985; Vol. toZ orthodontics, vol.9. adjustments. 7(2):119-122. No space maintainer, with the exception 7. Guideline on management of the of the primary tooth can fulfill all the developing dentition and occlusion in requirements of an ideal appliance, Pediatric dentistry. American including preservation of space, eruption academy of Pediatric dentistry, of adjacent, succedaneous, and abutment reference manual vol 36(6): 14-15.

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 056 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Condylar Fracture – A Case Report And 1 Surya Prakash Bhardwaj 2 Rudresh KB Management 3 Rohit Sharma 4 Vijay Rishra Abstract 1 Reader, Dept. of Oral Surgery, Mandibular condyle is one of the most common sites of injury in the facial skeleton, yet it is most Jodhpur Dental College, Rajasthan overlooked and least diagnosed site of trauma in the head and neck region. Condyle forms the 2 Reader, Dept. of Oral Surgery, very cornerstone of mandibular form and function and therefore injuries to the mandibular V.S. Dental College, Banglore 3 condyle in growing children may adversely affect growth and development of the jaws and the Reader, Dept. of Oral Pathology, occlusion. Awadh Dental College and Hospital, Jamshedhpur 4 Reader, Dept. of Oral Surgery, Key Words ITS Centre for Dental Studies & Research, Ghaziabad condyle, injury, trauma, fractures, diagnosis, treatment. Address For Correspondence: Dr. Surya Prakash Bhardwaj Introduction The patient visited local dentist from Reader, Dept. of Oral Surgery, Condyle forms the very cornerstone of where he was referred. Patient did not Jodhpur Dental College, Rajasthan Submission : 18th January 2013 mandibular form and function, the complain about any difficulty during th growth and development of the jaws and eating speaking or any mandibular Accepted : 20 October 2014 as a result, occlusion, also depends to a movement except a bit of inconvenience Quick Response Code large extent on the integrity and health of due to deviation. On inspection, the mandibular condyle.[1] Causes of roundness of the face on right side, shift condylar fractures in growing patients are in midline and deviation of mandible on Bicycles (6-1 2 year olds),Motor vehicle opening the mouth toward right side was accidents (6-18 year old),Falls (1-12 year observed. On palpation, there was no olds),Child abuse (1-5 year olds),Contact tenderness over the temporomandibular sports (12-18 year olds ).The joint and was not present. complications of condylar fractures include pain, restricted mandibular Orthopantomograph revealed Observations: movement, muscle spasm and deviation Mixed dentition stage, fractured condyle • Mild micrognathia and retrognathia. of the mandible, malocclusion, and seen on right side showing possible • Asymmetry of the face with chin and pathological changes in the TMJ, medial displacement. A computerized symphysis menti deviated to right. osteonecrosis, facial asymmetry and tomography scan of mandible was • Deformed and hypoplastic right ankylosis.[2] These complications can be advised for better assessment of the mandibular condyle. encountered irrespective of whether condition following clinical and • Hypoplasia of right glenoid fossa and treatment was performed or not. In terms Orthopantomograph examination of the flattening of articular eminence is of strength, the condylar neck constitutes patient. noted resulting in hypoplasia of right the weakest region of the entire mandible CT scan of mandible- A preliminary . and is therefore the most susceptible to lateral tomogram of mandible was • Left mandibular ramus, condyle and fracture. Because of the well protected performed. Volume scans were glenoid fossa are normal. position of the condylar process, performed through mandible employing however, injuries are often the result of 0.625mm sections. Multiplanar and 3D Treatment indirect forces, where the forces of reconstructions were performed which The treatment was performed under impact are transmitted along the revealed following conditions. general anesthesia considering the debate mandible from distant sites such as the angle, body or symphysis to the condylar neck.[3]

Case Report A male patient aged 8 years was referred from PSC center to the department of oral and maxillofacial surgery. The patient complained about deviation of the mandible during eating and speaking since 1year, as was observed by mother of patient. The child was asymptomatic. Figure 1 : Pre Operative Orthopantomograph Figure 2 : Costo Chondral Rib Graft

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 057 Patient was discharged after a week of era before the advent of antibiotics was postoperative care. Patient was put on a based chiefly on the threat of strict soft diet and instructed to perform osteomyelitis and the technical problem mouth opening excercises. Bimonthly of controlling a displaced condyle for f o l l o w u p a n d a m o n t h l y reduction and fixation. In 1945, Dr Kurt orthopantomograph was done to H. Thoma published articles on determine the condition of rib graft. “Functional and Dislocations of the Mandibular Condyle” and “A Method for Discussion Treating Fractures and Dislocations of There is consensus in the world literature treating the mandibular condyle” that regarding the treatment of both advocated open reduction for intercapsular and extracapsular condylar subcondylar fractures and expressed fractures in children, which must be with concern about malunion[9]. Figure 3 : Alkayat-bramley Incision closed treatment. When this type of The proponents of the non surgical opinion was challenged, some authors approach argue that the vast majority of now admitted the possibility of using these patients can be treated adequately open reduction in cases of condylar with a period of maxillomandibular fractures in children, provided that the fixation followed by sessions of training technique was minimally invasive, as for e l a s t i c s a n d o t h e r f o r m s o f example, by endoscopic surgery. physiotherapy. This group opinionates, Nussbaum et al. (2008) published a the advantages that might be gained with critical analysis of the past studies that an open procedure do not offset the have directly compared if open or closed morbidity and risks involved.Those treatment of condylar fractures produces advocating open reduction argue that the best results[4],[5]. The results were condylar deformity, mandibular Figure 4 : Exposure Of The Fracture Site inconclusive regarding whether open or dysfunction and asymmetry will result closed treatment should be used for the with closed management of displaced management of mandibular condylar fractures. fractures. Because of the relatively poor Age of patient, medical satus of patient, quality of the available data and the lack level of fracture, degree of displacement, of other important information, the direction of displacement, concomitant question of preferred treatment still injuries, presence of dentition, status of remains unanswered, and there is clearly existing dentition, ease in establishing a need for further research. The authors adequate occlusion and presence of propose that in future investigations the foreign body are factors that affect the patients need to be randomized into decision of performing closed or open Figure 5 : Post Operative Orthopantomograph After A Month treatment groups, and the examiners need reduction. to be blinded to the manner in which the As a consequence of these variables, the patients are treated. Similar methods of risk/benefit ratio in the choice of treatment need to be used[6]. treatment must be determined for each Standardized methods of fracture case. The burden still resides with the classification, as well as data collection surgeon as he or she attempts every and reporting, need to be established so trauma victim with this specific that valid comparisons among studies can condition.[10] be made. Studies with adequate sample sizes to determine clinically meaningful Conclusion effects should be undertaken[7]. All dental practitioners should be fully Nevertheless, after reviewing the various aware of the implications of condylar articles published over the last few years, injuries in growing Figure 6 : Post Operative Photograph it is believed that with exception of children. Unfortunately, too many of closed and open method and age of the absolute indication of closed treatment condylar injuries remain undiagnosed patient .The fracture site was exposed by used in children, there are still no rules which in rare situations may result in alkayat bramley surgical incison and and/or norms defined for treating serious adverse sequelae that are more dissection condyle. Displaced part was condylar fractures. The decision about difficult to treat at a later stage in the excised and height of the ramus replaced the choice of the type of treatment must patient’s growth and development. with rib graft supported by screws. always take into consideration some of Therefore, children who present with Surgical exposure site was closed in the factors, such as the patients’ general acute dental injuries should always be layers supported by minidrains for dead health status, type of fracture, diagnostic examined for the possibility of space management. Patient was precision, and mainly the capability, concomitant condylar injuries. It is hoped monitored for the first two days under experience and skill of the surgeons in that this article will help increase the intensive care unit and after shift to this type of lesion.[8] awareness of all dental practitioners, so general ward daily follow up was done. The aversion to surgical methods in the that early diagnosis of condylar injuries

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 058 can be made. Thus by close monitoring 3. LindhalL condylar fractures of facial asymmetry : an experimental and regular followup can decrease the mandible. Int J Oral Maxillofac s t u d y. J O r a l M a x i l l o f a c likelihood of severe long-term Surg1977;6:12-21. Surg;49:1181,1991. mandibular growth and functional 4. Raustia AM et al conventional 8. Raveh J etal ,Open reduction of the disturbances. radiographic and computed dislocated fractured condylar process radiographic finding in cases of indication and surgical procedures. J References condylar fractures of mandible J Oral Oral Maxillofac Surg1989; 47:120. 1. Myall RWT, Sandor GKB, Gregory Maxillofac Surg1990;48:1258-64. 9. Takenoshita et al: comparison of CEB. Are you overlooking fractures 5. George dimitroulis et al Condylar functional recovery after non surgical of the mandible condyle. Pediatrics injuries in growing patients. and surgical treatment of condylar 1987;79:639-41. A u s t r a l i a n D e n t a l fractures. J Oral Maxillofac 2. T a l w a r R M , E L L I S 1 1 1 Journal1997;42:367-71. Surg1990; 48:1191. E,Throckmorton GS adaptation of the 6. Motamedi MH treatment of condylar 10. James R. Hayward et al : Fractures of masticatory system after bilateral hyperplasia of the mandible using the Mandibular Condyle. J Oral fracture of mandibular condylar unilateral ramus osteotomies. J Oral Maxillofac Surg51:57-61,1993. fracture. J Oral Maxillofac Maxillofac Surg1996;54:1161-69. Surg1998;56:430-9. 7. Markey J et al ,condylar trauma and

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 059 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Lobular Capillary Haemangioma In An Elderly 1 Ahad M Hussain 2 Anirban Chatterjee Woman: A Case Report 3 Rosh R M 4 Ajmal F Abstract 1 Reader Lobular capillary haemangiomas (LCH) are common tumours of the oral cavity and pose 2 Professor and Head diagnostic challenge to the practitioner as they may resemble other serious lesions. Aetiology of 3 Senior Lecturer LCH is not well understood and it is reported that over expression of p-ATF2, p-STAT3 and 4 Post Graduate possibly p53 may have a role to play in genesis of cutaneous vascular tumours. This case report Dept. of Periodontics explains the clinical and histolopathological features of a LCH in a 55-year-old female patient. The Oxford Dental College The exact cause of this tumour could not be identified. The lesion was conservatively excised Address For Correspondence: Dr. Ahad M Hussain, Dept. of Periodontics under local anaesthesia and the histopathological report confirmed the diagnosis as LCH. The The Oxford Dental College lesion healed uneventfully and showed no recurrence after 6 months. (112 words) 455, 3rd cross, 16th main, 3rd block Key Words koramangala, Bangalore 560034 Lobular capillary haemangioma, Sessile papule, Benign mesenchymal Email: [email protected] Ph: 9845806778 Introduction location is head and neck followed by Submission : 29th April 2014 Pyogenic granuloma (PG) is a painless, trunk, upper and lower extremity. Only Accepted : 13th March 2015 benign, inflammatory hyperplasia seen 18% of the lesions occur in mucous on the skin and mucocutaneous membrane of oral cavity and Quick Response Code surfaces.[1] The term is misleading as it conjunctivae.[8] In the oral cavity, Harris does not produce any pus.[2] et al. have reported that these lesions are Histologically, the lobular arrangement primarily seen on the lips, gingiva and the of capillaries distinguishes it from the tongue.[7] Although the peak prevalence granulation tissue.[3] The term “lobular is seen in younger ages, however, it is not capillary haemangioma” (LCH) was rare in older patients. The treatment introduced for more accurate description involves surgical intervention, and it is hygiene with a 5-mm pocket in relation to and to distinguish it from the non-lobular important to distinguish it from other #41, #42 and #43. A provisional variant. LCH are characterised by a similar looking lesions which can be life diagnosis of LCH was made. distinct lobular arrangement of the threatening. Herein we report a case of a Differential diagnosis of fibroma, capillaries in an oedematous, fibroblastic 55-year-old female patient with LCH. peripheral giant cell granuloma and PG stroma. Superficially, the lesion may were considered. After the initial scaling show secondary non-specific changes Case Report and oral prophylactic treatment, excision like stromal oedema, capillary dilatation A 55-year-old female patient with chief biopsy of the lesion was performed under or inflammatory granulation tissue complaint of swelling in lower front local anaesthesia and the specimen was reaction.[4] region of the mouth was evaluated at the sent for the histopathological Clinically, LCH appears either as a single department. The patient complained of examination (Fig. 2). The lesion healed nodule or sessile papule with smooth or bleeding from the lesion and difficulty in uneventfully and the laboratory report lobulated surface, erythematous, eating due to the swelling. The patient elevated, and generally ulcerated.[5] The reported that she had noticed the swelling lesions typically evolve slowly, are a month ago, and it had gradually asymptomatic and painless, but increased to the present size. General occasionally may grow rapidly.[6] physical examination, past history and According to Patrice et al., more than family history were all non-contributory. 40% of the cases occur in the first five Intraoral examination revealed a pink- years of life. The lesions showed male coloured solitary swelling measuring 2.5 predisposition[8]. Mills et al. reported cm X 2 cm located in the lingual aspect of that incidence was higher in males who #41, #42, #43, #44, #45 and extending up are younger than 18 years, females in to the mesial aspect of #46 (Fig. 1). The reproductive years, and showed equal sex lesion showed areas of opacity and distribution beyond 40 years of age.[4] erythema. It was sessile papule, The prevalence is higher during lobulated, painless and firm in pregnancy and the influence of hormone consistency with bleeding on is postulated as the cause for it without p r o v o c a t i o n . O n p e r i o d o n t a l convincing evidence.[7] The common examination, the patient had poor oral Figure 1: Pre Surgical Photograph.

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 060 a tumour.[10] Chen et al. have reported and compression, and excision using that over expression of p-ATF2, p-STAT3 laser.[19],[20] The present case healed and possibly p53 may have a role to play uneventfully and the follow-up after 6 in genesis of cutaneous vascular tumours months showed no signs of recurrence. like PG.[11] The prevalence of LCH in Indian population is not available.[12] Conclusion The most favourable sites for occurrence LCH occur commonly in the oral cavity of LCH are on the lips, gingival and and may be often confused with other tongue. The peak incidence was seen in serious lesions of the oral cavity. early twenties and affected females more Accurate diagnosis based on the Figure 2: Surgical Photograph. by a ratio of 2:1, especially in the histopathological assessment and forties.[7] treatments are very important to rule out The differential diagnosis for LCH life-threatening conditions. Care should i n c l u d e s b e n i g n t u m o u r s o f be exercised during excision of these mesenchymal origin namely PG, fibroma vascular lesions that show increased and peripheral giant cell granuloma. PG tendency of bleeding. (1057 words) is one of the common benign lesions of mesenchymal origin and is usually References caused by reactive inflammatory 1. Xu Q, Yin X, Sutedjo J, Sun J, Jiang hyperplasia due to local irritation or L, Lu L. Lobular capillary trauma. PGs are small, deep red to hemangioma of the trachea. Arch Iran purplish in colour, sessile or Med 2015 Feb;18(2):127-9 doi: Figure 3: Histopathological Micro Photograph. pedunculated. The surface is smooth, 015182/AIM0013. frequently ulcerated and bleeds 2. Shafer WG HM, Levy BM, editor. easily.[13] However, PGs have a non- Shafer's Textbook of Oral Pathology. LCH variant and for accurate description, Amsterdam: Elsevier Health to evade uncertainty, the diagnosis of Sciences; 2006. LCH is used based on histological 3. Fechner RE, Cooper PH, Mills SE. examination.[4],[9] Fibroma or focal Pyogenic granuloma of the larynx fibrous hyperplasia is an inflammatory and trachea. A causal and pathologic hyperplastic lesion of the oral cavity due misnomer for granulation tissue. to irritation. It is commonly found on A r c h O t o l a r y n g o l 1 9 8 1 g i n g i v a a n d s h o w s f e m a l e Jan;107(1):30-2. Figure 4: Post Surgical Photograph. predilection.[14],[15] Histological 4. Mills SE, Cooper PH, Fechner RE. presentation of a fibroma appears as Lobular capillary hemangioma: the c o n f i r m e d i t a s L C H . T h e unencapsulated, solid, nodular mass of underlying lesion of pyogenic histopathological report showed areas of fibrous connective tissue. Peripheral granuloma. A study of 73 cases from stratified squamous fibroblasts along giant cell granuloma is also a benign the oral and nasal mucous with presence of proliferating and few reactive lesion that can occur at all membranes. Am J Surg Pathol 1980 dilated congested blood vessels (Fig 3). ages.[16] It arises due to local irritation Oct;4(5):470-9. The report confirmed the diagnosis of from the periosteum or periodontal 5. Regezi JA SJ, Jordon RCK, editor. LCH. membrane, especially in mandible. It Oral Pathology: Clinical Pathological The lesion showed no evidence of appears as reddish-purple nodule and Considerations. . 4th edn ed. recurrence during follow-up examination shows recurrence. The diagnosis is Philadelphia, London, Toronto: WB (Fig. 4). confirmed histologically. Saunders Company; 2003. Benign tumours of mesenchymal origin 6. Dahiya R, Kathuria A. Extragingival Discussion may pose a risk of erroneous diagnoses of pyogenic granuloma histologically PGs are benign mesenchymal neoplasms other serious lesions as they may appear mimicking capillary hemangioma. J that are often encountered in the oral similar to their life-threatening Indian Soc Periodontol 2014 cavity and histologically there are two counterparts. These lesions may include Sep;18(5):641-3 doi: 104103/0972- distinct varieties namely LCH and non- basal cell carcinoma, Kaposi’s sarcoma 124X142463. LCH. Clinically, the LCH appears as a or a metastatic carcinoma. Scalvenzi et 7. Harris MN, Desai R, Chuang TY, solitary, shiny red papule or nodule that is al. reported that malignant tumour-like Hood AF, Mirowski GW. Lobular susceptible to bleeding and ulceration. melanoma can imitate these lesions.[17] capillary hemangiomas: An Epivatianos et al. reported that LCH often Confirmation of clinical diagnosis with epidemiologic report, with emphasis appeared as sessile lesions, whereas the histological examination is highly on cutaneous lesions. J Am Acad non-LCH were pedunculated and often recommended. Dermatol 2000 Jun;42(6):1012-6. associated with aetiological factors.[9] Previously haemangiomas have been 8. Patrice SJ, Wiss K, Mulliken JB. The exact mechanism for the successfully treated using sclerosing Pyogenic granuloma (lobular development of LCH is poorly agents.[18] The treatment of PG also c a p i l l a r y h e m a n g i o m a ) : a understood and it is unknown whether the consists of ligation and surgical excision, clinicopathologic study of 178 cases. aetiopathogenesis is a reactive process or electrolysis and thermocautery, radiation Pediatr Dermatol 1991 Dec;8(4):267-

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 061 76. JE, editor. Soft tissue tumors (2nd ed). of a recurrent and eruptive lobular 9. Epivatianos A, Antoniades D, Oral and Maxillofacial Pathology: capillary hemangioma and resolution Zaraboukas T, Zairi E, Poulopoulos WB Saunders Company; 2004. with intense pulsed light. Cutis 2013 A, Kiziridou A, et al. Pyogenic 14. Zarei MR, Chamani G, Amanpoor S. Oct;92(4):E5-8. granuloma of the oral cavity: Reactive hyperplasia of the oral 18. Chin DC. Treatment of maxillary c o m p a r a t i v e s t u d y o f i t s cavity in Kerman province, Iran: a hemangioma with a sclerosing agent. c l i n i c o p a t h o l o g i c a l a n d review of 172 cases. Br J Oral Oral Surg Oral Med Oral Pathol 1983 immunohistochemical features. Maxillofac Surg 2007 Jun;45(4):288- Mar;55(3):247-9. Pathol Int 2005 Jul;55(7):391-7. 92 Epub 2006 Nov 9. 19. Asnaashari M, Mehdipour M, 10. Godfraind C, Calicchio ML, 15. de Santana Santos T, Martins-Filho MoradiAbbasabadi F, Azari-Marhabi Kozakewich H. Pyogenic granuloma, PR, Piva MR, de Souza Andrade ES. S. Expedited removal of pyogenic an impaired wound healing process, Focal fibrous hyperplasia: A review granuloma by diode laser in a linked to vascular growth driven by of 193 cases. J Oral Maxillofac Pathol pediatric patient. J Lasers Med Sci FLT4 and the nitric oxide pathway. 2014 Sep;18(Suppl 1):S86-9 doi: 2015 Winter;6(1):40-4. Mod Pathol 2013 Feb;26(2):247-55 104103/0973-029X141328. 20. Patil A, Pattanshetti C, Varekar A, doi: 101038/modpathol2012148 16. Zambrano-Galvan G, Reyes-Romero H u d d a r S B . O r a l c a p i l l a r y Epub 2012 Sep 7. M, Bologna-Molina R, Almeda- haemangioma mimicking pyogenic 11. Chen SY, Takeuchi S, Urabe K, Ojeda OE, Lemus-Rojero O. CTCFL granuloma: a challenge for diagnosis Hayashida S, Kido M, Tomoeda H, et (BORIS) mRNA expression in a and management. BMJ Case Rep a l . O v e r e x p r e s s i o n o f peripheral giant cell granuloma of the 2 0 1 3 F e b 1 4 ; 2 0 1 3 p i i : phosphorylated-ATF2 and STAT3 in oral cavity. Case Rep Dent bcr2012007874 doi: 101136/bcr- cutaneous angiosarcoma and 2 0 1 4 ; 2 0 1 4 : 7 9 2 6 1 5 d o i : 2012-007874. pyogenic granuloma. J Cutan Pathol 101155/2014/792615 Epub 2014 Jul 2008 Aug;35(8):722-30. 10. 12. Murthy J. Vascular anamolies. Indian 17. Scalvenzi M, Francia MG, Raimondo J Plst Surg. 2005;38:56-62. A, Lembo S, Scotto M, Balato A. 13. Neville BW DD, Allen CM, Bouquot Ultrasonography in the management

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 062 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Two Rooted Mandibular Second Premolar - A 1 Darpana 1 Post Graduate Student, Case Report Dept. Conservative Dentistry & Endodontics Faculty Of Dental Sciences M.S Ramaiah University Of Applied sciences Abstract Address For Correspondence: The possibility of two rooted mandibular second premolars is quite small, as per published Dr. Darpana Bhuyan endodontic literature studies. The presence of extra root canals may be occasionally detected in Dept. of Conservative Dentistry & Endodontics the preoperative radiograph, but in general they are more often not seen in the original film. M.S Ramaiah Dental College and Hospital, Failure to recognize and treat any additional canal may result in unsuccessful root canal therapy. New BEL Road,MSRIT Post Bangalore- 560054 th Consequently, awareness of the possible existence of these anatomical variations would be Submission : 9 April 2014 essential during endodontic treatment of mandibular second premolars. This report discusses Accepted : 7th March 2015 the endodontic therapy of a mandibular second premolar with two separate roots. Key Words Quick Response Code Two rooted mandibular premolars, variations, endodontic treatment Introduction which included 4119 specimens of The root canal system is a very complex mandibular second premolars, two o n e a n d u n d e r s t a n d i n g t h e s e rooted teeth were found in only 0.3% and complexities is crucial for the success of three rooted variations were extremely nonsurgical root canal treatment. One of r a r e w i t h o n l y 0 . 1 % the basic prerequisites to successful occurrence[5],[6],[7],[8],[9],[10],[11],[1 sensitive to percussion. There was no endodontic therapy is adequate 2],[13]. A table comparing the studies has radiographic evidence of apical knowledge of the root canal morphology been illustrated below (Table 1). periodontitis. There was no mobility, and as well as the possible variations that The present case report describes root probing with a did not exist in nature. canal treatment in a mandibular second reveal any periodontal pocket. Vitality Ingle observed that one of the main premolar with two separate roots and root tests [both cold and EPT (Digitest, causes of failure in endodontic treatment canals. Parkell, New York)]on the involved tooth is the inadequate mechanical preparation showed abnormal responses (lingering of the root canals, followed by Case Report: pain to cold, increased response at 9 EPT) incomplete obturation[1]. Slowey, in A 45-year-old female patient with a indicating irreversible . 1979, concluded that mandibular noncontributory medical history was The pre-operative radiograph revealed a premolars are probably the most difficult referred to the Dept. of Conservative complex root canal anatomy with two teeth to treat endodontically, possibly Dentistry and Endodontics, MS Ramaiah separate roots. Endodontic treatment was because of it exhibits wide variations in Dental College and Hospital for started and inferior alveolar nerve block its canal anatomy[2]. Variations in root endodontic treatment on the left was administered (2% Lignocaine, canal morphology were suggested as the mandibular second premolar. 1:100,000 epinephrine). Access cavity most likely reason for the high frequency The chief complaint of the patient was was prepared under rubber dam of flare-ups and failures in endodontic “pain in the lower left back tooth region”. (Hygenic, Coltene, USA) application. treatment. Clinical examination revealed a deep Two orifices were found, close to each The textbook description of a mandibular carious lesion at the left second other. One of the orifices was situated premolar is typically of a single-rooted mandibular premolar. The tooth was mesially, while the other orifice was tooth with a single root canal system. situated distally and more lingually. It However, the incidence in the number of Table 1 was not possible to visualize the mesially roots and canals vary greatly in literature, Reference Number of teeth 1 Root 2 Root 3 Root located orifice, which was confirmed in accordance to the anatomic studies in study with the operating microscope. conducted[3],[4]. The root morphology Singh and Pawar (2014) 100 92% 8% - Both the orifices were enlarged with the and the canal configuration of the Sert and Bayirti (2004) 100 100% - - SX Protaper hand file (Dentsply, Tulsa mandibular second premolar can be Zaatar et al. (1997) 64 95.6% 4.7% - Dental, PA, USA) and working length extremely complex and present several was determined using an apex locator Caliskan et al. (1995) 100 100% - - variations. There are several factors that (Root ZX, Dentsply, USA), following contribute to these differences in Geider et al. (1989) 328 97.6% 0.4% - which confirmatory radiographs were m o r p h o l o g y : e t h n i c i t y, r a c i a l Vertucci (1978) 400 100% - - taken. The working length of the mesial predilection, age, and gender, being the Zillich and Dowson (1973) 906 96.6% - 0.4% canal was 20mm while the distal canal major ones. Visser (1948) 2089 99.85% 0.05% 0.1% was 21.5 mm. Both the canals were then Out of the 9 studies, reported in literature, Barrett (1925) 32 100% prepared by hand using the ProTaper

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 063 Universal hand instruments upto F3 One of the main steps to successful Philadelphia: WB Saunders Co, using crown down instrumentation treatment is the observation of 1996. technique. anatomical landmarks in the pulp 4. Ash M, Nelson S. Wheeler’s dental Mechanical instrumentation was chamber floor that gives a good anatomy, physiology and occlusion. followed simultaneously with copious indication of the presence of additional 8th ed. Philadelphia: Saunders, 2003. irrigation with 3% sodium hypochlorite root canals or aberrations[15]. In the 5. Barrett M. The internal anatomy of and 17 % EDTA (Omin Prep, Omega, present case, the symmetry of the orifices the teeth with special reference to the Australia). Calcium hydroxide was used was evident under the operating pulp and R32;its branches. Dent as an intracanal medicament and the microscope. This finding is in agreement Cosmos 1925; 67: 581–92. R32; access cavity was sealed with IRM ( with the results of Krasner and 6. Ç a l i s k a n M K , P e h l i v a n Y, Dentsply, USA) between appointments. Rankow[16]. These results recommend Sepetçioglu F, Türkün M, Tüncer SS. The patient was recalled after 7 days for the use of the laws of symmetry to any Root canal morphology of human completion of the treatment. Calcium tooth, especially when unexpected or permanent teeth in a Turkish hydroxide was removed from the canals. unusual morphologic variation is present population. J Endod 1995;21:200 – 4. After drying the canals with paper points, or suspected. R32; ProTaper F3 master cones (Dentsply This article depicts a case report of a 7. Geider P, Perrin C, Fontaine M. Tulsa, PA, USA) were selected for both mandibular second premolar with two [Endodontic anatomy of lower the canals for apical tug back and roots and its successful endodontic premolars: apropos of 669 cases]. J radiographs were taken. The root canals management. Such cases are important to Odontol Conserv 1989:11–5. were obturated with gutta percha and AH diagnose as variations may pose a 8. Zaatar EI, al-Kandari AM, Plus (Dentsply, PA, USA) root canal complication in their endodontic Alhomaidah S, al-Yasin IM. sealer. The access cavity was restored management. After examining the Frequency of endodontic treatment in with a dual core composite restoration preoperative radiographs carefully, an Kuwait: radiographic evaluation of (HardCore, Pulpdent, USA). The patient optimal and well-defined access is the 846 endodontically treated teeth. J w a s r e c a l l e d a f t e r 6 m o n t h s prime necessity so as to adequately locate Endod 1997; 23:453– 6. postoperatively for clinical and the orifices of the root canals. Use of the 9. Vertucci FJ. Root canal morphology radiographic examination surgical operating microscope provides of mandibular premolars. J Am Dent excellent magnification to aid in its Assoc 1978; 97:47–50. Discussion: diagnosis and location. The use of nickel- 10. Zillich R, Dowson J. Root canal The wide variations in the root canal titanium instruments to prepare the morphology of mandibular first and system of mandibular premolars present canals makes the treatment outcomes second pre- molars. Oral Surg Oral a challenge in diagnosis and subsequent more predictable but these must be used Med Oral Pathol 1973; 36:738 – treatment of such cases. Hence, it is with caution. 44.R32; imperative to have adequate knowledge 11. SertS, Bayirli GS. Evaluation of the about the aberrant canal morphologies Conclusion: root canal configurations of the and consider their possible existence in Successful and predictable endodontic mandibularand maxillary permanent clinical practice. treatment requires clinicians to have teeth by gender in the Turkish It is important to carefully examine the adequate knowledge about the root canal population. J Endod 2004; 30:391– 8. preoperative radiograph, in respect to the system and its aberrancies. It is essential 12. VisserJ.Beitrag zur Kenntnis der root position, root shape, and the relative to diagnose such cases prior to the menschlichen Zahnwurzelformen. root outline, when variations are commencement of the root canal [medical dissertation]. Zurich, suspected. Radiographs must be obtained treatment with the help of radiographs Switzerland: Universität Zürich; at different horizontal angulations so as and newer modalities such as the surgical 1948. R32; to detect the presence of an extra root or operating microscope. Teeth with extra 13. Singh S, Pawar M. Root Canal root canal. The sudden radiographical roots and/or canals pose a particular Morphology of South Asian Indian disappearance of a canal may provide challenge like it is reported in the present Mandibular Premolar teeth. J Endod evidence of a dividing canal[14]. The case. 2014; 40(9): 1338-1341. level of bifurcation of the root must be 14. Giuseppe Cantatore, Elio Berutti & carefully interpreted. The cone beam References A r n a l d o C a s t e l l u c c i . computed tomography (CBCT) is 1. Ingle JI. A standardized endodontic Missedanatomy: frequency and extremely beneficial in cases where technique utilizing newly designed clinical impact. Endodontic Topics radiographs fail to provide accurate instruments and filling materials. 2009; 15: 3–31 dimensions of the root canal system. Oral Surg Oral Med Oral Pathol 15. Roeland JG, De Moor, Filip LG The importance of using optical aids in 1961;14:83-91. calberson. Root Canal Treatment in a magnification must be stressed upon. The 2. Slowey RR. Root canal anatomy: Mandibular Second Premolar with surgical operating microscope offers a road map to successful endodontics. Three Root Canals J Endod 2005; major advantage in locating and D e n t C l i n N o r t h A m 31(4): 310-13. negotiating extra root canals. It gives the 1979;23:555–73.R32; 16. Krasner P, Rankow HJ. Anatomy of operating clinician the opportunity to 3. Walton R, Torabinejad M. Principles the Pulp-Chamber Floor J Endod improve the optical field and to identify and practice of endodontics. 2nd ed. 2004; 30: 5-16. microstructures that are usually undetected by the naked eye. Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 064 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Talon Cusp () Of Anterior 1 Monika Kinra 2 Manveen Jawanda Teeth 3 Harleen Chhabra 1 Senior Lecturer Abstract 2 Prof. & HOD Dens evaginatus is a developmental anamoly characterized by the occurence of an extra cusp Department of Oral Pathology & Micro Biology shaped as a tubercle projecting from the palatal or buccal surfaces. In the anterior teeth, dens Luxmi Bai Dental College, Patiala 3 Consultant, Dept. of Endodontist evaginatus is more commonly found in the maxilla and on the palatal surface of the tooth. This Perfect Smile Dental Clinic, Abohar (Pb.) article reports a case of and its management. Address For Correspondence: Key Words Dr. Monika Kinra, Jaipur Hospital Talon Cusp accessory cusp, dental anamoly Civil Hospital Road, ABOHAR-152116 E-mail : [email protected] Introduction maxillary central incisor that required Phone : 98882-30412 Talon Cusp was first described as an endodontic treatment. Submission : 1st April 2014 anomalous hyperplasia of the cingulum Accepted : 17th March 2015 of maxillary or mandibular permanent Case Report Quick Response Code incisors resulting in the formation of a A 20 years old, male patient came to the supernumerary cusp resembling an department of oral surgery for extraction eagle's talon.[1],[2] However, there are but considering restoribility of tooth, reports of talon cusp occuring on the patient was referred to the department of facial surfaces, in deciduoes incisors and conservative and endodontics. His also in canines. Therefore, the talon cusp medical & dental history was uneventful. can now be defined as an uncommon No other family member had similar dental anamoly manifesting as an anamoly. Intra oral examination revealed followed by intra and extra coronal accessory cusp like structure, projecting no soft tissue abnormalities and absense bleaching using 35% H2O2 from the lingual or facial surface of of any tenderness to percussion. The anterior teeth of either dentition.[3] It was tooth in question showed a concial Discussion first described by WH Mitchell in 1892 prominent cusp on the palatal surface. Talon cusp or dens evaginatus is a rare and was named as "Talon cusp" by The cusp was 2 mm wide (mesio anomaly with multifactorial etiology Mellon and Ripa in 1970.[4] distally), 6 mm (inciso cervically) and 3 i n c l u d i n g b o t h g e n e t i c a n d mm thick (labiolingually) extending environmental factors. Various theories The etiopathogenesis is multifactorial, from cingulum area to the 0.5 mm short were proposed, however the most and is thought to be polygenetic with of incisal edge (Fig. 1) Electric and accepted one suggests that talon cusp some environmental influences.[5] thermal pulp vitality tests showed tooth Clinically it can pose esthetic and as a non vital entity. Radiographic f u n c t i o n a l p r o b l e m s t o t h e examination showed the presence of patient.[6],[7],[8],[9]. Histologically, it is enamel, dentin and pulp horn into talon composed of normal enamel & dentin & cusp along with periradicular changes it may or may not contain pulpul and rarefaction at periapical area (Fig. 2). tissue.[7] Radiographically the talon The diagnosis was talon cusp with pulp cusp is usually superimposed over the necrosis. Single visit endodontic tooth on which it occurs. Hattab et al have treatment was performed (Fig. 5) classified talon cusp as true talon, semitalon and trace talon based on the degree of formation & extension. The treatment objective of talon cusp should include preserving pulpal vitality, meeting esthetic and occlusal requirement, establishing caries p r e v e n t i o n o r e r a d i c a t i o n i n developmental grooves and eliminating tongue irritation.[7] The objective of this article is to report a case of talon cusp in a permanent Fig.1 : Preoperative Diagnostic Cast Depicting Talons Cusp Fig.2 : Pre –operative Radiograph

