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

Editorial Board Chief Patron Patron Prof. A. D. N. Bajpai Dr. V.K. Gupta Vice Chancellor-HP University, Shimla Chairman,Dr Puran Chand Medical Trust Editor in Chief: Assistant Editor Dr. Vikas Jindal Dr. Amrinder Tuli Director-Professor,Department of Periodontics Senior Lecturer,Dept of Periodontics Himachal Dental college,Sundernagar,HP,India HDC, Sundernagar, HP, India Co-Editors Dr. Vinod Sachdev 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 Pedodontics, HDC, Sundernagar, HP, India Orthodontics, HDC, Sundernagar, HP, India Prosthodontics Govt. Dental College, Shimla, HP Dr. Rajan Gupta Dr. Bharat Bhushan Dr. Gaurav Gupta Principal, Prof.and Head,Deptt of Principal, Prof and Head, Deptt of Director,Prof and Head,Deptt of Prosthodontics Periodontics HIDS, Paonta Sahib, HP Pedodontics DAV Dental College, Solan HIDS,Paonta Sahib,HP Dr. Jagmohan Lal Principal, Prof and Head, Deptt of Prosthodontics Bhojia Dental College, Nalagarh, HP Editorial Board Prof. H.S. Banyal Dr. K.S.Nagesh Dr. Ravi Kapoor Dean of Studies, Principal, D.A.Pandu Memorial Prinicipal Himachal Pradesh University R.V.Dental College, MM Mullana Dental Dr (Ms) Jaishree Sharma Bangalore College, Ambala Director, Medical Education & Research, Dr. R L Jain Dr. S G Damle Himachal Pradesh Principal, Prof and Head, Vice Chancellor Dr. Mahesh Verma Deptt of Pedodontics Guru MM Mullana Dental Director-Principal, Maulana Azad Nanak DentalCollege, College, Ambala Institute of Dental Sciences, Sunam, PB, India Dr. D K Gautam New Delhi Dr. Usha. H.L Prof and Head, Deptt Dr A S Gill Principal, of Periodontics, HDC, Director-Principal, Genesis Institute of V. S. Dental College, Sundernagar, HP. India Dental Sciences and Research, Bangalore Dr. Eswar Nagraj Ferozepur Punjab Dr. Sumeet Sandhu Prof and Head, Deptt Dr. Satheesh Reddy Prof and Head, of Oral Medicine, SRM Professor, Department of Orthodontics & Deptt of Oral surgery, dental College, Chennai, TN, India Dentofacial Orthopaedics, Sri Sai College SGRD, Sri Amritsar, PB, India Dr. Himanshu Aeran of Dental Surgery and Research, Vikarabad. Dr. SC Gupta Director PG studies, Seema Dr. Vimil Sikri Prof and Head, deptt of Dental College, Rishikesh, Principal, Prof and Head Community dentistry, Uttranchal Endodontics, Govt. Dental HDC, Sundernagar, Dr. Sameer Kaura College, Amritsar, PB, India HP, India Associate Prof, BJS Dental Dr. C S Bal Dr. Kundabala College, Ludhiana, PB, India Principal, Prof and Head Prof and Head,Manipal College Dr. Navneet Grewal Endodontics, Sri Guru Ram Dass of dental Surgery, Mangalore, Prof and Head,Deptt of Dental College, Sri Amritsar, PB, India Karnataka, India Pedodontics, GDC, Amritsar, Dr. Abi Thomas Dr. D S Kalsi PB,India Principal, Prof and Head, Deptt Principal, Prof and Head, Deptt of Pedodontics CDC, CMC, of Periodontics, BJS Dental Ludhiana, PB, India College, 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 , Directory 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 Now IndexedIndian Science with Index Abstracts Copernicus, (ISA), Open J-Gate, EBSCO of Open Access Journals (DOAJ)

Indian Journal of Dental E ISSN NO. 2231-2293 Sciences P ISSN NO. 0976-4003 Issue:2, Vol.:4 June 2012

© Indian Journal of Dental Sciences. (Issue:2, Vol.:4 June 2012) All rights are reserved a Editorial

During the last 50 years we have realized that science is the fuel for the engine of technology .Scientific discoveries from cellular ,developmental and molecular biology have truly revolutionized our collective understanding of biological processes ,human genetic variations ,the continuity of evolution and the etiology and pathogenesis of thousands of human diseases and disorders .This enormous accumulation of scientific discovery which encompases theory, principles, concepts and facts provides the fuel for clinical research and translation evolution of the 21st century .This is evident when we consider opportunities to understand the etiology, pathogenesis, treatment, and outcomes related to various dental diseases. Today the field of tissue engineering has established the essential foundations for the design and fabrication of neo-tissues in two or three dimensions for transplantation.

The discovery of the structure of DNA transformed biology engendered a new Dr. Vikas Jindal Editor in Chief biology as an information science. So this new post- genomic era provides the questions and tools to better define which modules of genetic information are critically significant in disease diagnosis and how to better understand the pathogenesis of disease biological processes which have truly revolutioned dentistry and hold promise for young graduates to pursue their career to this direction

Dr Vikas Jindal

Editor-in-chief

© Indian Journal of Dental Sciences. (Issue:2, Vol.:4 June 2012) All rights are reserved b Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 The Authenticity Of Use Of Gingival Crevicular 1 Harinder Gupta 2 Ruchika Arora Blood As An Early Indicator Of Elevated 3 Monika Kamboj 1 Professor & HOD Systemic Blood Glucose Levels In 2 Post Graduate Student 3 Post Graduate Student Undiagnosed Diabetes Mellitus Patients Department of Periodontology, Punjab Government Dental College & Hospital Abstract Amritsar (Punjab) Background & Objectives : The field of periodontal medicine can help in early detection of certain chronic systemic diseases like diabetes mellitus in a more easy and simplified manner. Diabetes Address For Correspondence: mellitus is undiagnosed in approximately ½ of the patients actually suffering from the disease. In Dr. Harinder Gupta addition, the prevalence of DM is more than twice as high as in patients with periodontitis when 31, North Avenue, Street No. 2, Bhadson Road, compared to periodontally healthy subjects. Thus, a high number of patients with periodontitis may Patiala - 147001 (Punjab) have undiagnosed DM. The purpose of the present study was to evaluate whether blood oozing from gingival crevice during routine periodontal examination can be used for determining glucose Submission : 25th November 2011 levels. Accepted : 19th April 2012 Methods : In the present study 50 patients( 23 diabetic and 27 non-diabetic) with bleeding on probing were selected. Blood oozing from the gingival crevices of anterior teeth following Quick Response Code periodontal probing was collected with a glucose self-monitoring device (one touch ultra 2, Johnson & johnson) and the blood glucose levels were measured. At the same time, capillary finger-stick blood was taken for glucometric analysis. Results : The patient's blood glucose values ranged from 69 mg/dl to 374 mg/dl. The comparison between gingival crevicular blood, finger-prick blood showed a very strong correlation with an r value of 0.988 ( p < 0.001) Conclusion : The data from this study has shown that GCB collected during diagnostic periodontal examination can be an excellent source of blood for glucometric analysis.