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 065 prominent cingula) and their variation. it may provide a substantial challenge The talon cusp described in this case is during diagnosis and treatment planning classified as type 1 talon. It is important to clinician. Early diagnosis may to remember that the talon cusp is minimize local problems such as caries, occasionally combined with other periodontal disease & carious problems. systemic anamolies. Clinically talon cusp differs from dens References evaginatus of posterior teeth. Lin et al 1. Shafer W G, Hine MK, Levy BM. A reported pulp exposure and textbook of oral pathology. 4th ed, in 14.1% to 40.2% of examined cases due Philadelphia : WB Saunders 1983, to attrition or trauma. Developmental 40-41 grooves and fissures at the junction of the 2. Goaz PW, White SC Oral Radiology, talon cusp and the tooth surfaces are more Missouri : CV Mosby company; susceptible to caries, depending on the 1987;447 shape, size and location of these 3. Sirace E, Cem Gugnor H, Taner B, structural defects, associated periodontal Cehrili ZC. Buccal & palatal talon involvement might occur. cusps with pulp extensions on a Gungor et al histologically detected supernumerary primary tooth. presence of pulp horn in accessory cusp Dentomaxillofacial Radiology 2006 : which increases the chances of pulpal 35(6) : 469-72 Fig.3 : Radiograph Showing Completed Endodontic insult & death. Teeth with talon cusp may 4. Mellor JK, Ripa LW, Talon cusp : A Treatment undergo pulpal necrosis if early diagnosis clinically significant anamoly. Oral is not done & management is neglected or surg 1970 ; 29 : 225-28 inappropriate to the case. 5. Segura JJ, Jemenez, Rubro A-Talon The treatment of talon cusp may be cusp affecting permanent maxillary conservative or radical, depending on the lateral incisiors in 2 family members accessory cusp like shape, location, size Oral surg Oral Med Oral Pathol Oral & tooth affected. Periodic & gradual Radiol Endod 1999 ; 88 (1) : 90-92 reduction of the cusp, with application of 6. Hattab FN, Yassin OM, al Nimri KS. the desensitizing agent, reduction of cusp Talon cuspin permanent dentition with or without endodontic therapy, associated with other dental Fig.4 : Preoperative Palatal View sealant application on the grooves and anamolies : Review of literature and esthetic restorations are options of reports of seven cases ASDCJ Dent treatment. Single visit root canal offers child 1996;63(5) : 368-76 several advantages likewise reduced 7. H. Cm Gungor, Nil Altay & Figen flare rate (Walton & Faud 1992), patient Kaymaz, Ankara. Pulpal issue in acceptance and practice management. bilateral talon cusps of primary 70% of dentists treat necrotic teeth in central incisor. Report of a case. Oral single visit since it has shown 6.3% Surg Oral Med Pathol Oral Radiol higher healing rate than multiple visit.[9] Endol 2000; 89:231-5 Bleaching can improve the appearance of 8. Andeesa Bolges Soares et al. discoloured teeth while preserving tooth Bilateral talon cusp : Case Report. structure and it avoids costly invasive Quintessence Int 2001;32-283-286 dental tratment. Cadanaro M et al showed 9. Salhorn C, Messer HH, Effectiveness Fig.5 : Post Operative View in vivo application of 38% H2O2 and of single wersus multiple visit might occur as a result of an outward 35% carbamide peroxide to be clinically endodontic treatment of teeth with folding of inner enamel epithelial cells safe & reliable, showing no structural apical periodontitis : a systemic and a transient focal hyperplasia of changes to enamel surface even after four review and meta analysis. Int Endod J mesenchymal dental papilla. Hattab et al applications.[10] The treatment objective 2005 ; 38 : 347-355 classified this anamoly into 3 types on the for taloned teeth may differ depending on 10. Cadenaro M et al, Effect of two in- basis of the degree of cusp formation and each case. However large, prominent office whitening agents on the enamel extension. Type 1 (talon) has an talon cusp calls for a definitive treatment surface in vivo : a morphological and additional cusp that projects from the to overcome esthetic, occlusal, non contact profilometric study. palatal surface of an anterior tooth and periodontal & carious problem. Operative dentistry 2008, 33-2:127- extend at least one half the distance from 134. the cemento enamel junction to the Conclusion incisal edge. Type II (Semitalon) has an Talon cusp is not an innocuous defect, as additional cusp 1 mm or more in length but extending less than one half the distance from the cement enamel junction to the incisal edge. Type III (trace talon) manifest enlarged and Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 066 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Prosthetic Management Of An Ocular Defect 1 Vinuta Hiremath 2 Veena Pinto Using Digital Photography: A Case Report 3 N. Lalitha 1 Lecturer , Dept. of Prosthodontics Abstract KLE VK Institute of Dental Sciences, Belgaum 2 The eye is a vital organ not only in terms of vision, but also esthetics. When the loss of an eye is Senior Lecturer , Dept. of Prosthodontics A.J. Institute of Dental Sciences, Kuntikana restored at an early age, it improves the physical and psychological behavior of an individual as 3 well as acceptance from society. The prime goal or objective of the maxillofacial prosthodontist is Senior Lecturer , Dept. of Prosthodontics Sri Siddhartha Dental College & Hospital, Agalakote to fabricate an ocular prosthesis which mimics the natural eye. The custom fabricated ocular Address For Correspondence: prosthesis has many advantages when compared to the prefabricated ocular prosthesis such as Dr. Vinuta Hiremath, Department of Prosthodontics improved iris matching, contour and movements of the natural eye. This article describes the KLE VK Institute of Dental Sciences, Belgaum-590010 fabrication of an ocular prosthesis using digital photography which is simple, requiring less Phone No: 09844992883 artistic skill and provides excellent esthetics. Email: [email protected] Submission : 2nd February 2014 Key Words th Ocular prosthesis, digital photography, ocular defect Accepted : 4 March 2015 Quick Response Code Introduction using light bodied elastomeric Orbital defects or loss of an eye could be impression material (Aquasil, Dentsply) because of congenital reasons, trauma or under the eyelids to completely fill the infection[1],[2]. It hampers the day to day socket. A 5ml disposable syringe was activities, and also compromises the incorporated into the impression for physical and emotional well being of a retention and the patient was instructed to patient[3],[4],[5]. Depending on the perform eye movements before the severity, there are different surgical impression material set. The ocular wax pattern was retrieved, sharp ridges modalities which cause orbital defects impression was retrieved from the socket and irregularities were removed. The wax such as evisceration or enucleation. and evaluated (Fig. 3). The impression pattern was then placed in the socket and Evisceration involves the removal of was poured till the height of contour with the fit was evaluated by lifting the eyelids contents of the globe leaving in place the Type III dental stone (Kalstone-Karson and even extensions into the medial and sclera and sometimes the cornea. Pvt Ltd Mumbai,India) . Then holes were lateral fornices were evaluated (Fig. 4). Enucleation involves removal of the created in the first layer of dental stone, Wax pattern sculpting was performed entire globe after the extraocular muscles separating media was applied and a until it resembled the natural eye and the and the optic nerve have been transected. second layer of dental stone was poured pattern was processed using white heat The surgeon should preserve as much to obtain a three piece dental cast . cure acrylic resin (DPI tooth moulding intact orbital content as possible[1],[5]. The wax pattern was obtained by pouring powder) to obtain the scleral portion of a Various techniques are used in molten modeling wax into the mold similar shade as that of the natural eye. fabricating ocular prostheses but the (Modelling wax, Hindustan Pvt Ltd). The The acrylic resin sclera was inserted in main disadvantages of these techniques is the socket; eye support, tissue extensions that it is difficult to adequately match the and eye movements were checked (Fig. i r i s t o m a k e i t e s t h e t i c a l l y pleasing[3],[4].

Case Report A 22 year old female patient reported to the department of Prosthodontics, College of Dental Sciences, Davangere with a loss of left eye. She gave a history of trauma due to an accident. Surgery was performed and a conformer was given Fig. 1 : Preoperative View soon after the surgery. On examination, the socket was healthy and with adequate depth for proper retention of the prosthesis. Mobility was also observed with the movement of the natural eye (Fig. 1 & 2).

Technique The first step involved making an impression of the anophthalmic socket Fig. 2 : Anophthalmic Socket Fig. 3 : Impression Using Light Body Polyvinyl Siloxane

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 067 The image was printed on a white photo esthetic result[5],[8],[9]. paper of different sizes that matched with the natural eye (Fig. 6). An iris sized Conclusion circle was created on the acrylic sclera Fabricating a custom ocular prosthesis is the same as the natural eye. The anterior the best option for a patient with an ocular scleral surface was reduced by 1mm, the defect and there are several options of photographic iris was cut and transferred reproduction of the iris. The technique to the scleral surface at a distance the d e s c r i b e d h e r e , u s i n g d i g i t a l same as the natural eye. Characterization photography, is simple, easy and less of the prosthesis was done using time consuming. The artistic skills professional quality colour pencils. Red required are also minimal. Advanced nylon threads were added for research is required on the durability of characterization and permanent markers the paper and colours used in were also added to replicate the natural m o d i f i c a t i o n o f t h e i r i s f o r Fig. 4 : Trial Of Scleral Wax Pattern eye. The prosthesis was covered with characterization. The ultimate goal is to clear self cure acrylic resin and finishing restore the natural appearance of the and polishing was done to retain the healthy eye as well as to restore the characterization. patient’s emotional and psychological The patient was instructed to wear the well-being. prosthesis day and night and to clean it with mild soap and warm water and to References visit at regular intervals for follow up and 1. Parr GR, Goldman BM, Rahn AO. adjustment if necessary (Fig. 7). Surgical considerations in the prosthetic treatment of ocular and Discussion orbital defects. J Prosthet Dent 1983; The loss of facial structures compromises 49: 3: 379-85. Fig. 5 : Trial Of The Acrylic Scleral Blank individual esthetic outcomes and in some 2. Cain JR. Custom ocular prosthetics. J c a s e s a l s o l e a d s t o s o c i a l Prosthet Dent 1982; 48: 690-4. exclusion[4],[6]. During removal of an 3. Taicher S, Steinberg MH, Tubiana I. eye, the surgeon should preserve as much Modified stock eye ocular prosthesis. of the remaining structures as possible. J Prosthet Dent 1985;54:95-7. Prosthetic rehabilitation with implants 4. S h a i k h S R , G a n g u r d e A P, and eye prosthesis are the treatment of Shambharkar VI. Changing ocular choice as they also simulate eye prostheses in growing children : A 5 movements. If implants are considered, year follow up clinical report. J the size of implants plays a vital role - Prosthet Dent 2014;111:346-8. Fig. 6 : Iris Images Of Different Sizes And Shades Printed On larger implants lead to an exophthalmic 5. Artopoulou LL, Montgomery PC, Photopaper appearance and extrusion and too small Wesley PJ, Lemon JC. Digital implants cause shrinkage of the contents imaging in the fabrication of ocular of eye. But due to economical factors, all prosthesis . J Prosthet Dent 2006; 95: p a t i e n t s c a n n o t a f f o r d 325-30. implants[1],[2],[6]. A custom made ocular prosthesis is hence a good 6. Benson P. The fitting and fabrication option[2],[7]. The main disadvantage of of a custom resin artifical eye. J using a prefabricated iris is that it is Prosthet Dent 1977; 38: 5: 532-8. difficult to replicate or match the iris of 7. Sykes LM. Custom made ocular the natural eye[3]. Most clinicians prostheses: A Clinical Report. J believe that selection of pigments and the Prosthet Dent 1996;75:1-3. iris painting procedure requires an artistic 8. Jain S, Makkar S, Gupta S, Bhargava. skill and knowledge of colour and if Prosthetic Rehabiliation of ocular unsuccessful, can impair esthetics defect using digital photography: A [8],[9],[10]. The use of the digital case report. J Indian Prosthodont Soc photography technique provides an 2010; 10: 3:190-3. e s t h e t i c a l l y p l e a s i n g r e s u l t 9. Buzayan MM, Ariffin YT,Yunus N, Fig. 7 : Custom Ocular Prosthesis In Place [5],[8],[9],[10]. It is simple and less Mahmood WA. Ocular defect 5). The patient was made to sit upright in artistic skills are required in this rehabilitation using photography and a relaxed position and to look straight technique [5]. A special digital camera for digital imaging:A Clinical Report. J ahead. Measurements were made photography and computer software are Prosthodont 2014 Oct 14. doi: between the medial and lateral canthus to the only requirements for matching the 10.1111/jopr.12235. pupil of the natural eye and marked on the size and colour of the iris. According to 10. Jayaswal GP, Dange SP, Khalikar scleral acrylic resin. literature many techniques and materials AN. Restoration of an atrophic eye A digital photograph of the patient’s iris have been used to fabricate an ocular socket with custom made eye using a digital camera was made and the prosthesis using a prefabricated and prosthesis, utilizing digital photo print of the iris was compared with custom made ocular prosthesis, however photography. Indian J Res 2011; the natural eye in relation to brightness, digital photography is simple, less time 22:482-5. colour and contrast. consuming and provides an optimum Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 068 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

A Simple Technique Of Esthetic Rehabilitation 1 Veena Pinto 2 Anisha Rodrigues Using A Loop Connector 3 Uma Mayoor Prabhu 1 Senior Lecturer Abstract 2 Reader A missing anterior tooth poses several treatment options to a clinician as well as a patient. Dept. of Prosthodontics A.J.Institute of Dental Sciences, Kuntikana Replacing a missing anterior tooth becomes a challenge when there are multiple diastemata in 3 the maxillary arch. Closure of such a space may require orthodontic treatment which takes a Senior Lecturer, Dept. of Prosthodontics longer duration. In addition, trying to close such a space with a fixed dental prosthesis may Century International Institute of Dental Science and Research Centre, Kerala require the pontic to be larger in its mesiodistal dimension, thereby making it unaesthetic. Address For Correspondence: Implants are a treatment option if the patient wishes to maintain the diastema, but the increased Dr. Veena Pinto costs usually compel patients to opt for a fixed partial denture. This article describes a simple Senior Lecturer, technique of replacing a missing anterior tooth with multiple diastemata in the maxilla, using a Dept. of Prosthodontics, fixed dental prosthesis with a loop connector A.J.Institute of Dental Sciences, Key Words Kuntikana, Mangalore-575004. Karnataka. Ph. No: 09945589132 Diastema, loop connector, Spacing Email: [email protected] Introduction Two treatment options were provided to Submission : 20th February 2014 A very common aesthetic challenge seen the patient; that of an implant supported Accepted : 17th March 2015 by many clinicians is the presence of restoration and a fixed dental prosthesis. Quick Response Code diastemata or spacing between teeth. The patient opted for the latter. Hence a These diastemata can be localized or three-unit porcelain-fused-to-metal fixed generalized and are difficult to maintain dental prosthesis was planned, using the when a fixed dental prosthesis is right maxillary central incisor and canine required. The etiology of a diastema is as abutments. varied and ranges from a normal finding in children to pathological conditions Procedure such as supernumerary teeth, mesiodens, In the first appointment, radiographs and 1.00 mm was provided on the palatal cysts, and pathological diagnostic impressions were made using aspect keeping the loop connectors in migration due to periodontal disease[1]. irreversible hydrocolloid (Plastalgin, mind (Fig 2). A rubber base impression The most common factors causing Septodont). The resulting diagnostic (Aquasil, Dentsply Int.) was made using midline diastema are dentoalveolar casts were prepared for a mock-up of the the two stage putty reline technique and discrepancy and excessive vertical final restorations and this was used to bite registration records were obtained. overlap of the incisors[2]. When a patient explain the procedure to the patient. The impressions were poured with Type is insistent on maintaining a diastema Next, tooth preparation was done on the IV dental stone (Kalrock, Kalabhai). A then one of the treatment options for a abutment teeth; sufficient clearance of facebow transfer was done and the casts missing maxillary anterior tooth is a fixed were mounted on a semi adjustable dental prosthesis with a loop connector. A articulator (Hanau Wide-Vue). A loop connector is on the lingual side of a provisional restoration was fabricated fixed dental prosthesis that serves to and cemented using non-eugenol cement connect adjacent retainers and/or (Integrity, Dentsply). pontics[3]. A 0.5mm thick wax sheet was lined on the maxillary cast in the edentulous area so as Case Report A 45-year old female patient reported to the Department of Prosthodontics with a chief complaint of a missing upper front tooth. Her main concern was the replacement of the missing tooth in addition to maintaining the diastema. On intraoral examination, the maxillary right lateral incisor was found to be missing and the edentulous space was found to be greater than the width of the lateral incisor in the contralateral arch (Fig 1). Fig. 1 : Intraoral view Fig. 2 : Tooth preparation w.r.t. 11 and 13

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 069 intaglio surface of the retainers, given adequate oral hygiene maintenance cementation of the fixed dental prosthesis instructions especially in not contacting was done using Type I Glass Ionomer the tip of the tongue into the space Cement (Fig 5 and 6). The patient was between the loop and the mucosa[5]. given instructions on how to maintain oral hygiene especially in the region of Conclusion the loop connector. The use of dental A fixed dental prosthesis with a loop

Fig. 3 : Wax pattern fabrication floss and an interdental brush were connector is an alternative to restoring an advised. The patient was recalled after 7 edentulous area with diastema. It is days to evaluate the oral hygiene aesthetic but can be a slightly difficult maintenance. region to maintain adequate plaque control. Following meticulous treatment Discussion planning as well as laboratory design will Connectors are the components of a ensure that this fixed dental prosthesis partial fixed dental prosthesis or splint has a successful form as well as function. that join the individual retainers and pontics together. They can be rigid or References non-rigid. Rigid connectors are further 1. Bhandari S, Bakshi S. Survival and classified as cast connectors, soldered complications of unconventional connectors and loop connectors[3]. The fixed dental prosthesis for presence of missing teeth and diastema in maintaining diastema and splint Fig. 4 : Metal Try-in the anterior maxillary region pose a pathologically migrated teeth: A case challenging esthetic problem in series up to 8 years follow-up. Indian maintaining the correct mesiodistal J Dent Res 2013; 24:375-80 width of the pontic. In this case, the 2. Oesterle LJ, Shellhart WC. Maxillary patient was keen on maintaining the midline diastemas: A look at the diastema between the central incisor and c a u s e s . J A m D e n t A s s o c lateral incisor. 1999;130:85-94. 3. Rosenstiel, Land, Fujimoto. Loop connectors can be fabricated from Contemporary Fixed Prosthodontics. sprue wax as it is circular in cross-section 4th ed. St.Louis (Missouri). Elsevier: and easy to clean, or from a platinum- 2008. gold-palladium alloy wire[4],[5]. A 4. Kamalakanth S, Arbaz S. Anterior Fig. 5 : 3- unit PFM Fixed Dental Prosthesis with loop connector should be designed to prevent loop connector fixed partial denture: connector plaque accumulation and prevent A simple solution to a complex periodontal breakdown and sufficient prosthodontic dilemma. Journal of access should also be provided for oral Indian Prosthodontic Society. 2008; hygiene aids. 8:162-4. Another variant of the loop connector is 5. Sharma N, Paleka U, Sharma S. Loop the spring cantilever FDP which is used connector - bridging the gaps…..a when the posterior abutments are sound case report. NJDSR. 2012;1:42-5 and are used to replace a maxillary 6. Taggart J. Resin bonded spring anterior tooth with diastema. But this cantilever bridge. Restorative connector produces displacement of the dentistry. 1990;6:4-5 pontic, discomfort and interference with 7. Dandekeri SS, Dandekeri S. Single speech[6]. Therefore, the loop connector Anterior Tooth Replacement by a Fig. 6 : Post cementation view is a better choice. A resin bonded FDP is Cast Lingual Loop Connector - A to create a space for oral hygiene also another option when there is a single Conservative Approach. Journal of maintenance. Wax patterns were missing anterior tooth[7]. The prosthesis Clinical and Diagnostic Research. fabricated using blue inlay wax and the design may sometimes interfere with oral 2014; 8:9: 7-8 loop connector was fabricated using hygiene maintenance and also in speech 8. Kalra A, Gowda M E, Verma K. sprue wax (Fig 3). Phosphate-bonded especially with linguopalatal sounds[8]. Aesthetic rehabilitation with multiple investment (Bellawest, BEGO) was used Hence keeping the loop size small as well loop connectors. Contemporary to invest the wax pattern and casting was as rounded in cross section is of utmost Clinical Dentistry 2013; 4 :1: 112-15. done using a base metal alloy (Wiron 99, importance. The patient should also be BEGO). Metal try-in was performed, (Fig 4) following which the porcelain facing (Vita, Germany) was fired according to the manufacturer’s Source of Support : Nill, Conflict of Interest : None declared recommendations. Occlusal correction was performed wherever necessary. After glazing, polishing and sandblasting the

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 070 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Mucocele On Tongue – An Unsual Case Report 1 Vadi V. Bharatham 2 Rajgopal Singh Mehta Abstract 1 Reader, Dept. Of Oral Medicine And Radiology Mucocele is one of the most common lesion of the oral mucosa that results from an alteration of M.E.S. Dental College And Hospital minor salivary glands due to a mucous accumulation. Mucocele involves mucin accumulation 2 Professor , Dept. Of Oral Medicine causing limited swelling. Two histological types exist - extravasation and retention. Mucoceles Jodhpur Dental College And Hospital can appear at any site of the oral mucosa where minor salivary glands are present. Diagnosis is Address For Correspondence: principally clinical; therefore, the anamnesis should be carried out correctly, looking for previous Dr. Vadi V. Bharatham Mes Dental College And Hospital Palachode, trauma. The most common location of the extravasation mucocele is the lower lip, while retention Via Kolathur, Perinthalmanna Kerala mucoceles can be found at any other site. Mucoceles can affect the general population, but most Submission : 28th March 2013 commonly young patients (20-30 years old). Clinically they consist of a soft, bluish and th Accepted : 13 August 2014 transparent cystic swelling which normally resolves spontaneously. Treatment frequently involves surgical removal. Never-theless micro marsupialization, cryosurgery, steroid injections Quick Response Code and CO2 laser are also described. Mucocele is a common lesion and affects the general population. For this reason we felt it would be interesting review the clinical characteristics of mucoceles, and their treatment and evolution in order to aid decision-making in daily clinical practice. Key Words Mucocele, mucocele treatment, Minor salivary glands Introduction extravasation or a retention mechanism. Mucocele is a common lesion of the oral Extravasation mucoceles are caused by a mucosa that results from an alteration of leaking of fluid from surrounding tissue size of a peanut initially and did not cause minor salivary glands due to a mucous ducts or acini. This type of mucocele is her any disocomfort. However the accumulation. Mucocele involves mucin commonly found on the minor salivary swelling has now gradually increase in accumulation causing limited swelling. glands. size to the present size which is about the There are basically two types of Physical trauma can cause a leakage of size of a grape. The patient did not mucocele. extravasation and retention salivary secretion into surrounding however have any pain or other type. Extravasation mucocele results submucosal tissue. Inflammation associated symptoms. Intra oral from a broken salivary glands and becomes obvious due to stagnant mucous examination revealed that the solitary the consequent spillage into the soft resulting from extravasation swelling was about 1.5 cm in its greatest tissues around this gland. Retention There is no clinical difference between dimention, pale blue in color, with mucocele appears due to a decrease or extravasation and retention mucoceles. smooth surface and no ulcerations. On absence of glandular secretion produced Mucoceles present a bluish, soft and palpation, all the inspectory findings by blockage of the ducts transparent cystic swelling which were confirmed. The swelling was [2].When located on the floor of the frequently resolves spontaneously. The smooth, non mobile, non compressible or mouth these lesions are called blue colour is caused by vascular non reducible in nature. It was non tender because the inflammation resembles the congestion, cyanosis of the tissue above as well. There were no other significant belly of a frog[3]. Mucocele is a common and the accumulation of fluid and below. oral findings. Based on the chief lesion and affects the general population. Coloration can also vary depending on complaint, history and clinical findings, a For this reason we felt it would be the size of the lesion, proximity to the working diagnosis as mucocele was interesting review the clinical surface and upper tissue elasticity . given. However, a differential diagnosis characteristics of mucoceles, and their Lesion duration can vary from a few days of hemangioma, pyogenic granuloma, treatment and evolution in order to aid to 3 years . fibroma was also considered. decision making in daily clinical practice. Case Report Management A 17-year-old female patient reported to an excisional biopsy was carried out in Etiopathogenisis the department of oral medicine and the department of oral and maxillofacial There are two crucial etiological factors radiology with the chief complaint of surgery under local anesthesia and the in mucoceles formation trauma and swelling on the dorsal surface of tongue excised specimen was sent to the obstruction of salivary gland ducts. for the past 6 months. History of department of oral pathology for Mucus is produced exclusively by the presenting illness revealed that the histopathological evaluation. minor salivary glands and is also the most patient was apparently normal 6 months important substance secreted by the back when she suddenly she noticed a Histopathology major sublingual salivary glands. swelling on the dorsal surface of tongue. The histomicrograph revelaed salivary M u c o c e l e s c a n a p p e a r b y a n The swelling was very small about the gland acini, abundance of chronic

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 071 inflammatory cells and fibrous tissue marsupialization would avoid damage to Furuse C, Thomaz LA, Teixeira RG, stroma consistent with feature of an vital structures. Clinically, there is no de Araújo VC. Mucocele of the gland inflamed salivary gland difference between both types of of Blandin-Nuhn: histological and mucocele, and are therefore treated in the clinical findings. Clin Oral Investig. Discussion And Conclusion same manner. Nevertheless when an 2009 ;13:351-3. Mucoceles found in deeper areas are obstruction of retention mucoceles is 10. Tran TA, Parlette HL 3rd. Surgical usually larger. Mucoceles can cause a detected treatment involves the removing pearl: removal of a large labial convex swelling depending on the size the top of the cyst and introducing a mucocele. J Am Acad Dermatol. and location, as well as difficulties in lacrimal catheter into the duct to dilate 1999;40:760-2. speaking or chewing [3]. Mucoceles can it[3].A study of 14 pediatric patients[14] 11. Andiran N, Sarikayalar F, Unal OF, appear at any site of the oral mucosa describes micro marsupialization Baydar DE, Ozaydin E. Mucocele of containing salivary glands. Occasionally techniques with 85% success. the anterior lingual salivary glands: mucoceles can involve the glands of from extravasation to an alarming Blandin-Nuhn. These glands are located References mass with a benign course. Int J on the muscle of the ventral side of the 1. Bagán Sebastián JV, Silvestre Donat P e d i a t r O t o r h i n o l a r y n g o l . tongue. FJ, Peñarrocha Diago M, Milián 2001;61:143-7. The histological diagnosis is always Masanet MA. Clinico-pathological 12. Zancopé E, Pereira AC, Ribeiro- extravasation type, and normally study of oral mucoceles. Av Rotta RF, Mendonça EF, Batista AC. affecting young patients. Odontoestomatol. 1990;6:389-91, Mucocele in posterior dorsal surface A histopathologic study is crucial to 394-5. of tongue: an extremely rare location. confirm the diagnosis and to ensure that 2. Boneu-Bonet F, Vidal-Homs E, J O r a l M a x i l l o f a c S u r g . glandular tissue is completely removed. M a i z c u r r a n a - T o r n i l A , 2009;67:1307-10. Two types of mucoceles exist: retention GonzálezLagunas J.Submaxillary 13. Layfield LJ, Gopez EV. Cystic mucoceles and extravasation mucoceles. gland mucocele: presentation of a lesions of the salivary glands: In the case of retention mucoceles a cyst case. Med Oral Patol Oral Cir Bucal. cytologic features in fine-needle cavity can be found, this is generally well 2005;10:180-4. a s p i r a t i o n b i o p s i e s . D i a g n defined with an epithelial wall covered 3. Baurmash HD. Mucoceles and Cytopathol. 2002;27:197-204. with a row of cuboidal or flat cells ranulas. J Oral Maxillofac Surg. 14. Delbem AC, Cunha RF, Vieira AE, produced from the excretory duct of the 2003;61:369-78. Ribeiro LL. Treatment of mucus salivary glands[3]. Compared to 4. Yamasoba T, Tayama N, Syoji M, retention phenomena in children by extravasation mucoceles, retention Fukuta M. Clinicostatistical study of t h e m i c r o - m a r s u p i a l i z a t i o n mucoceles show no inflammatory lower lip mucoceles. Head Neck. technique: case reports. Pediatr Dent. reaction and are true cysts with an 1990;12:316-20. 2000;22:155-8. epithelial covering[5]. 5. Guimarães MS, Hebling J, Filho VA, 15. Marcushamer M, King DL, Ruano E x t r a v a s a t i o n m u c o c e l e s a r e Santos LL, Vita TM, Costa NS. Cryosurgery in the management pseudocysts without defined walls. The C A . E x t r a v a s a t i o n m u c o c e l e of mucoceles in children. Pediatr extravasated mucous is surrounded by a involving the ventral surface of the Dent. 1997;19:292-3. layer of inflammatory cells and then by a tongue (glands of Blandin-Nuhn). Int 16. Gill D. Two simple treatments for reactive granulation tissue made up of J Paediatr Dent. 2006;16:435-9.29. lower lip mucocoeles. Australas J fibroblasts caused by an immune 6. Bentley JM, Barankin B, Guenther Dermatol. 1996;37:220. Erratum in: reaction. Even though there is no LC. A review of common pediatric lip Australas J Dermatol 1997;38:104. epithelial covering around the mucosa, lesions: /recurrent 17. Yeh CJ.Simple cryosurgical this is well encapsulated by the , impetigo, mucoceles, treatment for oral lesions. Int J Oral granulation tissue[2], [3], [5]. and hemangiomas. Clin Pediatr Maxillofac Surg. 2000;29:212-6. (Phila). 2003;42:475-82. 18. Luiz AC, Hiraki KR, Lemos CA Jr, Treatment 7. Yagüe-García J, España-Tost AJ, Hirota SK, Migliari DA. Treatment of Conventional treatment is commonly Berini-Aytés L, Gay-Escoda C. painful and recurrent oral mucoceles surgical extirpation of the surrounding Treatment of oral mucocele-scalpel with a high-potency topical a mucosa and glandular tissue down to the versus CO2 laser. Med Oral Patol corticosteroid: a case report. J Oral muscle layer. With a simple incision of Oral Cir Bucal. 2009;14:e469-74.e21 Maxillofac Surg. 2008;66:1737-9. the mucocele the content would drain out J Clin Exp Dent. 2010;2(1):e18-21. 19. Pick RM, Colvard MD. Current status but the lesion would reappear as soon as Oral Mucocele. of lasers in soft tissue dental surgery. J the wound heals [8]. There is no need for 8. Huang IY, Chen CM, Kao YH, Periodontol. 1993;64:589-602. treatment if superficial extravasation Worthington P. Treatment of 20. Kopp WK, St-Hilaire H. Mucosal mucoceles resolve spontaneously. Small mucocele of the lower lip with carbon preservation in the treatment of mucoceles can be removed completely dioxide laser. J Oral Maxillofac Surg. mucocele with CO2 laser. J Oral with the marginal glandular tissue before 2007;65:855-8. Maxillofac Surg. 2004;62:1559-61. suture. In the case of larger mucoceles, 9. de Camargo Moraes P, Bönecker M,

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 072 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Detection Of Multiple Canal Morphology In 1 M.Swamy Ranga Reddy 2 M Daneswari Maxillary Molars With The Aid Of Spiral 3 Rathna Velugu 1 Professor, Dept. Of Endodontics Computerized Tomography - A Case Report Panineeya Dental College 2 Reader , Dept. Of Pedodontics Mamata Dental College Abstract 3 Ex-post Graduate , Dept. Of Endodontics Thorough knowledge of the unusual canal morphology in multirooted teeth, the methods of Panineeya Dental College detecting additional canals and the use of latest adjuncts in successfully diagnosing and Address For Correspondence: negotiating them can contribute to the successful outcome of root canal treatment. This present Dr. M.Daneswari, Reader case report discusses the successful endodontic management of a maxillary first molar with Department of Pedodontics three roots and seven canals which was confirmed with spiral computerized tomography. We Mamatha Dental College,Khammam Contact no:9246366944 also report a bilateral evidence of multiple canals in both maxillary first and second molars in a E-mail - [email protected] single patient , a rare entity viewed in this three dimensional images. Submission : 23rd January 2014 Key Words Accepted : 4th September 2014 Root canal morphology, maxillary molars ,spiral computerized tomography Quick Response Code Introduction: A healthy 36-year-old man was referred The “hidden” internal root anatomy is the by a private dentist to Department of most unpredictable factor of an Conservative Dentistry and Endodontics, endodontic treatment, nevertheless the Panineeya Mahavidyalaya Institute of knowledge of the “normal” pulp system Dental Sciences who attempted root and its most frequent variations is basic canal in the left maxillary first molar #26 for clinical success. The goal of root .On careful clinical evaluation a #26. canal therapy is the thorough cleaning diagnosis of irreversible pulpitis with A conventional endodontic access and obturation of the entire root canal apical periodontitis was made with tooth opening was already present without any system.[1] coronal restoration. After rubber dam Hess and Zurcher’s landmark study in Table1: Previous Case Reports Of Maxillary Molars Having isolation,the carious tooth structure was 1925 showed the mesial root of the lower More Than 4 Canals removed,the three principal root canals first molar and the mesiobuccal root of References Type of study Number of canals w e r e i d e n t i f i e d : M e s i o b u c c a l the upper molars had the most Vigouroux and Bosaans (1978)(5) Extracted teeth 5 (2MB,1DB,2P) (MB),Distobuccal (DB),and Palatal. On ramifications of any teeth.[2] The Cecic et al (1982)(5) Clinical Case 5 (2MB,1DB,2P) probing with DG 16 endodontic explorer incidence of two canals in the Stabolhz and Friedman (1983)(4) Clinical case 5 (3MB,2P) (Hu-Friedy,Chicago,IL) and scrapping mesiobuccal root has been reported to be Martınez-Berna and Ruiz-Badanelli(1983)(4) Clinical case 6 (3MB,2DB,1P) calcifications with a spoon excavator, 18% and 96.1% for maxillary first molar Beatty (1984)(5) Clinical case 5 (3MB,1DB,1P) two canal openings in each of the and 58% for maxillary second mesiobuccal, distobuccal and palatal root Bond et al (1988)(5) Clinical case 6 (2MB,2DB,2P) molars.[3]Of the 140 extracted maxillary were revealed. During examination with first molars, only one tooth showed seven Wong(1991)(5) Clinical case 5 (1MB,1DB,3P) a m a g n i f y i n g l o u p e , a s m a l l root canals in which three mesiobuccal Hulsmann (1997)(5) Clinical case 5 (3MB,1DB,1P) haemorrhagic point was noted canals, 3 distobuccal canals, and one Lior Holtzman (1997) (4) Clinical case 5 (2MB,1DB,2P) approximately 3mm from the MB in the palatal canal were identified.[4] The Johal (2001)(5) Clinical case 5 (2MB,1DB,2P) palatal direction. The conventional review of cases that had more than 4 Maggiore et al(2002)(5) Clinical case 6 (2MB,1DB,3P) triangular access was modified to a canals in maxillary molars is summarized trapezoidal shape to improve access to in Table 1. Ferguson et al (2005)(5) clinical case 5 (3MB,1DB,1P) Favieri et al (2006)(4) Clinical case 5 (3MB,1DB,1P) the additional canals (Figure 1). A The purpose of this case report is to nickel-titanium ProTaper series orifice highlight the importance of using SCT in Pasternak et al (2006) (5) Clinical case 6 (2MB,1DB,3P) shaper (Denstply Maillefer, Ballaigues, successful endodontic management of a (second molar) S w i t z e r l a n d ) w i t h maxillary first molar with three roots and Filho et al(2009) (5) Ex vivo 7 (3MB,3DB,1P) 17%ethylenediaminetetraacetic acid seven canals. This advanced endodontic Holderreith and Gernhardt (2009)(3) Clinical case 5 (2MB,1DB,2P) (Glyde; Denstply Maillefer, Ballaigues, aid interestingly identified bilateral Karthikeyan and Mahalaxmi (2010) (5) Clinical case 6 (2MB,2DB,2P) Switzerland) was used to preflare coronal evidence of multiple canal system in both Kottoor et al (2010)(4) Clinical case 7 (3MB,2DB,2P) portion of the canals to improve the maxillary first and second molars all in Kottoor et al (2010) (6) Clinical case 5 (2MB,1DB,2P) straight line access. The working length single patient, a rare entity. was determined with the help of an apex (Second molar) locator (RootZX;Morita,Tokyo,Japan) Case History: Kottoor et al (2011) (7) Clinical case 8 (3MB,3DB,2P)