Key Words DM, gingival crevicular blood, capillary finger prick blood.

Introduction high number of patients with Numerous advances in preventive periodontitis may have undiagnosed medicine have provided methods for DM3 . detecting serious chronic diseases which presently threaten our public health. The ability to collect gingival crevicular Today's clinician must direct his efforts to blood (GCB) for glucose measurement the “gray” areas of undiagnosed using readily available glucometers that asymptomatic disease as well as to the measure glucose in a few seconds seems treatment of existing disease. The early to be a good method of screening diabetic 3,4,6,7,8 detection of subclinical disease by patients. Several studies in the past Image 1- One Touch Ultra 2 Glucometer advanced screening procedures is have reported significant correlation making considerable progress in the field between GCB & CFB (capillary finger- of preventive medicine to reduce the stick blood) but few fail to accept this nonstop progression of certain chronic correlation5 . So, the aim of our study is to diseases. The field of periodontal evaluate the authenticity of use of medicine can also help in early detection gingival crevicular blood as an early of certain chronic systemic diseases like indicator of elevated systemic blood diabetes mellitus in a more easy and glucose levels in diabetes mellitus simplified manner1 . Diabetes mellitus is patients. 1 undiagnosed in approximately /2 of the patients actually suffering from the Materials And Method disease. The prevalence of DM patients is For this study, subjects were selected more than 2 times as high in patients with randomly from the general OPD of the periodontitis when compared to Department of Periodontics, Image 2 - Isolation Of Site For Gingival Crevicular Blood periodontally healthy patients. Thus, a Government Dental College & Hospital, Collection.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 001 measurement of probing depth, attachment level, and bleeding on probing. A site with more profuse bleeding was chosen for collecting the gingival crevice blood (GCB) sample on the anterior segment of the mouth. The area was isolated with cotton rolls to prevent saliva contamination and dried with compressed air. Probing was repeated until a sufficient amount of blood appeared in the gingival crevice. The one touch ultra 2, Johnson & Johnson was used according to the manufacturer's recommendations. Immediately after measuring glucose levels in GCB, a Image 3 - Probing To Induce Gingival Bleeding. capillary finger-stick blood (CFB) sample was drawn from the index finger Image 7 - Glucometer Showing Blood Glucose Reading. using a disposable sterile lancet.

Statistical analysis using Pearson's Amritsar, Punjab. The study was correlation coefficient was performed to performed randomly on a total of fifty assess the correlation between the patients including 26 males and 24 glucose measurements in the gingival females with evident bleeding on blood samples and those obtained by probing. finger puncture. Paired t-test was The following criteria were considered performed to test the significance of the for the selection of subjects: difference in glucose level between the Selection Criteria gingival and finger readings. 1. Patients with evident bleeding on probing. Results The range of the gingival crevicular Exclusion Criteria blood glucose measurements varied from 1. Patients with requirement for 69mg/dl to 374 mg/dl, with a mean value antibiotic premedication. of 154.7 mg/dl and a standard deviation Image 4 - Bleeding On Probing 2. Patients with disorder that was of 85.77mg/dl. accompanied by an abnormally low or The range of the finger-prick blood high haematocrit. For example, glucose measurements varied from 77 Polycythaemia Vera, anaemia, and mg/dl to 372 mg/dl, with a mean value of dialysis. 157.4 mg/dl and a standard deviation of 3. Patients with intake of substances that 84.93 mg/dl. interfere with the coagulation system for On comparison of gingival crevicular example, Coumarin derivatives, Non- blood glucose and finger-prick blood steroidal anti-inflammatory drugs or glucose measurements, finger prick Heparin. capillary blood glucose showed a higher 4. Sites with suppuration. mean value (157.4 mg/dl) than gingival Periodontal examination included crevicular blood glucose mean

Image 5 - Method Of Inducing Finger Prick Capillary Bleed.

Sulcular Blood Finger Blood Comparison Correlation

Overall (n=50) 154.70 ± 85.77 157.48 ± 84.93 t = 1.469; r = 0.988;

p = 0.148NS p < 0.001*

Diabetics (n = 23) 224.52 ± 82.29 230.30 ± 75.10 t = 1.505; r = 0.977;

p = 0.146NS p < 0.001*

Non-Diabetics (n= 27) 95.22 ± 12.13 95.44 ± 11.50 t = 0.194; r = 0.875;

p = 0.847NS p < 0.001* NS: p > 0.05; Not Significant

Image 6 - Finger Prick Capillary Blood Elicited.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 002 Since periodontal inflammation with or 1. Stein GM, Nebbia AA. A chairside without complication factor of DM is method of diabetic screening with known to produce ample extravasate of gingival blood. Oral Surg Oral Med blood during diagnostic periodontal Oral Pathol 1969; 27: 607-612. examination (Ervasti 1985)2 no extra 2. Ervasti T, Knuuttila M, Pohjamo L, procedure, e.g. finger puncture with a Haukipuro K. Relation between sharp lancet is necessary to obtain blood control of diabetes and gingival for glucometric analysis. Even in the case bleeding. J Periodontol 1985; 56: of very low gingival crevicular bleeding, 154-57. a glucose measurement is possible with 3. Parker RC, Repley JW, Isley W. the use of self monitoring device (Ultra Gingival Crevicular Blood for Touch 2, Johnson & Johnson), due to the assessment of blood glucose in low amount of blood necessary to diabetic patients. J Periodontal 1993; perform the analysis. Moreover, the 64: 666-672. technique described is more familiar and 4. Beikler T, Kuczek A, Petersilka G, less traumatic to the patient than a finger Flemming TF. In-dental-office puncture4 . screening for diabetes mellitus using The strong correlation obtained in the gingival crevicular blood. J Clin present study on comparison between the Periodontol 2002; 29: 216-218. various blood glucose measurements 5. Muller HP, Behbehani E. Methods for indicates the feasibility of using measuring agreement: glucose levels periodontal sulcular blood as an in gingival crevice blood. Clin Oral alternative to the FP blood in accordance Invest 2005; 9: 65-69. to the previous studies. On analysis of our 6. Khader YS, Judeh A, Rayyan M. study, finger prick capillary blood Screening for type 2 diabetes mellitus glucose showed a slightly higher mean using gingival crevicular blood. Int J value than gingival crevicular blood Dent Hygiene 2006; 4: 179-182. value(154.7 mg/dl) and showed r = glucose mean value, may be due to 7. Ardakani MR, Moeintaghavi A, 0.988; p < 0.001, thus giving statistically contamination of GCF which dilutes the Haerian A, Ardakani MA. significant results. glucose concentration producing lower Correlation between levels of On analysis of the glucose measurements measurements in GCB. sulcular and capillary blood glucose. of the randomly included 50 patients, 23 J Contemp Dent Pract. 2009; 10: 10- patients were found to be diabetic and 27 Conclusion 17. patients were non diabetic. And Within the limitations of this study, the 8. Strauss SM, Wheeler AJ, Russell SL, surprisingly, only 15 patients out of the following conclusion can be made that Gluzman R. The Potential use of 23 diagnosed to be diabetic by our GCB collected during diagnostic gingival crevicular blood for measurements were aware of their periodontal examination may be an measuring glucose to screen for diabetic status. The diabetic status of the excellent source of blood for glucometric diabetes: An Examination based on unaware 8 patients was further confirmed analysis. The technique is safe, easy to characteristics of the blood collection by intravenous laboratory method of perform, and comfortable for the patient site. J Periodontal 2009; 80: 907-914. glucose measurement which is and therefore, helps to increase the considered as the gold standard for blood frequency of glucose measurements. diagnosing diabetes during routine periodontal therapy which provides a The patients were further divided into more two groups- objective indicator for referral to Group I- Diabetic group (n=23) and physicians than traditional methods. Group II- Non-Diabetic group (n=27) Thus, the and intra group analysis was done. dentist may increase his importance as a On comparison of gingival crevicular member of the health team by blood glucose and finger-prick blood participating in the search for glucose measurements of Group I undiagnosed asymptomatic DM. patients, the Pearson's correlation coefficient showed r-value = 0.977 and a P-level <0.001. References On comparison of gingival crevicular blood glucose measurements and finger- prick blood glucose measurements of the Group II patients, the Pearson's correlation coefficient showed r-value = Source of Support : Nill, Conflict of Interest : None declared 0.875 and a P-level of <0.001.