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 073 systems. Paul,MN).After three months follow-up To confirm this multiple canal period , the patient was clinically morphology of this tooth, dental imaging asymptomatic and was advised a full- with Spiral Computer Tomography was coverage porcelain crown. planned. Access cavity was sealed with Cavit G (3M ESPE,}3;efeld, Germany) Discussion: and an informed consent from the patient Cohen and Burns described the maxillary was obtained. A multislice helical or SCT first molar as “...Possibly the most was performed of maxilla (Sensation 64, treated, least understood, posterior Siemens-Somatom Erlangen, Germany) tooth”.[8] This case report emphasizes using dental software Dentascan. The the methods of detecting additional Figure 1: Access opening showing seven canal orifices tooth in question was focused and its canals using the latest adjuncts in (#26) morphology was obtained in transverse, successfully diagnosing and negotiating axial and sagittal sections of 0.5mm them which contribute to the successful thickness using 14.10 mgy, Scan time: 11 outcome of root canal treatment. seconds, MAS - 90, KV - 120; field of Endodontic access should be designed to view - 180 mm. The scan revealed not provide direct access to apical third of only seven canals (three mesiobuccal, root canal system, not merely to locate two palatal and two distobuccal) in left the canal orifice. Normally, MB3 canal is maxillary first molar (Figure 3A, 3B, 0.5-5mm palatal to the main MB canal 3C) but also existence of multiple canals seen as discolored dot area. Therefore, in both maxillary first and second molars full extent of the grooves on the floor of bilaterally (Figure 4A, 4B). At the pulp chamber from mesiobuccal orifice second appointment, the patient was to palatal orifice must be explored.[9] asymptomatic. After administering local Hence, in this present case traditional Figure 2: Working length radiograph(#26) anaesthesia 2% lignocaine containing triangular access opening was modified 1 : 1 0 0 , 0 0 0 e p i n e p h r i n e to trapezoidal shape. (Xylocaine;Astrazeneca Pharma Ind The magnification plays another Ltd,Bangalore,India) cleaning and critically essential element giving the shaping was done using crown down clinician unsurpassed vision, control, and technique under rubber dam isolation confidence in identifying or chasing extra with ProTaper nickel-titanium rotary canals. With the help of conventional instruments (Denstply Maillefer, radiographs, complexity of canal system Ballaigues, Switzerland).Irrigation was cannot be characterized due to the performed using normal saline,2.5% superimposition effects of the zygomatic sodium hypochlorite solution, and bone.[10] Newer diagnostic methods 17%EDTA (ethylenediaminetetraacetic such as computerized axial tomography acid).The final irrigation was done with (CT) and its applications in endodontics 2% digluconate. The were first reported by Tachibana and canals were dried with absorbent Matsumoto in 1990. Spiral CT is a recent points(Denstply Maillefer, Ballaigues, advance in CT technology. By using Switzerland), master cone selection and simultaneous patient translation through Figure 3: SCT images of #26 showing axial sections at the (A) Apical 3rd, (B) Middle 3rd and (C) Coronal 3rd. the root canal space was obturated using the X-ray source with continuous rotation cold lateral compaction of gutta percha of the source-detector assembly, SCT (Denstply Maillefer, Ballaigues, acquires raw production data with a spiral Switzerland) with AH Plus resin sealer sampling locus during relatively short (Maillefer, Denstply, Konstanz, period viewed as conventional transaxial Germany) (Figure 5).The tooth was then i m a g e s s u c h a s m u l t i p l a n e r restored with a posterior composite resin reconstructions or as 3-dimensional core(P60;3M Dental Products,St reconstructions, the possibility for m i s s i n g d e n t a l s t r u c t u r e s i s lessened.[11]CBCT scanning is a relatively newer diagnostic modality limited to major metropolitan areas, very expensive and include medicolegal Figure 4: Enlarged SCT axial images of #16, #17 and #26, issues.[4] #27 (arrows) showing multiple canal orifices respectively. and later confirmed using a radiograph Methods of detecting additional canals (Figure 2). Though, multiple :[5],[12] radiographs were taken at different 1. Additional off- angle radiographs angulations, it did not reveal the number 2. Use of magnification (loupes and microscopes) and morphology of the root canal Figure 5: Post obturation radiograph(#26)

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 074 3. Examine the pulpal floor for “lines” second molar(#27) presented four canal Pathol Oral Radiol Endod. 2010 feb; to areas where additional canals can orifices (Figure 4A, 4B ) .In doubtful 109(2):e162-5. be located. cases where there is diagnostic dilemma 7. Kottoor J, Velmurugan N, Surender 4. Ensure adequate “straight line about unusual canal systems; SCT is a S.Endodontic management of a “access to improve visibility. good three dimensional investigative tool maxillary first molar with eight root 5. Look for heamorrhagic spots. to confirm root canal morphology. canal systems evaluated using cone- 6. Perform champagne test with sodium beam computed tomography hypochlorite. References scanning: a case report. J Endod. 2011 7. Staining the pulp chamber with 1. Malagnino V,Gallottini L,Passariello May; 37(5):715-9. 1%methylene blue. P. Some unusual clinical cases on root 8. Burns RC. Access openings and tooth 8. Modify the conventional outline form anatomy of permanent maxillary morphology. In: Cohens S, Burns RC, to include extra canals. molars. J Endod 1997; 23:127-8. eds. Pathways of the pulp.4th ed. 9. White line test. 2. Hess W, Zurcher E. The anatomy of St.Louis: C.V.Mosby; 1987:120. 10. Removal of small amount of tooth the root canals of the teeth of the 9. Johal S. Unusual maxillary first structure that often may occlude a permanent and deciduous dentitions. molar with 2 palatal canals within a Canal Orifice (ultrasonic tips, round New York: William Wood & Co., single root:A case report. J Can Dent burs, tapering finishing burs) 1925. Assoc 2001; 67:211–4. 3. Holderrieth S, Gernhardt CR. 10. Slowey RR. Radiographic aids in the In the present case, SCT confirmed the Maxillary molars with morphologic detection of extra root canals. Oral presence of three roots and seven canals, variations of thepalatal root canals: a Surg Oral Med Oral Pathol 1974; the following new nomenclature of report of four cases. J Endod 2009; 37:762-72. additional canals MB1 (mesiobuccal / 35:1060–5 11. Matherne RP, Christos A, Kulid JC, MB), MB2 (middle mesiobuccal / m- 4. Kottoor J, Velmurugan N,Sudha R, Tira D. Use of cone-beam computed MB), MB3 (palato mesiobuccal / P-MB), Hemamalathi S. Maxillary first molar tomography to identify root canal D B 1 ( d i s t o b u c c a l / D B ) , D B 2 with seven root canals diagnosed with systems In Vitro.J Endod 2008; (palatodistobuccal / P-DB)and MP( cone beam computed tomography 34:87-9 mesiopalatal), DP (Distopalatal).[12] scanning:A case report.J Endod 2010; 12. Kottoor J, Albuquerque DV, The images showed that both distobuccal 36:915-21. Velmurugan N. A new anatomically and palatal root presented Vertucci's type 5. Karthikeyan K, Mahalaxmi S. New based nomenclature for the roots IV canal pattern(two canal orifices exit as nomenclature for extra canals on four androot Canals—Part 1: Maxillary two apical foramina),where as the reported cases of maxillary first m o l a r s . I n t J D e n t 2 0 1 2 ; mesiobuccal root had Vertucci's type VIII molars with six canals.J Endod 2010; 2012:120565. canal pattern (three canal orifices and 36:1073-8 13. Vertucci FJ. Root canal morphology exiting three foramina).[13] Another rare 6. Kottoor J, Hemalathi S, Sudha R, and its relationship to endodontic entity in this patient is the bilateral Velmurugan N. Maxillary second p r o c e d u r e s . E n d o d To p i c s . existence of multiple canals. The molar with 5 roots and 5 canals 2005;10:3–29. maxillary right first molar(#16) also evaluated using cone beam showed seven canals ,the right second computerized tomography: a case molar(#17) had five canals and the left report. Oral Surg Oral Med Oral

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 075 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Fabrication Of Feeding Appliance For A Four - 1 Dhirja Goel 2 Gaurav Kumar Goel day Old Infant - A Case Report And Discussion 3 Desh Raj Jain 1 Senior Lecturer , Dept. Of Pedodontics Abstract School Of Dental Sciences, Greater Noida Cleft Lip and palate is a common congenital deformity that requires a multidisciplinary approach 2 Private Practice, Dept. Of Prosthodontics 3 for its management. The immediate concern for a baby born with Cleft lip na dpalate is to enable Head Of Department , Dept. Of Prosthodontics the baby to feed comfortably. A Feeding appliance helps the child in feeding ang obtaining Govt. College Of Dentistry, Indore Address For Correspondence: necessary nutrition for its growth and development. This article explains an easy procedure for Dr. Dhirja Goel fabrication of feeding appliance And also discusses the various aspects of its fabrication and use. A-72, Alpha-I, Key Words Greater Noida U.P. 201308 Cleft Lip and Palate, Obturator, Feeding appliance Submission : 18th February 2013 Accepted : 4th September 2014 Introduction: infants require some form of obturator for Clefts of lip and palate are the most defect to be able to feed properly. A Quick Response Code common congenital deformities feeding plate is an appliance which involving the oro-facial region[1] with an obturates the cleft and restores the estimated incidence of 0.28-3.74 per live separation between oral and nasal births.[2] It is a complex trait caused due cavities. It creates a rigid platform to multiple genetic and environmental towards which the baby can press the factors.[3] nipple and extract the milk[9]. It The individuals with cleft lip or palate facilitates feeding[4],[7], reduces nasal have to deal with numerous problems regurgitation,[6],[7] reduces the associated with functions related to the incidence of choking and shortens the oral and nasal cavities[4] and higher risk length of time required for feeding. It also of ear infections[5].The oro-nasal helps to position the tongue in correct communication diminishes the ability to position to perform its functional role in create negative pressure which is the development of jaws, and contributes necessary for suckling.[6],[7],[8] The to speech development. Feeding plate feeding process is also complicated by restores the basic functions of nasal regurgitation of food, excessive air mastication, deglutition and speech intake that requires frequent burping and production until the cleft lip and/or palate choking. Feeding time is significantly can be surgically corrected. longer and fatigues both baby as well as Fig. 1 - Preoperative View Showing Bilateral Cleft Lip And mother.[6], [7] Case Report Palate Most individuals with cleft lip, cleft A four day old infant was brought to us as palate, or both require the coordinated the infant was having difficulty in care of providers in many fields of feeding due to the presence of bilateral m e d i c i n e a n d d e n t i s t r y ( l i k e cleft lip and palate. A thorough paediatrician, paediatric surgeon, examination was done for the infant to maxillofacial surgeon, Paediatric dentist, evaluate the extent of the defect. (Fig.1) Orthodontist , Prosthodontist) , as well as The History and examination revealed t h o s e i n s p e e c h p a t h o l o g y, that the patient had Veau’s Class IV otolaryngology, audiology, genetics, Bilateral cleft lip and palate[10]. No other nursing, mental health, and social extra oral or intraoral deformity was medicine. detected during the examination. As the The immediate concern for a newborn immediate concern at this time was with Cleft lip/palate is feeding. In infants feeding and nutrition of the infant, it was Fig. 2 - Impression Made With Polyvinylsiloxane Impression with mild defects, feeding may be decided to fabricate a feeding appliance Material possible with some modification in for the infant, to enable him to be fed until material putty consisitency (Aquasil soft mother and child position so as to further course of treatment was decided Putty, Dentsply DeTrey, GmbH) (Fig. 2). obdurate the defect with mothers breast. by the team. The parents were explained The child’s face was kept towards the But with most infants with Cleft palate, about the procedure and the benefits of ground during the impression procedure breast feeding may not be possible the same. so as to prevent any aspiration of the because of inability to create negative An Impression of the oral cavity was impression material. The child was pressure necessary for suction. These made with polyvinylsiloxane impression continuously crying during the procedure

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 076 As the child grows, the appliance no 2. McDonald R, Avery D, Dean J. longer fits properly, so at that time it may Dentistry for the Child and the need to be remade. Adolescent. 8 th Ed St. Louis, After 9 Months, it was found that the Missouri: Mosby; 2004 appliance has become ill-fitting due to 3. Murray, JC. Gene/environment the growth of the child, thus a new causes of cleft lip and/or palate. Clin. Obturator was fabricated at that time. Genet. 2002. 61:248-256 Similar procedure was followed at this 4. Osuji OO. Preparation of feeding time also, and the appliance delivered obturators for infants with cleft lip with care instructions to the parents. and palate. J Clin Pediatr Dent 1995;19: 211-14. Fig. 3 - Cast Poured With Dental Stone Discussion 5. Sheahan P, Miller I, Sheahan JN, The child born with required special Earley MJ, Blayney AW. Incidence attention. The treatment of Cleft Lip and and outcome of middle ear disease in palate required comprehensive planning cleft lip and/or cleft palate. by a team of specialists to ensure normal International journal of pediatric physical, mental and psychological o t o r h i n o l a r y n g o l o g y . growth and well being of the patient. 2003;67(7):785-93. During the early period of the child’s life, 6. Jones JE, Henderson L, Avery DR. the health of the child can be severely Use of a feeding obturator for infants affected due to the cleft because of with severe cleft lip and palate. Spec inadequate Nutrition to the child. The Care Dentist 1982;2:116-20. child usually takes about one-third to 7. Choi BH, Kleinheinz J, Joos U, three fourth of the amount required for Komposch G. Sucking efficiency of Fig. 4 - Obturator Appliance With Wire Extensions proper nutrition. This is due to the early orthopaedic plate and teats in increased effort needed to suckwhich infants with cleft lip and palate. Int J causes early fatigue in these infants, and Oral Maxillofac Surg 1991;20: 167- the greatly increased and prolonged 69. muscular action ted to widen the palatal 8. Shprintzen RJ. The implications of deformity. The fatigue produced by the the diagnosis of Robin sequence. prolonged feeding and the necessary C l e f t P a l a t e C r a n i o f a c J extra muscular activity, coupled with 1992;29:205-09. insufficient caloric intake can lead to 9. Samant A. A one-visit obturator severe malnutrition in these infants.[11] technique for infants with cleft palate. The fabrication of a feeding appliance for J Oral Maxillofac Surg 1989;47:539- the new born baby with cleft palate can be 40. Fig. 5 - Obturator Fitting Well In The Infants Mouth. highly beneficial in ensuring proper 10. Kernahan DA, Stark RB. A new which has an added advantage of n u t r i t i o n a n d p r e v e n t i o n o f classification system for cleft lip and ensuring a patent airway during the infection.[12],[13],[14]. It helps in cleft palate.Plastic reconstr. Surg procedure. creating a rigid platform against which 1958,;22(5);441 The impression was poured with Dental the infant can press the nipple and suck 11. John A Foote. Malnutrition in infants Stone (type III) to obtain a cast of the oral effectively, reduces nasal regurgitation, with cleft palate: with a description of cavity. The feeding Obturator was reduces the time and effort required for a new external obturator. Am J Dis fabricated using autopolymerising feeding, helps to keep the tongue away child. 1925; 30(3):343-346. acrylic resin. Two 18G Orthodontic wires form the cleft to allow unhindered growth 12. Turner L, Jacobsen C, Humenczuk were attached to the plate which extended of the palatal shelves and provides much M, Singhal VK, Moore D, Bell H. The out of the mouth. At the ends of the needed reassurance to the parents. effects of lactation education and a orthodontic wires, some acrylic resin was prosthetic obturator appliance on applied to prevent any injury to the child Conclusion feeding efficiency in infants with or parents due to the sharp ends of the Management of new born babies with cleft lip and palate. Cleft Palate wires. These wires are attached to prevent cleft lip and palate is usually challenging. Craniofac J 2001;38:519-24. accidental ingestion or aspiration of the A team approach is usually required for 13. M. Rathee, A. Hooda, A.K. Tamarkar, appliance. correct treatment planning. Until surgical S.P.S. Yadav: Role of Feeding Plate in The appliance was finished and polished correction of the defect is carried out, an Cleft Palate: Case Report and Review and tried in the childs mouth. The accurately fabricated feeding appliance of Literature. The Internet Journal of appliance was delivered and the parents plays an important role for the child to be Otorhinolaryngology. 2010 Volume were explained about the use and the care fed properly and ensure adequate 12 Number 1. of the appliance. The parents were nutrition and growth of the child. 14. Oliver HT. Construction of advised to follow regular check-up visits orthodontic appliances for the every three months so that the growth can References: treatment of newborn infants with be monitored.The parents were very 1. Profit WR, Fields HW, Sarver DM. clefts of the lip and palate. Am J happy with the apploiance and the child Contemporary Orthodontics.4th ed Orthod 1969;56:468-73 was able to feed well with the obturator in india: Mosby (an imprint of Elsevier) place. 007,p. 287-88. Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 077 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Acquired Unilateral Lower Double Lip 1 Rajdeep Kaur Gill 2 Satya Pal Yadav Abstract 3 Hemant Shakya Double lip is an uncommon congenital or acquired anomaly that can have important 4 Ravi Gupta consequences for the patients. The term double lip is used to describe a deformity of either the 1 upper or the lower lip in which a fold of labial mucosa is apparent at rest or smiling.This case was Medical Officer , Oral Medicine & Radiology Shri Ganganagar presented to revisit an entity seldom seen in the literature and show a unique presentation of 2 Senior Lecturer lower unilateral double lip which oftenly get un-noticed. 3 Reader Oral Medicine & Radiology Key Words 4 Senior Lecturer Double Lip, Unilateral, Cupid's Bow Department of Prosthodontics Mahatma Gandhi Dental College and Hospital Introduction condition bothered him as it appears Address For Correspondence: Double lip is an uncommon congenital or unaesthetic on smiling. A provisional Dr. Rajdeep Kaur, Medical Officer Oral Medicine & Radiology, Shri Ganganagar acquired anomaly that can have diagnosis of acquired unilateral lower Contact no. 09587777948 important consequences for the patients. double lip was made, and excision by Email i.d. [email protected] th The term double lip is used to describe a laser was suggested to the patient. Submission : 7 March 2013 th deformity of either the upper or the lower Accepted : 14 August 2014 lip in which a fold of labial mucosa is Discussion Quick Response Code apparent at rest or smiling.[3] A number Double lip is a rare anomaly of the upper of authors have described a “cupid’s or lower lip, in which a fold of excess or bow” appearance when the upper lip is redundant labial tissue is apparent at rest contracted. Tension of the lip leads to the or while smiling. It is usually seen after pars villosa sagging below the pars the eruption of the permanent teeth. glabrosa.[2] Although occurrence of Never seen it to develop in patients after unilateral upper double lip has been twenty years of age. This might pose mentioned in some articles, no such case cosmetic or functional problems, as well has been reported to our knowledge. This as serious impact on psychological well- glandularis and double lip. Oral Surg case was presented to revisit an entity being.[1] The reported case is unusual Oral Med Oral Pathol Oral Radiol seldom seen in the literature and show a with respect to site and presentation as Endod 1988;66:397-9. unique presentation of lower unilateral affecting left side of lower lip only. 3. Kenny KF, Hreha JP, Dent CD. double lip which oftenly get un-noticed. Whereas literature advocated affecting Bilateral redundant mucosal tissue of upper lip more frequently than the lower the upper lip. J Am Dent Assoc Case Report and unilateral case also reported in upper 1999;120:193-4. A medically fit 20-year-old male was lip[5], with male gender predilection of 4. M. C. Palma and D. I. Taub, seen at O.P.D. of Jaipur Dental College, 7:1 for this anomaly.[4] “Recurrent double lip: literature who came to seek orthodontic treatment. review and report of case,” Oral Patient gave history of trauma 15 years Treatment is indicated when the Surgery, Oral Medicine, Oral ago to the lip and got treated. Extra tissue condition interferes with speech or Pathology, Oral Radiology, and formed at the site of injury, which was of mastication or for cosmesis.[6] Endodontology. 2009;107(3):20–23. same size and color with no any other Treatment for this anomaly used is 5. W. D. Martins, F. H. Westphalen, R. associated symptom. He occasionally surgical excision and lasers. Sandrin, et al. Congenital Maxillary “sucked in” the extra tissue during times Double Lip: Review of the Literature of stress. During the course of the References and Report of a Case. J Can Dent examination, a unilateral extra fold of 1. Anura Ariyawardana. Congenital Assoc 2004; 70(7):466–8. tissue was noted in the left lower lip. The double upper lip: review of literature overlying mucosa was intact and and report of a case. Journal of appeared normal which was similar in I n v e s t i g a t i v e a n d C l i n i c a l consistency as of the adjacent mucosa. Dentistry.2011; 2: 212–215. There were no other associated 2. Cohen DM, Green JG, Diekmann SL. congenital abnormalities. Although the Concurrent anomalies:

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 078 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Herpes Zoster Involving I I Nd And I I I Rd 1 Snehal Bansod 2 Barkha Verma Divisions Of Trigeminal Nerve-a Case Report 3 Biswajit 1 Reader Abstract 2 Lecturer 3 Herpes zoster is categorized as a viral infection caused by varicella zoster virus. It is commonly Post Graduate Student known by the names , zona or zoster. The varicella-zoster virus (VZV) is a member of the Dept. Of Oral And Maxillofacial Surgery Maitri College Of Dentistry And Research Centre human herpes virus family and is responsible for causing chicken pox and herpes zoster. Most of Address For Correspondence: the living adults are exposed to VZV naturally and thus, are at risk for developing recurrence, a Dr. Snehal Bansod condition called herpes zoster . About 10% to 20% of patients harboring latent VZ virus will Lig-242, Dd Nagar, develop herpes zoster and this risk increases with age. Unique feature of this disease includes Sector-2 Raipur, Chhattishgarh blisters or sores which are most often confined to one side of the body and usually trace out a Email- [email protected] predictable pattern. Submission : 2nd March 2013 Key Words Accepted : 3th September 2014 Herpes Zoster, Shingles, varicella zoster virus. Quick Response Code Case Discussion the region of 15 16 17 18 were seen. A 60 year old male patient reported to the Patient’s oral hygiene was poor. Based on OPD of our college, with a chief patient’s history and clinical examination complaint of painful ulcers on right side provisional diagnosis was made as herpes of face and in upper right back region of zoster. Acyclovir tablets and topical jaw since 7 days. Initially patient application of acyclovir was prescribed developed fever which was followed by to the patient. After 10 days patient intense itching and burning sensation on restored to normal health. (Fig. 3, Fig.4 right side of face. After 1-2 days small & Fig. 5). painful vesicles developed over the face (Fig.1) and in the palate. Some vesicles Discussion soon ruptured forming painful ulcers on Herpes zoster is categorized as a viral right side of face and on palate (Fig. 2). The lesions did not cross the midline of the face. Patients past medical and dental history were not contributory. On clinical examination several clusters of vesicles and ulcers were seen on right side of face. The ulcers were having erythematous base. On intra oral examination, several Fig. 4 - Same Patient After Treatment With Healed Vesicles. white vesicles along with erythematous, (Side View) shallow ulcers on right side of palate in

Fig. 2 - Unilateral Painful Ulcers In Palate

Fig. 5 - Healed Ulcer In Palate, After Treatment infection caused by varicella zoster virus. It is commonly known by the names shingles, zona or zoster. Shingles- It comes from the Latin “cingulus”’which means girdle. Gird means to encircle as Fig. 1 - Patient Having Vesicles In Affected Area Of The Face Fig. 3 - Same Patient After Treatment With Healed Vesicles

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 079 with a belt or band. A girdle is a device individuals (50 yrs of age) with nerves and blood vessels, inflammatory which encircles in such a fashion. With immunocompromise status due to age, processes within nerves have the varicella tendency to follow a dermatome psychological stress, cancer therapies, potential to extend adjacent vessels. It is around the body, it is clear to what underlying malignancy, mechanical postulated that the gnathic osteonecrosis cingulus refers. It is an acute infectious trauma, hereditary or exposure to may be secondary to damage of the blood viral disease of an extremely painful and immunotoxins, intrauterine exposure to vessel supplying alveolar ridges and incapacitating nature which is varicella (i.e., chickenpox), and outbreak teeth, leading to focal ischeamic necrosis. characterized by inflammation of dorsal of varicella at younger than 18 months In children the clinical picture may root ganglia, or extramedullary cranial etc. recurrence is rare; in HIV patients the manifest with erythema multiform-like nerve ganglia, associated with vesicular recurrence rate is quite high[7]. reaction characterized by sudden eruptions of the skin or mucous appearance of round red papules. membranes in areas supplied by the Clinical Presentation may be recurrent in affected sensory nerves[1]. Clinically, it can be grouped under 3 the spring or precipitated by exposure to phases namely prodrome, acute and sunlight or after corticosteroid treatment . Natural History of VZV infection chronic. The incubation period is 1-2 The patient’s initial or primary VZV weeks. The disease is most common in Congenital Herpes Zoster infection is called chicken pox and adult life and affects males and females Congenitally acquired herpes zoster in usually occurs during childhood. During with equal frequency. Although rare it the newborn occurs due to transplacental healing, the patient’s immune system is does occur in children. Initially the adult infection with varicella -zoster virus . only rarely able to totally eliminate VZV patient exhibits fever, general malaise. This is a serious problem that produces from the body. However, in most cases During initial viral replication active congenital abnormalities . Congenital the immune system forces the virus into a ganglionitis develops with resultant varicella zoster may be acquired by dormant or latent state within the nerves. neuronal necrosis and severe neuralgia. transplacental varicella-zoster virus If the immune system becomes weakened This is responsible for the prodromal infection . The manifestations that appear in the future, VZV may be reactivated to symptom of intense pain. As the virus after birth are cutaneous scars, limb and cause the recurrent infection known as travels down the nerve the pain eye abnormalities . The manifestations shingles.[2] It occurs during the lifetime intensifies and is described as burning, are serious if infection occurs in late of 10%-20% of individuals and the tingling, itching, boring, prickly, or pregnancy. prevalence of attack increases with age. A knifelike[8]. After 1 - 4 days skin and cross immunity is believed to exist mucosal lesions develop. The skin Complications between chicken pox and herpes zoster eruption usually is limited to a single The most common complication of diseases. Children infected by varicella dermatome; the most commonly herpes zoster is postherpetic neuralgia are immune to herpes zoster and vice i n v o l v e d d e r m a t o m e s a r e t h e (i.e., pain along cutaneous nerves versa.[3]. Herpes zoster is contagious to thoracolumbar region and the face. The persisting more than 30 days after the those who have not had varicella or have initial rash is erythematous, with multiple lesions have healed). The incidence of not received the varicella vaccine. While maculopapular lesions that subsequently postherpetic neuralgia increases with age the Herpes Zoster virus is contagious, become vesicular, The appearance of the and is uncommon in patients younger Shingles, surprisingly is not. Since a cutaneous rash due to herpes zoster than 60 years (Table 1[10]). Herpes large percentage of the population coincides with a profound VZV-specific zoster lesions can become secondarily already has been exposed to Chicken pox, T-cell proliferation. Interferon-alpha infected with staphylococci or most people harbor an immunity, and the production appears with the resolution of streptococci, and cellulitis may develop. probability that anyone will develop this herpes zoster. The patient has a long- Herpes zoster involving the ophthalmic disease depends more on the state of their lasting, enhanced, cell-mediated division of the trigeminal nerve can lead immune system than on recent exposure immunity response to VZV.The lesions to ocular complications and visual loss, to the virus[4]. Approximately 500,000 are limited to one side of the body and do so referral to an ophthalmologist is cases of herpes zoster occur in the United not cross the midline. New crops of recommended. States each year.[5] In one large study[6] vesicles may continue to appear for up to Other less common complications of primary care patients, the annual seven days. After a few days, the includes incidence was two per 1,000 persons. vesicular fluid becomes cloudy (i.e., pustulation). Finally, the lesion forms a Motor paresis Pathophysiology crust that falls off after two to three Gangrene of the zoster lesions especially This particular virus is responsible for the weeks[9]. The rash may leave scarring in debilitated patients. acute onset of chicken pox, usually and changes in pigmentation and heal in Cellulitis and pustular lesions due to occurs in children and young adults. 2-3 weeks. Ophthalmic division of secondary bacterial infection. Herpes zoster is a continuation of this trigeminal nerve is most commonly Kerato-conjunctivitis in ophthalmic infection as the virus is not eliminated involved. The oral lesions are 1-4mm, lesions may cause scarring and blindness from the body but becomes latent in the white, opaque vesicles that rupture to cranial nerves, dorsal roots, nerve cell form shallow ulcerations. Several reports Table-1 : Incidence Of Post Herpetic Neuralgia bodies or autonomic ganglion. The virus have documented significant bone Age Incidence at Incidence at Incidence at may travel from one ganglion to another necrosis with loss of teeth in areas one month (%) three months (%) one year (%) thereby infecting other dermatomes. involved with herpes zoster. Because of Younger than 60 years 8.8 2.0 0.6 Herpes zoster mainly occurs in older close anatomic relationship between Older than 60 year 40.8 13.0 7.8

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 080 Table 2 : Sensitivity And Specificity Of Tests Used To Treatment 6162. Diagnose Herpes Zoster Antiviral Medications Used to Treat 3. Principles of pediatric dermatology, Test Sensitivity (%) Specificity (%) Herpes Zoster viral skin infection. Immunofluorescent antigen staining 77 to 82 70 to 76 4. Martin S. Spiller, Oral viral infection. Polymerase chain reaction 94 to 95 100 These medications are safe and well 5. Gnann JW Jr, Whitley RJ. Clinical Varicella zoster specific immunoglobulin M 48 to 61 — tolerated, with minimal side effects (e.g., practice. Herpes zoster. N Engl J Virus culture 20 100 headache, nausea). Valacyclovir and Med. 2002; 347:340–6. famciclovir usually are preferred because 6. Gudmundsson S, Helgason S, due to progressive ophthalmic they are administered three times daily as Sigurdsson JA. The clinical course of involvement. opposed to acyclovir, which must be herpes zoster: a prospective study in Encephalitis and ataxia due to cerebellar given five times daily. primary care. Eur J Gen Pract. disturbance is a rare complication. 1996;2:12–6. Pneumonitis with cough, dyspnea , Steroid therapy 7. Oral Medicine and Radio-Diagnosis" cyanosis and scattered calcified nodules Controversial results have been THE OMR CAFE" Herpes Zoster, of the lung. mentioned in various studies due to their Dr.Dipika Bumb, April 2010. Ramsay Hunt syndrome (RHS)- first high risk of inducing post herpetic 8. Neville, Damm, Allen, Bouquet, Oral described by James Ramsay Hunt in neuralgia. But, in immuno compromised and maxillofacial pathology, 3rd ed, 1907, [11] is caused by reactivation of elderly patients corticosteroids along Elsevier, pg 250. VZV which lies latent in sensory root with antiviral drugs have proved to be 9. Anne L. Mounsey, M.D., Leah G. ganglion for years in a patient who had useful in healing and crusting of lesions. Matthew, M.D., And David C. chickenpox earlier. Involvement of Slawson, Herpes Zoster and geniculate ganglion of sensory branch of Prevention Postherpetic Neuralgia: Prevention facial nerve leads to herpes zoster oticus In 2006, the Food and Drug a n d M a n a g e m e n t , A m F a m (HZO) also known as RHS. Involvement Administration licensed the vaccine Physician. 2005 Sep 15;72(6):1075- of facial nerve leads to otalgia, lower Zostavax® to be used to prevent shingles 1080. motor neuron homolateral facial in patients who are 60 years of age or 10. H e l g a s o n S , P e t u r s s o n G , paralysis, and vesicular eruptions in older. For those who underwent Gudmundsson S, Sigurdsson JA. auricle. vaccination against chicken pox, their Prevelance of postherpetic neuralgia risk of developing shingles appears to be after a first episode of herpes zoster: Diagnosis of Herpes Zoster lower than those who were exposed to prospective study with long term The dermatomal pattern of distribution chicken pox naturally.Prevention of follow up. BMJ. 2000; 321:794–6. and the appearance of the herpes zoster varicella is very important in neonates 11. Hunt JR. On herpetic inflammation of rash are so distinctive that the diagnosis and immunocompromised individuals. the geniculate ganglion. A new usually is clear. In cases where the P a s s i v e i m m u n i z a t i o n i s b y syndrome and its complications. J diagnosis is in doubt, polymerase chain administering varicella zoster Nerv Ment Dis 1907;34:73-96 reaction (PCR) techniques are the most immunoglobulin (VZIg) to abort or 12. Bezold GD, Lange ME, Gall H, Peter sensitive and specific diagnostic tests; modify the clinical infection and should RU. Detection of cutaneous varicella however, these techniques are not widely be administered within 4 days of z o s t e r v i r u s i n f e c t i o n s b y available. PCR techniques detect the exposure to the infected case. Active immunofluorescence versus PCR. varicella DNA in fluid taken from the immunization with a live attenuated VZ Eur J Dermatol. 2001; 11:108–11. vesicles. Viral culture has a low virus reduces the risk of acquiring 13. Sauerbrei A, Eichhorn U, Schacke M, sensitivity because the herpes virus is infection; however it should be given Wutzler P. Laboratory diagnosis of labile and difficult to recover from the within 48 hours to high risk individuals. herpes zoster. J Clin Virol. 1999; v e s i c u l a r f l u i d . T h e d i r e c t 14:31–6. immunofluorescent antigen-staining test References 14. Sauerbrei A, Sommer M, Eichhorn U, has a higher sensitivity and is more rapid 1. Shafer, Hine, levy, Shafer’s textbook Wutzler P. Laboratory diagnosis of than culture; it provides an alternative of oral pathology, 6th ed, pg 344-345 herpes zoster: virology or serology?. diagnostic test when PCR is not available 2. R. Balasubramaniam, E. Stoopler, Med Klin (Munich). 2002; 97:123–7. (Table 2 [12],[13],[14]). varicella zoster disease, American academy of oral medicine, (425) 778-

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Management Of Clipped Tongue Associated 1 Kamal Garg 2 Saneev Kumar Salaria Speech And Ice Cream Licking Difficulty 3 Navjot Kaur 4 Kusum Jain Through An Interdisciplinary Approach: A 1 Reader 2 Professor And Head Case Report 3 Post Graduate Student, Dept. Of Periodontology Surendera Dental College And Research Institute 4 Consultant , Speech Tharapist, Arpan Hospital Abstract Address For Correspondence: so called clipped tongue/ tongue tie constitutes an oral developmental anomaly Dr. Kamal Garg, Reader characterized by alteration in tongue's frenulum, which restricts the tongue movement. Department Of Periodontology Ankyloglossia may also lead to number of problems like infant feeding difficulties, lack in self Surendera Dental College And Research Institute cleansing property, speech disturbance with cosmetic and social difficulties etc. because ventral H. H. Gardens, Sriganganagar, Rajasthan. Pin - 335001 part of the tongue is fused completely or partially to the floor of mouth leads to restricted tongue Submission : 8th April 2014 movements. Treatment options such as frenotomy without anesthesia, and frenectomy under Accepted : 23th February 2015 local anesthesia by various methods followed by speech therapy have all been suggested in the Quick Response Code literature. In the present case report Kotlow’s class III ankyloglossia with history of speech and ice cream licking difficulty was managed through an interdisciplinary approach of periodontist and speech therapist using diode laser assisted frenectomy followed by speech therapy resulted in excellent outcome 6 months post operatively. Key Words Granuloma, Giant-cell, Peripheral, Central Introduction consonants and diphthongs.[5] The tongue appears in the embryos of Many descriptions of ankyloglossia are cream cone since childhood. On intraoral approximately 4weeks as paired lateral prefaced with statements such as, "Little examination, partial ankyloglossia of lingual swellings (tuberculum impar )and research has identified the positive kotlow’s class III [4] was observed with a medial lingual swelling (hypobranchial relationship between tongue-tie and inability to protrude his tongue up to eminence). These swellings originate speech disorders. lower lip ,shape of tongue was heart from the first pharyngeal arch in the floor The present case report describes the shape with notch on the tip of tongue (Fig of the developing mouth.[1] Incomplete management of clipped tongue 1). Patient was made aware and fusion or lack of proper orientation will associated speech articulation and ice motivated for the management of same lead to numerous congenital anomalies of cream licking difficulty through diode during phase I therapy. Patient was found tongue. Clipped tongue or ankyloglossia laser assisted frenectomy followed by to be periodontally healthy with bilateral is a condition in which the midline sheath speech therapy by interdisciplinary team angle’s class I malocclusion (Fig 2) of tissue attached to the base of the tongue approach. without marginal tissue recession on the (lingual frenulum) causing restriction of lingual aspect of mandibular incisors. tongue motion.[2] Case Report The ENT and general physical The incidence of ankyloglossia ranges A 24-year-old male patient reported to examination was normal and speech from 0.002% to 4.8% with a male to the Department of Periodontology, therapist; after evaluating the general and female ratio of 3:1.[3] Several studies Surendera Dental College and Research functional test, lingual frenectomy establish diagnostic criteria based on the Institute, Sriganganagar for routine oral followed speech therapy sessions length of the lingual frenulum, amplitude prophylaxis. During the conversation recommended. Lingual frenectomy by of tongue movement, heart-shaped look with patient, difficulty in speech diode laser (Biolase) was advised to the when the tongue is protruded and articulation for consonants like t, d, n, l patient and written informed consent was thickness of the fibrous membrane. etc. was observed along with it patient Kotlow’s (1999) classified the also reported his inability to lick the ice ankyloglossia on the basis of free tongue length into four classes as follows: Class I-Mild ankyloglossia 12-16mm, class II- moderate ankyloglossia 8-11mm, class III- ankyloglossia3-,7 mm and class IV- complete ankyloglossia <3mm.[4] In ankyloglossia, due to restricted movements, patients exhibit speech Fig.1: Kotlow's class III ankyloglossia ,with Heart shape difficulties in pronunciation of certain tongue and notch on tip of tongue. Fig.2: Bilateral angle's Class 1 malocclusion.

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 082 taken. After administration of topical anesthesia, few drops of 2% lignocaine hydrochloride and 1:80,000 adrenaline was injected in the frenum. Diode laser 940nm (Biolase) (Fig 3) utilizing 300 micro meter fiberoptic was used in for the frenectomy procedure (Fig 4) at 1.4W in contact and pulse mode utilizing brushing stroke method from coronal to apical direction. The attachment of Fig.7: Post operative healing at one week. frenum to the alveolar ridge was also excised to prevent tension on the gingiva .Vitamin-E solution was applied to the Fig.5: Vitamin E solution application. wound site (Fig 5). Tongue movement was evaluated immediately after Frenectomy (Fig 6). No suturing and periodontal dressing was applied. Immediate post operative instructions and post operative excersises were advised as per recommendation of speech therapist. Post operative healing at one week was uneventful and satisfactory (Fig 7). Then patient was referred to speech therapist for speech therapy session. One month post operatively reported his ability to lick the ice cream comfortably whereas speech articulation

Fig.8: Complete protrusion of 13-15mm without notch at the Fig.6: Free tongue immediately after procedure. tip of tongue at six months post operatively. was highly improved after 6 months of Diode laser assisted frenectomy was speech therapy session (Fig 8). carried out after stripping the 300 micro meter fibreoptic wire tip activation by Discussion firing it into a piece of cork at 1.4W in Clipped tongue is an uncommon contact pulse mode to facilitate the congenital oral developmental anomaly formation of small amount of carbon at characterized by very short lingual the tip, referred to as “hot tip effect”. It frenulum capable of resulting in variable focuses a large amount of energy at degree of reduction in tongue mobility, contact point and allows accelerate tissue speech difficulty ,chiefly in the incision. As continuous mode of laser pronunciation of certain consonants and application leads to rapid rise in diphthongs.[5] In the case reported here, temperature in the target tissue therefore Kotlow’s class III clipped tongue patient we preferred pulsed mode which provide presented with mechanical and speech time for the tissue to cool down and to relevance since it cause mechanical- prevent collateral tissue damage incident Fig.3: Diode laser 940nm (Biolase). functional modification. Patient reported to excessive heat production.[8] Patient difficulty in licking the ice cream cone hardly reported any discomfort and and difficulty in speech articulation in bleeding during and after the procedure association with altered frenulum because heat build up leads to the sealing attachment which was diagnosed on the of the small blood vessels through tissue basis of kotlow’s classification (1999)[4] protein denaturation and stimulation of as well as on general & functional test factor VII resulting in reduced post evaluation score reported as 5 and 29 operative as well.[9] Lingual respectively[6] by speech therapist frenulum was completely eliminated and which was in accordance with the reports immediately after the procedure patient of Lalakea ML and Messner AH 2003.[7] was able to protrude the tongue up to 13- and was advised frenectomy followed by 15 mm. Laser’s sterilization of the speech therapy. surgical wound reduces the need for Fig.4: Laser assisting Frenectomy.

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 083 postoperative care and antibiotics. As personnel and functional difficulty will Textbook of Oral Pathology, 4th Ed. number of myofibroblasts found after be best diagnosed and managed by Philadelphia: Saunders, 2003:2-85. laser treatment are found to be less,[10] interdisciplinary team for the better 6. Marchesan,IQ. Lingual frenulum this helps in less wound contraction and clinical, morphological and functional Protocol. Int journal of Orafacial scarring.Immediate post operative outcome as well as to meet patient Myology 2012 Nov; 38:89-103. exercises advised;are not intended to expectations . 7. L a l a k e a M L , M e s s n e r A H . increase muscle-strength or to improve Ankyloglossia: The adolescent and speech, but to: 1 develop new muscle References adult prospective. Otolaryngol Head movements, particularly those involving 1. Langman J.: Head and neck section. Neck Surg 2003 May; 128(5):746-52. tongue-tip elevation and protrusion, Medical Embryology, 4th Ed. 8. Ewart NP. A lingual mucogingival inside and outside of the mouth, 2 Baltimore: The Williams & Wilkins p r o b l e m a s s o c i a t e d w i t h Increase kinesthetic awareness of the full Company.1981; 363-402. ankyloglossia: a case report. N Z Dent range of movements the tongue and lips 2. Obladen M. Much Ado about J 1990 Jan; 86(383):16-17. can perform. In this context, kinesthetic N o t h i n g : Tw o M i l l e n i a o f 9. Pirnat S. Versatality of an 810 nm awareness refers to knowing where a part Controversy on Tongue-Tie. diode laser in dentistry: an overview. of the mouth is, what it is doing, and what Neonatology.2010; 97(2):83-9. J Laser Health Acad 2007; 4:19. it feels like, and 3.Encourage tongue 3. L a l a k e a M L , M e s s n e r A H . 10. Zeinoun T, Nammour S, Dourov N, movements related to cleaning the oral Ankyloglossia: Does it matter? A f t i m o s G , L a o m a n e n M cavity, including sweeping the insides of Pediatr Clin North Am 2003 Apr ; :Myofibroblasts in healing laser the cheeks, fronts and backs of the teeth, 50(2):381-97. excision wounds. Lasers Surg Med and licking right around both lips; 4. Kotlow L. Ankyloglossia (Tonue tie): 2001; 28(1):74-9. followed by speech therapy for 6 months A diagnosis and treatment quandary. which resulted in excellent outcome. Quintessence Int 1999 Apr; 30(4):259-62. Conclusion 5. Shafer W, Hine M,Levy BM, Tomich Clipped tongue associated speech CE. Developmental disturbances of articulation , cosmetic, social or oral and paraoral structures. A

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Impaction Of All Permanent First Molars In 1 Samridhi Sharma 2 Bimal Chandra Kirtaniya Transitional Dentition : A Case Report 3 Heena Soni 1 Post Graduate Student Abstract 2 Head Of Department 3 Failure of eruption of all permanent molars is an uncommon condition. The purpose of this report Postgraduate Student was to present the case of an 8-year and six months old patient with impaction of all permanent Dept. Of Pedodontics And Preventive Dentistry Himachal Dental College, Sundernagar maxillary and mandibular first molars. Clinically, all the teeth were palpable beneath a thick Address For Correspondence: mucosa which was confirmed radiographically. Right side molars were surgically exposed and Dr. Samridhi Sharma were allowed to erupt in the oral cavity whereas other teeth were kept as control. The surgically Dept. Of Pedodontics And Preventive Dentistry treated teeth erupted into the oral cavity spontaneously. This case demonstrates that when this Himachal Dental College, Sundernagar problem is identified and treated early, pediatric dentists have the opportunity to minimize the Submission : 8th April 2014 complexity of future orthodontic treatment and limit the extent of malocclusion in the permanent Accepted : 23th February 2015 dentition. Key Words Quick Response Code Delayed Eruption, Impaction, Surgical Exposure, Fibrous Mucosa.

Introduction incidence of impacted canine in maxilla Tooth eruption is a process of biological is 0.92% and of other non-third molar maturation, which comprises the axial impaction is to be 0.38%. The Impaction movement of a tooth from its of permanent first molars is very low; the intraosseous location through the prevalence is 0.01% in normal towards the functional population. The first permanent molar involved but the causes were local. position in the occlusal plane.[1] seems to be impacted more frequently Angle has postulated that permanent first Impaction is the cessation of the eruption than the second permanent molars.[7] molars are "key teeth" in occlusion, as of a tooth caused by a clinically or Impaction of primary teeth is rare and they support the main mastication, radiographically detectable physical when it happens the teeth are maxillary influence the vertical distance between barrier in the eruption path or due to an primary second molars. upper and lower arches and their eruption abnormal direction of the tooth.[2] Local factors for impaction are is especially important for the co- Delayed tooth eruption is the emergence supernumerary teeth, odontogenic ordination of facial growth. Therefore, of a tooth into the oral cavity at a time that tumors (such as ameloblastic fibroma, impaction of permanent first molar can deviates significantly from norms of odontogenic fibroma and ), alter the “key of occlusion” and result eruption established for different races, cysts, malformed teeth, delayed tooth disturbed mastication, short lower facial ethnicities, and sexes.[3] Impaction may development, insufficient arch space, height.[9] Moreover, management of be bony or soft tissue impaction. inclination against the second primary these teeth after root development is Impaction of permanent teeth is one of molar, and mucosal barrier due to complete and adaptive movements of the severe problems that can occur during gingival fibrosis.[8] Any failure of the adjacent teeth have occurred is difficult the mixed dentition period or beyond. follicle of an erupting tooth to unite with and the prognosis is poor.[10] There may The most common impacted tooth is third the mucosa will entail a delay in the be development of , pre- molar, followed by maxillary permanent breakdown of the mucosa and constitute eruptive caries, periodontal problems or canine and mandibular second a barrier to emergence. infection from the impacted tooth. premolar.[4] Primary retardation refers to There are systemic factors that influence the failure of eruption before emergence delayed eruption or impaction of teeth. Case Report without a physical barrier in the eruption The systemic factors include a familial An 8-year, 6-month-old girl reported to path and not due to an abnormal position tendency to retardation of eruption and the department of Pedodontics and and is caused by the disturbance in the metabolic or endocrine disturbances Preventive dentistry, Himachal dental primary follicle which fails to initiate (hypothyroidism, hypopituitarism and college, Sundernagar with the complaint bone resorption in eruption path.[5] Vitamin D deficiency), syndromes of not erupting permanent teeth. Medical While secondary retardation refers to the (Gardner’s syndrome, Cleidocranial history revealed no hypothyroidism or cessation of eruption of a tooth after dysplasia, Cleft lip and palate, Aarskog hypopituitarism and Vit D deficiency as emergence without a physical barrier in syndrome, Zimmerman laband well as no familial history of impacted the eruption path and not due to an syndrome).[3] In all these conditions teeth. On clinical examination, all the abnormal position and ankylosis is the multiple teeth are involved or entire maxillary and mandibular first main etiological factor.[6] dentition is involved. In the present case permanent first molars were impacted Dachi and Howell, 1961 found the all the first permanent molars were (Figure 1, 2). The maxillary and

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 084 the impacted teeth was found which was Discussion very firm. There was no other The sequential and timely eruption of abnormality found on clinical teeth is critical in overall development of examination. dentition of the child. Failure of eruption The panoramic radiograph showed of single tooth or a group of teeth is an vertical position of the impacted teeth asymptomatic pathology, which means with a thick band of mucosa covering the that it is usually a casual discovery and its crown of the teeth and root formation of diagnosis is made late. When this is so, all the first permanent molars was almost repercussions on the permanent dentition Figure 1 & 2:Intraoral Preoperative Photographs Showing All complete i.e. Nolla’s 9th stage (Figure may be already present. These include: Impacted First Permanent Molars 7). There was no bone covering the , shortening of the facial crowns of the impacted teeth. All the height, incomplete development of the teeth were developing at normal pace on alveolar process and risk of root radiographic evaluation. resorption of neighboring teeth. On the basis of following diagnosis, a Tooth eruption is a complex process and decision of surgical exposure of the is divided into five stages: pre eruptive impacted teeth was made. Prior to movements, intra-osseous stage, surgical procedure routine blood mucosal penetration, preocclusal and Figure 2:Intraoral Preoperative Photographs Showing All examinations were carried out which post occlusal stages.[11] The eruption Impacted First Permanent Molars were within normal limit. The operation time of both primary and permanent teeth was performed under local anesthesia in have got a specific date and variations of the department of pediatric dentistry. The six months on either side of the usual overlying gingivae on the right side of eruption date may be considered normal maxillary and mandibular first for a given child. Rasmussen and permanent molars were excised to expose Kotsaki[12], suggest when the the crowns of the impacted teeth and left emergence of a tooth is more than 2 side molars were kept as control (Figure standard deviations (SDs) from the mean 3, 4). The exposed occlusal surfaces were of established norms for eruption times, it covered with Coe-pack to prevent should be considered delayed eruption. and epithelization. The Because the age at detection in most patient was instructed to take soft and reported cases is around 10 years, cold diet for 24 hours and an antiseptic pediatric dentists are more likely than Figure 3 & 4:Intraoral Photographs Showing Surgical mouth rinse was prescribed to maintain general practitioners to encounter and Exposure Of Right Maxillary And Mandibular Impacted Teeth oral hygiene. diagnose such cases. Routine check up and radiographs were The eruption of permanent maxillary and taken after regular interval to assess the mandibular first molar is observed to be improvement of eruption of the tooth. around 6-7 years (Table 1, 2).[13] The The right maxillary and mandibular tooth dental age of a patient is calculated on the erupted into the oral cavity whereas left basis of last group of teeth erupted into side molars failed to erupt (Figure 5, 6). the oral cavity, root resorption of the

Table 1:Eruption Date Of Permanent Maxillary Teeth Maxillary Figure 4:Intraoral Photographs Showing Surgical Exposure Central Incisor 7-8 Years Of Right Maxillary And Mandibular Impacted Teeth Lateral Incisor 8-9 Years First Bicuspid 11-12 Years Second Bicuspid 10-11 Years First Molar 6-7 Years Second Molar 12-13 Years Third Molar 17-21 Years Figure 6:Impacted Right Maxillary And Mandibular Have Erupted In The Oral Cavity Table 2:Eruption Date Of Permanent Mandibular Teeth Mandibular Central Incisor 6-7 Years Figure 5 & 6:Impacted Right Maxillary And Mandibular Have Lateral Incisor 7-8 Years Erupted In The Oral Cavity Cuspid 9-10 Years mandibular central incisors were First Bicuspid 10-12 Years erupted; therefore, the dental age of the Second Bicuspid 11-12 Years patient is 8 years. On palpation, the crowns of the impacted teeth were First Molar 6-7 Years Second Molar 11-13 Years palpable in their respective position and a Figure 7:Panoramic Radiograph Showing Soft Tissue thick band of mucosa over the crowns of Impaction Of All Permanent First Molars. Third Molar 17-21 Years

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 085 respective adjacent primary teeth and authors.[14] Impaction is very common Surg Oral Med Oral Pathol 1961; root development of the succedaneous among teeth with malformations 1165-69. permanent teeth.[11] Therefore, in the confined either to root or crown after 8. Di Salvo NA. Evaluation of present case the dental age of the patient trauma.[15],[16],[17]. unerupted teeth: orthodontic is 8 years and all the permanent first But in this case thick mucosa was formed viewpoint. J Am Dent Assoc 1971; 82 molars were impacted for more than two due to trauma of chronic masticatory (4):829-35. years. The impacted permanent first forces and fortunately there was no 9. Angle E.H. Behandlung der molar should be diagnosed and treated as malformation or ectopic eruption of the Okklusionsanomalien der Zähne, early as possible to prevent various permanent molars as depicted by OPG Angle´s System, Hermann Meusser complications as discussed earlier. (Figure 7). Kramer et al.[18] pointed out Verlag, Berlin 1908. Kaban proposed that when roots have that a dental follicle may become 10. Kaban LB, Needleman HL, developed more than 50 % the impacted thickened when a tooth fails to erupt and Hertzberg J:Idiopathic failure of tooth should be exposed for spontaneous that the thickened follicular fibrous tissue eruption of permanent molar eruption.[10] In the present case the root is often myxoid. It has been found that teeth.Oral Surg Oral Med Oral Pathol development was almost complete and when multiple deciduous maxillary 42:155-163, 1976. we didn’t delay the operation after incisors have been lost before age of 5, 11. Proffit WR, Fields HW, Sarver DM. diagnoses. soft tissue over the alveolus becomes Contemporary orthodontics. 5th ed. The present case is very interesting hypertrophic and fibrotic, preventing the St. Louis, Mo: Mosby; 2012. because the prevalence of impaction of eruption of permanent central 12. Rasmussen P, Kotsaki A. Inherited permanent first molar is very rare. The incisors.[10] Whatever the cause for retarded eruption in the permanent management of an impacted tooth often formation of fibrous mucosa, the affected dentition. J Clin Pediatr Dent 1997; necessitates a complex surgical and tooth gets impacted. 21:205-11. orthodontic treatment as indicated by 13. McDonald RE, Avery DR, Dean JA. clinical observation of the particular Refrences Dentistry for the child and impacted tooth. We opted for surgical 1. Ten Cate AR.Oral histology: adolescent.9th ed. Maryland Heights, exposure (Figure 3, 4) only and periodic development, structure, and function. Mo: Mosby Elsevier; 2011. follow up for their eruption since the 3rd ed. St Louis, CV Mosby 1989; 14. DtBlase DD.Mucous membrane and teeth were impacted with soft tissue 275 -298. delayed eruption .Dent practit 1971; (Figure 7) and the child was in the 2. Raghoebar GM, Boering G, Vissink 21(7):241-50. growing stage. The surgical objective is A, Stegenga B. Eruption disturbances 15. Andreasen JO, Sundstrom B, Ravn to remove the impediment and to assist of permanent molar: a review. J Oral JJ.The effect of traumatic injuries to physiologic eruption by exposing the Pathol Med 1991; 20:159-66. primary teeth on their permanent crown. After exposure of the crown, we 3. Suri L, Gagari E, Vastardis successors.1.Aclinical and histologic usually give surgical pack to prevent H . D e l a y e d t o o t h e r u p t i o n : study of 117 injured permanent teeth. epithelial growth over the tooth. In some Pathogenesis, diagnosis, and Scand J Dent Res 1971; 79:219-83. cases a second surgical exposure may be treatment. A literature review. Am J 16. Broglia ML.Consideartions su un necessary, if the wound closed with Orthod Dentofacial Orthop 2004; 126 caso di intrusion traumatic di un dente gingival growth following surgical (4) :432-445 deciduo causa di ritenzione del exposure. When the tooth shows no 4. Shafer WG, Hine MK, Levy BA:A correspondente permanente.Minerva tendency to erupt, then orthodontic textbook of oral pathology, Stomatol 1959; 8:811-3. traction is indicated. Philadelphia, 1974, WB, Saunders. 17. Kamat SS, Kumar GS, Raghunath V, In this case the thick fibrous band of 5. Oliver RG, Richmond S, Hunter B. Rekha KP.Permanent maxillary mucosa over the impacted permanent Submerged permanent molars: four central incisor impaction: report of first molars did not allow the teeth to case reports. Br Dent J 1986 two cases. Quintessence Int 2003; erupt but at the same time the teeth were ;160(4):128-30 34:50-2. not ectopically erupting. Mucosal barrier 6. Raghoebar GM, Boering G, Jansen 18. Kramer IRH, Pindborg JJ, Shear M: has been suggested as the etiologic factor HWB, Vissink A. Secondary Histological Typing of Odontogenic in impaction in present case. Disturbance retention of permanent molar: a Tumors, 2nd Ed. Berlin: Springer- in permanent tooth eruption or impaction histologic study. J Oral Pathol Med Verlag, pp 23, 1992. may occur after trauma to primary 1989; 18 (8): 427-31. dentition that is related to abnormal 7. Dachi SF, Howell FV. A survey of change in the connective tissue overlying 3874 routine full mouth radiographs. the tooth germ as suggested by various IL A study of impacted teeth. Oral

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 086 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Overdenture Ball Attachment : Three Case 1 Richa Vats 2 Bismad Kaur Reports 3 Amitoj Singh 4 Rupandeep Kaur Samra Abstract 1 Pg Student Use of ball attachments for overdentures is very common consisting of a male and a female part, 2 Pg Student female part is inserted in to denture. There are two methods of attaching the same –chair side 3 Senior Lecturer and laboratory procedure. Three patients were given ball attachments for mandibular 4 Reader, Dept. Of Prosthodontics overdenture. The use of remaining roots to aid in the stability, support and retention of root- Himachal Dental College supported overdentures is of great importance. However a clinician faces different problems Address For Correspondence: Dr. Richa Vats during prosthetic procedures. This article emphasizes in and out of ball attachment prosthesis for Dept. Of Prosthodontics overdenture. Two different systems were used EDS (essential dental systems) for chairside and Himachal Dental College Sundernagar CEKA PRECI-CLIX for laboratory procedure. One patient was treated for implant supported Submission : 18th April 2014 overdenture with chair side attachment procedure. Accepted : 25th February 2015 Key Words Quick Response Code Overdenture, Abutment tooth, Preci-clix attachments, EDS attachments. Introduction thereby enable the patient with Patients with complete denture often overdentures to masticate food more complain of reduced masticatory efficiently [1] efficiency as compared to their natural counterparts. From previous studies, Rationale for over denture concept dentists have become more aware that • Extraction of all natural dentition and tooth retention in association with replacement with complete denture is complete dentures is valuable for the not the most desirable treatment A tooth retained overdenture is an preservation of the structure of the • P r e v e n t i v e p r o s t h o d o n t i c s excellent way of maintaining healthy a l v e o l a r b o n e a n d s e n s o r y emphasizes the importance of any viable bone around the roots of the teeth proprioception.[1] procedure that can delay or eliminate and a great way to support and retain a The concept of overdentures developed further prosthodontic problems denture for improved speech, breathing, as a simple and economic alternative to • The over denture is a logical method tongue position and increased taste. prolong the retention and function of the for a dentist to use in preventive In a 4-year-study, Renner et al showed remaining few teeth in a compromised prosthodontics.[2] that 50% of roots, used as overdenture dentition. This concept is not new but its abutments remained immobile. In use has been in literature back over 100 Indications addition, 25% of roots that were initially years. An overdenture is a removable • For patients who face the loss of mobile became less mobile.Hence, they complete or removable partial denture remaining natural adult dentition. suggested, that teeth that are generally that has one or more roots of remaining Therefore, younger the patient compromised can be used for teeth to provide support. Rather than greater the indication overdentures after root canal therapy and extracting all compromised teeth, the • Patents with badly worn out dentition decoronation.The use of attachments can crowns and pulpal tissue of selected teeth • Cleft palate cases re¬direct occlusal forces away from are removed. The remaining root • For congenital anomalies like weak supporting abutments and onto soft projecting through the mucosa is restored , in selected partial tissue, or redirect occlusal forces toward and/or contoured. Overdentures with cases. Amelogenesis stronger abutments and away from soft roots are more stable, retentive and imperfecta and dentinogenesis tissues. They act as shock absorbers and patients can chew better than with imperfecta stress redirectors as well as provide denture supported on residual alveolar • D e n t u r e f o r p a t i e n t s w i t h superior retention.[3] bone and mucosal tissue alone. maxillofacial trauma.[2] Implant supported overdenture help in The presence of natural teeth under regaining the lost supported structures for dentures can increase the lateral stability Contra indications edentulous patients. The mandible is well and retention of the denture base. These • Uncooperative and under motivated suited for implant-retained overdentures, conditions in turn aid the patient in patients particularly when placed in the becoming accustomed to the prosthesis • Mentally and physically handicapped intercanine region. Various attachment m o r e r e a d i l y. I n t h e o r y, t h e patients for whom good oral hygiene systems are used nowadays amongst proprioception provided by retained is difficult to maintain which, ball attachments have been teeth should result in better perception of • E c o n o m i c a l l y c o m p r o m i s e d proved to be quick.[4] food particle size during chewing and patients.[2] Dental precision attachments connect

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 088 removable partial dentures a to fixed Post space was prepared with the drilling male/female locking mechanism. Some bur, diamond bur was used to prepare the advantages to dental precision base of the post. Finally, the reamer was attachments include maintainable used to prepare the diameter of the periodontal health, less force on post.Cementation of the post was done abutment teeth, cosmetic appearance, with glass ionomer cement FUJI II. longevity and stability. Following conventional technique The ‘male’ part is fixed to the crown or segmental border moulding of the tray bridgework whereas the ‘female’ part was done with low fusing impression holds the removable partial denture. compound. Then the spacer was removed There are a variety of male/female and vent holes were made in the tray. locking mechanisms available, these Final impression was made with addition Figure 4. Showing The Intaglio Surface Of The Mandibular include ball and socket, friction grip slide silicone (3M). Stainless steel post Denture (With Female Housing). attachment, latch burs, post and socket, analogues were taken and re-indexed into spring retained socket and snap-on/screw the recess within the impression and Case Report – 2 in. The male part of dental precision master casts was made. (Figure 1, 2, 3, A 40-year-old female patient had attachments is often a high strength 4). reported to the Department of precious alloy whereas the female part Prosthodontics with few remaining consists of a more elastic alloy. natural teeth and a chief complaint of A patient might prefer one precision difficulty in chewing. Clinical attachment over the other depending on examination revealed completely ease of attachment. Some dental edentulous maxillary and partially precision attachments are better suited edentulous mandibular arch. Teeth for different areas of the jaw. Type of present in lower arch were 44, 43,33. locking mechanism, material of precision Metal coping was given for 44. attachment and intended use, all should EDS system was used for this be considered when choosing a dental overdenture. Female part of this system precision attachment. In this case report consists of only plastic ring which is various ball attachments were used in directly inserted into denture in the chair different patients. Figure 1. Showing Metal Housing With Retention Caps side procedure. There is freedom from Placed Over The Posts On The Cast. metal housing as seen in other system Case Report - 1 (Figure 5, 6, 7, 8). A 50-year-old male patient had reported to the Department of Prosthodontics with few remaining natural teeth and a chief complaint of difficulty in chewing. Clinical examination revealed partially edentulous maxillary and mandibular arch. Teeth present in lower arch were 43,33,34. Loss of teeth had occurred due to decay, mobility and lack of oral hygiene practice in earlier life. Pre- Figure 5. Showing Final Mandibular Prosthesis With Eds o p e r a t i v e i n t r a o r a l p e r i a p i c a l Attachments. radiographs were taken which revealed Figure 2. Showing Large Tin Spacer Placed Over The Ball Coping And Is Contoured Around It And Gingival Area. Black that the tooth roots were surrounded by Rubber Space Maintainer Was Placed On The Ball Over The healthy periodontium and bone. It was Tin Spacer.Female Component Was Seated Over Both The concluded that mandibular canines could Ball Copings. serve as abutments for an overdenture thus providing required retention and stability and a coping for 34 was planned. Diagnostic mounting revealed adequate interarch distance for necessary components and esthetic and functional Figure 6. Depicting Posts With Female Housing In Place. placement of acrylic teeth. Considering patient’s complaint, background and condition of the oral cavity; an overdenture was planned with attachments ( Preci-Clix- DFS Belgium). First part involved intentional endodontic preparation with subgingival Figure 3. Denture Was Processed In Conventional finish line in relation to 33,34 and 43. A Manner.Thetin And Black Rubber Spacers Were Removed. short metal coping was given for 34. The Rubber Insert Could Be Easily Changed In The Metal Figure 7. Preparation Of Two Holes Corresponding To The Housing To Adjust Retention. Posts.

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 089 have problems adapting to their complete material have been proven to have higher dentures, especially to the mandibular mechanical properties when compared to prosthesis. auto polymerised material[8]. Tooth supported overdenture is a viable Insufficient flexural strength of auto and tissue tested alternative technique for polymerizing acrylic resin is lower than those who cannot have implants due to that of Heat polymerizing acrylic various reasons like medical contra- resin.[9] Breakage of prosthesis occurs indications, cost factors and also for around attachment region in chair side patients who are not willing for the made overdenture. Common problems Figure 8. Self-cure Acrylic Used For Embedding The Female implants. The advantages includes like denture sore occurs at gingival level Housing And Sealing The Holes Within The Denture. effective and superior method of of abutments as there is excessive treatment for edentulous case, ease of bulging of tissue. Trimming of denture maintenance, stable and retentive, for such reasons further causes loss of reasonable cost compared to implants, thickness and strength. familiar procedure and excellent patient Compared with the chair side processing acceptance.[5] of attachments there is no incidence of Preserving the teeth and making the discoloration in laboratory technique. denture, tooth and tissue borne, helps in Also wax up can be recontoured in the preserving the supporting structures, laboratory processing to provide more both in health and function. room for future adjustments in acrylic The literature reports that in the elderly around attachment areas. population it is common to observe poor Figure 9. Female Metal Housing Was Attached To Implant. Holes Were Made In The Prosthesis To Make Room For dentition, affected by periodontal disease Conclusion Attachments. and dental caries. In certain situations, Ball attachments are economical and the patient is limited to being easily available for overdenture. rehabilitated with complete dentures due Fabrication with them is easier as to the fact that no other option is compared with other attachments such as available. However, the use of selective Graber, Dalbo, Rotherman and Zest remaining teeth in strategic positions can anchor. greatly improve the final treatment result Laboratory procedure for attaching ball in terms of overdenture stability and attachments provides more durable and retention. [6] long lasting prosthesis as compared with In a study done by Li Chen, the patients in chair side procedure. These attachments the comparative masticatory efficiency are reliable and more acceptable by the test restored with implant-supported patient. overden-tures and tooth-supported Figure 10. Showing Implant Overdenture Attachments o v e r d e n t u r e s s h o - w e d h i g h e r References Case Report- 3 comparative masticatory efficiency than 1. Rissin L, House JE, ManlyRS and A 35-year-old completely edentulous those restored with conventional Kapur KK. Clinical comparison of lady reported to department. Overdenture complete dentures.[7] masticatory performance and was planned with two implants in Attachment stabilizes the prosthesis and electromyographic activity of mandibular arch in canine region. After the patient is able to consistently p a t i e n t s w i t h c o m p l e t e doing clinical (visual inspection, bone reproduce a determined centric dentures,overdentures and natural mapping) and radiographic investigation occlusion. However, it is important to teeth. J Prosthet Dent 1978; 39:508- two Bio horizon implants 3.0 diameter minimize stress on abutment without 11. with 12 mm length were planned and compromising the denture strength. 2. Prakash VS, Shivaprakash G, Hegde placed in the mandibular arch. The The ball and socket type of attachment is S, Nagarajappa. Four and two tooth intangilo surface of the denture was seen to be user friendly for the patients. suppoeted-conventinal overdenture: relieved and relined with temporary soft The snap fit of the denture in mouth 2 case reports. Int J Oral Health Sci liner material (monoplast – B). After 3 makes the patient more comfortable 2013; 3:61-4. months when satisfactory bone during functional movements.[5] 3. Gupta N, Goyal D, Agarwal M, Gupta formation was observed, precision With incorporation of attachments in the P, Mathur M. Overdenture with attachment placement was planned. denture there is loss of considerable access post system : A case report.Int (Figure 9). denture material from that site, which J Dent Clincs 2012;4:77-9. Rest of the procedure of attachment is further leads to loss of strength at that 4. Mhatre S, Ram SM, Mahadevan J, similar to that of chairside technique as in portion of denture. Karthik M. Rehablitation of an EDS system (Figure 10). Follow up of four months for above three edentulous patient with implant cases showed discoloration of denture supported overdenture. J Prosthet Discusson around the area of attachments which Dent 1998;80:559-64. Conventional dentures rely upon the were inserted by chairside procedure. 5. Hallikerimath RB, Patil V, Sh, residual alveolar ridge and mucosa for This is due to deterioration of self-cure M a g a d u m S . P r o s t h o d o n t i c support and retention. Many patients resin in oral cavity. Heat polymerized rehabilitation with Preci-clix

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 090 overdenture system- A case report. Int implant-supported overdenture as an 9. Nagai E, Otani K, Satoh Y, Suzuki S. J Clin Dent Sci 2010; 1:73-6. alternative to the complete Repair of denture base resin using 6. De Souza BE, De Faria ADA, Ferrira mandibular denture.J Am Dent woven metal and glass fiber : Effect SJJ, Goncales VAC, Piza PE, Assoc. 2003;134:1455-8 of methylene chloride pretreatment. J FellippoRamos V. Root-supported 8. Arioli Filho JN, Butignon LE, Pereira Prosthet Dent 2001; 85:496-500. overdenture associated with RDP, Lucas MG, MolloJunior FDA. temporary immediate prosthesis - A Flexural strength of acrylic resin case report. Oral Health Dental repairs processed by different Management 2014; 13:159-63. methods: water bath, microwave 7. Doundoulakis JH, Eckert SE, energy and chemical polymerization. Lindquist CC, Jeffcoat MK.The J Appl Oral Sci 2011; 19:249-53.

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 091 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Utilization Of Neutral Zone Concept And Metal 1 Mamata Mahajan 2 Mandeep Kaur Gill Weighted Mandibular Denture Base In 3 Archana Nagpal 4 Vishal Katna Severely Atrophic Ridge 1 Pg Student 2 Pg Student Abstract 3 Head Of Department 4 Neutral zone technique is a physiologic and functional approach which is widely used treatment Reader, Dept. of Prosthodontics modality for severely resorbed ridges. It serves as a guide for the placement of teeth in a manner Himachal Dental College, Sundernagar Address For Correspondence: to ensure optimal stability, retention and facial support. In patients with compromised support and Dr. Mamata Mahajan poor denture stability, this technique is considered as a valuable tool where dental implants are Dept. of Prosthodontics contraindicated or unfeasible. So the aim of this article is to describe the concept and technique Himachal Dental College, Sundernagar of neutral zone in fabrication of mandibular denture with metal reinforcement. Submission : 10th May 2014 Key Words Accepted : 14th March 2015 Mandibular atrophic ridge, Neutral zone, Metal beads Quick Response Code Introduction other, that area or the position where the The management of severely resorbed forces between the tongue and cheeks or ridge has always posed a challenge to the lips are equal. dental profession. In particular, the Proper positioning of the artificial teeth resorption of the lower ridge is more within this neutral zone plays an common because the mandible atrophies important role in providing stability to at a greater rate than the maxilla. prosthesis. Dental implants placed within neutral zone technique in management of The successful denture fabrication for the neutral zone stabilize the denture severely reso-rbed mandibular ridge. such patients begins with an accurate fabricated over atrophic mandibular i m p r e s s i o n c o o r d i n a t e d w i t h ridge. However there may be certain Case Report neuromuscular function so as to provide medical, surgical or economical A 65-year-old-male patient reported to stability and physiological comfort to the conditions when it is not possi-ble to the Department of Prosthodontics, patient. Complete dentures are primarily place implants. In such complex cases, Himachal Dental College, Sundernagar, mechanical devices, but since they the placement of denture in neutral zone with a chief complaint of difficulty in function in the oral cavity, they must be is the only option left for the stabilization mastication and speech.On clinical fashioned so that they are in harmony ofcomplete denture.[4] This treatment examination, the patient had no gross with normal neuromuscular function. All modality can also be used in patients with facial asymmetry or muscle tenderness. oral functions such as mast-ication, partial glossectomy, motor nerve damage The Temporomandib-ular joint, muscles speech, swallowing and laughing involve to the tongue which have led to either of mastication and facial expression were the synergistic actions of tongue, lips, atypical movement or an unfavourable palpated and found to be asymptomatic. cheeks, and floor of the mouth which are denture bearing area and surgical On intraoral examin-ation the maxillary very complex.[1] Failure to recognize the reconstruction of mandible. and mandibular arches were completely importance of tooth position and flange Weighted mandibular dentures have been edentulous. No gross abnormalities were form and contour often results in dentures used for the management of severely detected in the overall soft tissue of the which are unstable and unsatisfactory. resorbed mandibular residual alveolar lips, cheeks, tongue and oral mucosa. The After the loss of all remaining natural ridges. Advocates claim that the denture mandibular arch was severely resorbed teeth, there exists within the oral cavity a aids in retention if it weighs (Atwood’s class VI) with shallow sulcus void that may be called the potential approximately 30 dwt.[5] When the depth (Fig. 1). denture space. This denture space is supporting edentulous alveolar mucosa is bounded by the tongue internally and by not appropriate for loa-ding with a cast Treatment Procedure the muscles and tissues of the lips and metal base, an internally weighted The patient was explained about the cheeks externally. Within the denture mandibular denture can be used. This treatment procedure. As the residual space, there is an area that has been technique avoids direct contact of the alveolar ridges were resorbed and the termed the neutral zone.[2] Fish first metal base with the mucosa but provides sulcus depth was shallow, a good exposed the dental profession to the the benefit of the additional weight to the preliminary impression with impression concept of neutral zone for complete denture. compound was difficult to achieve. To denture treatment.[3] The neutral zone is This article describes a method for overcome this problem following the potential space between the lips and fabricating an internally weighted procedure was planned. cheeks on one side and the tongue on the mandi-bular complete denture using 1. In the first step, alginate impressions

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 092 of maxillary and mandibular arches allowed to cool to room temperature. were made using patient’s old Separating medium (Cold mould dentures as trays as shown in Fig.2. seal, DPI) was applied with camel The impressions were poured in hair brush on exposed stone. dental plaster. Over this cast a double 11. A heat cure acrylic resin (Dental thickness full spacer (to provide Prod-ucts of India Ltd, India)dough space for impression material) using was made by mixing the powder and modelling wax (Trulon) and a custom liquid.When the mixture had reached tray using autopolymerising resin the doughy stage, material was placed (Rapid repair, DPI) was fabricated. over the teeth in the flask and trial 2. The special tray was trimmed and packing was done using cellophane Fig. 1 : Intra Oral View (Mandible) checked in the patient’s mouth and sheet (DPI) (Fig. 8). then border moulding was done with 12. Then the flask was opened and eight green stick and final impressions metal beads were placed evenly over were made in zincoxide eugenol the mandibular mold. Additional impression paste (DentalProducts of resin was added over the beads in the India Ltd., Mumbai). mold (Fig. 9 & 10). 3. Record bases and wax occlusal rims 13. Then the flask was closed completely were fabricated on the master casts. without the separating sheet and Jaw relations were recorded and processing, finishing and polishing of Fig. 2 : Preliminary Impressions mounted. d e n t u r e s w a s d o n e u s i n g 4. Following this the lower rim was conventional method (Fig. 11). removed and a second record base 14. Then the dentures were placed in the with a vertical occlusal stops and patient’s mouth and evaluated. retentive loops to retain the material used to record the neutral zone was Discussion constructed(Fig. 3). For every patient the treatment 5. This new record base was trimmed andchecked in the patient mouth and admix material (a mix of impression compound and low fusing compound in the ratio of 3:7) was placed over the retentive loops and the neutral zone Fig. 3 : Denture Base With Retentive Loops was recorded (Fig. 4). During this procedure the patient was asked to make the movements like pucker the lips, swallowing and sucking to record the neutral zone 6. The baseplate carrying recording material was placed on the articula- ted mandibular cast and plaster index was made around the neutral zone record. Three orientation grooves were placed, that helped in repositioning the index on the master cast (Fig. 5). 7. The admix material was removed Fig. 4 : Neutral Zone Recording from the record bases and the indices rearranged. Then wax was made to flow into the space to make an occlusal rim to conform to the Fig. 6 : Admix Material Replaced By Wax patient’s neutral zone (Fig. 6). 8. The teeth were arranged and the try-in was done in the patient’s mouth. (Fig. 7). 9. After the trial placement is assessed to be satisfactory, invest trial denture with dental stone (Kalabhai Karson Pvt. Ltd, India)for denture processing. Remove wax during the dewaxing stage. 10. After dewaxing, the flask was Fig. 5 : Plaster Indices Fig. 7 : Teeth Arrangement According To Plaster Indices