Discussion

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 003 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Prevalence Of Dental Caries Among Pre-school 1 Arora Sachit A 2 Setia Sumeet Children Of Greater Noida City, UP (India) 3 Ahuja Puneet 4 Singh Darrel Abstract 5 Chandna Anil This study was conducted to estimate the prevalence of dental caries among pre -school children 1 MDS, Professor, Department of Periodontics of Greater Noida city [U.P.], India. Estimation of dental caries was done using the dft Index. The 2 overall prevalence of dental caries in this study of 1031 children aged 3-5 years was 30.06% with a MDS, Professor Dept of Preventive and Paediatric Dentistry mean dft score of 1.68. Out of the total sample, 68.56 % of children in the age of 5 years were caries 3 MDS, Principal, Professor and Head free. This was short of W.H.O. Global Goals for Oral Health 2010 [90 % at age of 5 years should be Dept of Oral And Maxillofacial Pathology caries free]. 4 MDS, Senior Lecturer Dept of Paediatric and Preventive Dentistry Key Words 5 MDS, Professor and H.O.D Key Words: Dental Caries, Pre-school, Dft Index, Caries Free, Oral Health Goals Department of Orthodontics ITS Dental College, Hospital & Research Centre

Address For Correspondence: Dr. Sachit Anand Arora Introduction group of 3 - 5 years. Out of these, 582 ITS dental college, Hospital and research centre Dental caries is a disease which afflicts were males and 449 were females. From Plot No 47, Knowledge Park III Greater Noida, Gautam Budh Nagar District persons across all ages and in different the total sample, 544 children of 5 years Uttar Pradesh, India parts of the world. Ramchandran K. et al1 age were further segregated to estimate Phone:9910222799 reported 60-65% prevalence of dental their caries free prevalence in order to E mail:[email protected] 2 compare it with the W.H.O. global goals Submission : 15th September 2011 caries in India. R. Mahajabeen et al th reported a prevalence of 54.1% in pre- for Oral Health 2010. Accepted : 09 February 2012 school children and similar findings were Clinical examination and assessment of reported by Yevenes et al3 in Chile. dental caries was conducted by two Quick Response Code Unequal distribution of dental caries in trained examiners. The subjects were pre-school children was also reported in examined on an upright chair under both the genders, developed and adequate natural light using mouth mirror developing nations, rural and urban areas and explorer. The caries was recorded and amongst various socio - economic using dft index.10 The data obtained was strata around the world [4,5,6,7] . subjected to statistical analysis using W.H.O. has set global goals for Oral Pearson's Chi-Square test at 95% 8 9 confidence interval. health for 2000 and 2010 that is 50% and Table I Study Sample Distribution 90% should be caries free at the age of 5 Results years respectively. Age (In Years) Males Females Total Data was collected from the region of The study group comprised of 1031 pre- Greater- Noida city to draw attention to school children, 582 males and 449 No. % No. % No. % females in the age group of 3-5 years the prevalence of dental caries in pre- 3-5 582 56.45 449 43.54 1031 100 school children in this region. [Table I, Graph I]. Therefore the aim of this study was to Graph I evaluate the prevalence of dental caries in pre - school children in Greater - Noida City [U.P.], and to correlate the percentage of caries free children at the age of 5 years with the W.H.O Global Goals for Oral Health for 20109 .

Materials and Methods This study was conducted in Greater- Noida city of Uttar Pradesh, India. Five private schools were selected randomly after taking permission from the school authorities. The study sample consisted of 1031 pre- school children in the age

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 004 The overall prevalence of dental caries in this age group was 30.06% with the mean Graph II dft of 1.68. Children at the age of 5 years in the study group showed caries prevalence of 31.44 % with the mean dft score of 1.20 and caries free were 68.56% [Table II, Graph II].

Table II Number Of Children (In Percentage) With And Without Caries With Mean Dft Scores.

S.No Age Sample Caries free Caries affected Mean dft (Yrs) Size

No % No %

1 3-5 1031 721 69.94 310 30.06 1.68

2 5 544 373 68.56 171 31.44% 1.20

Graph III

Statistically significant difference was not observed between both the genders in caries prevalence, although males showed higher caries prevalence than females [Table III, Graph III].

Table III Prevalence Of Caries Among Males And Females (3-5 years)

Age Group (Yrs) Males Females p-value

3-5 No % No %

a 169 29.03 141 25.68 0.139

Significance taken at 95% confidence interval P value <0.05

males and females in this age group, but .Investigators have reported different in general males were slightly more prevalence at 5 years in different regions affected [29.03 %] than females around the world [27, 28,29] The results show Discussion [25.68%]. This marginal difference could that the prevalence of caries free children The overall prevalence of dental caries in be attributed to the diet as more priority is at the age of 5 was short of W.H.O goals the age group of 3 to 5 year old children of given to a male child than a female child for Oral Health for all 2010 [90% at age 5 Greater -Noida city was 30.06 % with a in the Indian society. Moreover females years should be caries free]. mean dft score of 1.68. Similar trends in are found to have better personal hygiene This emphasizes that sincere efforts have caries prevalence were reported by than males. These findings are similar to to be put to improve preventive and Gangwar et al11 in Lucknow and Tewari the studies of Yevenes et al3 , Mahajabeen curative dental services among pre- S12 in Haryana which was 36% and et al2 , Al Ghanim et al22 , Franscisco J et school children so that they have 33.8% respectively in pre-school al23 and Masiga MA, Holt RD24 . The healthier dentition. This can be children. Varied caries prevalence had present study showed that percentage of accomplished by regular School Dental also been reported in this age group in caries free children at the age of five years Health Programme which should India by Mahajabeen et al2 , Gupta Ak13 , was 68.56% which was in accordance encompass Dietary advice, Health Sethi B and Tandon S14 , Rao A, Sequeira with the goals set by W.H.O. Global Oral Education, Teacher and Parent awareness SP and Peter S15 , which ranges from 50 - Health Goals for the year 2000. Similar training programmes, Topical fluoride 70 %. In the present study a lower finding has been reported in U.P. state, in application and Rinses. percentage of caries prevalence could be Lucknow by Gangwar et al11 in 1990, attributed to the children in the study which was 64% caries free at age of 5. sample were from private schools where Caries prevalence at the age of 5 years Conclusion they usually belonged to affluent society was found to be 31.44% with a mean dft This study reported: and belonging to good socio-economic of 1.20, which was less than that reported 1. Lower prevalence of dental caries in status.[20,21] Similarly, international trends by National Oral Health Survey and preschool children [3 - 5years] of also show varied pattern of caries fluoride mapping done by D.C.I, New Greater - Noida city, U.P. India. prevalence in pre- school children[16,17,18,19] . Delhi in 2004.25 2. No statistical significant difference in No statistically significant difference was Saravan S26 reported a prevalence of 44.4 prevalence of caries in both the found in the caries prevalence between % in Pondicherry, at the age of 5 years genders.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 005 3. Present status is short of achieving 13. Gupta AK, Tewari A, Chawla H S. Lucknow school children. JIDA goals set by W.H.O. for 2010. Assessment of treatment needs of 1979; 51:109 dental caries and gingival diseases of 22. Al-Ghanim NA ,Wyne AA, Adenubi South Indian population and JO, Khan NB. Caries prediction References correlation with specific risk factors. model in pre school children in 1. Ramchandran K, Rajan B.P., Thesis submitted in partial Riyadh, Saudi Arabia. IJPD 1998; Shanmungan S. Epidemiological fulfillment of degree of M.D.S. 8:115-22. studies of dental disorders in Tamil Panjab University: Chandigarh; 23. Franscisco J, Ramos G, Gravay F, Nadu population, prevalence of 1987. Cluadia MM, Ramond LB. Infant dental caries and Periodontal 14. Sethi B,Tandon S .Caries pattern in caries prevalence and treatment cost diseases. J. Indian Dent. Assoc 1973; pre school children. JIDA 1996; of infant caries in Northern 45: 65 - 70. 67:141-5 California. J Dent Child 1996; 2. Mahajabeen R, Sudha P, Kulkarni SS, 15.Rao A, Sequeira S.P, Peter S. 63:108-12 Anegundi R. Dental caries Prevalence of dental caries amongst 24. Masiga MA, Holt RD. The prevalence among pre - school school children of Moodbidri. J Ind Prevalence of dental caries and children of Hubli. J. Ind. Soc. Pedod Soc Pedod Prev Dent 1990; 17:45-8 gingivitis and their relationship to Prev Dent. 2006; 24: 19-22. 16. Fabio Silva de Carvalho, Cristiane social class among nursery school 3. Yevenes I, Bustos BC, Ramos AA, Alves Paz de Carvalho, Reosevelt da children in Nairobi, Kenya. J Espinoza RM, Jara MN, Petrasic Silva Bastos, Angela Xavier, Sabrina Pediatric Dent 1993; 3:135-40 Smith L. prevalence of dental caries Pulzatto Merlini, Jose Roberto de 25. National Oral health survey and in pre-school children in Penaflor, Bastos. Dental caries in pre - school Fluoride Mapping. An Santiago, Chile. Rev. Odonto Cienc. children of Bauru, S.P., Brazil. Braz J epidemiological study of Oral health 2009; 24:2: 116- 19 Oral Sci. 8:2:97 - 100. problems and estimation of fluoride 4. Holm AK. Caries in the pre- school 17. Shang Xiao - hong, Lida - lu, Huang levels in drinking water. Dental Child - International Trends. J Dent Yi, Chen Hui, Sun Ruo Peng. Council of India New Delhi, 2004. 1990; 18: 291 - 5. Prevalence of dental caries among pre 26. Saravan S., Madhavan I, Subashini B, 5. Chatufale JD, Goyal R. C. A Cross - school children in Shanghe County Felix J.W. Prevalence pattern of Sectional study of factors related to of Shandong Province and relevant dental caries in the primary dentition Oral health in rural areas of Loni, prevention and treatment strategies. among school children. Indian J Dent Western Maharashtra. Indian J. Chinese Med Journal 2008;12:22: Res 2005; 16: 140 Community Med 2002; 27: 74 - 6. 2246 - 49. 27. Dutta A. A study of prevalence of 6. Holbrook WP, de Soet JJ, de Greaff J. 18. J.M. Tang, D S Altman, D C periodontal disease and dental caries Prediction of dental caries in Robertson, DM O" Sullivan, JM among school going children in preschool children. J. Caries Res Douglass and N Tinanoff, Dental Calcutta. JIDA. 1971; 51: 267 - 70 1993; 27: 424 - 30. Caries prevalence and treatment 28. Dash J.K., Sahoo P.K, Bhuyan S.K, 7. Peterson PE, Steengard M. Dental levels in Arizona Pre - school Sahoo S.K. Prevalence of dental caries among urban school children children. Public Health Rep. 1997; caries and treatment needs among of Madagascar. J Comm. Dent Oral 112:4:319 - 31 children of Cuttack (Orissa) J Ind Soc Epi 1988; 16: 163 - 6. 19. A. Adeniyi Abiola, O. Ogunbobede, Pedo Prev Dent 2002; 20:4:139 - 43. 8. Federation Dentaire Internationale. O. Ilboda Sonny, O. Sofola, O. 29. R. Lalloo, M H Hobdell, H J Mosha, F Goals for the Oral health in the year Yinkan. Dental caries occurrence and Mobli, A Tanda. Dental Caries status 2000. Int Dent J 1982; 32:74 - 7. of 5 - 7 years in Tanzania, Uganda & 9. Hobdell MH, Myburgh NG, Kelman associated Oral hygiene practices Mozambique. M, Hansen H. Setting global goals for among rural and urban Nigerian pre - Oral Health for the year 2010 Int Dent school children. J. Dent. Oral Hyg J. 2000 Oct; 50:5:245 -9. 2009; 1:15: 64 - 70. 10. Gruebbel AO. A measurement of 20. Singh S, Kaur G, Kapila V.K. Dental dental caries prevalence and disorders in primary school children treatment service for deciduous teeth. of faridkot city. JIDA 1985: 57: 305-8 J Dent Res 1944;23:163 21. Chandra S, Chawla T.N. 11. Gangawar, S.K Idris, M.Z. Bhushan, Incidence of dental caries in S. Saimbi, C.S., Jain V.C. Biosocial Correlates of dental caries in rural area of Lucknow. JIDA 1990; 61: 93 - 7. Source of Support : Nill, Conflict of Interest : None declared 12. Tewari S, Tewari S. Caries experience in 3 - 7 year old children in Haryana [India]. J. Ind. Soc. Ped. Prev. Dent 2001; 19:2: 52 - 56.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 006 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Swallowed Partial Dentures 1 D. Agrawal 2 T. K. Lahiri 3 Abstract Abhijot Parmar AIMS : This study has tried to elicit the different factors responsible for impacted dentures in the 4 Shweta Sharma esophagus with regard to types of dentures, predisposing factors, age and sex distribution, 1 Reader and Head duration of the impaction of the denture, symptomatology, sites of impaction, characteristics of the 2 dentures plates, material used, diagnosis including the role of investigations, interventions for Professor Emeritus Dept of Preventive and Paediatric Dentistry retrieval, complications both preoperative and postoperative and mortality with an idea of 3,4 Junior Residents providing surgical perspective . Dept of Cardiothoracic Surgery Settings : A tertiary referral University Hospital Institute of Medical Sciences, Study Design : A retrospective chart review. Institute of Medical Sciences, Materials And Methods : A retrospective analysis of 64 cases presenting in cardiothoracic Banaras Hindu University, Varanasi,(U.P.), India surgery department for 16 years from 1992 to 2008 (September). Stastistical Analysis Used : The statistical package for social sciences (SPSS) 13.0 frequency, Address For Correspondence: explore and crosstabs windows frequency, explore and closure compatible program with Dr. D. Agrawal, Reader & Head significance levels of p < 0.05. Dept of Cardiovascular & Thoracic Surgery, Results : Acrylic upper dentures having two teeth which have been worn for more than 5 years by Institute of Medical Sciences, Banaras Hindu University, patients aged above 45 years were most common (82.81%). The eventful and uneventful patients Varanasi - 221005, U.P. were similar in age and percentage of presentation. The most common site of impaction was the INDIA. upper one third of the esophagus. The current modalities of localization of impacted dentures by E-mail: [email protected] esophagoscopy, barium studies or CT Scan were excellent. Ingested dental prostheses with or Phone : 0091-542-2309484, without hooks not removable by esophagoscopy could be removed by direct surgical exposure Fax : 0091-542-2367568 using synchronous direct manipulation with horizontal rotation and vertical traction. or vice versa. th The complications were directly proportional to duration of impaction i.e. interval between Submission : 10 September 2011 ingestion and presentation. (RR = 11.7, CI 95% = 1.9 - 79.3). Mortality occurred in 3 cases Accepted : 04th February 2012 (4.68%) as a result of massive hemorrhage, esophageal leak, empyema, peritonitis and septicemia. Conclusion : Foreign body swallowing is common but denture impaction in the esophagus is occasional. Partial acrylic denture prostheses are radiolucent if there are no clasps or hooks. The Quick Response Code location of swallowed denture often is accomplished radiologically but this is difficult with denture constructed entirely of acrylic resins without hooks. When they catch or get impacted in the esophagus edema, ulcer, perforation, abscess, penetration and fistula can be produced. Retrieval is obligatory either by esophagoscopy or by surgical exposure. Key Words Impacted Dentures, Oesophagus, Oesophagoscopy, Surgical Removal