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 093 requirements are different. So proper technique is that the metal weight can be diagnosis and treatment planningform customized at the clinician’s request with the first important step for the successful minimal esthetic compromise. The accomplishment of prosthodontic rehabi- predictable labo-ratory technique litation. In patients with severely atrophic described may benefit the patient with a mandibular ridges, fabrication of stable minimal residual ridge when implant mandibular denture is a great challenge. therapy or preprosthetic surgery is not an To overcome this problem, dentures are option. fabricated with their contours harmonizing neutral zone. A denture References shaped by neutral zone technique will 1. Beresin VE, Schiesser FJ. The neutral ensure that the mus-cular forces are zone in complete dentures. J Prosthet working more effectively in harmony and Dent 1976; 36: 356-67. Fig. 8 : Trial Packing With Cellophane Sheet gives advantage of stabilizing potential 2. Srivastava V, Gupta NK, Tandon A, of oral and perioral musculature.[6] The Kaira LS, Chopra D. The neutral neutral zone impression technique may zone: Concept and technique.J be utilized for fabrication of any Orafac Res 2012; 2: 42-7. complete denture. Setting teeth and 3. Wee A, Cwynar RB, Cheng AC. contouring polished surfaces of the lower Utilization of the neutral zone complete denture within this zone makes technique for a maxillofacial patient. the prosthesis less subjected to J Prosthodont 2000; 9: 2-7. dislodging forces and adds more to 4. Porwal A, Jain P, Birader SP, Nelogi stability.[7] Due to loss of teeth and S, HC Naveen. Neutral zone supporting tissues, most lower dentures approach for rehabilitation of weight less than half the original. The severely atrophic ridge. Int J Dent reduction in weight in turn leads to Clin 2010; 2: 53-7. Fig. 9 : Metal Beads Placed Over The Mold improper muscle function and increased 5. Hurtado AJ. Internally weighted vertical distance between occlusal table mandibular dentures. J Prosthet Dent and tissue support causing denture 1988; 60: 122-23. instability. These deficie-ncies can be 6. Agarwal S, Gangadhar P, Ahmad N, overcome by reinforcing metal in lower Bhardwaj A. A simplified approach denture base and adequate extension of for recording neutral zone. J Indian the base.[8] The utilization of neutral Prosthodont Soc 2010; 10: 102-04. zone technique along with internal metal 7. Jum’ah AA. Neutral zone in complete reinfo-rcement provides a stable denture dentures: Systematic analysis of base foundation by neutralizing all evidence and technique. Smile Dental internal and external forces directed Journal 2011; 6: 8-12. against the denture with added weight. 8. Grunewald AH. Gold base lower dentures. J Prosthet Dent 1964; 14: Conclusion 432-41. Fig. 10 : Additional Resin Added The neutral zone is an alternative technique for the construction of lower complete dentures on highly atrophic ridges.This article describes a new fabrication technique for a weighted dent-ure base using neutral zone technique. A significant advantage of this

Source of Support : Nill, Conflict of Interest : None declared

Fig. 11 : Finished Mandibular Denture

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 094 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

An Approach For Velopharyngeal Prosthetic 1 Kamal Kishore 2 Jasjeet Singh Rehabilitation : Case Report 3 Rajeev Gupta 4 Ramit Verma Abstract 1 Post Graduate Student Pharyngeal obturator prostheses restores the congenital or acquired defects of the soft palate 2 Post Graduate Student and allows adequate closure of palatopharyngeal sphincter. Prosthetic management of 3 Professor palatopharyngeal insufficiency requires a close co-operation between a prosthodontist and a 4 Reader, Department Of Prosthodontics speech pathologist. As a result, the patient can be socially and physically rehabilitated with the Himachal Dental College improved speech quality as well as prevention of leakage of liquids. Palatopharyngeal Address For Correspondence: dysfunction may take place when palatopharyngeal valve is unable to perform its own closing Dr. Kamal Kishore Department Of Prosthodontics due to a lack of tissue (palatopharyngeal insufficiency) or lack of proper movement Himachal Dental College ,Sundernagar (palatopharyngeal incompetence). Palatopharyngeal insufficiency induces nasal regurgitation of Distt. Mandi ,175002 Himachal Pardesh liquids, hypernasal speech, nasal escape, disarticulations and impaired speech. This case report Submission : 1st April 2014 describes rehabilitation of a patient with soft palate defect.In this case report patient with soft th Accepted : 17 February 2015 palate defect and subsequent velopharyngeal insufficiency was rehabilitated using pharyngeal obturator prostheses which had different retention mechanisms. Since it is necessary for Quick Response Code swallowing and intelligible speech, the patients were examined in terms of adequate velopharyngeal closure after prosthetic treatment with satisfying results. Key Words Pharyngeal Obturator; Velopharyngeal Insufficiency; Hypernasality; Speech Retention. Introduction psychological problems together with The soft palate acts as a dynamic physical difficulties.[13] These problems separator between oral and nasal are demonstrated especially in child- intensity.[15], [16] An effective cavity.[1] The soft palate, lateral and hood and continue lifelong if left prosthesis will restore speech, allow posterior pharyngeal walls form the untreated. Surgery in combination with proper swallowing, and have an velopharyngeal closure so that all of them speech therapy is a common approach to acceptable appearance.[16] However, it create a three dimensional muscular the treatment of Velopharyngeal dys- should have sufficient retention and valve which is known as velopharyngeal function[7], [9] There are several surgical stability.[17], [18], [19], [20] In sphincter.[2] This muscular valve is procedures that can be performed to dentulous and partially edentulous located between the oral and nasal correct the physical mal-function. Some patients the retention and stability of the cavities, consisting basically of the of these are palatal pushback with a pharyngeal obturator prosthesis is easily lateral and posterior pharyngeal walls pharyngeal flap lining, sphincter achieved by the existing teeth.[8], [21] and the soft palate, and controls the pharyngoplasty, a superiorly based However, it may be hard to achieve passage of air.[3] Impairment of obturating pharyngeal flap, and Furlow adequate retention with conventional velopharyngeal function can be due to in- palatoplasty.[14] However, when prostheses in edentulous patients but not sufficiency or incompetency. [4], [5], [6], surgical treatment is not considered as an imposible.[8], [13], [20], [22] However, [7] The primary effects of the option, pros-thetic management of it should have sufficient retention and velopharyngeal insufficiency are air- Velopharyngeal insufficiency is carried stability. It is important to note that if the flow escape and hypernasality.[8], [9] out by means of a pharyngeal obturator, pharyngeal portion of velopharyngeal Secondary effects are disorders in speech whereas Velopharyngeal incompetence prosthesis is immobile and fix, it will articulation (distortions, substitutions is traditionally managed by a palatal lift irritatethe tongue during the movement and omissions). [8], [10], [11] prosthesis.[5], [10] A pharyngeal of the soft palate. Therefore we report Velopharyngeal insufficiency is obturator is a removable maxillary edentulous case with soft palate defect distinguished by speech and nasal prosthesis which has a posterior rehabilitated by velopharyngeal resonance abnormalities related to extension to separate oropharynx and prostheses using hinge joint of the defects of the soft palate, which may be nasopharynx.[6], [8] This obturator spectacles joining the hard and soft congenital as in cleft lip and palate (CLP) prosthesis re-stores the defects of the soft palatal parts of the prostheses.[1] or acquired as in palatal tumor palate and allows adequate closure of Adequate velopharyngeal closure was resection.[6], [7], [11] Velopharyngeal palatopharyngeal sphinter." When a obtained with applied prosthetic insufficiency causes communication pharyngeal obturator is placed, the t r e a t m e n t s . T h e r e b y, o r o n a s a l problems because of distortion in speech, patient can exhibit adequate separation communication was prevented, esthetics resonance and articulation apart from between the oral and nasal cavities during and speech were improved. swallowing disturbance.[8], [12] In this production of plosives consonants or r e g a r d , p a t i e n t s u s u a l l y h a v e w h i l e b l o w i n g w i t h v a r i a b l e Case

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 095 A 62 year male patient reported to the Department of Prosthodontics ,Himachal Dental college Sundernagar with a chief complaint of missing teeth and hypernasility (Fig-1). Patient had a history of infection in soft palate and had a surgery for soft palate and tonsils during his early childhood. Speech defect and hypernasility were also detected in cilinical examination. The impression was examined for contact with the pharynx bilaterally and posteriorly.The extension was positioned at the level of the hard palate during the most active movement of the pharyngeal sphincter.'" This movement was achieved by asking Figure 1 Figure 4 the patient to say ‘ah or by touching to posterior wall of the pharynx with an instrument to initiate gag reflex. An acrylic resin extension must be formed functionally. This extension must be in static contact with the soft tissues and must not affect the stability of the prosthesis. The success of the soft palate defect prosthesis depends on the functional adaptation of the impression material.In current case, low fusing green stick compound was used in functional contouring of the palatal defect and velopharyngeal portion. Light body addition silicon impression material was added to make the final impression (Fig- 2). The cast was poured in dental stone Figure 5 Figure 2 (Fig-3). Try in was done and the hinge was attached within the wax during wax up at posterior most extension of the maxillary impression (Fig-4). Hinge was covered by plaster to secure its position (Fig-5). Packing and trial closure was done with heat cure resin. Denture was finished and adjustments were done in the patient’s mouth (Fig-6).

Discussion Prosthetic rehabilitation of the patients suffering from velopharyngeal deficits with obturator prostheses varies according to the location and nature of the defect or deficiency. There are differences between obturator prostheses Figure 3 c o n s t r u c t e d f o r p a t i e n t s w i t h achieve normal speech with a prosthesis, Figure 6 d e v e l o p m e n t a l o r c o n g e n i t a l an accurate prognosis is extremely malformations of the soft palate, as important for the patients exhibiting patients related an improvement with the compared with those constructed for considerable movement of the residual palatal prosthesis.[3] Because the patients with acquired defects. [1], [5], velopharyngeal complex during movement of the lateral pharyngeal walls [8], [10], [11], [23] However, the function.[1], [2], [9], [23] However, it is essential for the control of nasal objectives of obturation are to provide the must be underlined that some patients are emission, little or no movement of capability for the control of nasal not in need of a prosthesis to chew, and it velopharyngeal mechanism makes it emission and inappropriate nasal is made just to improve speech.[3] difficult to achieve normal speech with resonance during speech and to prevent Henrique J et al stated that judgement of either surgical reconstruction or the leakage of material into the nasal the speech performed by the patients prosthetic therapy.[1], [2], [5], [9], [16], passage during degtutition.[6], [9] To themselves revealed 85.4% of the [23] In the literature, several types of

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 096 prostheses have been described to especially due to the weight of the pros- 2. Skolnick L, McCall GN, Barnes M. improve speech ability.[1], [5], [6], [9], thesis and the inability to obtain a border The sphincteric mechanism of [11], [21], [23], [24] A pharyngeal seal.[17], [23] The weight and length of velopharyngeal closure. Cleft Palate obturator prostheses may prevent the obturator portion increases the effect of J. 1973;10:286-305. hypernasality and/or nasal emission gravitational forces.[23] Moreover, a 3. Nogueira JH and Ines M evaluation of associated with velopharyngeal complete denture may be contra- palatal prosthesis for treatment of inadequacies.[1], [5], [6], [23] In order to indicated in the patients with irregular velopharyngeal dysfunction J Appl obtain adequate velopharyngeal closure palate anatomy, shallow vestibular sulci Oral Sci 2003;11(3):192-7 during speech and swallowing a posterior or lower muscle attachments." Therefore, 4. Johns DF, Rohrich RJ, Awada M. extension is added to prosthesis.[1], [6], dental implants have great importance for Velopharyngeal incompe-tence: a [23] The impression should be examined these patients.[23], [24] The degree of guide for clinical evaluation. Plast for contact with the pharynx bilaterally defect affects the functions of the Reconsir Surg J 2003; 112:1890- and posteriorly.[1], [15] The extension obturator. If the defect includes both soft 1897. must be positioned at the level of the hard and hard palate resections, the discomfort 5. Wotfaardt JF, Wilson FB, Rochet A, palate during the most active movement in the usage of obturator increases.[26] McPhee L. An appliance based of the pharyngeal sphincter.'" This The treatment of velopharyngeal approach to the management of movement can be achieved by asking the insufficiency requires multidisciplinary palatopharyngeal incompetency: A patient to say ‘ahh. or by touching to approach. Accordingly, a speech clinical pilot project. J Prosthet Dent posterior wall of the pharynx with an pathologist should participate in 1993;69:186-195. instrument to initiate gag reflex.[8], [15], treatment of these cases to test 6. Saunders TR, Oliver NA. A speech- [23] An acrylic resin extension must be articulation errors and inappropriate aid prosthesis for an-terior maxillary formed functionally. This extension must oronasal resonance balance.[11] implant-supported prostheses. J be in static contact with the soft tissues Perceptual and instrumental measures of Prosthet Dent 1993;70:546-547. and must not affect the stability of the hypernasality and nasal escape along 7. Ragab A. Cerclage sphincter prosthesis.[8], [22], [23] In this report, with a profile of the patient's articulation pharyngoplasty: a new tech-nique for patient was allowed to drink water to test provide the diagnostician information velopharyngeal. insufficiency. Int J the complete closure of the anatomical about the frequency and consistency of P e d i a t r O t o r h i n o l a t y n g o l defect of soft palate. The water should not velopharyngeal insufficiency. These 2007;71:793-800. reflux into the nasal cavity when the measures, however, provide only limited 8. Beumer III J, Curtis TA, Marunick patient is in upright position.[8] The information about the functioning of the MT. Maxillofacial Rehabilitation: success of the soft palate defect velopharyngeal mechanism. The use of Prosthodontic and Surgical prosthesis depends on the functional Multiview video floroscopy (MVF) or C o n s i d e r a t i o n s ; S p e e c h , adaptation of the impression material.[8], Nasopharyngoscopy Evaluation (NE) Velopharyngeal Function, and [11], [15] In current case, low fusing may contribute to the diagnostic Restoration of Soft Palate Defects. St. green stick compound was used in confirmation of the assessment of velar Louis: Ishiyaku EuroAmerica, Inc; functional contouring of the palatal mobility, pattern of velar elevation, size 1996. p. 285-324. defect and velopharyngeal portion. Light of residual velopharyngeal gap and 9. Yoshida H, Michi K, Yamashita Y, body addition silicon impression lateral pharyngeal wall displacement Ohno K. A comparison of surgical material was added to make the final while the patient is producing a and prosthetic treatment for speech impression. In relation to stability, the standardized sample of connected disorders attributable to surgically patients considered their palatal speech. It may also contribute the acquired soft palate defects. J Oral prostheses more stable in speech than assessment of treated patients with Maxillofacial Surg 1993;51:361-365. mastication. This may be due to the fact velopharyngeal insufficiency.[1], [14], 10. Shifman A, Finkelstein Y, Nachmani that the articulatory movements are finer [23], [27] While neither of Multiview A, Ophir D. Speech aid prostheses for during speech, presenting contact only v i d e o f l o r o s c o p y ( M V F ) n o r n e u r o g e n i c v e l o p h a r y n g e a l between soft tissues, or between them Nasopharyngoscopy Evaluation (NE) incompetence. Prosthet Dent and the teeth. Patients needed implants to can substitute for perceptual speech 2000;83:99-106. make prosthetic retention and stability assessment in the diagnosis of VPI, they 11. Abreu A, Levy D, Rodriguez E, possible. When the complete denture are complementary tools in the Rivera I. Oral rehabilitation of a presents poor stability, an attempt to assessment of velopharyngeal function." patient with complete unilateral cleft construct the pharyngeal bulb would be In present cases, no nasopharyngoscopic lip and palate using an implant worthy while. This stability may possibly evaluations were made. However, retained speech-aid prosthesis: be preserved after adapting the bulb.[3] perceptual speech evaluations were Clinical report. Cleft Palate Retention of pharyngeal obturator can be demonstrated significant improvements Craniofac J2007;44:673-677. obtained by retainers or palatal coverage in speech ability and velopharyngeal 12. Werkmeister R, Szulczewski D, as in completely edentulous patients.[8], function.[23], [26] Wa l t e r o s - B e n z P, J o o s U J . [11], [25] In edentulous patients, Rehabilitation with dental implants achieving an effective retention by References o f o r a l c a n c e r p a t i e n t s . J conventional prostheses for the 1. Ram H K, ShahInternational RJ. of Craniornaxillofac Surg 1999;27:38- edentulous patients with both hard and Healthcare & Biomedical Research, 41. soft palate defects is very difficult, if not Volume: 1, Issue: 2, January 2013, P: 13. Hickey AJ, Salter M. Prosthodontic impossible.[11], [19], [20] This is 70-76 and psychological fac-tors in treating

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 097 patients with congenital and osseointegrated implants to sup-port Rehabilitation of an edentulous cleft craniofacial defects. J Prosthet Dent a maxillary denture for a patient with lip and palate patient with a soft 2006;95:392-396. repaired cleft lip and palate. Cleft palate defect using a bar-retained, 14. Seagle MB, Mazaheri MK, Dixon- Palate Craniofacl 1993;30:418-420. implant-supported speech-aid Wood VL, Williams WN. Evaluation 20. Lefkove MD, Matheny B, Silverstein prosthesis: a clinical report. Cleft and treatment of velopharyngeal L. Implant prosthodontic procedures Palate Craniofac J. 2009;46:97-102, insufficiency: the University of for a completely edentulous patient 25. Branemark P-I, Higuchi KW, Florida experience. Ann Plast Surg with cleft palate. J Oral Implantol O l i v e i r a d e M F. I l l i n o i s : 2002;48:464-470. 1994;20:82-87. Quintessence; 1999. Rehabilitation 15. Keyf F, Sahin N, Asian Y. Alternative 21. De Carvalho WR, Barboza EP, Caula of complex cleft palate and impression technique for a speech- AL. Implant-retained removable craniomaxillofacial defects: the aid prosthesis. Cleft Palate Craniofac prosthesis with ball attachments in challenge of Bauru; pp. 17-30. J 2003;40:566-568. partially edentulous maxilla. Implant 26. Rieger JM, Wolfaardt JF, Jha N, 16. Tachimura T, Nohara K, Wada T. Dent 2001; 10:280-284. Seikaly H. Maxillary obturators: the Effect of placement of a speech 22. Zarb GA, Blonder CL. Prosthodontic relationship between patient appliance on levator veil palatini Treatment for Edentulous Patient: satisfaction and speech outcome. muscle activity during speech. Cleft Complete Dentures and Implant- Head Neck. 2003;25:895-903. Palate Craniofac J 2000;37:478-482. Supported Prostheses. In: Jacob RF. 27. Lam DJ, Starr JR, Perkins JA, Lewis 17. Harrison JW. Dental implants to Maxillofacial prosthodontics for the CW, Eblen LE, Dunlap J, Sie' KC. A rehabilitate a patient with an edentulous patient. St. Louis: Mosby comparison of nasendoscopy and unrepaired complete cleft of the hard Inc; 2004. p. 449-470. multiview videofluoroscopy in and soft palate: a clinical report. Cleft 23. Tuna SH ,Gurelpekkan, Gumus HO a s s e s s i n g v e l o p h a r y n g e a l Palate Craniofac J 1992;29:485-488. and Aktas A Prosthetic Rehablitation insufficien-cy. Otolaryngol Head 18. De Carvalho WR, Barboza EP, Caula of Velopharyngeal insufficiency : Neck Surg 2006;134:394-402. AL. Implant-retained removable Pharyngeal Obturator Prosthesis with prosthesis with ball attachments in different retention mechanisims partially edentulous maxilla. Implant .European Journal of dentistry ; Jan Dent 2001; 10:280-284. 2010- Vol .4 19. Lund TW, Wade M. Use of 24. Tuna SH, Pekkan G, Buyukgural B.

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 098 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Prenatal Fluoride - Necessity Or A Myth 1 Sudhir Mittal 2 Kavita Mittal Abstract 3 Vasundhara Pathania There are many views regarding the passage of Fluoride across the placenta. Some authors 4 Akhil Sharma suggest placenta as a complete barrier to Fluoride and some say that it is a partial barrier. The 1 Professor, Dept Of Pedodontics fact that primary dentition has less severe degree of Fluorosis than permanent dentition, may Himachal Dental College. indicate the presence of placental barrier but the similar fluoride concentration in cord blood and 2 Professor, Dept Of Pedodontics, Gndc Sunam maternal blood in mothers receiving fluoridated water also shows placenta as a partial barrier. 3 Senior Lecturer Key Words 4 Post Graduate Student Fluoride, placental barrier, primary dentition, F supplements Dept Of Pedodontics, Himachal Dental College. Address For Correspondence: Introduction but generally an inverse relation exists Dr. Sudhir Mittal Professor, Dept Of Pedodontics The forerunner to the finding that between the molecular weight of Himachal Dental College. fluorine and dental caries are related was compound and their ability to pass Submission : 8th June 2014 discovered by Eager, in 1901, of a dental through placenta (Villey, 1960)[5]. The Accepted : 7th January 2015 condition characterized by white flecks presence of Fluoride in primary teeth that Quick Response Code and brown stains in person living in develop during the intrauterine phase and Naples, Itlay. Mckay of Colorado the rapid increase in Fluoride level of springs, USA, made a similar fetal blood when medications containing independent observation and called the F are administered to pregnant women stain mottled enamel.[1] Mottling of indicate that Fluorides’ rapidly cross the now known as Dental placenta. The skeletal F also increases fluorosisis characterized by white spots with fetal age in areas where water or flecks in mild form to brown or dark supplies has 0.1,0.5 ppm of Fluoride placenta in the fifth and sixth months of stained, pitted in severe form. Mottling of (Gedalia, 1970)[6], thus indicating that pregnancy which is the time when the the enamelis a developmental placental tissue does not selectively milk teeth start to develop in the disturbance of dental enamel caused by inhibit the transfer of F to the fetus, uterus.[9] Another study was conducted the consumption of excess fluoride although at higher levels of F ingestion , a on 25 healthy women residing in during tooth development.[2] A tooth is partial barrier to F transfer may exist. optimum fluoride areas, who were to no longer at risk of fluorosis after Armstrong et al[7] suggested that there is deliver normally through vaginal route, eruption into the oral cavity. Fluoride has no placental F barrier sufficient to to correlate the maternal and cord plasma both systemic and topical actions that are maintain disequilibrium of Fluoride fluoride levels and evaluate the placental of importance in dental health. concentration in maternal and fetal transfer of fluoride. A wide variation was Systemically, fluoride acts on teeth prior circulations under normal physiologic found in the maternal and cord plasma to their eruption by being built into the condition. Consequently, Fluoride may fluoride levels. The difference between crystal structure of the enamel and be expected to pass through the placenta cord fluoride and maternal fluoride making it resistant to decay. The in physiological concentrations into the suggest that placenta acts as a partial mineralization of primary teeth begins in fetal circulation and subsequently filter for F. A possible explanation of F utero, and this has led to the suggestion incorporated into developing teeth and loss during transmission from maternal to that fluoride supplements to be given in bones. The F concentration was found fetal has been presented by Chlubek et pregnancy. However there is little around 0.68 and 0.88 micro M in cord and al[10] which suggests that F can be evidence of the effectiveness of fluoride maternal blood using specific F accumulated in marginal parts of the supplementation in pregnancy.[3], [4] electrodes in 16 mothers receiving placenta as a result of higher potable water containing low levels of F. concentrations of calcium in those areas. Fluoride Transfer Through Placenta High correlation between cord and According to Caldera et al[11], Maternal The placenta is an organ that connects the maternal blood indicates passive F and cord F levels depends on intake and developing fetus to the uterine wall to diffusion of F across the placenta (Shen movement of F. They propose the allow nutrient uptake, waste elimination, and Taves, 1974).[8] Fetal blood levels of concept of maternal fetal amniotic pool and gas exchange via the mother's blood fluorides in mothers who had taken that regulates maternal and fetal plasma supply, fight against internal infection sodium fluoride was statistically higher levels according to F intake. Moreover, and produce hormones to support than in the controlled group (2.6 mumol/l haemodynamic and haematochemical pregnancy. The placental tissue is and less than 1 mumol/l); this variations at the time of delivery also permeable to high molecular weight demonstrates in a statistically significant appear to affect cord F levels as suggested compounds such as gamma globulins, way that fluoride passes across the by Brambilla et al.[12] Higher maternal age can be related to low blood flow at

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 099 placental bed. In only 8 percent of the amount of tooth mineralization that Blayney[26] and Tank and Storvick,[27] cases the fluoride levels in cord plasma occurs prenatally. Although calcification who suggested that the use of F water were higher than maternal plasma. It was of most of the primary teeth (except the during prenatal years and continuing with deduced that the placenta allows passive incisors) begins in utero, most of the post natal use increased the protection of diffusion of fluoride from mother to fetus caries susceptible surfaces calcify after primary teeth over that provided by only and does not act as a barrier.[13] A recent birth. Thus F acquired during pregnancy post natal exposure. The findings were study[14] supports the view that the has an insignificant effect on caries in discarded by many other workers. placenta has a protective role on fetus by primary teeth. Glenn[28], [29] in her study claimed that preventing transfer of excess F to the The American Dental Association the teeth of the children whose mother growing fetus and the capacity of (ADA) endorses the daily use of fluoride had received prenatal F supplements placenta as F filter is still a point of supplements (as drops, tablets or were denser white with shallower debate. When the drinking water and lozenges) by children 16 years old or occlusal grooves and had no pitting. The food has high F concentration, the F younger.[18] While the ADA and the difference of 93% DFS was seen in the content of the placenta is significantly American Academy of Pediatric children of mothers who had NaF tablets higher than that of the mother serum, Dentistry revised the supplementation in pregnancy and in control group. She while the cord blood has the least. Thus, schedule in 1994 in response to concerns also suggested that enamel surface of these findings indicate that the placenta about the increase in the prevalence of prenatally protected teeth remains caries represents a natural barrier to the passage Fluorosis.[19] The Canadian Dental free in acidic environment. The results of of larger quantities of F to the fetus Association recommends supplements Glenns studies are remarkable but the probably by binding to calcium ions in only for children who have had high study was not a carefully controlled, the placenta. caries experience and whose total intake double blind one. In 1966 U.S Food and J Opydo-Szymaczek, M Borysewicz- of fluoride is below 0.05 to 0.07 Drug administration banned the Lewicka[15] evaluated placental transfer milligrams of fluoride per kilogram of advertising and marketing of drug of fluoride (F) in 30 pregnant women at body weight.[20] A group of European manufacturers of Fluoride products that the time of giving birth, who were living experts recommended in 1991 that claimed caries preventive benefits when in Poznan, Poland, where the F “fluoride supplements have no ingested as prenatal supplements. concentration in the drinking water application as a public health measure” ranges from 0.4 to 0.8 mg/L. The mean and that “a dose of 0.5 mg/day fluoride Conclusion concentration of F in maternal plasma should be prescribed for at-risk There is no doubt that F passes through was significantly higher than in venous individuals from the age of 3 years.”[21] the placenta because it is found in fetal cord plasma (3.54 vs. 2.89 µmol/L, In 2006, the Australian Research Centre blood and calcified tissues. Consequently respectively), and both values were for Population Oral Health's workshop F may be expected to pass through the similar to those previously documented on the use of fluorides in caries placenta in physiologic concentration in pregnant women taking prenatal F prevention concluded that “fluoride into fetal circulation and subsequently supplements. These results confirmed supplements in the form of drops or incorporated into developing teeth and that Fluoride readily passes through the tablets to be chewed and/or swallowed bone. However, placenta may have a placenta. should not be used.”[22] regulatory function in preventing excessive F in maternal blood from Mechanism Of Action The Prenatal F Supplementation reaching the fetal circulation. The placenta may have a regulatory Systemic fluoride dosage to prevent Another important factor in considering function in preventing excess Fluoride in caries appearsto be 0.05 to 0.07 the prenatal F supplementation is related maternal blood from reaching the fetal mg/kg/d.[23] The narrownessof the to the amount of tooth mineralization that circulation – a hypothesis described by therapeutic range is emphasized by the occurs prenatally. Although, calcification Gedalia et al[16] and Ericson and factthat mild fluorosis has been seen with of primary teeth (except incisors) begins Wei[17]. This may explain why there is oral intakesgreater than 0.1 mg/kg/d.[24] in utero, most of the caries susceptible less enamel fluorosis in primary teeth of Thus, it is important toexamine carefully surfaces of teeth calcify after birth. children who live in communities with the data on the age at which fluoride Therefor, as long as F ingestion is even 8-10 ppm F concentration. Fluoride supplementation is started and its initiated shortly after birth, it is probably passes from the mother to fetal teeth. relationship to caries prevention. The sufficient. Much of the fluoride is taken up in critical period during which the fluoride Results of studies by Leverrett et al secretary enamel, probably by the must be ingested systemically in order to 2005[30] and Fontele et al 2006[31] forming mineral apatite crystals. Some is exert maximum cariostatic effects is don’t support the hypothesis that F retained with residual proteins. The low during the mineralization of the surface supplements by pregnant women benefit concentration of fluoride in the inner of crown. For primary teeth, this process their offspring. Moreover, modern enamel is incorporated mainly during the is mostly post natal except for the anterior research provides little support for secretary stage, while the enhanced incisors. For maximum benefit, the recommendation of both prenatal and concentration in the surface enamel is ingestion of F supplements should be postnatal fluoride supplements. produced during the much longer started shortly after birth and continued According to data collected, the area maturation stage. Mature, hard enamel is until the age of about 12 depending on the where drinking water fluoride conc. generally absent during fetal life. fluoridated areas. ranges from 0.4 to 0.8mg/l, fluoride Another important factor in considering The use of prenatal F was based on the levels in mother plasma and cord plasma prenatal supplementation is related to the water F studies done by Arnolda et al,[25] are comparable to those documented in

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 100 patients from other areas who are taking Tortrat D, Laurent AM. Maternal- 21. Clarkson, J. A European view of fluoride supplements (1.5mg/day). Thus, fetal transfer offluoride in pregnant fluoride supplementation. Br Dent J. the additional fluoride supplements w o m e n . B i o l N e o n a t e 1992; 172: 357 should not be encouraged or indicated in 1988;54(5):263-9. 22. Australian Research Centre for these populations. This practice could 11. Chlubek D, Mokrzynski S, Machoy Population Oral Health. The use of result in further increase in fluoride Z, Samujlo D, Wegrzynowski J. fluorides in Australia: guidelines. exposure to the fetus, which raises Fluoride concentration in mother and Aust Dent J.2006; 51: 195–199 concerns in view of the potential negative fetus. I. Placental transport of 23. F o r r e s t e r D J , S c h u l t z E M : effects of excessive amounts of fluoride f l u o r i d e . G i n e k o l P o l International Workshop on Fluorides on fetal development. 1994;65(11):611-5. and Dental Caries Reductions. 12. Brambilla E, Felloni A, Gagliani M, Baltimore, University of Maryland, References Malerba A, Garcia-Godoy F, 1974 1. M c K a y F S , B l a c k G V. A n Strohmenger L. Caries prevention 24. Forsman B: Early supply of fluoride investigation of mottled teeth: an during pregnancy: results of a 30- and enamel: Fluorosis. Scand J Dent endemic developmental imperfection month study. Am Dent Assoc Res 1977;85:22-30 of the enamel of the teeth, heretofore 1998;129(10):1372-4. 25. Arnold, F.A., Dean, H.T and unknown in the literature of dentistry. 13. Malhotra A, Tewari A, Chawla HS, Knutson,J: Effect of fluoridated Dental Cosmos 1916;58:477-84. Gauba K, Dhall K Placental transfer public water supplies on dental caries 2. McKay FS. Relation of mottled of fluoride in pregnant women prevalence- tenth year of grand rapids enamel to caries. J Am Dent A consuming optimum fluoride in – Muskegon study ,public health 1928;15:1429-37 drinking water. J Indian Soc Pedod Rep.71:652,1956 3. Stookey GK: Perspective on the use Prev Dent. 1993 Mar; 11(1):1-3) 26. Blayney, J.R., Tucker, W.H. Evanston of prenatal fluoride: A reactor’s 14. Sastry. M, Shruti Mohanty, Pragna Dental Caries Study. II. Purpose and c o m m e n t s . J D e n t C h i l d Rao. Role of Placenta to combat mechanism of the study. J. D. Res. 1981;48:126-127 fluorosis (In Fetus) in endemic June 1948; 27:279. 4. Marthaler TM: Fluoride supplements fluorosis area gurumurthy. NJIRM 27. Tank, G., Storvick, C.A. Dental caries scoll WS: A review of clinical 2010; Vol. 1(4).Oct- Dec. experience of school children in prenatal fluoride administration for 15. Opydo-Szymaczek J, Borysewicz- Corvallis, Oregon, after 7 years of prevention of dental caries. J Dent Lewicka M. Urinary fluoride levels fluoridation of water. J. Pedal. April Child 1981;48:109-117 for assessment of fluoride exposure 1961; 58:528. 5. Villee, C.A. (1960) Placenta and fetal of pregnant women in Poznan, 28. Glenn FB, Glenn WD, Burdi A R. membranes. Baltimore, Williams and Poland. Fluoride 2005;38(4):312-7. Prenatal fluoride for growth and Wilikin,p.29 16. Gedalia,I.: Fluoride tablets , Int. Dent development: Part X. JDent Child 6. Gedalia I, Goldhaber P, Golub L.In J.17:18, 1967 1997; 64(5):317-21. vitro uptake of fluoride in sodium 17. Ericsson, Y., Angmar – Mansson, B: 29. Glenn FB, Glenn WD. Optimum fluoride-treated vital mice calvaria.J Plasma Fluoride and enamel dosage for prenatal fluoride tablet Dent Res. 1970 Nov-Dec;49(6) F l u o r o s i s , supplementation: PartIX. J Dent 7. Armstrong W.D., Singer, L and Calcif.Tiss.Res.22:77,1976 Child 1987; 54(6):445-50. Makowsky, E.L: Placental transfer of 18. American Dental Association. in: 30. Leverett DH, Adair SM, Vaughan Fluoride and calcium, Am. J. Obstet. Accepted Dental Therapeutics. BW, Proskin HM, Moss ME. Gynecol.107:432, 1970. Council on Dental Therapeutics of Randomized clinical trial ofthe effect 8. B Shen YW, Taves DR. Fluoride the American Dental Association, of prenatal fluoride supplements in concentrations in the human placenta Chicago; 1970–1984: 399–402 preventing dental caries. Caries Res and maternal and cord blood. 19. Dosage schedule for dietary fluoride 1997;31(3):174-9. American Journal of Obstetrics and supplements. Proceedings of a 31. Sa Roriz Fonteles C, Zero DT, Moss Gynecology 1974; 119: 205-207. workshop. Chicago, Illinois, USA. ME, Fu J. Fluoride Concentrations in 9. Forestier F, Daffos F, Said R, Brunet January 31–February 1, 1994. J Enamel andDentin of Primary Teeth CM, Guillaume PN [The passage of Public Health Dent. 1999; 59: after Pre- and Postnatal Fluoride fluoride across the placenta. An intra- 203–281 E x p o s u r e . C a r i e s R e s uterine study].J Gynecol Obstet Biol 20. Swan, E. Dietary fluoride supplement 2005;39(6):505-8. Reprod (Paris). 1990;19(2):171-5) protocol for the new millennium. J 10. Caldera R, Chavinie J, Fermanian J, Can Dent Assoc. 2000; 66: 362–363

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 101 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Smile Prejudice : A Review 1 Devendra Chaudhary 2 Artinder Kaur Abstract 3 Abhishek Bansal Esthetic dental treatment involves artistic and subjective components design to create the 4 Navneet Kukreja illusion of beauty. An organized systematic approach is required to evaluate, diagnose and 1 Hod,Vice-principal And Director Pg Studies resolve esthetic problems predictably. Our ultimate goal is to achieve pleasing composition in the Dept. Of Conservative Dentistry & Endodontics smile by creating an arrangement of various esthetic elements. One of the most important tasks Maharaja Ganga Singh Dental College Ganganagar in esthetic dentistry is creating harmonious proportions between the widths of maxillary anterior 2 Pg Student, Dept. Of Conservative Dentistry & Endodontics teeth when restoring or replacing these teeth This review article describes application of the Mm College Of Dental Sciences & Research, Mullana 3 Golden Proportion and Red Proportion in dentistry and the future scope for designing smile Associate Professor, Dept. Of Conservative Dentistry & Endodontics Key Words Mm College Of Dental Sciences & Research, Mullana Smile design, smile proportions, elements of smile designing, denture esthetics. 4 Professor Dept. Of Conservative Dentistry & Endodontics I) Introduction Mm College Of Dental Sciences & Research, Mullana Can a New Smile Make You Look More II) History Address For Correspondence: Dr. Artinder Kaur Intelligent and Successful? Vulcanite was the first universally Hostel No. 8 Mm University Mullana,Ambala.133203 A smile has a tremendous impact on acceptable denture material. Patented by Submission : 10th April 2014 perceptions of one’s attractiveness and Nelson Goodear in 1851, it was made by Accepted : 23rd March 2015 o n e ’ s p e r s o n a l i t y. P r e v i o u s heating caoutchouc (Indian rubber) with Quick Response Code psychological research has shown that sulphur, resulting in a firm yet flexible attractive people are perceived as more material. The open-faced crown was successful, intelligent, and friendly - i n v e n t e d a r o u n d 1 8 8 0 , t h e Anne E. Beall interchangeable porcelain facing (a One who works with his hands is a ridged facing that fitted into a grooved Labourer, pontic) was developed in the 1880s,and One who works with his hands and mind the porcelain jacket crown came into reported the use of hypochloric acid to is a Craftsman, vogue in the early 1900s.By 1897 a treat fluorosis. In 1937, Ames reported a One who works with his hands, mind and relatively modern composition of silicate technique using a mixture of hydrogen heart, is an Artist cement was developed. Further peroxide and ethyl ether on cotton, heated modifications continued until 1938, with metal instrument for 30 minutes and Dentist have been making beautiful when the American Dental Association applied over 5 to 25 visits to treat mottled smiles for centuries. Indeed, a dentist is (ADA) published its definitive enamel. The first commercially available an artist & esthetic dentistry an “Artist specification of acceptability known as 10% carbamide peroxide was developed science”. "ADA Specification No.9." This was the and subsequently marketed by Omni In the field of dentistry, the esthetic first cosmetic dental material to be International in 1989. Success can be approach always has always been based acceptedby the ADA. However, newer attributed to great attention to detail in on the imitative elaboration of forms, and more exciting innovations were areas of planning the case, tooth colors and structures whose intrinsic about to arrive. In the 1930s chemically preparation of teeth, fabrication and beauty is supposed to enhance the activated acrylic resins were developed. maintenance of this restorations.[1] patient’s appearance. However the By the 1970s composite resins virtually mental perception of an object and its replaced acrylic resins and silicate III) Esthetics In Restorative Dentistry: concrete realization based on the cements as "permanent" restorations. Why It Is Important? perception must be considered purely Refinements of this basic formula of Esthetic or cosmetic dentistry has static.[1] resin matrix and glass filler are currently become one of the main areas of dental Personality, motivations, desires, in use. Acid etching, often called practice, emphasis and growth for several expectations, self-esteem ability to bonding, radically changed cavity years. Increasingly, patients seeking accept change, and willingness to treatment by emphasizing conservation treatment for their oral condition with the cooperate are important factors for of tooth structure. It also allowed for the primary concern of an esthetic successful treatment. Therefore an numerous veneering techniques enhancement[3]. In social interactions, awareness of self theory and a broad introduced in the 1970s. Variations our attention appears mainly on mouth application of psychologic and i n c l u d e d i r e c t r e s i n v e n e e r s , and eyes of the face of the person sociologic principles can greatly enhance commercially produced acrylic "shells," speaking. As the mouth is the centre of a dental practice that emphasizes and laboratory-processed veneers of communication in the face, the esthetic esthetics.[2] resin and porcelain. In 1916, Adams appearance of the oral region during

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 102 smiling is a conspicuous part of facial attractiveness[4]. The last 50 years have witnessed an unimaginable amount of change in restorative dentistry.

Wayr23;S To Assess Smile: There are certain vital elements of smile designing which includes the following: 1. Tooth Components : Dental midline, Incisal length , Tooth dimensions, Zenith Point Axial inclinations Zenith points , the smile line, to central vertical line. The evaluation of axial inclination can be Incisal embrasures, Interdental Gradation 1 contact area and Interdental contact done on a photograph of the anterior teeth points Sex, personality and age in a frontal view. A line is sketched on ,Symmetry and balance. each tooth from the midline of the incisal 2. Soft Tissue Components: Gingival edge through the midline of the tooth at health ,Gingival level ,Smile line its gingival interface[1]. ,Interdental embrasure. Zenith points: Dental Midline: It is the most apical point of the gingival These are least noticed by the patients tissues along the long axis of the tooth. and dental personnel. As long as the midline is parallel with the long axis of Incisal embrasures and contact points: the face, midline discrepancies of up to 4 From central to canine, an open space is mm will generally not be perceived as formed between the proximal surfaces of Gradation 2 unesthetic. Slight corrections of midline incisal edges from the contact points. observed as the eyes move distally from can be corrected by restorative dentistry. These embrasure spaces terminate at the the midline, so that both the sides of the The ideal treatment is orthodontics[3]. contact points with the adjacent teeth. smile are well balanced[1]. Failure to provide adequate depth and Incisal Length: variation to the incisal embrasure will Gradation Published reports have shown that the make the teeth appear too uniform and When similar structures are aligned one average 30year old woman displays contact areas too long which gives box after the other, they undergo a about 3.5 mm of maxillary incisor tooth like appearance of the dentition[1]. progressive visual reduction of size from structure when the lips are at rest. The the nearest to the farthest. The prosthodontic literature has generally Sex, Personality and Age (SPA): prerequisite of the "front-back recommended setting denture teeth so Minor differences in the length, shape progression" of the teeth is the alignment that 2 mm of tooth structure is displayed and positioning of the maxillary teeth of the outline or contour of the buccal at rest[2]. If patient displays less than 4 allow for dramatic differences. surface, incisal 1/3rd, median 1/3rd, and, mm of the maxillary centrals at rest, the For Female, the maxillary incisors should at a lower rate, the gingival 1/3rd, as well teeth need to be lengthened and this be round smooth, soft delicate and for as the alignment of the incisal¬ length will be achieved by adding to the male, should be cuboidal, hard and mesiobuccal Inclines. The presence of a incisal edge. vigorous. poorly shaped tooth, differences in tooth Youthful teeth: unworn incisal edge, length, gingival disharmonies and Tooth Dimensions: defined incisal embrasure, low chroma colored restorations create problems with If the incisal display at rest is 3 mm to 4 and high value respect to the gradation effect. The buccal mm, and it is determined that the teeth are Aged teeth: shorter; so less smile display, corridor or lateral negative space too short, then surgical crown minimal incisal embrasure, high chroma between the buccal outline of posterior lengthening procedures should be and low value. teeth and the corner of the mouth helps in considered[3]. If there is insufficient ach iev in g g r ad atio n eff ect in tooth display at rest, normal lip mobility, Personality: progressively altering tooth illumination. the teeth are of the correct length, and Aggressive, hostile angry: pointed long The front-back progression is determined there is inadequate tooth display during “fangy” cusp form, passive soft: blunt, by arch form and a key element, usually smiling, then this is diagnosed as vertical rounded , short cusp form[1]. the canine or the premolar, is a maxillary insufficiency. This is not a case p r e r e q u i s i t e f o r e n s u r i n g t h e that should be treated with esthetic tooth Symmetry and Balance: visualization of the gradation effect. lengthening. This is an orthognathic Lip symmetry involves the mirror image problem and should be referred for appearance of each lip when smiling. Soft Tissue Component Of Smile proper treatment[5]. Independent evaluation of upper and Design lower lip is essential when analyzing both Gingival health, level and harmony: Axial inclinations: symmetry and fullness. Sometimes The gingival frame the teeth and add to Tooth inclinations compares the vertical plastic surgery is necessary to provide the symmetry of the smile. The health, alignment of maxillary teeth, visible in results desired by the patients. Balance is colour and texture of the gingival tissues

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 103 are paramount for long term success and view width between the distal aspects of the esthetic value of the treatment. the 2 maxillary canine teeth which is Healthy gingiva is usually pale pink in (frontal view of the anterior 6 colour, stippled, firm and should exhibit a teeth)/2(1+RED+RED2) =width of matte surface. A normal healthy gingival central incisor[8]. sulcus should not exceed 3 mm in depth. Esthetics In Implants Dentistry Smile Line: A partial denture or an implant often Its an imaginary line drawn along the replaces missing teeth. Dental implant incisal edges of the maxillary anterior Golden Proportion provides several advantages over the teeth. In an esthetic smile, the edges of the Interpupillary line: conventional tooth-borne fixed maxillary anterior teeth follow a convex This should be parallel with the horizon prosthesis. New requirements have or gull-wing course matching the line and perpendicular to the midline of emerged for surgical and prosthetic curvature of the lower lip[2]. In a reverse the face. Also it should be parallel with requirements when implants are smile line, the centrals appear shorter the commisure line and occlusal plane. involved. The use of an implant avoids than the cuspids along the incisal plane. unnecessary sacrifice of intact tooth Lip line should not be confused with the Esthetic Smile: structure and avoids long span dentures. smile line. Golden Proportions: The application of Cylindrical shaped implants provide long the golden number to dentistry was first lasting support to the prosthesis and also Interdental embrasures: mentioned by Lombard and developed by provides better survival rates. Studies on The darkness of the oral cavity shouldn’t Levin. Levin observed that the most the longevity of implants consider the be visible in the inter-proximal triangle harmonious recurrent tooth-to-tooth ratio survival time and esthetic consideration between the gingival and the contact area. was found in the golden proportion. This of the implant. Functional and esthetic The black triangles will be avoided if the implies that the maxillary central incisor success is essential to long term most apical point of the restoration is 5 should be approximately 60% wider than successful outcome. mm or less from the crest of the bone. the lateral incisor, which in turn should be Sometimes this will require long contact 60% wider than the mesial aspect of the Periodontics To Enhance Esthetics area and will be extended towards the canine, the distal aspect of the canine The combination of periodontal esthetic cervical. Which encourage the formation being obscured from the facial aspect. He surgery with other restorative procedures of healthy pointed papilla instead of the further demonstrated that the lateral can create a synergistic esthetic result. blunted tissue form that often negative space, the area that appears Periodontal treatment consists of a accomplishes a black triangle.[6] between the anterior segment of the teeth variety of solutions to improve smile and the corner of the mouth on smiling, is 1. Teeth stains - Scaling-polishing and Facial Composition: in golden proportion to one half the width vital bleaching Lip line: of this anterior segment. He developed a 2. Black triangle- placing restoration When smiling, the inferior border of the grid to help the prosthodontist detect 5mm or less from crest of bone lip as it relates to the teeth and gingival what is esthetically wrong in the anterior 3. Aberrant frenulum-Frenotomy or tissues is the lip line. Dentistry has proportional relationship. Frenectomy arbitrarily classified 3 types of smiles 4. Excessive gingival display - Crown that, relating the height of the upper lip Recurring Esthetic Dental (Red) lengthening procedure relative to the maxillary anterior central Proportion: 5. Loss of papillae - Reconstruction of incisors which are referred to as The successive width proportion when papilla presenting a low lip line, middle lip line, viewed from the facial aspect should 6. Exposed root surfaces - Root high lip line. remain constant as we move posteriorly coverage Average lip line-exposes the maxillary from midline which offers great 7. Loss of tooth - Implant supported teeth and only the interdental papilla. flexibility to match tooth properties with restorations Low lip line: exposes no gingival tissues facial proportions-Ward1. Generally the 8. Loss of adjoining hard and soft when smiling. values of the RED proportions used are tissues -Ridge augmentation High lip line: exposes the teeth in full between 60% and 80%. Once the ideal 9. Excessive gingival pigmentation - display also gingival tissues above the size of the central incisor has been Gingival dipigmentation gingival margins [7]. calculated, the width of the central incisor 10. Asymmetry in gingival contours - is multiplied by the desired RED proportion to determine the frontal view width of the lateral incisor. The resulting lateral incisor width is multiplied by the same RED proportion to yield the desired frontal view of the canine. A mathematical formula has been arrived to calculate the width of the maxillary central incisor for any RED proportion given a fixed view width. And this width is determined by measuring the frontal Lip Line Crown Lengthing

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 104 final restorations. 2. Vig RG, Brundo Gc. The Kinetics of anterior tooth display. J Prosthet R a t i o n a l F o r O r t h o d o n t i c Dent. 1978:39; 502-504. Intervention 3. Edward A. McLaren, DDS, MDC : 1) To enhance masticatory efficiency and Phong Tran Cao, DDS Smile 2) Periodontal protection Analysis and Esthetic Design: “In the 3) Maintaining the oral hygiene Zone” INSIDE DENTISTRY 4) Temporomandibular joint protection JULY/AUGUST 2009. Diastema Closure 5) Speech improvement 4. Pieter Van der Geld , Paul Oosterveld 6) Esthetics and Annie Marie Kujjpers-Jagtman. Gingival recontouring Age-related changes of the dental V) Conclusion: aesthetic zone at rest and during Smile Design In Prosthodontics: From the above discussion, it is vivid that spontaneous smiling and speech Smile Design For Full Mouth the smile we create should be esthetically European Journal of Orthodontics R e h a b i l i t a t i o n : F u l l m o u t h appealing and functionally sound too. We 30(2008)366-373. rehabilitations deals with the science of the dentist should carefully dignose 5. Robbins JW.Differential diagnosis treating a mutilated dental situation analyze and deliver the best to our and treatment of excessive gingival which involves treatment of many or all patients by considering all the above display. Pract Periodontics Aesthet teeth and helps them function in harmony factors. In todayR23;s world, the smile is Dent.1999;2:265-272. with the surrounding muscles and the TM consider an important component of an 6. Tarnow DP, Manager AW, Fletcher P. joint. Full mouth rehabilitation is needed individualR23;s over all appearance and The effect of the distance from the when the teeth are worn down, broken, well being. Scientific analysis of contact point to the crest of the bone missing or if u experience pain in the jaw beautiful smiles has shown that the on the presence or absence of the joint, headaches , muscle tenderness or principle of Golden Proportion or RED interproximal papilla . J Periodontal . clicking of the jaw. This utilizes current proportions can be systematically 1992; 63:995-6. technologies to reshape and rebuild ones applied to evaluate and to improve 7. Patil Ratnadeep. Esthetic dentistry: teeth, gums and surrounding areas. denture esthetics in predictable ways. An artistR23;s science .1st The aim of smile design must be less e d . M u m b a i : P R Role Of Orthodontics For Esthetics tooth structure reduction and greater Publications;2002.p.16-36. The restorative dentist should consider esthetics and durability. 8. Ward DH. Proportional smile design pre-restorative orthodontic correction using the recurring esthetic dental and should modify the treatment plan to References: (RED) proportion. Dent Clin North accommodate the patient’s wishes. An 1. Mohan Bhuvaneswaran. Principles of Am. 2001; 45:143-154. esthetic treatment plan must consider smile design. J Conserv Dent . 2010 whether orthodontic movements will Oct – Dec; 13(4): 225-232. enhance the success or stability or the

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 105 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Determination Of Biologic Width And Its 1 Sunil Chandra Verma 2 Vivek Govila Relevence In Periodontics And Restorative 3 Smita Govila 4 Sumedha Mohan Dentistry 1 Reader 2 Professor And Head Abstract Dept. Of Periodontics The dimension of space that the healthy gingival tissue occupy above the alveolar bone is 3 Reader, Dept. Of Conservative Dentistry & Endodontics defined as biologic width. It can be identified for each individual patient by probing to the bone 4 Post Graduate Student , Dept. Of Periodontics level and substracting the sulcus depth from the resultant measurement. Biologic width violations BBD College Of Dental Sciences, Lucknow can be corrected by either surgically removing bone away from proximity to the restoration Address For Correspondence: Dr. Sunil Chandra Verma margin or orthodontically extruding the tooth and thus moving the margin away from the bone. Department Of Periodontics Restoration of fractured, severely decayed, partially erupted, worn or poorly restorated teeth is Bbd College Of Dental Sciences often difficult for the dentist without surgical and orthodontic intervention. Surgical crown Bbd University Lucknow (Up) lengthening of these teeth is necessary to provide adequate tooth structure for restoration or Submission : 10th April 2014 Esthetics enhancement, thus adhering to basic biological principles by preventing impingement Accepted : 23rd March 2015 on the periodontal attachment apparatus or biological width. Hence the purpose of this article is to describe the biologic width anatomy, evaluations & its correction. Quick Response Code Key Words Dentogingival unit, Biologic Width, Periodontics, Restorations,, Gingival inflammation. Introduction underlying connective tissue). It was first Maintenance of gingival health described by Sicher in 1959. This term constitutes one of the keys for tooth and was based on the work of Gargiulo et al., dental restoration longevity.[1] The on the dimensions and relationship of the concept of biologic width is important to dentogingival junction in humans. The and pronounced scalloped. Spear both restorative dentistry and dentogingival components of 287 suggested that additional 1.5 to 2.5mm of periodontics.[2] The marginal individual teeth from 30 autopsy interproximal gingival tissue height compartments of the periodontium have specimens were measured, concluding require the presence of adjacent teeth for been analyzed and debated for several that there is a definite proportional maintains of interproximal gingival decades.[3] An adequate understanding relationship between the alveolar crest, volume. Without the adjacent tooth the of these compartments both in health and the connective tissue attachment, the interproximal gingival tissue would disease are needed to ensure adequate epithelial attachment, and the sulcus flatten out, assuming a normal 3.0mm form, function and esthetics, and comfort depth. They reported the following mean biologic width. Tarnow and colleagues to the dentition. The aim of our dimensions: A sulcus depth of 0.69 mm, found that for the gingival tissue to manuscript is to describe about the an epithelial attachment of 0.97 mm, and assume complete filling of the interdental biologic width anatomy and evaluation in a connective tissue attachment of 1.07 space, the distance from the contact point health and disease. mm. Based on this work, the biologic to alveolar crest should not exceeded 5 width is commonly stated to be 2.04 mm, mm to 5.5mm.Greater distance result in Biologic Width Anatomy which represents the sum of the epithelial significant loss of alveolar height. [7] Ectodermal tissue serves to protect and connective tissue measurements.[4] This was confirmed by Cho et al (2006) against invasion from bacteria and other In 1977, Ingber et al. described “Biologic who also found that as the interproximal foreign materials, in human body. Width” and credited D.Walter Cohen for distance between the teeth increased the Biologic width is the term applied to the first coining the term.[5] number of papilla that filled the dimensional width of the dentogingival Interproximally the biological width is interproximal space also decreased. junction (epithelial attachment and similar to that of the facial surface [6] but The dimension of biologic width alters, it the total dentogingival complex is not. depends on the location of the tooth in the Kois and Spear pointed out that the alveolus, varies from tooth to tooth, and dentogingival complex is 3.0mm facially also from the aspect of the tooth. It has and 4.5mm to 5.5mm interproximally. been shown that 3 mm between the They noted that the height of interdental preparation margin and alveolar bone papilla can only be explained by maintains periodontal health for 4 to 6 increased scalloping of the bone. Becker months.[8] It is essential for preservation and colleagues (1970) defined variation of periodontal health and removal of of gingival scalloping as flat scalloped irritation that might damage the Estimation Of Biologic Width periodontium. The millimeter that is

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 106 needed from the bottom of the junctional placement guidelines to prevent biologic patients are susceptible to gingival epithelium to the tip of the alveolar bone width violation. Kois proposed three recession while others have a quite stable is held responsible for the lack of categories of biologic width based on the attachment apparatus. The difference is inflammation and bone resorption, and as total dimension of attachment and the based on the depth of the sulcus, which such the development of periodontitis, sulcus depth following bone sounding can have a wide range. which in turn may impact our approach to measurements, namely: NormalCrest, surgical intervention. High Crest and Low Crest.[10] Importance of determining the crest category Evaluation Of Biologic Width Normal Crest Patient This allows the operator to determine the Violation In the Normal Crest patient, the mid- optimal position of margin placement, as facial measurement is 3.0 mm and the well as inform the patient of the probable Clinical method proximal measurement is a range from long-term effects of the crown margin on If a patient experiences tissue discomfort 3.0 mm to 4.5 mm. Normal Crest occurs gingival health and esthetics. Based on when assessed with a periodontal probe, approximately 85% of time. In these the sulcus depth the following three rules it is a good indication that a biologic cases, the gingival tissue tends to be can be used to place intracrevicular width violation has occurred. The signs stable for a long term. The margin of a margins: of biologic width violation are: Chronic crown should generally be placed no 1. If the sulcus probes 1.5 mm or less, progressive gingival inflammation closer than 2.5 mm from alveolar bone. the restorative margin could be around the restoration, bleeding on Therefore, a crown margin which is placed 0.5 mm below the gingival probing, localized gingival hyperplasia placed 0.5 mm subgingivally tends to be tissue crest. with minimal bone loss, gingival well-tolerated by the gingiva, and is 2. If the sulcus probes more than 1.5 recession, pocket formation, clinical stable long term in the Normal Crest mm, the restorative margin can be attachment loss and alveolar bone loss. patient. placed in half the depth of the sulcus. Gingival hyperplasia is most frequently 3. If the sulcus is greater than 2 mm, found in altered passive eruption and High crest patient could be performed to subgingivally placed restoration High Crest is an unusual finding in nature lengthen the tooth and create a 1.5 margins.[8] and occurs approximately 2% of the time. mm sulcus. Then the patient can be There is one area where High Crest is treated as per rule 1.[9],[11] Bone Sounding seen more often: In a proximal surface The biologic width can be identified by adjacent to an edentulous site. In the High Methods to correct biologic width probing under local anesthesia to the C r e s t p a t i e n t , t h e m i d - f a c i a l violation bone level (referred to as “sounding to measurement is less than 3.0 mm and the Biologic width violations can be bone”) and subtracting the sulcus depth proximal measurement is also less than corrected by either surgically removing from the resulting measurement. If this 3.0 mm. In this situation, it is commonly bone away from proximity to the distance is less than 2 mm at one or more not possible to place an intracrevicular restoration margin, or orthodontically locations, a diagnosis of biologic width margin because the margin will be too extruding the tooth thus moving the violation can be confirmed. This close to the alveolar bone, resulting in a margin away from the bone. measurement must be performed on teeth biologic width impingement and chronic with healthy gingival tissues and should inflammation. Surgical crown lengthening be repeated on more than one tooth to Crown –lengthening surgery is designed ensure accurate assessment, and reduce Low crest patient to increase the clinical crown length individual and site variations. In the Low Crest patient group, the mid- facial measurement is greater than 3.0 Indications[12] Radiographic Evaluation mm and the proximal measurement is 1. Inadequate clinical crown for Radiographic interpretation can identify greater than 4.5 mm. Low Crest occurs retention due to extensive caries, interproximal violations of biologic approximately 13% of the time. subgingival caries or tooth fracture, width. However, on the mesiofacial and Traditionally, the Low Crest patient has root perforation, or root resorption distofacial line angles of teeth, been described as more susceptible to within the cervical 1/3rd of the root in radiographs are not diagnostic because of recession secondary to the placement of teeth with adequate periodontal tooth superimposition.[9] Sushama and an intracrevicular crown margin. When attachment. Gouri have described a new innovative retraction cord is placed subsequent to 2. Short clinical crowns. parallel profile radiographic (PPR) the crown preparation; the attachment 3. Placement of sub gingival restorative technique to measure the dimensions of apparatus is routinely injured. As the margins. the dento gingival unit (DGU). The injured attachment heals, it tends to heal 4. Unequal, excessive or unaesthetic authors infer that the PPR technique back to a Normal Crest position, resulting gingival levels for esthetics. could be used to measure both length and in gingival. 5. Planning veneers or crowns on teeth thickness of the DGU with accuracy, as it with the coronal to was simple, concise, non-invasive, and a Low crest, stable or unstable the cemeto enamel junction (delayed reproducible method. However, the Low Crest attachment is passive eruption). actually more complex because all Low 6. Teeth with excessive occlusal wear or Perio-Restorative Interrelationship Crest patients do not react the same to an incisal wear. Categories of biologic width and margin injury to the attachment. Some Low Crest 7. Teeth with inadequate interocclusal

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 107 space for proper restorative mm on multiple teeth. 21 weeks for soft tissue gingival margin procedures due to supraeruption. stability. Therefore, restorative treatment 8. Restorations which violate the Apical repositioned flap with osseous should be initiated after 4-6 months. The biologic width. reduction margin of the provisional restoration 9. In conjunction with tooth requiring This technique is used when there is no should not hinder healing before the hemisection or root resection. adequate zone of attached gingiva and the biologic width is established by surgical 10. Assist with impression accuracy by biologic width is less than 3 mm. The procedures. [18] Shobha et al. in a study placing crown margins more alveolar bone is reduced by ostectomy on clinical evaluation of crown supragingivally. and osteoplasty, to expose the required lengthening procedure had concluded tooth length in a scalloped fashion, and to that the biologic width can be re- Contraindications[12] follow the desired contour of the established to its original vertical 1. Deep caries or fracture requiring overlying gingiva. As a general rule, at dimension along with 2 mm gain of excessive bone removal. least 4 mm of sound tooth structure must coronal tooth structure at the end of six 2. Post surgery creating unaesthetic be exposed, so that the soft tissue will months.[19] outcomes. proliferate coronally to cover 2-3 mm of 3. Tooth with inadequate crown root the root, thereby leaving only 1-2 mm of C o m p l i c a t i o n s A f t e r C r o w n ratio (ideally 2:1 ratio is preferred) supragingivally located sound tooth Lengthening 4. Non restorable teeth. structure.[15] Sugumari et al. in a report As with any procedure, the patient needs 5. Tooth with increased risk of furcation on surgical crown lengthening with to be informed of any potential involvement. apical repositioned flap with bone complications such as possible poor 6. Unreasonable compromise of resection performed in the fractured aesthetics due to ‘black triangles’, root esthetics. maxillary anterior teeth region, showed hypersensitivity, root resorption and 7. Unreasonable compromise on satisfactory results both in terms of transient mobility of the teeth. adjacent alveolar bone support. functional (restoring biologic width) and esthetic outcomes. Periodontal Pathology External bevel gingivectomy Phases 3 and 4 of paasive eruption are Gingivectomy is a very successful and Orthodontic Techniques termed periodontitis because the loss of predictable surgical procedure for Heithersay and Ingber were the first to attachment has occurred. The most reconstruction of biologic width; suggest the use of “forced eruption” to consistent reported component of the however, it can be used only in situations treat “non-restorable” or previously histologic biologic width was the width with hyperplasia or pseudopocketing (> 3 “hopeless” teeth.[16] According to Starr, of the supracrestal connective tissue, mm of biologic width) and presence of there are two concepts of forced eruption: which averaged 1.08mm in phase , adequate amount of keratinized Forced eruption with minimal osseous 1.07mm in phase 2, 1.06mm in phase 3 tissue.[13] resection, and forced eruption combined and 1.06mm in phase 4.[20]Greater with fiberotomy. Frank et al. described variability was seen in the length of the Internal bevel gingivectomy forced eruption of multiple teeth.Since , averaging Reduction of excessive pocket depth and then, different clinicians have used 1.35mm in phase 1, 1.10mm in phase 2, exposure of additional coronal tooth various techniques to extrude teeth using 0.74mm in phase 3 and 0.71mm in phase structure in the absence of a sufficient removable devices or fixed brackets.[17] 4. [20] zone of attached gingiva with or without Forced eruption should be considered in The observations of the work done by the need for correction of osseous cases where traditional crown M.John Novak[21] was that the average abnormalities requires internal-bevel lengthening via ostectomy cannot be clinical biologic width in cases of severe, gingivectomy.[14] accomplished, like in the anterior area, as generalized, chronic periodontitis is ostectomy would lead to a negative nearly twice as large as previously Apical repositioned flap surgery architecture and also remove bone from reported for the histologic width in cases the adjacent teeth, which can of health to mild periodontitis (3.95mm Indication compromise the function of these teeth. versus 2.04mm). The most surprising Crown lengthening of multiple teeth in a Some of the contraindications to forced were the range of values obtained for quadrant or sextant of the dentition, root eruption are inadequate crown-to-root biologic width, based on initial PD or caries, fractures. ratio, lack of occlusal clearance for the CAL, with values <1 to >9mm. It was required amount of eruption and any observed that the sites with the Contraindication possible periodontal complications. shallowest PDs and least CAL had the Apical repositioned flap surgery should greatest biologic width.This observation not be used during surgical crown Healing after Crown Lengthening provided significant implications for the lengthening of a single tooth in the Restorative procedures must be delayed selection of surgical or non-surgical esthetic zone. until new gingival crevice develops after approaches in the treatment of patients periodontal surgery. In non esthetic areas, with severe periodontitis.It was Apically repositioned flap without the site should be re-evaluated atleast 6 demonstrated that surgical interventions osseous resection weeks post surgically prior to final in sites with shallow PDs resulted in post This procedure is done when there is no restorative procedures. In esthetic areas, surgical loss of attachment at that site. adequate width of attached gingiva, and a longer healing period is recommended [22], [23] In cases of severe, generalized, there is a biologic width of more than 3 to prevent recession. Wise recommends chronic periodontitis in which the

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 108 biologic width at shallow sites may be at (2003) The junctional epithelium: crown extension: A rationale basis for least twice as much as first described, from strength to defense. Journal of treatment. Int J Periodont Restor Dent with extremes of up to 9mm, there is Dental Research 82, 158–161. 1997;17:464-77. considerable potential for extensive 4. Gargiulo AW, Wentz FM, Orban B. 14. Khuller N, Sharma N. Biologic attachment loss as the result of open flap Dimensions and relations of the width: Evaluation and correction of debridement with scaling and root dentogingival junction in humans. J its violation. J Oral Health Co mm planing or with apically positioned flap. Periodontol 1961;32:261-7. Dent 2009;3:20-5. 5. Ingber JS, Rose LF, Coslet JG. The 15. E l a v a r a s u S , K e r m a n i K , Conclusion “biologic width”—a concept in Thangakumaran S, Jeyaprakash GS, The homeostasis of periodontal tissues is periodontics and restorative dentistry. Maria R. Apically repositioned flap in determined by accurately placed Alpha Omegan 1977;70:62-5. reconstruction of mutilated teeth. restorative materials. Overhanging 6. Vacek JS, Gher ME, Assad DA, JIADS 2010;1:63-6. restorations and open interproximal Richardson AC, Giambarresi LI. The 16. Durham T, Goddard T, Morrison S. contacts should be addressed and d i m e n s i o n s o f t h e h u m a n Rapid forced eruption: A case report corrected during the disease control dentogingival junction. Int J and review of forced eruption phase of periodontal therapy. Periodontics Restorative Dent 1994; techniques. Gen Dent 2004;48:167- Conceptually restorative margins can 14(2):154-65. 75. remain coronal to the free gingival 7. Tarnow DP, Magner AW, Fletcher P. 17. Uddin M, Mosheshvili N, Segelnick margin. Subgingival margin placement The effects of the distance from the SL. A new appliance for forced should avoided. If subgingival margin is contact point to the crest of bone on eruption. N Y State Dent J unavoidable then care must be taken to the presence or absence of the 2006;72:46-50. involve a highly precise finish line. interproximal dental papilla. J 18. Shobha KS, Mahantesha, Seshan H, Evidence suggests that even minimal Periodontol 1992;63:995. Mani R, Kranti K. Clinical evaluation encroachment on the subgingival tissue 8. Jorgic-Srdjak K, Plancak D, of the biologic width following can lead to deleterious effects on the Maricevic T, Dragoo MR, Bosnjak A. surgical crown lengthening periodontium. If restorative margins are Periodontal and prosthetic aspect of procedure: A prospective study. J faulty they often lead to a more biological width part I: Violation of Indian Soc Periodontol 2010;14:160- p r o n o u n c e d p l a q u e - i n d u c e d biologic width. Acta Stomatol Croat 7. inflammatory response. If restorative 2000;34:195-7. 19. Robbins JW. Tissue management in margins need to be placed near the 9. Galgali SR, Gontiya G. Evaluation of restorative dentistry. Funct Esthet alveolar crest, crown-lengthening a n i n n o v a t i v e r a d i o g r a p h i c Restor Dent 2007;1:40-3. surgery or orthodontic extrusion should t e c h n i q u e - p a r a l l e l p r o f i l e 20. Gargiulo A, Krajewski J, Gargiulo M. be considered to provide adequate tooth radiography- to determine the Defining biologic width in crown structure while simultaneously assuring dimensions of the dentogingival unit. lengthening.CDS Rev 1995;88:20- the integrity of the biologic width. Indian J Dent Res 2011;22:237-41. 23. Although individual variations exist in 10. Kois JC. The restorative-periodontal 21. M John Novak, Huda M Albather, the soft tissue attachment around teeth interface: Biological parameters. John M Close. Redefining the there is general agreement that a Periodontol 2000. 1996;11:29-38. biologic width in severe, generalized, minimum of 3 mm should exist from the 11. Freeman K, Bebermeyer R, Moretti chronic periodontitis: Implications restorative margin to the alveolar bone, A, Koh S. Single-tooth crown f o r t h e r a p y. J P e r i o d o n t o l allowing for 2 mm of biologic width lengthening by the restorative dentist: 2008;79:1864-1869. space and 1mm for sulcus depth. A case report. J Greater Houston Dent 22. Ramfjord SP, Caffesse RG, Morrison Soc 2000;2:14-6. EC et al. 4 modalities of periodontal References 12. Jorgic-Srdjak K, Dragoo MR, treatment compared over 5 years. J 1. Felippe LA, Monteiro Júnior S, Bosnjak A, Plancak D, Filipovic I, Clin Periodontol 1987; 14:445-452. Vieira LC, Araujo E. Reestablishing Lazic D. Periodontal and prosthetic 23. Lindhe J, Westfelt E, Nyman S, biologic width with forced eruption. aspect of biological width part II: Socransky SS, Haffajee AD. Long- Quintessence. 2003;34:733-8. Reconstruction of anatomy and term effect of surgical/non-surgical 2. Hildebrand CN. Crown lengthening function. Acta Stomatol Croat treatment of periodontal disease. J for optimum restorative success. 2000;34:441-4. Clin Periodontol 1984;11:448-458. Compendium 2003;24:620-629. 13. Smukler H, Chaibi M. Periodontal 3. Schroeder, H. E. & Listgarten, M. A. and dental considerations in clinical

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Neutral Zone : Rationale, Concept, Merits And 1 Sharad Vaidya 2 Archana Nagpal Demerits Of Special Techniques 3 Rajeev Gupta 4 Rupandeep Kaur Samra Abstract 1 Senior Lecturer The goal of dentistry is to keep teeth in a healthy state. If the teeth are lost despite all efforts to 2 Professor & Head save them, re-establishment should be made such that teeth function efficiently and comfortably 3 Professor in harmony with muscles of the stomatognathic system and temporomandibular joints (TMJ). 4 Reader, Dept. of Prosthodontics & Implantology One of the most common problems encountered among long term denture wearers is the Himachal Dental College, Sundernagar diminution in the denture foundation area. Rehabilitation of a patient with severely resorbed ridge Address For Correspondence: is a challenging therapy a prosthodontist can undertake. In order to ensure a favorable Dr. Sharad Vaidya, Senior Lecturer Department of Prosthodontics and Implantology prognosis, the impression technique, impression material and tooth moulds selected should be Himachal Dental College based on the present state of the basal tissue support. This article discusses the concept, Sundernagar, Himachal Pradesh muscles involved, technique, advantages and indications of neutral zone technique to achieve Submission : 10th April 2014 stability in highly resorbed mandibular edentulous ridge and also an insight into the rationale of rd Accepted : 23 March 2015 using these techniques. Key Words Neutral Zone, Stability, Resorbed Ridges Quick Response Code Introduction: enlarged tongue. To beat such problems, The fabrication of complete removable the neutral zone technique was dentures has evolved noticeably over the advocated.[4],[6],[7] The neutral zone is last 20 years with the advent of new the zone of minimal conflict, zone of materials and a better understanding of equilibrium, potential denture space and patient’s expectations. There is a general the dead space area where forces agreement about one aspect of complete generated in an outward direction from arranged to occupy as central a location denture treatment i.e. an accurate the tongue are being neutralized or as possible, relative to the denture impression of the edentulous alveolar balanced by the inward forces generated foundation, without disturbing adequate ridges and adjacent functional structures by lips and cheeks during functional tongue function. This tooth arrangement must be obtained before proceeding to activities. Setting teeth and contouring is said to facilitate mandibular denture fabricate the complete dentures. Without polished surface of lower CD within this stability during occlusal loading. Various this foundation, there is no hope of zone adds more to stability.[5] The concepts have been suggested about the providing patients with idyllic function, neutral zone technique is most effective arrangement of posterior denture comfort, and aesthetics. The lower for patients who have had numerous teeth.[10],[11],[12],[13],[14] denture commonly presents the most unstable, unretentive lower complete Neutral zone is that region where forces difficulties with pain and sloppiness dentures.[1],[8],[9] This article discusses imposed by the tongue directed outward being the most common complaint, the concept, muscles involved, technique are neutralized by inwardly directed because the mandible atrophies at a and indications of neutral zone to achieve forces originating from the cheeks and greater rate than the maxilla and has less stability in highly resorbed mandibular lips during normal neuromuscular residual ridge for retention and edentulous ridge and also an insight into function. In general, boundary conditions support.[1],[2],[3],[4] Looseness and the rationale of using this technique. that define the neutral zone are developed discomfort are the most frequent through muscular contraction and complaints reported by patients and they Various Concepts Regarding relaxation during the various functions of are quite often difficult to manage by Arrangement Of Posterior Teeth mastication, phonation, deglutition, and dentists. Neuromuscular control is said to (Table I). [14], [15], [16], [17], [18], facial expression. These neuromuscular be the key determinant in stability of [35], [36], [37], [38] forces vary in magnitude and direction in lower complete denture as the area Regardless of the fabrication technique different areas of the oral cavity, in available for support is far less than used, functionally inappropriate denture different individuals, and at different maxillary support area.[5] tooth arrangement or physiologically periods of life. The trajectory of force Throughout time, many theories emerged unacceptable denture base volume or applications to prosthetic surfaces will to illustrate where prosthetic teeth of contour have been implicated in poor either serve to stabilize or dislodge the denture should be positioned. These prosthesis stability and retention of the complete dentures. [15], [16], [17], [18], approaches have been challenged from denture. Neutrocentric concept by Devan [21], [22], [24], [25] time to time and found insufficient in has been used practically to enhance this patients with severely atrophic stability. This concept states that Muscles Invcolved In Neutral Zone mandibular ridges and patients with posterior mandibular denture teeth are (Table II) [16], [17], [18], [19], [20],

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 110 patients losing their teeth at a later stage of life. Compounded by increased life expectancy, this has led to the majority of complete denture wearers to be elderly and has increased the proportion of those who have poor neuromuscular control, poor adaptive capacity and severely atrophic ridges. The rationale of Neutral Zone is: To fabricate a lower complete denture that is optimally situated and in harmony with the structures and forces discussed above. By doing so, these forces are more likely to be stabilizing rather than unseating.