Non retentive unstable swallowed partial years. subsequent complications. dentures when impacted in the oesophagus can be a diagnostic and Materials And Methods All the patients were subjected to routine therapeutic challenge. The incidence of Over a period of 16 years (JANUARY blood tests, soft tissue X-Ray of the swallowing partial denture is reported in 1992 to SEPTEMBER 2008), a total of anterior-posterior and lateral neck range of 3.6% to 27.7% with adult 64 patients with presentation suggestive region, X-Ray of the chest, thin barium or preponderance1. Other ingested foreign of swallowed denture were admitted in gastrograffin swallow study. Very few bodies of dental origin are transpalatal Cardiothoracic surgery department at required computerized tomographic arch, a fragment of upper removable university Hospital of BANARAS (CT) Scan for localization. Cases were appliance, a piece of arch wire and a HINDU UNIVERSITY. Data collection divided on the basis of site of use (upper lower spring retainer2. Controlled consisted of, sorting out of all these cases or lower denture), the number of teeth prospective studies of impacted denture of dental impaction from the operation present, with hooks made of pointed steel have not been conducted because of theatre register and analysis of patient wires, and unhooked dentures. An location, size, shape and duration of files. The records were analyzed for each abnormal cervical or thoracic radiogram impaction, experience and availability of patient's age, sex, time of ingestion to consisted of one or many features such as, flexible and rigid esophagoscope presentation, presenting symptoms, presence of a radio-opaque denture, resulting in report of institution or author preceding event, duration of denture widening of the prevertebral space, air in only3. This study is based on wearing, the type of denture (upper, the esophagus, loss of normal lordosis, restrospective analysis of 64 cases of lower, hooked, unhooked), masking effect of soft tissue mass and denture impaction during a period of 16 complications, modes of removal and free air in tissues consistent with surgical

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 007 Table No. 1 Clinical Characteristics of Impacted Partial emphysema, and hydropneumothorax. A This study revealed accidental Dentures Total No. 64 diagnosis of an impacted denture in the swallowing of dentures in 64 cases. Item Number % esophagus was made on a combination of which were found impacted in the history, examination and radiological cricopharyngeal region or the Gender M-55 M (85.95%), findings. The age and sex distributions, oesophagus. The patients were managed F-9 F (14.06%) duration of the use of the denture, events in the department of Cardiothoracic preceding and contributing factors Surgery in the University hospital, over a Age (Years) Range 21-78 responsible for denture impaction were period of 16 years. noted. Median : 53 The male to female ratio was 55 (85.9%) : Time Interval to presentation Barium study was the investigation of 9(14%), and the age range was 21 years to choice, it could outline the site, shape and 78 years (41.3 9.6) with a median age of < 24 hours - 50 78.12% size of the impacted denture. To some 53 years. Patients with more than 45 24 hours - 17 days 11 17.18% extent, it revealed the degree of tissue years of age constituted 75.03% of the damage by showing the tenting of the cases. None of the cases were below 21 More than 30 days 3 4.68% esophageal mucosa, pressure necrosis years. Only one female patient had Symptomatology : with danger of impending rupture, and dentures due to congenital absence of fistula. In CT Scan the impacted denture upper 2 incisors, otherwise all dentures Foreign Body Sensation 51 79.69% with a thickened segment, regional (upper or lower incisors) were used Odynophagia 61 95.3% inflammation, localized air space, because of loss of teeth due to trauma or perforation with air fluid leakage could infection. Pooling of saliva 48 75% be identified. Table 1 Total Dysphagia 3 4.68%

Flexible or rigid hypo-pharyngoscopy, The time interval from accidental Stridor 2 3.12% esophagoscopy, and in selected cases swallowing to presentation varied. Fifty Massive hemorrhage 1 1.56% panendoscopy including tracheo- patients (78.12%) presented within 24 bronchoscopy if impaction into trachea hours. This was followed by 11 patients Characteristics of denture was suspected were used for diagnostic (17.18%) presented between 24 hours to Partial 62 96.87% and elective therapeutic purpose. 17 days, and the rest 3 (4.68%) presented Strategy for removal of impacted denture more than one month after dental Complete 2 3.2% in cervical esophagus was impaction, one patient presented 4 years Upper Denture 53 82.81% esophagoscopy along with horizontal after the incident with massive rotation and vertical traction with a hemorrhage which later turned out to be Lower denture 11 17.18% forceps. Dentures removed surgically hemorrhage from aberrant left Wearing using synchronous direct manipulation subclavian artery. (A setting for after surgical exposure (oesophagotomy) dysphagia lusoria) > 5 yrs 49 75.56% with the assistance of a forceps, and open < 5 yrs - 15 23.4% surgical removal by cervical The symptomatology at the time of oesophagotomy, or right posterolateral presentation was odynophagia in 61 Number of teeth -1 17 26.5% thoracotomy. Feeding gastrostomy or (95.3%), foreign body sensation in 51 -2 32 50% jejunostomy was performed in indicated (79.6%), pooling of saliva 48 (75%), total cases with esophageal laceration, edema, dysphagia in 3 (4.68%) and stridor in 2 -3 5 7.81% severe peri-esophageal inflammation, (3.12%), septicaemia was noticed in 2 -4 8 12.5% mediastinitis abscess formation pre- (3.12%) lastly massive hemorrhage in operative pleural empyema, impaction 1(1.56%) cases. Radio-opaque Steel Hooks on dental plate 27 42.18% over aberrant subclavian artery with pre- 1- hook 12 44.2% operative massive haemorrhage. The impacted dentures were divided into partial in 62 cases (96.87%) and complete 2- hooks 15 55.76% During the evaluation of the data from the in 2 cases (3.2%), upper incisors' Worn out Hooks 18 67.18% () study, bivariate analysis was performed dentures in 53 cases (82.81%) and lower and odds ratio for the respective incisors denture in 11 cases (17.18%) (p < No Hook 37 57.82% diagnostic, pre operative and 0.01). They were also divided according Size of Acrylic Plate 3 cms 5 (7.81%), postoperative variables along with its to steel hooks (clasps) present. In 27 95% confidence interval was calculated. cases (42.18%). Figure 3 4-5 cms 54 84.37%, The results were evaluated with > 5 cms 5 (7.81%) significance levels of p < 0.05. The One metal hook was present in 12 cases, statistical package for social sciences two hooks were present. In 15 cases, Site of impaction of dentures : (SPSS) 13.0 windows compatible worn out hooks were noted in 18 cases program was used for statistical analysis and lastly there were no hooks in 37 cases Cricopharynx 4 6.25% as measure of event frequency, the (57.82%). Figure 2 Upper one third esophagus 46 71.87% cumulative incidence or risk. The number of teeth present in dentures Lower one third 4 62.5% Result were one in 17 cases (26.5%), two in 32 Middle one third 10 15.62%

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 008 Figure No. -2 Extracted dentures without metallic wires cases (50%), 3 in 5 cases (7.81%) and 4 in 8 cases (12.5%). The sizes of polymethyl acrylate plates in denture were 3 cms in 5 cases (7.81%), 4-5 cms in 54 cases (84.3%) and more than 5 cms in 5 cases (7.81%).

The sites of impaction of the dentures in this study were pharyngoesophageal junction in 4 (6.25%), upper one third of the oesophagus in 46 (71.87% , p < 0.01), middle one third of the oesophagus in 10 (15.62% p < ns), lower one third of the esophagus in 4 (12.5% p < ns). The patients were wearing the teeth for more than 5 years in 49 (75.56%, z test with correction 3.65 p value < 0.01), and less than 5 years in 15 cases (23.4%). Table 1

The events preceding the impaction of denture revealed elderly people, poor oral sensitivity from dental prosthesis Figure No. - 3 Extracted dentures with metallic wires with wrong manner of drinking, or taking medicines in 62 cases (96.37%, RR = 11.2 (CI 95% = 1.9-76.6, p value < 0.0001).

In 19 (29.65%) patients cervical X-Rays were normal and in 14 patients (21.87%) X-Rays of the chest were normal. Table 2

All these patients had dentures identified, and, removed with esophagoscopy or by surgery. In 31 patients (48.43%) an abnormal radio-opaque shadow in cervical X-Ray and in 14 cases (21.87%) abnormal radio-opaque shadow in X-Ray of the chest was detected. In this study, barium swallow study was carried out in 39 cases (60.93%) and CT Scan study was conducted in 7 cases (10.93%). Esophagoscopy was performed in 58 cases (90.62%) with failure of retrieval in 50 (78.12%). No esophagoscopy but direct surgical intervention was done in 5 cases (7.81%) of which 3 (4.68%) had cervical and 2 (3.2%) had thoracic Table 2 impaction. Table 3 Role of investigations (64)

1. Normal cervical X-Ray 29.68% (19) Table 3 Most of the cases 50 (78.12%) of failure Role of Surgery 2. Abnormal cervical X-Ray 48.43% (31) to retrieve had inflammatory reaction 1. Oesophagoscopy And Removal 6.25% (4) with edema, ulceration, tear and food 3. Abnormal X-Ray of the Chest 21.87% (14) particle impaction. The relative risk of 2. Cervical Oesopahgotomy 71.87% (46) 4. Barium studies of oesophagus 60.93% (39) events was > 13 (RR = 13.6; CI 95% = 3. Right Posterolateral Thoracotomy 21.87% (14) 1.7-74.5); p for tendency < 0.005). 5. CT Scan studies 10.93% (7) 4. Gastrostomy 10.93% (7) Our strategy for management of 6. Oesophagoscopy 58 (90.62%) 5. Jejunostomy 7.81% (5) impacted denture in the oesophagus was (Failed To Retrieve 51) removal. Esophagoscopic removal of 6. Mortality 4.68% (3/64) impacted denture was by identification 7. No oesophagoscopy 5 (3-Cervical), followed by direct vertical traction in 3 2 - Middle 1/3 Oesophagus cases, and identification, disimpaction by

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 009 Figure No. 4 Closer view of dentures denture along with a partially cut snare had been removed. The relative risk of this event did not exceed 1.5, and the 95% confidence intervals comprised the null hypothesis (i.e. RR = 1) therefore corresponding to values of p > 0.05.