Indications and Materials (Table III) [29], [30], [31], [32] In general, neutral zone technique is indicated when stability and patient’s acceptance of lower complete denture are in question. This technique is found to be Table 1 used in the following clinical situations: • Severely atrophic mandibular ridge • Patients with prominent and highly attached mentalis muscle, lateral spreading of tongue as a result of poor transition from dentate to edentulous state and severe resorption. • P a t i e n t s w i t h d i m i n i s h e d neuromuscular control such as those with a history of stroke, Parkinson’s disease or patients with impaired motor innervation to oral and facial muscles. • Patients with atypical shape or consistency of oral and perioral structures. Patients with scleroderma Table 2 or patients who have undergone marginal or segmental mandi bulectomy are also candidates for this technique. • This technique can be used to locate optimal position for implants in cases of implant-supported or retained overdentures, which enhances the overall outcome of treatment.

Technique [5],[7],[8],[9],[10],[11] 1. Primary impression is made in stock tray with alginate hydrocolloid material/impression compound. Table 3 2. Impression is poured in dental plaster and special tray is fabricated with [21], [22], [23], [24], [25], [26] polished surface. spacer (Fig 2 ). These can be further divided according to 3. Extensions of the special tray are The musculature of the denture space their location on the vestibular (labial & checked intra-orally. A secondary cam be divided into two groups (Fig 1) buccal) side or lingual side of the impression is made with polyvinyl - Dislocating Muscles: Muscles dentures. silicone impression material. primarily involved in dislocating 4. Master cast is obtained. Heat cure denture during activity. Rationale [18], [21], [22], [23], [24], denture base is fabricated over it. - Fixing Muscles: Muscles that fix the [25], [26] 5. Wax block is added to the base plate denture by muscular pressure on the Increased access to dental care has led to and occlusal registration is made in

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 111 a) By use of tissue conditioning agent: Mandibular wax block is removed and replaced by wire loops attached to acrylic denture base (Fig 3). These are carefully positioned within the contours of the wax block and conformed to the same vertical dimension of occlusion. Tissue conditioning material is applied to the wire loops and placed inside mouth. (Fig 4). Patient is instructed to Figure 6 Figure 1 carry out simple oral movements – swallowing, chewing, puffing of lips and sipping water. (Fig 5). These movements will help to shape tissue conditioning material to the contours of neutral Figure 7 zone. Figure 2 b) Neutral zone can also be recoded using “ADMIX” technique.[49] Wax block is removed from the mandibular base and is replaced with admix compound (7 parts of Figure 8 green stick compound and 3 parts zone record on the mandibular of red compound). This material definitive cast. Prepare laboratory removes any folds on the putty (Poly V Putty; Accurate Set, edentulous tissue and its Inc, Newark, NJ) to a workable increased flow helps in recording consistency and adapt it into the neutral zone effectively (Fig 6). tongue space and buccal surface of Compound rim is conformed to the neutral zone record (Fig 7). Figure 3 t h e e s t a b l i s h e d v e r t i c a l Mould the putty so that it: (a) dimension. Place the completed completely fills the tongue space; (b) record base and recording rim in adapts accurately to the lingual the water bath (1400 F for contours of the neutral zone record; approximately 2 minutes in (c) is level with the occlusal plane of preparation for the clinical the record; and (d) extends over the Figure 4 procedure. Remove the base and posterior land area of the cast. Teeth rim from the water bath and arrangement is done within the quickly place it intra-orally. confines of the index without of any Instruct the patient to swallow. consideration to achieve balance (Fig Next, provide a cup of warm 6, 8). water to the patient and instruct the patient to sip and swallow. Discussion: Have the patient repeat this sip The ultimate aim of the prosthodontist is and swallow exercise several to restore form, function and esthetics. times. When the neutral zone Many approaches to set teeth have been record has cooled and hardened, advocated and used in complete denture remove and inspect the record for treatment. However, there is substantial accuracy and completeness. If debate on which of these provide optimal necessary, repeat the procedure to position in the facio-lingual dimension ensure proper recording of the and guarantee a favourable outcome in entire neutral zone. Eliminate terms of stability, facial support, chewing excess impression compound that Figure 5 efficiency, aesthetics and patient has been displaced superior to the comfort. Some authors have defined the conventional manner. intended occlusal plane during the biometric measurements and location of 6. Maxillary cast is mounted on semi- recording procedure and, if relatively stable anatomical landmarks to adjustable articulator using face bow necessary, repeat the recording set teeth; whereas, some relied on transfer. Centric registration and process, beginning with warm difference in resorption patterns to set mounting of lower cast. This is from water bath. denture teeth where their natural here that techniques to record neutral 7. To develop the facial and lingual predecessors were thought to have been. zone vary. neutral zone index, seat the neutral Some authors adopted a mechanical

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 112 concept and advocated setting teeth the concept that in each patient there is a 9. Shipmon TH, Massad JJ. Optimum directly in the centre of denture support zone of neutrality that helps to keep dentures, part 1: the need for patient area where the least amount of leverage is denture in place without displacement. In management. Dent Today. 1993; present which in turn enhances the patients with extreme resorption of the 12(8): 84-89. s t a b i l i t y o f l o w e r d e n t u r e . alveolar ridges, it becomes necessary to 10. Massad JJ, Shipmon TH Sr. Optimum [1],[4],[5],[6],[7],[8],[9],[10],[43],[44],[ record this position for long term success dentures, part 2: patient evaluation 46],[47] All of these approaches were and of the denture. for success. Dent Today. 1993; 12(9): are still being used and each of them 82-87. proved to have advantages and Conclusion: 11. Massad JJ, Shipmon TH Sr. Optimum disadvantages when compared to others. N Z c o n c e p t i s c o n s i d e r e d a s dentures, part 3: internal and external It has been found that neutral zone is e x c e p t i o n a l l y i m p o r t a n t w h e n i m p r e s s i o n s . D e n t To d a y. closely related to the crest of residual considering treatment options for 1993;12(10):46-51. ridge in patients who have been patients complaining from unstable 12. Massad JJ, Shipmon TH Sr. Optimum edentulous for less than two years and lower CD predominantly if implant dentures, part 4: a perspective on significantly differs in those who were treatment is not feasible. It aims to place vertical and centric relationships. edentulous for a period more than that.[5] lower CD where forces generated by lips, Dent Today. 1994;13(1):42-45. The neutral zone approach registers the cheeks and tongue have a stabilizing 13. Utz KH, Muller F, Bernard N, et al. neutral zone to determine the proper rather than dislodging effect. With Comparative studies on check-bite placement of teeth after resorption has improvement in dental material science and central-bearing-point method for taken place.[2] Denture fabricated over a and development of newer techniques in the remounting of complete dentures. severely resorbed mandibular ridge by prosthodontics, the neutral zone J Oral Rehabil. 1995;22:717-726. neutral zone impression technique i m p r e s s i o n t e c h n i q u e m a y b e 14. Massad JJ. Denture retention: neutral ensures that the muscular forces aid in the incorporated into fabrication of any zone utilization. Independent retention and stabilization of the denture complete denture. Dentistry. 1998;3:44-52. rather than dislodging the denture during 15. Salinas TJ. Contemporary materials function. The dentures will also have References for removable prosthodontics. Pract other advantages such as reduced food 1. Zinner ID, Sherman H. An analysis of P e r i o d o n t i c s A e s t h e t D e n t . lodgment, good esthetics due to facial the development of complete denture 1999;11:888. support, proper positioning of the impression techniques. J Prosthet 16. Rungcharassaeng K, Kan JY. posterior teeth which allows sufficient Dent. 1981; 46: 242-249. Fabricating a stable record base for tongue space.[38],[39],[40] 2. Kois JC, Fan PP. Complete denture completely edentulous patients This technique has been criticized based impression technique. Compend treated with osseointegrated implants on claims that it is supported by practical Contin Educ Dent. 1997;18 : 699- using healing abutments. J Prosthet evidence. However, other authors 708. Dent. 1999;81:224-227. maintain that NZ technique is inaccurate 3. Utz KH. Studies of changes in 17. Hyde TP, McCord JF. Survey of based on significant clinical observations occlusion after the insertion of prosthodontic impression procedures on the role of destabilizing forces the complete dentures (part II). J Oral for complete dentures in general muscles apply to CDs during functional Rehabil. 1997; 24: 376-384. denture practice in the United movements. Furthermore, the large 4. D r a g o C J . A r e t r o s p e c t i v e Kingdom. J Prosthet Dent. number of case reports accumulated in a comparison of two definitive 1999;81:295-299. short period of time and clinical studies impression techniques and their 18. Soni A. Use of loose fitting copper conducted by Stromberg & Hicke and associated postinsertion adjustments bands over extremely mobile teeth Fahmy & Kharat add to the validity of in complete denture prosthodontics. J while making impressions for this technique.[41],[42],[43],[44] Prosthodont. 2003; 12 : 192-197. immediate dentures. J Prosthet Dent. The principle of the neutral zone concept 5. Fattore L, Malone WF, Sandrik JL. 1999;81:638-639. has remained the same since it has been Clinical evaluation of the accuracy of 19. Bissasu M. Use of lingual frenum in first described by Beresin and interocclusal recording materials. J determining the original vertical Schiesser.[50] However; this technique Prosthet Dent. 1984; 51: 152-157. position of mandibular anterior teeth. has been subjected to various 6. Young L, Johnson C. Adjusting J Prosthet Dent. 1999;82:177-181. modifications. Type of retention complete denture occlusion with an 20. Massad JJ, Connelly ME. A incorporated in the baseplate (acrylic intraoral balancer. Compendium. simplified approach to optimizing pillars or wire loops), recording materials 1987; 8: 54-58. denture stability with lingualized used and further refinement to the initial 7. Massad JJ. A metal-based denture occlusion. Compend Contin Educ record are among the variations between with soft liner to accommodate the Dent. 2000;21:555-570. clinicians. Mostly the preference is to use severely resorbed mandibular 21. Cheng AC, Wee AG, Shiu-Yin C, et combination of thin acrylic pillars in alveolar ridge. J Prosthet Dent. 1987; al. Prosthodontic management of premolar region connected by a wire loop 57: 707-711. limited oral access after ablative which maintains the VDO and provides 8. Muller J, Gotz G, Bruckner G. An tumor surgery: a clinical report.J maximum retention at the same time as experimental study of vertical Prosthet Dent. 2000;84:269-273. explained earlier in this article. deviations induced by different 22. AbuJamra NF, Stavridakis MM, [45],[46],[47],[48] interocclusal recording materials. J Miller RB. Evaluation of interarch The neutral zone philosophy is based on Prosthet Dent. 1991; 65: 43-50. space for implant restorations in

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 113 edentulous patients: a laboratory J Prosthodont. 2003;12:280-287. Update. 2006;33:21-6. t e c h n i q u e . J P r o s t h o d o n t . 31. Ling BC. A three-visit, complete- 42. Miller Wp, Monteith B, Heath Mr. 2000;9:102-105. denture technique utilizing visible The Effect of Variation of The 23. Ockert-Eriksson G, Eriksson A, light-cured resin for tray and base Lingual Shape of Mandibular Lockowandt P, et al. Materials for plate construction. Quintessence Int. Complete Dentures on Lingual interocclusal records and their ability 2004;35:294-298. Resistance to Lifting Forces. to reproduce a 3-dimensional jaw 32. Weinberg L. Tooth position in Gerodontology. 1998;15(2):113-9. relationship. Int J Prosthodont. relation to the denture base 43. Allen Pf, Wilson Nhf. Teeth for Life 2000;13:152-158. foundation. The Journal of Prosthetic for Older Adults. Quintessence;2002. 24. Alfano SG, Leupold RJ. Using the Dentistry. 1958;8(3):398-405. 44. F.M F. The Position of the Neutral n e u t r a l z o n e t o o b t a i n 33. Payne A. Factors influencing the Zone in Relation to the Alveolar maxillomandibular relationship position of artificial upper anterior Ridge. The Journal of Prosthetic records for complete denture patients. teeth. The Journal of Prosthetic Dentistry. 1992;67(6):805-9. J Prosthet Dent. 2001;85:621-623. Dentistry. 1971;26(1):26-32. 45. Raja Hz Sm. Relationship of Neutral 25. Karkazis HC. Prosthodontic 34. Murray C. Re-establishing natural Zone and Alveolar Ridge with management of a patient with tooth position in the endentulous Edentulous Period. J Coll Physicians neurological disorders after resection environment. Australian Dental Surg Pak. 2010;20(6):395-9. of an acoustic neurinoma: a clinical Journal. 1978;23(5):415. 46. Memarian Lsfgsfam. Using Neutral report. J Prosthet Dent. 2002;87:419- 35. Watt DM. Tooth positions on Zone Concept in Prosthodontic 422. complete dentures. J Dent. Treatment of a Patient with Brain 26. Eriksson A, Ockert-Eriksson G, 1978;6(2):147-60. Surgery: A Clinical Report Journal of Lockowandt P, et al. Clinical factors 36. Beresin VE, Schiesser FJ. The neutral P r o s t h o d o n t i c R e s e a r c h . and clinical variation influencing the zone in complete dentures. J Prosthet 2011;55(2):117-20. reproducibility of interocclusal Dent. 1976;36(4):356-67. 47. Hina Z. Raja Mns. Neutral Zone recording methods. Br Dent J. 37. Fahmi F. The position of the neutral Dentures Versus Conventional 2002;192:395-400. zone in relation to the alveolar ridge. Dentures in Diverse Edentulous 27. Koshino H, Hirai T, Ishijima T, et al. The Journal of Prosthetic Dentistry. Periods Biomedic. 2009;25:136-45. Influence of mandibular residual 1992;67(6):805-9. 48. Cagna Dr, Massad Jj, Schiesser Fj. ridge shape on masticatory efficiency 38. Lammie GA. Aging changes in the The Neutral Zone Revisited: From in complete denture wearers. Int J complete lower denture. J Prosthet Historical Concepts to Modern Prosthodont. 2002;15:295-298. Dent 1956;6:450-64. Application. The Journal of 28. Rignon-Bret C, Dupuis R, Gaudy JF. 39. Lott F, Levin B. Flange technique, an P r o s t h e t i c D e n t i s t r y . Application of a 3-dimensional anatomic and physiologic approach 2009;101(6):405-12. measurement system to complete to increased retention, function, 49. M c C o r d J F, Ty s o n K W. A denture impressions. J Prosthet Dent. comfort, and appearance of denture. J conservative prosthodontic option for 2002;87:603-612. Prosthet Dent 1996;16:394-413. the treatment of edentulous patients 29. Hayakawa I, Watanabe I. Impressions 40. Gahan Mj, Walmsley Ad. The Neutral with atrophic (flat) mandibular for complete dentures using new Zone Impression Revisited. Br Dent ridges. Br. Dent. J 1997; 182: 469 - silicone impression materials. J. 2005;198(5):269-72. 472. Quintessence Int. 2003;34:177-180. 41. C.D Lynch Pfa. Overcoming the 50. BeresinVE, Schiesser FJ. The neutral 30. Petropoulos VC, Rashedi B. Current Unstable Mandibular Complete zone in complete dentures-principles concepts and techniques in complete Denture: The Neutral Zone and technique, Reprint 1973, C.V. denture final impression procedures. Impression Technique. Dental Mosby company

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Host Modulation Therapy In The Management 1 Aneet Kaur 2 Navkiran Of Periodontal Diseases 3 Ashish Verma 1 Mds Student Abstract 2 Professor And Head 3 Traditionally, only antimicrobials have been used as the chemotherapeutic modality for the Reader treatment of periodontitis. Though bacteria are the primary etiologic factors of periodontal Dept. of Periodontology & Oral Implantology Sri Guru Ram Das Institue Of Dental diseases, yet the extent and severity of tissue destruction seen in periodontitis is determined by Sciences And Research, Amritsar the host immuno-inflammatory response to these bacteria. This increasing awareness and Address For Correspondence: knowledge of the host microbial interaction in periodontal pathogenesis has presented the Dr. Aneet Kaur opportunity for exploring new therapeutic strategies for periodontitis by means of targeting host 49 - Guru Har Rai Avenue, Opposite Khalsa response via host modulating agents. This has lead to the emergence of the field of College, Amritsar (Punjab) India-143001 “Perioceutics” i.e. the use of parmacotherapeutic agents including antimicrobial therapy as well Submission : 15th May 2014 as host modulatory therapy for the management of periodontitis. These host modulating agents Accepted : 19th March 2015 used as an adjunct tip the balance between periodontal health and disease progression in the Quick Response Code direction of a healing response. In this article the host modulating role of various systemically and locally delivered perioceutic agents will be reviewed. Key Words bisphosphonates, host modulation, nonsteroidal anti inflammatory drugs, perioceutics, tetracycline Introduction worse the periodontal disease) and that Host can be defined as "the organism disease progression occurred in a from which a parasite obtains its continous, linear manner throughout life. for wound healing and periodontal nourishment" or "the individual who But the recent observation led stability. Host Modulation Therapeutic receives the graft."Modulation is defined researchers to realize that host response agents are systemically or locally as "the alteration of function or status of to the bacterial challenge presented by delivered pharmaceuticals that are something in response to a stimulus or an subgingival plaque is the important prescribed as a part of periodontal a l t e r e d c h e m i c a l o r p h y s i c a l determinant of disease severity[1]. therapy and are used as adjuncts to the environment".[1] In diseases of the Although plaque bacteria are capable of conventional periodontal treatments, periodontium that are initiated by causing direct damage to the periodontal such as scaling root planing (SRP) and bacteria, the "host" clearly is the tissues (e.g., by release of H2S, butyric surgery1.Various Host Modulation individual w ho harbors thes e acid, and other enzymes and mediators), Therapeutic agents have been developed pathogens.Host modulation with it is now recognized that the great or proposed to block pathways chemotherapeutic therapy or drugs is a majority of the destructive events responsible for periodontal tissue break promising new adjunctive therapeutic occurring in the periodontal tissues result down.Now a days, the field of option for the management of periodontal from activation of destructive processes ‘ P e r i o c e u t i c s ’ i . e . , u s e o f diseases. So, here an attempt has been that occur as a part of the host immune- pharmacological agents specifically made to review various host modulation inflammatory response to plaque developed to better manage periodontitis, therapies and ongoing development of bacteria. The host response is essentially is emerging to aid in the management of safe, effective pharmacotherapies that protective by intent but paradoxically can susceptible patients who develop specially target host response also result in tissue damage, including p e r i o d o n t a l d i s e a s e . I t mechanism, as an adjunct to traditional, breakdown of connective tissue fibers in includesantimicrobial therapies that can antimicrobial interventions, representing the periodontal ligament and resorption be used to address changes in the a new integrated approach in the long of the alveolar bone1. The concept of host microflora andhost modulatory therapy term management of periodontal modulation was first introduced to that can be used to address a host diseases. dentistry by Williams (1990)[2] and response consisting of excessive levels of Golub et al (1992)[3]. enzymes, cytokines, prostanoids & Discussion Host Modulation Therapy (HMT) is a excessive osteoclast function that may be Until the 1970s, periodontists believed means of treating the host side of the host related to risk factors[4]. that periodontal disease was an inevitable bacteria interaction. Host Modulation Host Modulation Therapy (HMT)is a consequence of ageing and was Therapies do not “switch off” normal treatment concept that aims to reduce u n i f o r m l y d i s t r i b u t e d i n t h e defense mechanisms or inflammation; tissue destruction and stabilize or even population.They thought that disease instead, they ameliorate excessive or regenerate the periodontium by severity was directly correlated with pathologically elevated inflammatory modifying or downregulating destructive plaque levels (i.e. worse the oral hygiene, processes to enhance the oppurtunities aspects of the host response and

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 115 upregulating protective or regenerative therapy, often referred to as a "rebound and subsequent hydrolysis to form PGE2. responses. It includes systemically or effect"[43]. Long-term use of NSAIDs as Nutrients, which include major locally delivered pharmaceuticals that an adjunctive treatment for periodontitis extracellular antioxidants, like vitamin are prescribed as adjuncts to other forms has never really developed beyond C, vitamin E, carotenoids, reduced of periodontal treatment[5]. research studies. glutathione can also act as modulators of inflammation by scavenging free radicals A. Systemically administered host ii. Omega-3 Fatty Acids as they are formed, sequestering modulating agents: Omega-3 fatty acids such as dietary fish transition metal ions and catalyzing I) Modulation of arachidonic acid (AA oil has beendemonstrated to protect mice formation of other molecules[13] . )metabolites against infection with numerous extra Over decades, Arachidonic Acid cellular bacterial pathogens that regulate I I ) M o d u l a t i o n o f M a t r i x metabolites have been established as t h e s e r u m t r i g l y c e r i d e s a n d Metalloproteinases(MMPs) mediators of tissue destruction in various cholesterollevels, inhibit synthesis of MMPs endopeptidases which are inflammatory diseases including lipid mediators of inflammation(PGE2, secreted by a variety of host cells, play rheumatoid arthritis and periodontal arachidonic acid, cyclo-oxygenase, 5- key roles in the degradation of the diseases[6]. Free Arachidonic acid is lipoxygenase), alter cellular functions of extracellular matrix, basement m e t a b o l i z e d v i a e i t h e r t h e polymorphonuclear leukocytes, membrane and modify the action of cyclooxygenase (COX) or the modulate lymphocyte proliferation and cytokines as well as activation of Lipooxygenase (LO) pathways. cytokine production, and increase osteoclasts[14]. During active Arachidonic acid is enzymatically endogenous host anti-oxidant capacity, periodontal diseases, microbial attack oxidized by either cyclooxygenase for e.g., SOD and catalase [7]. leads to excessive production as well as u n s t a b l e c y c l o e n d o p e r o x i d e activity of these MMPs which, if not intermediated (PGG2 and PGH2) leading iii. Lipoxins (endogenous modulators adequately controlled by the endogenous to prostanoid synthesis (prostaglandins, of inflammation) metalloproteinases inhibitors, results in prostacyclin and thromboxane) or by the Lipoxins and aspirin-triggered lipoxin enormous tissue destruction. To impede action of lipooxygenase to form the (AXL) are bioactive lipid mediators this destruction of host tissues synthetic Leukotrienes (LTs ) and other involved in the Arachidonic Acid cascade inhibitors of Matrix metalloproteinase as monohydroxy-eicosatetraenoic acids[3]. and are formed by the interaction of 5- host modulating agents have been and 15- Los[8]. Like most lipid developed which generally contain a i. Modulation of Arachidonic acid mediators, lipoxins are rapidly chelating group, inhibiting MMPs by metabolites with NSAIDS synthesized, act within a local binding to the catalytic zinc atom at its The majority of NSAIDs are weak environment and are rapidly degraded active site. organic acids that selectively (COX-2) enzymatically. The lipoxins (LX) , were and non-selectively (COX-1) inhibit the the first to be identified and recognized as i.Tetracycline analogues as host synthesis of arachidonic acid endogenous anti-inflammatory lipid modulating agents metabolites, thereby blocking the mediators of resolution that function as The ability of tetracyclines and p r o d u c t i o n o f p r o s t a g l a n d i n s , “braking signals” for neutrophils in doxycycline, in particular, to inhibit thromboxane and prostacyclin[3]. inflammation[9]. Thus, it is of particular MMP activity was first identified in the • NSAIDs inhibit prostaglandins and interest that aspirin ,a widely used early 1980s[3]. In addition to its therefore reduce tissue inflammation. NSAID with many beneficial properties antimicrobial activity, this group of • These are used to treat pain, acute in addition to its well-appreciated action compounds has the capability of inflammation, and a variety of to inhibit prostaglandins also triggers the inhibiting the activities of neutrophils, chronic inflammatory conditions. endogenous generation of 15- epimeric osteoclasts, and matrix metalloproteinase NSAIDs include salicylates (e.g., LX via acetylation of cyclooxygenase 2 (specifically matrix metalloproteinase- aspirin), indomethacin and propionic (COX-2) that have both anti- 8), thereby working as an ‘anti- acid derivatives (e.g., ibuprofen, inflammatory and antiproliferative inflammatory’ agent that inhibits bone flurbiprofen, naproxen). Studies have properties at sites of inflammation in destruction[15].Tetracyclines are shown that systemic NSAIDs such as vivo[10],[11],[12]. considered to be bacteriostatic agents but indomethacin, flurbiprofen and naproxen may have a bactericidal effect in high admin¬istered daily for up to 3 years iv. Steroids concentrations[16]. Tetracyclines have significantly slowed the rate of alveolar Steroids inhibit PLA2 (phospholipase2) non antimicrobial properties that appear bone loss compared with placebo. But by stimulating the production of to modulate host response. The disadvantages have been associated with annexins/lipocortins. They stabilize the mechanism by which tetracyclines affect long term use of NSAIDS. These include; lysosomal membranes and suppress the and, possibly, diminish bone resorption Gastrointestinal problems, Hemorrhage cellular degranulation. Steroids like are: (from decreased platelet aggregation), dexamethasone cause degradation of pre- • Direct inhibition of the activity of Renal and hepatic impairment. Research existing mRNAs for IL-1b, TNF-a extracellular collagenase and other shows that the periodontal benefits of thereby dampening PGE release[48]. matrix metalloproteinases such as taking long term NSAIDs are lost when gelatinase; patients stop taking the drugs, with a v. Antioxidants • Prevention of the activation of its return to, or even an acceleration of the They serve to prevent oxidation of proenzyme by scavenging reactive rate of bone loss seen before NSAID arachidonic acid by molecular oxygen oxygen species generated by other

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 116 cell types (e.g. neutrophils, from human gingival fibroblasts, and TNF in inflamed gingiva and high osteoclasts); significantly decreased the activity of levels in the GCF of periodontitis • Inhibition of the secretion of other matrix metalloproteinase at higher patients, several studies have suggested c o l l a g e n o l y t i c e n z y m e s ( i . e . doses[21]. A novel synthetic retinoid, that increased production of these lysosomal cathepsins); seletinoid G, designed by using computer cytokines may play an important role in • Direct effect on other aspects of aided molecular modeling, has potential periodontal tissue destruction[22]. To osteoclast structure and function. anti matrix metalloproteinase activity. A counteract tissue destruction and novel sulfonamide derivative, S- 3304, maintain homeostasis, cytokine Chemically Modified Tetracyclines was discovered to be a potent matrix antagonists such as IL-1 receptor (CMTS) metalloproteinase inhibitor. This antagonist (IL-1Ra) or soluble TNF Golub and McNamara et al. synthesized a derivative is a more specific inhibitor of receptors can competitively inhibit chemically modified tetracycline (CMT) matrix metalloproteinase - 2 and matrix receptor-mediated signal transduction. by removing the dimethylamino group metalloproteinase – 9[21]. To prevent an uncontrolled inflammatory from the carbon-4 position of the “A” response with rapid tissue destruction, r i n g , r e s u l t i n g i n t h e 4 - III) Modulation of Bone Remodelling the activities of IL- 1 and TNF – α are dedimethylaminotetracycline, i.e. CMT, i.Bisphosphonates naturally counteracted by the production w h i c h e l i m i n a t e d t h e d r u g ’s Bisphosphonates are ‘bone sparing’ of cytokines such as IL-4, IL-10 and IL- antimicrobial efficacy but did not reduce agents used in the management of various 11[22]. the ability of the drug to block the activity diseases associated with bone resorption. of collagenases[17],[18]. Certain These compounds inhibit osteoclastic V) Tumor necrosis factor blocking chemically modified tetracyclines have activity by blocking acidification by local agents advantages over commercially available release and represent a class of chemical Tu m o r n e c r o s i s f a c t o r - α , a n tetracyclines because, structures related to pyrophosphate. inflammatory cytokine that is released by • They are absorbed more rapidly, Pyrophosphate regulates mineralization activated monocytes, macrophages and T • Can reach higher levels in the blood , by binding to hydroxyapatite crystals in lymphocytes , promotes inflammatory • Have longer serum half lives, vitro but it is not stable in vivo, responses that are important in the • More potent inhibitors of matrix undergoing rapid hydrolysis of its labile pathogenesis of rheumatoid arthiritis and metalloproteinases [2]. P – O – P b o n d a s a r e s u l t o f periodontal diseases[23]. Tumor necrosis p y r o p h o s p h a t a s e a c t i v i t y. T h e factor – α binds to two receptors that are Their long-term systemic administration replacement of the linking oxygen atom expressed by a variety of cells :Type I does not result in gastrointestinal with a carbon atom (e.g. P–C–P) results tumor necrosis factor receptor (p 55); toxicity, Higher plasma concentrations in the formation of a bisphosphonate andType 2 tumor necrosis factor receptor can be reached for prolonged time period molecule. This compound is chemically (p75). Activation of tumor necrosis àless frequent administration regimens. stable and completely resistant to factor-R1 upregulates the inflammatory e n z y m a t i c h y d r o l y s i s v i a response, while tumor necrosis factor-R2 Subantimicrobial Dose Doxycycline p y r o p h o s p h a t a s e a n d a l k a l i n e appears to dampen the response[21]. Though numerous MMP inhibitors have phosphatase. Patients with periodontal disease have been investigated, only tetracycline Given their affinity to bind to high concentrations of tumor necrosis based host modulating agent, i.e. SDD – hydroxyapatite crystals and prevent their factor in the gingival crevice fluid . subantimicrobial dose of doxycycline growth and dissolution and to their ability Studies have shown a very strong (Doxycycline hyclate 20 mg; Periostat, to increase osteoblast differentiation and association of active bone resorption CollaGenex, Pharmaceuticals Newton inhibit osteoclast recruitment and coincident with high local levels of tumor PA) has been approved by Food and drug activity, bisphosphonates are widely used necrosis factor at the diseased sites. administration (FDA) to be used as an in the management of systemic metabolic Interleukin-1, interleukin-6 and tumor adjunct to periodontal treatment[19]. A bone disorders such as tumour-induced necrosis factor have all been found to be typical prescription for Periostat (20 mg hypercalcemia, osteoporosis and Paget's significantly elevated in diseased doxycycline tablets) is for at least 3 disease . The ability of bisphosphonates periodontal sites compared with healthy months (180 tablets, 1 tablet twice a day to modulate osteoclast activity clearly or inactive sites . until complete), and refills may be may be useful in the treatment of provided for longer courses of periodontitis.Bisphosphonates appear to VI) Modulation of nitric oxide therapy[20]. Doxycycline has the ability inhibit Matrix metalloproteinase activity synthase (NOS) activity t o d o w n r e g u l a t e m a t r i x through a mechanism that involves the Nitric oxide is a free radical with metalloproteinases (MMPs), a family of chelation of cations. important physiological functions of zinc-dependant enzymes that are capable maintaining homeostasis. While of degrading extracellular matrix IV) Modulation of Host Cell Receptors homeostasis requires low nitric oxide molecules, including collagen. Cytokines are defined as regulatory tissue levels, proR09;inflammatory proteins controlling the survival, growth, stimuli such as endotoxins leads to ii. Antiproteinases (Tranilast, differentiation and functions of cells. increased expression of the inducible Seletinoid G, S-3304) Cytokines are produced transiently at nitric oxide synthase enzyme (iNOS) that The effect of tranilast, which suppresses generally low concentrations, act and are produces a large amount of nitric oxide collagen synthesis and cell proliferation, degraded in a local environment. Based (NO) and peroxynitrite, which acts on matrix metalloproteinase-1 secretion upon the increased expression of IL-1 beneficially for the host as a cytotoxic

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 117 molecule against the invading clinical use in certain oral surgery response, thereby acting as a modulator microorganism, yet, it may also cause procedures, including localized alveolar of inflammation and immunity by deleterious effects to host such as DNA ridge augmentation, under the name inhibiting neutrophil chemotaxis and damage, lipid peroxidation, protein INFUSE® Bone Graft (Medtronic, superoxide production, increasing cyclic damage, and stimulation of inflammatory Minneapolis, MN, USA)and Induct adenosine monophosphate (cAMP) cytokine release[24],[25],[26]. Lohinai OS™ (Wyeth, Maidenhead, UK). These l e v e l s a n d d o w n r e g u l a t i n g et al.[27] demonstrated the protective ACS releasethe protein over time in the cytokines.Hasturk et al. (2006) provided effects of mercaptoethylguanidine location where it is implanted and morphological and histological evidence (MEG), which is a selective inhibitor of provides a scaffold on which new bone to prove that topically active cimetidine iNOS, against bone destruction in can grow. As the graft site heals, the ACS is a potent inhibitor of P. gingivalis ligature induced periodontitis in the rat. is absorbed and replaced by bone[35]. ;elicited periodontal inflammation and Leitao et al. (2005) also proved that NOS can arrest and/or prevent tissue inhibitors prevent alveolar bone iv.Platelet derived destruction and influence cell r e s o r p t i o n i n e x p e r i m e n t a l FDA has approved GrowthR09;factor populations present in the inflammatory periodontitis[28]. Enhanced Matrix, GEM 21S® cell infiltrate[50]. (Osteohealth, Shirley, NY) which is a B. Local agents combination of a bioactive highly vii. Bisphosphonates I. purified recombinant human PDGFR- Role and action of BPs have already A compound which has received interest BB with an osteoconductive bone being discussed above. Due to serious as both an antibacterial and anti- matrix[35]. Platelet derivedgrowth factor side effects of systemically administered inflammatory agent is triclosan. (PDGF), as a host modulating agent BPs leading to osteonecrosis of the jaws Triclosan (2, 4, 41-trichloro-2-hydroxy- canincrease chemotaxis of neutrophils (ONJ) additional studies using topically diphenyl ether) is a non-ionic and monocytes, stimulate fibroblasts administered bisphosphonates have been antimicrobial agent. Tri¬closan also proliferation and extracellular matrix carried out which have reported a inhibits CO and LO and thus may synthesis, increase proliferation and significant increase in the postoperative interfere with the production of AA differentiation of endothelial cells, percentage of bone defect fill, prevention metabolites[49]. stimulate proliferation of mesenchymal of bone resorption as well as the boosting progenitor cells and differentiation of effect of locally delivered BPs on the ii. Enamel matrix proteins fibroblasts. Nevins et al. demonstrated osteoconductive and regenerative It is believed that during development of that the purified rhPDGFR-BB mixed potential of bone grafts used in root and attachment apparatus, there is a with bone allograft results in robust periodontal therapy[39],[40],[41]. secretory phase in which Hertwig’s periodontal regeneration in both Class II epithelial root sheaths secretes enamel furcations and interproximal intrabony viii. NSAIDS related matrix proteins[29]. Enamel defects[36]. Role of NSAIDs as a host modulating matrix derivative is now commercially agent has also been discussed above. available forthe treatment of periodontal v.Hypochlorous Acid and Taurine N Since NSAIDs are lipophilic and are well defects as Emdogain® (Biora AB, Monochloramine absorbed into gingival tissues, its topical Malmo, Sweden) which has received It has been reported that hypochlorous application is possible. NSAIDs that FDA approval[30].The basic rationale a c i d ( H O C l ) a n d t a u r i n e - N - have been evaluated for topical behind using Emdogain is that it will act monochloramine (TauCl) which are the administration include ketorolac as a tissue healing modulator that would end products of the neutrophilic tromethamine rinse and S-ketoprofen mimic the events thatoccur during root respiratory burst, modulate the host dentifrice[42], piroxicam[43] and development and help stimulate inflammatory response by inhibiting the meclofenamic acid[44] in inhibiting periodontal regeneration[30],[31],[32]. p r o d u c t i o n o f i n t e r l e u k i n - 6 , gingivitis and progression of Enamel matrix proteins (EMD) initiates p r o s t a g l a n d i n s , a n d o t h e r periodontitis. periodontal regeneration through proinflammatory substances. Thus, recruitment of cementoblasts to the root HOCl and TauCl, playing a crucial role in C. Other host modulatory agents surface and stimulates these to form root the periodontal inflammatory process i.Probiotics cementum, which will thereafter offer opportunities for the development Probiotics have demonstrated significant secondarily lead to regeneration of of novel host modulating therapies for the potential as therapeutic options for a periodontal fibers and alveolar treatment of periodontitis[37]. Lorenz et variety of disease as they have been bone[33].The above mentioned actions al.assessed the influence of 2 and 3% N- known to modulate cytokine secretion of EMD justify its role as a host chlorotaurine mouth rinse on dental profiles, influence TR09;lymphocyte modulating agent. plaque and demonstrated that rinsing populations, protect against physiologic with 10 mL of the test solution two times stress, and enhance intestinal epithelial iii. Bone morphogenetic proteins daily for 4 days reduced the plaque cell function and antibody secretion[45]. Bone morphogenetic protein (BMP) vitality[38]. Teughels et al. explored the use of guides modulationand differentiation of probiotics in influencing the periodontal mesenchymal cells into bone andbone vi. Cimetidine microbiota and periodontal health and marrow cells[34]. Absorbable collagen Cimetidine is a powerful H2 (Histamine) concluded that probiotics might offer sponge (ACS)containing recombinant receptor antagonist, and hence eliminates opportunities to manipulate the oral human BMP-2 has been approved for histamine’s inhibitory effects on immune microbiota, and periodontal health by

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©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 120 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Digitization In Prosthodontics - A 1 Pankaj Dhawan 2 Garima Mahajan Contemporary Revolution 1 Professor Head of Department 2 PG Student (Final Year) Abstract Department of Prosthodontics There is endless scope of digitization and technology in prosthodontics. Be it for clinical chairside Manav Rachna Dental College use, that includes diagnostic or treatment procedures or for laboratory purposes that involve Address For Correspondence: prosthesis designing and fabrication, digitization has not only modified, but in some cases, even Dr. Pankaj Dhawan, Head of Department replaced the conventional prosthodontic therapies. The purpose of this article is to outline the Department of Prosthodontics relevant technologies that are directly or indirectly involved with prosthesis designing, fabrication Manav Rachna Dental College Sector 43 Delhi- Surajkund Road and delivery. Aravalli Hills Faridabad- 121001 Haryana, India.