Discussion The phenomenon of the swallowed denture is well documented4,5,6 . Dentures are one of the most notorious foreign bodies in the esophagus. Sharp, pointed, serrated edges, metal wire or clasps can lead to damage of the strongest mucosal and submucosal layers of esophagus. This produces direct injury, linear ulceration, compression edema with mucositis, penetration, perforation and fistula7,8 .

The occurrence of denture impaction in our study was four per year : Male out numbered the female patients by a ratio of 6 : 1 which was much higher than earlier reported as 3 : 14,10 . horizontal rotation followed by vertical gastrostomy was done in 4 cases (6.25%), Denture made of acrylic material with or traction with forceps in one case. Left feeding jejunostomy in 3 cases (4.68%). without hook wire or clasp and sharp cervical oesophagotomy, disimpaction of A Ryles tube was routinely inserted in all edges (collects) used for more than five the denture and removal was performed surgical cases. year, were not retentive or rugged, and in 46 cases (71.87%). In four cases with could not readily withstand the forces four teeth synchronous direct Complications in this series noticed generated during daily use. Moreover, an manipulation with forceps after exposure preoperatively and intra operatively upper partial denture without the contact was necessary along with gastrostomy in caused by sharp impacted denture were of the lips during drinking could be a 2 cases and jejunostomy in one case. (p < abscess in 16 cases (25%), perforation in predisposing factor or denture impaction. 0.01). Right posterolateral thoracotomy 15 (23.43%), hemorrhage in 5 cases The incidence of upper denture 53 after prior esophagoscopy, esophageal (7.81%) and fistula in 2 cases (3.12%). (82.81%) impaction compared to lower exploration, identification, Post operative complications were denture 11 (17.14%) was significant (p < esophagotomy and removal of impacted abscess in 5 (7.81%), haemorrhage in 3 0.01) on carrying out a single sample denture was performed in 14 cases (4.68%), perforation in 3 (4.68%) and analysis. The incidence of worn out (21.87%). Disimpaction with horizontal fistula in one (1.56%). Table 4 hooks (67.18%) found to be significant (p rotation and removal of impacted denture < 0.05), so was the duration (> 5 years of was performed after carefully observing No statistically significant (p = 0.082) wearing denture (p < 0.001)4, 9,10 . the reactionary edema, inflammation, tendency was observed in RR for ulceration, linear tear, perforation and association between the level of Symptoms varied from odynophagia fistula. Repaired oesophagus was impaction and preoperative (95.3%), foreign body sensation reinforced with pleural flap and complications. (79.69%) and pooling of saliva (75%) to intercostals muscle bundle. Temporary unusual symptoms like total dysphagia The intra operative abscess, perforation (4.68%) or stridor (3.12%). No fistulae and haemorrhage were tackled hoarseness of voice or respiratory while removal of denture by debridement distress could be noted. Neck tenderness closure and good haemostasis esophagus was present frequently in cervical Table No. 4 was then meticulously closed. Distribution of Complications by percentage impaction. The presence of MACKLER Three deaths (4.68%) occurred in this triad (vomiting, chest pain and Pre & Intra Operative Postoperative series. First one due to tracheoesophageal subcutaneous emphysema) or fistula along with pulmonary infection, 1. Abscess 16 (25) % 5 (7.82) % ANDERSON triad (subcutaneous poor nutrition and septicalmia. The emphysema, rapid respiration and 2. Perforation 15 (21.43) % 3 (4.68) % second case was due to esophageal abdominal rigidity) indicated the perforation, mediastiinitis mediastinal suspicion of esophageal perforation11 . 3. Fistula 2 (3.12) % 1 (1.56) % abscess and erosion of aberrant left 4. Hemorrhage 5 (7.81) % 3 (4.68) % subclavian artery. In the third case the The commonest site of the impaction in mortality occurred after 49 days due to 5. Massive Hemorrhage 1 (1.56) % 1 (1.56) % this study was upper one third of the jejunostomy leakage along with esophagus to be followed by 6. Empyema 1 (1.56) % 2 (3.12) % peritonitis where the oesophageal cricopharyngeal junction and then other

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 010 sites of anatomical narrowing. Plain extraction by esophagoscopy has been hemorrhage (4.68%) and fistula (1.56%). radiological imaging could determine the reported to be up to 87% of cases but in Figure 1 exact site of radio-opaque impacted our series it was 6.25% only10,14,15 . denture as well as soft tissue edema and The indexed series of impacted denture Preoperative complications predisposed air entrapment in cases of penetration, removal by cervical oesophagotomy or to post operative complications. Table 4 ulceration and perforation but could be of right posterolateral thoracotomy was limited value in detecting radiolucent 93% (60 out of 64 cases). This was one of Mostly, abscesses, perforations etc were dentures of acrylic resin origin. The the largest series reported. Routinely, repaired at time of surgery. Only in one radio-opaque wire clasps of the denture preoperative and post operative patient there was postoperative empyema could be seen. Barium contrast study of endoscopy was performed and a Ryles due repair leak. the esophagus performed in 60.93% of tube inserted routinely in all cases. cases helped in delineating the denture. Endoscopy performed for surgical cases Etiology could be attributed to delayed Sometimes it was contraindicated due to to check for preceding injuries, to detect presentation, size of the denture, wavy risk of aspiration. Radio-opaque dentures size, sharp edges, imbedded hooks or collets and presence of hooks or clasps. included barium acrylate, barium clasps, degree of impaction and to Delayed presentation was associated fluoride, bismuth glass and barium determine the methods of repair or with excessive edema, longitudinal sulfate and rarely lead foil amalgam. reconstruction9 . The surgical removal of ulcers, scratched mucosa, penetrated Chest compound tomography was impacted denture necessititated cervical mucosa due to horizontal rotation which conducted in 10.93% of cases to further esophagotomy or right posterolateral precluded safe extraction. Mortality (3 locate the denture and condition of the thoracotomy using synchronous direct cases) was attributed to mediastinitis, surrounding structures and soft tissues manipulation including horizontal sepsis and in one case hemorrhage from including pneumo-mediastinum, rotation, disimpaction and removal. aberrant left subclavian srtery following periesophageal fluid collection, Recently, by minimal access surgery with impacted denture removal extravasated luminal contrast or actual thoracoscopy, small impacted communication of an air filled esophagus esophageal denture could be removed16 . Although this study showed interesting and effusion pointing towards Delayed treatment of impacted denture in findings, limitations of a methodological perforation. Esophagoscopy was the the esopahgus leads to perforation, fistula nature could not be ignored. Among them investigation of choice for evaluating the and necrosis of oesophageal wall and were inter observer disagreement and the site, size, mucosal edema, ulceration, might result in mediastinitis and possibility of error in applicability of the impaction, abscess, perforation, fistula empyema. Operation at this stage could treatment by oesophagoscopic removal and occasionally of therapeutic value. produce higher incidence of leakage, and surgical removal. It was very Fluid obscuration, a ridged edematous sepsis and mortality12 . unlikely that the probability of incorrect mucosa, mucosal erosion with diagnosis and therapy could have been impending rupture, bacterial overgrowth The number of complications found intra different (i.e. of differential or non and trans location, and systemic sepsis operatively caused by impacted denture random type) in the group of eventful or were indications for cervical were more than suspected preoperatively. uneventful patients. Actually, the esopahgotomy or right posterolateral Scanning of the complications in this existence of a random error would tend to 6 , 1 2 , 1 3 thoracotomy . Successful study disclosed pre & intra operative revelence the strength of the association esophagoscopic extraction needed good complications abscess (25%), between swallowing of the partial visualization, use of shear forceps and perforation (23.43%), fistula (3.12%) denture and the event they created. considerable experience to prevent and hemorrhage (7.81%) but Post Therefore, the real association between esophageal perforation which may be up operative complications were scanty. swallowing of the partial denture and the to 23%4 . Successful impacted denture Abscess (7.81%) perforation (4.65%), subsequent events including complications and mortality might be stronger than found in our study. It was also important to consider that not all patients were examined at the beginning of their swallowing the denture. Thus the Figure-1 validity of the associations was restricted to the premise that the findings during operations represent the condition of the patients at time of presentation. Should these results be generalized with regard to other populations, the local conditions of the study should also be taken into account.