Key Words th Digitization, Prosthodontics, Technology, Recent Advances Submission : 18 June 2014 Accepted : 27th January 2015 Introduction requires staff training, infrastructure and The history of dentistry is almost as clinical software. Customized clinical Quick Response Code ancient as the history of humanity and software can improve communication civilization itself, with the earliest within the office team, increase patient evidence dating from 7000BC.[1] It is acceptance of treatment plans, make staff thought that dental surgery was the first more productive, allow access to patient specialization from medicine.[2] Hence, records from anywhere and enable better dentistry, as a clinical profession, has and faster delivery of care. All of this is come a long way, from carved blocks of possible with today’s technological ivory and bone used as substitutes to advances in clinical software and a secure 3Ddigital diagnostic imaging, implant replace missing teeth during the 18th computer hardware infrastructure.[7] planning software and computer century[3] to the digitally fabricated The role of digital technology in generatedsurgical guides empower CAD/CAM zirconia crowns used as prosthodontic laboratory procedures was prosthodontists to establish themselves fixed prostheses in present times. With revolutionized by the introduction of as effectiveleaders providing optimal the passing years, the endless growth in technologies such as the dental treatment solutions for both simple and research has increased the treatment CAD/CAM in the 1980’s.[8] Since then complexrestorative protocols.[7] The options, and upgraded the materials as the technology has evolved in two first and most important step before well as the equipment used in dental d i r e c t i o n s - t h e c h a i r s i d e o r beginning any kind of treatment procedures, especially in the field of intraoperatory application for the procedure is patient education and prosthodontics. The contemporary dental fabrication of single appointment motivation. In order to make the patient practice provides the patient with endless restorations[9] and the CAD/CAM understand his/her poor oral health treatment options that include newer, systems for dental laboratories.[10],[11] condition better and evaluate the various faster and more advanced therapies. Hence the scope of digital technology in treatment options present, the clinician These latest materials and digitized prosthodontics will be discussed under can take the help of intraoral cameras, techniques not only enhance the quality two broad categories: the Clinical aspect education softwares, videos, 2D and 3D of treatment but also reduce the overall and the Laboratory procedures. images of dental procedures.[13] treatment time.[4],[5] Hence, the Softwares like XCPT (Trade name transition from old to new occurs with the Role Of Digitization In Patient SYNAPSHOT), Dentrix and Bite FX sole aim of making both, the patient’s and Motivation And Practice Management (Registered trade names) can be used for the dentist’s life simpler. Today a practicing dentist needs to be a better understanding of treatment plans abreast with the latest developments in portrayed in a visually convincing way. Prosthodontic Aspects Of Digitization technology to be able to sustain himself Such softwares digitize analogue The impact of digitization has been so in the cut throat competitive field of radiographs or capture any digital significant and large, that it has managed prosthetic dentistry.The continued radiograph (panaromic, periapical, CT to influence all the aspects of the field of improvement of computer based clinical scan) and give the dentist the ability to prosthodontics. Digital Technology has hardware and softwareapplications has explain the image and to place a variety of immense influence over the clinical enabled the computerR08;based objects such as implants, crowns, aspect, the laboratory procedures, prosthodontic practice model.Today abutments and bone grafts to depict to the training of students, patient motivation, prosthodontic graduates are using patient the exact treatment that he is practice management and dental electronic records to maintain patient suggesting.[14] Hence the patient not research.[6] The digital dental practice details.[12] Newer capabilities like only grasps the idea which is being

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 121 with an increase in computerization of practices has made digital imaging a superior alternative, in many respects to conventional film imaging.[18] The prosthodontic application of digital dental imaging is observed in the use of a cone beam CT scan, which not only offers reduced exposure to radiation, as compared to a conventional CT scan, it is also enhances the study of the functioning, pathophysiology and disorders of the temporomandibular joint.[19] A number of new, enhanced Fig 2 (d) : The reformatted computed tomographic images Fig 1 (a) : The Dentrix© software system useful for storing and upgraded options are available for for implant treatment planning (Source: Internet) patient information, photographs and radiographs. (Source: Internet) TMJ imaging. These include CT with positron emission tomography.[20] cone beam technology, MRI and nuclear These latest diagnostic imaging imaging including single photon techniques increase the understanding of emission computed tomography and the TMJ thus leading to better treatment options. Diagnostic imaging is also a very essential component of implant treatment planning. It is required for the evaluation of the quality, quantity and density of bone as well as for the assessment of potential sites for implant placement.[21] Although Digital Fig 1 (b) : The Bite X© software system (Source: Internet) Panoramic imaging is the most popular and the most commonly used technique, presented, he/she can visualize the newer cross sectional imaging treatment in a 3 dimensional manner techniques such as spiral tomography and which helps motivate the patient better reformatted computerized tomograms and saves a lot of time, effort and are also gaining popularity in the miscommunication.[15] [Fig 1a,b].The preoperative assessment and treatment computerized data base technology has Fig 2 (a) : A cone beam CT scan being done for TMJ analysis (Source: Internet) planning of implants.[22] [Fig 2 a, b,c,d] made the storage of patient information, Dental photographyhas been one of the including radiographs and photographs oldest diagnostic aids used in dentistry. so much easier and reliable for follow up Apart from being easy to store, regular appointments and less space consuming photographic records taken of a patient as even the plaster casts can now be hold so much importance as they can be converted into 3D virtual models.[6] viewed from any angulation and can be Hence, the role of digitization in practice used to judge the changes taking place in management has become very essential tooth form, colour and size along with the for a successful clinical practice. facial changes over time.[23] With the level of awareness and the demand of Role Of Digitization In Diagnosis And Fig 2 (b) : The final images for the cone beam CT done for TMJ analysis (Source: Internet) cosmetic dentistry, increasing day by day Treatment Planning among patients, the introduction of the A correct diagnosis is the most important digital single lens reflex cameras, step for a successful treatment and is also popularly known as the DSLR digital considered the hallmark of a good cameras, has made digital dental clinician. Dental X rays are one of the photography an invaluable aid in most essential diagnostic tools used in procedures such as smile analysis of the clinical practice.[16] Digital radiography patients. Use of digital photographs has presents some obvious advantages over also been explored in the field of the traditional dark room radiography. maxillofacial prostheses to digitally These include enhanced image quality, replicate and fabricate custom made immediate viewing of the images, which prostheses for maxillofacial defects is highly desirable for patient education involving the eye, ear and nose.[24] and for post operative viewing, lesser Digital technology has also proven to be processing errors, lesser radiation an excellent aid in the diagnosis of exposure due to fewer retakes and better occlusal errors. It is difficult to analyse storage of the radiographic data.[17] The and assess problems of occlusion as the development of cost effective intra and human occlusal system is highly extra oral digital technology coupled Fig 2 (c) : A computed tomography machine (Source: Internet) complex. However, digital occlusal

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 122 Fig 3 : Digital Evaluation done by a T Scan© Occlusal Recording Device (Source: Internet) recording devices such as T-Scan III and Fig 4 (a) : The conventional Vita shade guide© (Source: Metscan, have been used to evaluate the Internet) distribution of time and force in occlusal balance and can be useful as a diagnostic screening method for occlusal stability in Fig 5 :The CEREC© device which can be used for in office intercuspal position.[25] These devices design and milling (Source: Internet) can examine even the slightest of occlusal interferences which proves to be Charlotte, NC), E4D Dentist (D4D very significant in full mouth Technologies, Richardson, TX), iTero rehabilitation cases and implant (Cadent, Carlstadt, NJ), Lava COS (3M ESPE, St Paul, MN), and 3Shape TRIOS protected occlusion.[26], [27][Fig 3] Fig 4 (b) : The Digital Vita Easy shade guide© and its clinical Spectrophotometers and colorimeter use for matching tooth shade (Source: Internet) (3Shape, Copenhagen, Denmark). The shave been developed to aid the clinician CEREC and E4D devices can be restorations. With the CAD/ CAM i n t a k i n g a c o r r e c t s h a d e . A combined with in-office design and systems, restorations can be produced spectrophotometer is employed to milling, whereas the iTero and Lava COS quicker, which eliminates the need for measure the amount of light that a sample devices are reserved for image temporary restorations. Moreover, with absorbs. The instrument operates by acquisition only. In-office milling allows CAD/CAM, it is possible to make passing a beam of light through a sample same-day restorations.[33] [Fig 5] prostheses with consistent quality.[30] and measuring the intensity of light CAD/CAM technology is prevalent There are 3 main sequences to reaching a detector. Spectrophotometers within Implant prosthodontics too, CAD/CAD systems. The first sequence is can also measure luminescence. For encompassing the design and fabrication to capture or record the intraoral example, the machine can shine of surgical guides,[34] design fabrication condition to the computer. This sequence ultraviolet light of one frequency on the of custom abutments and frameworks, involves the use of a scanner or intraoral sample. This will excite the sample and and even surgical guidance during camera. Once the data have been make it glow. The detectors can then implant placement.[35] CAD/CAM recorded to the computer, a software measure the light glowing from the production involves three consecutive program (CAD) is used to complete the sample at a different frequency. steps: scanning, CAD modeling, and custom design of the final desired Comparing the Vita Easy shade to CAM production. The scanner is the data restoration, which may involve a full conventional visual means of shade acquisition system that records the 3D contour design of the restoration or just selection, it has been noted that the geometry of the infrastructure and the internal coping or substructure of the spectrophotometer method resulted in a converts the actual dental model into final restoration. The final sequence five times more likely match to the virtual dental model. The CAD requires a milling device to fabricate the original shade color.[28] Crowns component virtually designs the 3D restoration from the design data in the f a b r i c a t e d u s i n g d e d i c a t e d contour of the final implant component. CAD program.[31] The development of spectrophotometric techniques have The CAM system produces the actual CAD/CAM is based around the data been shown to have a significantly better implant component according to the acquisition, data processing, and digital color match and decreased rate of virtual design. In implant dentistry, the fabrication processes. The oral rejection as a result of color discrepancy implant abutments and frameworks are information for the patient can be directly compared with crowns produced using produced by milling at a central extracted from a patient’s mouth or c o n v e n t i o n a l s h a d e s e l e c t i o n production facility. Examples of these indirectly by means of a stone model methodologies.[29] [Fig 4 a ,b] systems are Procera (Nobel Biocare), generated through making an impression. Etkon (Straumann), CAMStructure The acquisition systems are divided into Role Of Digitization In Chairside And (Biomet 3i), and Atlantis (Astra 2 basic categories: contact and Laboratory Based Procedures Tech).[36] noncontact digitizers. The digital data Over the past 25 years, computer-aided acquired through various techniques and design (CAD) and computer-aided Custom CAD/CAM abutments combine instruments are converted into a standard manufacturing (CAM) have become most of the advantages of stock and cast format so that the data can be processed increasingly popular parts of dentistry. custom abutments. In addition to a using the capabilities of a CAD/CAM Dental CAD/ CAM technology has been predictable fit and durability, all the system.[32] This process is exemplified used to replace the laborious and time- prosthesis parameters are modifiable by the recent introduction of intraoral consuming conventional lost-wax including the emergence profile, scanners, a number of which are now on technique for efficient fabrication of thickness, finish line location, and the market: CEREC AC (Sirona, external contour. This is performed by

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 123 copying resin or wax pattern list of new techniques and materials 66:634R08;42. manufactured by a dental technician or needs to be known and understood well 13. Feuerstein P.Can technology help by computer software modelling. as they will have a deep impact on one’s dentists deliver better patient care? J Initially, CAD/CAM was used to contemporary practice as well as on A m D e n t A s s o c 2 0 0 4 ; fabricate implant components from futuristic outcomes. 135(Suppl):11S–16S titanium and titanium alloy. To date, 14. Levine LN. XCPT® (Accept) CAD/CAM is the only way of producing References software: the future of case-analysis implant components from high-strength 1. Coppa, A. et al. Early Neolithic and patient acceptance of treatment ceramics such as densely sintered tradition of dentistry. Nature 2006 planning. Dent implantol update alumina and partially stabilized ;440. 2006; 17(4):25–29 zirconia.[36] In relation to implant 2. Suddick, RP; Harris NO . "Historical 15. Wong NK, Kassim AA, Foong KW. prosthodontics, the use of CAD/CAM perspectives of oral biology: a Analysis of esthetic smiles by using has three merits: accuracy (or precision series". Critical reviews in oral computer vision techniques. Am J of fit), durability, and simplicity of biology and medicine : an official Orthod Dentofacial Orthop 2005; construction. publication of the American 128(3):404–411 Rapid Prototypingis a process of additive Association of Oral Biologists 1990; 16. Brennan J. An introduction to digital manufacturing which is ideally suited to 1 (2): 135–51 radiography in dentistry. J orthod dentistry.[37] Models are designed using 3. André Besombes, Phillipe de 2002; 29(1):66–69 data from a computed tomography scan Gaillande. Pierre Fauchard (1678- 17. Child PJ, Christensen GJ. Digital or magnetic resonance imaging. The 1761): The First Dental Surgeon, His radiography: an Improvement. Dent image is downloaded to a CAD machine Work, His Actuality;1993 Today 2010; 29(8):100–102 and converted to an STL file.[38] Rapid 4. Gutmann JL. The evolution of 18. Miles DA. The future of dental and prototyping technologies such as America’s scientific advancements in maxillofacial imaging. Den Clin N Stereolithography (SLA), which builds dentistry in the past 150 years. J Am Am 2008 52(4):917–928 models by laser fusing a photopolymer Dent Assoc 2009;140(Suppl 19. Lewis E, Dowlick MF, Abramowicz layer by layer, is now routinely used to 1):8S–15S S, Reeder SL. Contemporary imaging produce surgical guides for the 5. Gratton D. Digital Technology in of temporomandibular joint. Dent placement of dental implants. Its use is Prosthodontics – Historicaland Clin N Am 2008; 52(4):875–890 gradually being extended to include the Future Perspectives. Perpectives in 20. Guttenberg S. Oral and maxillofacial manufacture of temporary crowns and Prosthodontics 2010: 81-88 pathology in three dimensions. Dent bridges and resin models for lost wax 6. Bhambhani R, Bhattacharya J, Sen Clin North Am 2008; 52(4):843–873 casting.[39] [Fig 6] KS. Digitization and its futuristic 21. Sukumaran A, Al-Ghamdi HS. A approach in Prosthodontics. J Indian m e t h o d o f g a u g i n g d e n t a l Conclusion Prosthodont Soc 2013;13(3): 165- radiographs during treatment The world of digital technology is ever 174 planning for dental implants. J changing and in order to be a successful 7. Guichet D. Computer based C o n t e m p D e n t P r a c t practising dentist it is very important to technology in the prosthodontic 2007;8(6):82–88 be updated about the latest developments p r a c t i c e . P e r p e c t i v e s i n 22. Elian N, Ehrlich B, Jalbout ZN, Classi in this field of digitalization. The endless Prosthodontics 2010: 72-81 AJ, Cho SC, Kamer AR et al. 8. Kelly JR, Benetti P. Ceramic Advanced concepts in implant materials in dentistry: historical dentistry: creating the aesthetic site evolution and current practice. Aust foundation. Dent Clin N Am 2007; Dent J 2011;56(Suppl 1):84–96 51:547–563 9. Birnbaum NS, Aaronson HB. Dental 23. Wagner IV, Carlsson GE, Ekstrand K, impressions using 3D digital Odman P, Schneider N. A web based scanners: virtual becomes reality. comparative study of assessment of Compend Contin Educ Dent dental appearance by dentists, dental 2008;29(8):494–505 technicians and laymen using 10. Miyazaki T, Hotta Y.CAD/CAM computer-aided image manipulation. systems available for the fabrication J Esthet dent 1996; 8(5):199–205 of crown and bridge restorations. 24. Artopoulou II, Montgomery PC, Aust Dent J 2011;56(Suppl Wesley PJ, Lemon JC. Digital 1):97–106 imaging in the fabrication of ocular 11. Rekow ED, Silva N, Coelho PG, prostheses. J Prosthet Dent 2006; Zhang Y, Guess P, Thompson VP 95(4):327–330 .Performance of dental ceramics: 25. Mizui M, Nabeshima F, Tosa J, challenges for improvements. J Dent Tanaka M, Kawazoe T. Quantitative Res 2011 90(8):937–952 analysis of occlusalbalance in 12. Atkinson JC, Zeller GG, Shah C. intercuspal position using the Electronic patient records for dental TR08;Scan system. Int J Prosthodont school clinics: more thanpaperless 1994;7:62R08;71. Fig 6 : Stereolithographic model of the lower jaw (Source: systems. J Dent Educ 2002; 26. Szentpétery A. Computer aided Internet)

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 124 dynamic correction of digitized technology to enhance restorative M a x i l l o f a c occlusal surfaces. J Gnathol 1997; dentistry.Compend Contin Educ Dent Implants2007;22:785R08;790. 16:53–60 2012; 33(9):666–77. 36. Abduo J, Lyous K. Rationale for the 27. Lund J. Occlusion: the “Science- 32. Miyazaki T, Hotta Y, Kunii J, et al. A use of CAD/CAM technology in Based” approach. J Can Dent Assoc review of dental CAD/CAM: current implant Prosthodontics. Int J of Dent 2001; 67:84 statusand future perspectives from 20 2013; article id:76812 28. Judeh A, AlR08;Wahadni A. A years of experience. Dent Mater J 37. Azari A, Nikzad S. The evolution of comparison between conventional 2009;28(1):44–56. rapid prototyping in dentistry: a v i s u a l a n d 33. Davidowitz D, Kotick P. The use of review.Rapid Prototyping J 2009; spectrophotometricmethods for CAD/CAM in dentistry. Dent Clin 15(3):216–25. shade selection. Quintessence Int North Am2011; 55:559–70. 38. Van Noort R. The future of dental 2009;40:69R08;79 34. M a r c h a c k C B . devices is digital. Dent Mater 29. Da Silva JD, Park SE, Weber HP, CAD/CAMR08;guided implant 2012;28:3–12. IshikawaR08;Nagai S. Clinical surgery and fabrication of an 39. Silva NR, Witek L, Coelho PG, et al. performance of a newlydeveloped immediately loadedprosthesis for a Additive CAD/CAM process for spectrophotometric system on tooth partially edentulous patient. J dental prostheses.J Prosthodont color reproduction. J Prosthet Dent Prosthet Dent 2007;97:389R08;394. 2011;20:93–6. 2008;99:361R08;368. 35. Wittwer G, Adeyemo WL, Schicho 30. Zandparsa R. Digital Imaging and K, Birkfellner W, Enislidis G. Fabrication. Dent Clin N Am Prospective randomizedclinical 2014;58:135-158 comparison of 2 dental implant 31. Fasbinder D. Using digital navigation systems. Int J Oral

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 125 Indian Journal of Dental Sciences. www.ijds.in June 2015 Issue:2, Vol.:7 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

Customized Radiation Prostheses – A 1 (Gp. Capt.) Satish Gupta 2 Shailesh Jain Preventive Approach For Head & Neck 3 Bhumika Sardana 4 Nishant Gaba Radiotherapy 1 Professor 2 Senior Lecturer Abstract 3 Pg Student The term head and neck cancer refers to a group of biologically similar cancers originating from 4 Pg Student the upper aero digestive tract , including the lip, oral cavity, nasal cavity, paranasal sinuses, Dept. of Prosthodontics pharynx and larynx.1Radiation therapy is used as a single modality in the curative treatment of Subharti Dental College early stage head and neck cancer or as a part of multimodality therapy in the curative treatment of Address For Correspondence: (Gp. Capt.) Satish Gupta locally advanced head and neck cancers.2A majority of patients have side effects that occur Professor during treatment and then over the first year dissipate to a point that they return to a normal Dept. of Prosthodontics existence. Some have certain effects that are permanent. These adverse tissue reactions are Subharti Dental College painful and also diminish the quality of life, oftendiscouraging the patient from taking treatment. Submission : 10th April 2014 Customized intraoral stents can help prevent the unnecessary irradiation of the surrounding Accepted : 23rd March 2015 normal tissues, thus reducing the severity of reactions. Since the use of these stents is individualized, close collaboration between the radiotherapist and the prosthodontist is Quick Response Code essential.1 Key Words Radiation devices, head and neck cancer, intraoral stents, radiotherapy Introduction result in needless morbidity[2]. In India, around 40% of the cancers Radiation therapy uses high energy detectedare oral cancers. In addition to photons (X-Rays)for treatment of this, there arepatients with cancer of the cancers. The photons are generated using nose,nasopharynx, paranasal sinuses and linear accelerators or radioactive 2 ) I n t e r n a l b e a m r a d i a t i o n theoropharynx, where treatment involves isotopes. These photons have the (Brachytherapy, Implant therapy, theoral cavity as well as the head and property of ionizing the atoms and Interstitial radiation, Intracavitary neck area[1]. Radiation therapy has been damages biologically important radiation) -Radiation sources are placed used with an increasing frequency in molecules like DNA within the irradiated within the tumor directly. The recent years in the management of the cell. This results in the cell losing its radioisotopes used in brachytherapy neoplasms of head and neck region.[2] capacity for indefinite proliferation (loss include Radium, Cesium, Iridium, Cobalt Radiation therapy is defined as o f c o l o n y f o r m i n g o r are used for this treatment. “thetherapeutic use of ionizing radiation clonogenicpotential).Radiation therapy in themanagement of neoplasms of the is usually given as small doses (fractions) 3)Modern radiotherapy - It uses bodywithout surgery, or as an over a period of 5 to 7 weeks.[3] computerized treatment planning and adjunctivepalliative treatment after sophisticated radiation treatment surgery, either incombination with or Methods Of Radiation Delivery machines for the delivery of high without chemotherapy”[1]. In some Patients are usually treated at 1.8 Gy to 2 precision radiation. The newer tumors it is the preferred treatment Gy per fraction. The treatments are technologies include – whereas in others it is employed in usually from Monday to Friday with no -3D Conformal Radiation (3DCRT) combination with surgery or sometimes treatments on Saturday and Sunday. The -Intensity Modulated Radiation Therapy with chemotherapy.[1] The therapist’s treatment course lasts from 4 to 7 weeks. (IMRT) intent in most patients is to cure but in This type of schedule is called -Image Guided Radiotherapy (IGRT) some instances radiation provides useful conventional fractionation schedule -Tomotherapy p a l l i a t i o n . T h e i n d i c a t i o n s o f 1) External beam radiation -Rapid Arc Therapy[3] radiotherapy includes squamous cell 2) Internal beam radiation carcinomas of soft palate, floor of mouth, 3) Modern radiotherapy Adverse Effects t o n g u e , l i p s a n d b u c c a l There is a wide range of effects that a mucosa; of salivary and 1 ) E x t e r n a l b e a m r a d i a t i o n patient may experience based upon the mucous glands; primary of (Teletherapy) -The photon beam is type of radiation, the treatment field (area nasopharynx and tonsils; carcinomas of delivered from distance (80 to 100 cm) of the body that is treated), location of maxilla, mandible, piriform sinus and from the patient. Linear accelerators and tumor, total dosage , proximity to critical subglottic area.Post radiation sequelae telecobalt machines are used for this organs , individual resilience , general are significant and well known and may technique. health and mental attitude. The adverse effects include radiation mucositis,

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 126 ulcers, fungal infections, xerostomia, caries from decreasedsalivary flow and pH changes,possibilities of infection in t h e j a w s o r t h e p o t e n t i a l f o r frominfection or trauma to irradiated bone. Damage to the normal tissues can bereduced by using biological methods such asan appropriate method of radio t h e r a p y a n d b y u s i n g t h e fractionationregime. Various physical methods are alsocommonly used to Tongue Depressing Stent reduce damage, whichinclude shielding Perioral Cone Positioning Stent placethe tip of the tongue between the and proper positioning.[1] anterior portionsof the superior and trauma site is required .The actual cone or inferior horseshoeshapedrims.[4] (Fig 2) Radiation Prosthesis cylinder of the same diameter as the Radiation prosthesis can be defined as conesis used to forman acrylic resin ring Advantages: any device artificially fabricated that aids of 5 to 6 cms long. Tinfoil is wrapped Earlier cork and tongue blades were used in the efficient administration of around the cone as a separator from for the depression of tongue but these radiotherapy to the affected areas and acrylic resin. In the presenceof a stents provide more accuracy and great thereby helps in limiting the post therapy radiotherapist,the cylinder is attached to patient comfort. Numerous minor morbidity.These devices shield the vital the maxillary record base (edentulous salivary glands & taste buds can be saved structures during treatment , positions the patient) or occlusal indices (dentulous from radiation injury. This reduces beam , carry the radioactive material to patients) and the cone is centered over the xerostomiaand hence improves the the tumor site and recontour the lesion. The treatment cone is inserted into patient’s quality of life.[1] According to a tissues.[1] the positioning stent for verification of study done by Bart Johnson in the year the position.It lowers the tongue & places 2013, a significant decrease in oral They can be classified into three it in repeatable & the exact position mucositis,xerostomia& taste dysfunction groups: during therapy.It separates the mandible was seen. 1) Positioning Stent and maxilla.[1] (Fig 1) a) Perioral cone positioning stent Shielding stent b) Tongue depressing stent b) Tongue depressing stent: They are used to shield the vital 2) Shielding Stent It is a custom made device which structures which are adjacent to radiation a) Tissue recontouring stent positionsthe mandible, depresses the therapy sites from excess dosage of b) Tissue bolus compensators tongue andspares the parotid gland radiation. Low melting alloy like wood’s 3) Radiation Carriers Incorporated With during radiotherapyof head and neck metal is used as a shielding material. It is Radioisotopes tumours[1]. Controlled depression of preferred because of its low melting a) Preloaded carriers tongue allows the radiation to better temperature and it effectively prevents b) Afterloaded carriers focus on the clinical tumor volume, the transmission of the electron beam. thereby reducing the dose delivered to the Materials used for the fabrication are- adjacent normal tissues. Initially the They are of 2 types- Heat cure acrylic resin, tin foil and clinician takes upper and lower a) Tissue recontouring stent wood’s metal (cerrobend alloy) alginateimpressions of the existing b) Tissue bolus compensators Wood’s metal is a eutectic fusible alloy of dentition or edentulousridges and then a 50% bismuth, 26.7% lead, 13.3% tin & bite registration is donewith the intent to a) Tissue recontouring stent: 10% cadmium by weight and has a place the inter-incisal distancebetween These stents are effective when treating melting point of 158°F.[1] 10 and 15 millimeters. The models are skin lesions which are associated with poured, trimmed and articulated on a lips when the beam is adjusted for Positioning stents standard hingearticulator.Thenhorse- midlines.Low doses are delivered at the These devices are used to displace the shoeshaped segments of the light cure corners of the mouth because of the positions of various structures to assist in acrylic material is placed overeach model curvature of the lips.A stent can be made the efficient administration of arch to engage the cusp tips andlight to flatten the lip and the corner of the radiotherapy.They are of 2 types- cures them. He or she then places mouth, thereby placing the entire lip in a) Peri- oral cone positioning stent twovertical struts between the posterior the same plane. These stents are b) Tongue depressing stent segmentsof the horse- shoe shaped fabricated by modeling plastic and are a) Peri- oral cone positioning stent: segments and lightcures them. A processed in acrylic resin. (Fig 3) triangular-shaped paddle with rounded These stents are indicated where corners is constructed for the patient's b) Tissue bolus compensators: treatment of superficial lesions involving comfort. The paddle is made concave on These prostheses help in the treatment of is required the tongueside by fabricating it against superficial lesions of the face with They position the cone in an exact theouter surface of a tablespoon. irregular contours.Due to irregularities in position when boosting the dose to the Instructions are given to the patient to the lesions, some areas within the field

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 127 location and the number of sources are These prosthetic devices are useful for determined by the radiotherapist and are adjusting the anatomic position of tissues marked on the dental model.They are and blocking sensitive tissues from the used to carry the radiation sources close direct radiation beam, and they may serve to the site of treatment (intracavitary) or as a “carrier” to contain actual d i r e c t l y i n t o t h e t u m o u r radiationsources.Brachytherapy, a (interstitial).They are of two types: technique used to deliver radiation over a a) Preloaded carriers short distance, uses radioisotopes b) After loaded carriers (Fig 5) positioned in or close to the tumor. Tissue Recontouring Stent Radiotherapy Mask Rapid Prototyping Radiotherapy has to be aimed very Radiation therapy for the treatment of precisely to make sure that exactly the head and neck skin cancer poses right area of the body is treated each time. challenges because of the inherently It is important that a person having uneven tissue topography of the face and radiotherapy lies still while the treatment the need to protect surrounding is in progress. This is because any unaffected tissues. The use of a movement could change the area that gets customized radiation shield that treated. To help with this, a radiotherapy combines tissue-equivalent bolus mask (sometimes called a mould, a head material with protective material Tissue Bolus Compensator shell or a cast) is made to be worn during addresses these issues. A technique the treatment. known as rapid prototyping is used to Once the mask is fitted, it is fixed to the design and fabricate an extra -oral radiotherapy treatment table. This radiation shield. This innovative ensures that head and neck are held in application provides an expedient, exactly the right position for the standardized approach for delivering treatment. Wearing a mask reduces the radiotherapy to the face, which is not only Radiation Carriers With Radiation Isotopes possibility of any movement while the more comfortable for the patient, but radiotherapy is given. The mask is only allows more precise treatment delivery. worn during the planning procedures and Rapid prototyping (RP) is a method by during the treatment itself, which usually which physical models are automatically takes about 10-15minutes at a time each constructed from computerized 3- day.One technique uses wet plaster dimensional (3D) data.It operates on the bandages and the finished mask is made principle of depositing material in of perspex. The other technique uses a layersor slices to build a model (additive type of mesh plastic, which is moulded to technique), rather than milling a model Radiotherapy Mask fit the shape of the face. (Fig 6) from a solid block (subtractive may be untreated, while others may technique). develop isolated hotspots. BOLUS is a Advancements in prosthetic carriers The primary advantage of this process is tissue equivalent material which is placed Early methods of fabricating customized that the model created directly retains all directly onto or into the irregularities, that radiation carriers for inaccessible areas, the detail of the internal geometry rather helps in converting irregular tissue such as the nasopharyngeal space, than just the outer surface contours. contours into flat surfaces which are normally required the patient to be under perpendicular to the central axis of the conscious sedation or general Conclusion i o n i z i n g b e a m , t o t h e r e b y anaesthesia toallow impressions for Many oral complications associated with moreaccurately aid in the homogenous indirect processing techniques. radiotherapy can be controlled with the distribution of the radiation. Themost So to overcome this disadvantage,recent treatment prostheses provided by the commonly used materials for bolus are advances play an important role in the prosthodontist. At times, the head and tissue conditioners, water, saline, waxes fabrication of prosthetic carriers: neck surgeon and radiotherapist are not and acrylic resin. (Fig 4) a) Computerised Axial Tomography fully aware of the many primary and Scan supportive services that the maxillofacial Radiation carriers incorporated with b) Rapid Prototyping prosthodontist can perform through the radioisotopes use of the prostheses. It is recommended This type of prostheses is needed when Computerised Axial Tomography that such a specialist be on the team for radiation therapy is to be administered to Scan consultation before planning any head confined areas by means of capsules, Ituses computer processed X-Rays to and neck cancer surgery or before beads, tubes or needles of radiation produce tomographic images of specific starting radiotherapy.These measures emitting materials. The main purpose of areas of the scanned object.When the make the patient’s treatment course these prostheses is to hold the radiation need for a custom prosthetic device smoother and simplify the surgeon’s source securely in the same place during arises, a prosthodontic consultation is treatment plan. the entire period of treatment. It should be frequently sought for its fabrication to easy to load and unload. The exact facilitate the deliveryof radiation therapy. References

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 128 1. MantriS S, Bhasin A S. Preventive Institute of Medical Sciences Kochi tomography for the fabrication of a Prosthodontics For Head And Neck 4. Bart Johnson, Lindsay Sales,Amy custombrachytherapy carrier: A Radiotherapy. Journal of clinical and Winston, Jay Liao, George Laramora, clinical report (J Prosthet Dent Diagnostic Research 2010 August UpendraParvathaneni, Fabrication of 2003;89:15-8.) ;(4)2958-2962 Customized tongue displacing stents 8. Candice Zemnick,Shermian A. 2. Beumer J, Curtis TA. Firtell D N JADA2013;144(6):594-600. Woodhouse,Richard M. Gewanter, Radiation therapy of head and neck 5. Khan. Treatment Planning in Michael Raphaeland John D. tumors : oral effects and dental Radiation Oncology. 2nd edition. Piro,Rapid prototyping technique for manifestation. In maxillofacial 2007. Lippincott Williams and creating a radiation shield(J Prosthet Rehabilitation(Prosthodontic & Wilkins. Dent 2007;97:236-41.) Surgical Consideration). The 6. Souhami, Tobias. Cancer and its CVMosby Company, 1979. Chp.3, Management. 5th edition. 2005. pg. 23. Blackwell 3. Principles of Radiation Therapy in 7. Patrick M. Van Derhei, Walter C. Head and Neck Cancers SajuDivakar Lim, Robert D. Timmerman, and Carl Radiation Oncologist Amrita J. Andres. Use of computed

Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2015, Issue:2, Vol.:7) All rights are reserved. 129