Despite its limitations, the presented results could represent a basis for the development of prospective investigations for a better understanding of the factors related to the prognosis for a patient with partial denture impaction.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 011 The duration of impactions, type of 739-51. with a sharp clasp, embedded in the symptoms, type, of the denture, age, the 2. HASHMI S, WALTER J, SMITH W, esophagus. Endoscopy 2007; 39 : E level of denture impaction, positive LATIS S. Swallowed partial 303-E304. radiographs and complications were the dentures. J Royal Soc Med 2004; 97 : 10. JASWAL A, JANA AK, HALDAR A, risk factors. 72-5. SIKDAR B, JANA U, NANDI TK : 3. WILLIAMS EW, CHAMBERS D, Role of prosthodontist with regard to A higher rate of complications with ASHMAN H, WILLIAM S, impacted esophageal dentures from morbidity and occasional mortality could JOHNSON J, SINGH P, an ENT perspective. J Indian not be used separately for the MCDONALD AH, REID M, Prosthodont Soc. 2007; 7 : 126-31. determination of a therapeutic conduct, a BROWN B. Oesophageal Foreign 11. JOSHI SW, PAWAR A, LAKHKAR correlation with the clinical data being Bodies at the university hospital of D. Denture in esophagus mimicking mandatory. the WEST INDIES. W E S T Carcinoma. Indian J Radiol Imaging This study illustrated that prompt Indian Med J 2005; 54 : 47-51. 2005; 15 : 229-30. management of an impacted denture 4. NWAORGU OG, ONAKOYA PA, 12. CHUA YKD, SEE JY, TI TK : leads to quick and uneventful recovery. SOGEBI OA , KOKONG DD, Oesophageal impacted denture When esophagoscopic removal of DOSUM OO. Esophageal impacted requiring open operation. Singapore impacted denture was not possible, dentures. J Natl Med Assoc. 2004; 96: Med J 2006; 47 : 820-1. immediate surgical extraction after 1350-3. 13. FIRTH AL, MOOR J, GOODYEAR esophagotomy through cervical or 5. SHIVKUMAR AM, NAIK AS, PWA, STRACHAN DR. Dentures transthoracic route along with PRASHANTH KB, HONGAL GI, may be radiolucent. Emerg Med J disimpaction, horizontal rotation and CHATURVEDY G : Foreign bodies 2003; 20 : 562-3. vertical traction should be performed2,4 . in upper digestive tract. Indian J 14. SAMARASAM I, CHANDRAN S, Otolaryngol and Head and Neck SHUKLA V, MATHEW G. A missing The major lesson learnt from the Surgery 2006; 58 : 63-8. denture's misadventure. Dis published literature was that a partial 6. CHEN CY, LEE SC, CHEN CW, Esophagus 2006; 963-5 dentures being small were easy target for CHEN JC: Denture Mis swallowing 15. SUTCLIFFE RP, ROHATGI A, accidental swallowing and dangerous in the sliding esophageal hiatal hernia FORSHAW MJ, YASON RC. due to their configuration, dimension and mimics esophageal perforation. J. Recurrent laryngeal nerve palsy due over all rotation in the esophagus. The Formos Med Assoc 2008; 107 : 663- to impacted denture plate in the hazard of small side plate and hook or 6. thoracic oesophagus. Case report. clasp had long been recognized. The 7. TRESKA TP, SMITH CC. World J Emerg Surgery 2007; 2 : 30. principles of direct and indirect retention Swallowed Partial denture. Oral Surg 16. PALANIVELU C, RANGARAJAN and cross arch bracing were important. Oral Med Oral Pathol 1991; 72 : 756- M, PARTHASARATHI R, Medical personnel should be aware of 7. SENTHILNATHAN P. multiple hazards. 8. SINGH RK, VARSHNEY S, BIST Thoracoscopic retrieval of a 'smiling' SS, GUPTA N : An iatrogenic foreign body from the proximal esophageal perforation with denture : oesophagus. An impacted denture. Reference How does it happen ? The Internet J Surg Laparoscopy, Endoscopy and 1. TAMURA N, NAKAJIMA T, Head and Neck Surg 2008; 2 : 2. Percutaneous Techniques 2008 : 18 : MATSUMOTO S, OHYAMA T, 9. MORIWAKI Y, SUGIYAMA M, 325-8. OHASHI Y. Foreign bodies of dental ARATA S, TOYODAH, KOSUGE T, origin in the air and food passages. Int SUZUKI N : Therapeutic strategy for J Oral Maxullofac Surg 1986; 15 : removal of a large dental prosthesis

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

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 012 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Influence of McInnes bleaching agent on 1 Baljeet Singh Hora 2 Amandeep Kumar hardness of enamel and the effect of 3 Rajinder Bansal 4 Manu Bansal remineralizing gel GC tooth mousse on 5 Taruna Khosla 6 bleached enamel -An in vitro study Anupam Garg 1 MDS, Professor & HOD 2 MDS, Senior Lecturer Abstract 3 MDS, Professor Aim: To evaluate the influence of bleaching agent (McInnes solution) on the micro hardness of 4 MDS, Senior Lecturer enamel and the effect of remineralizing gel (GC Tooth Mousse) on bleached enamel surface. 5 1 st Year PG Student 6 Materials & Method: Twenty maxillary anterior teeth were selected, cut sagittaly, subjected to BDS, Lecturer Vickers microhardness test for baseline. McInnes solution was applied & samples were again Dept. of Conservative Dentistry & Endodontics Guru Nanak Dev Dental College tested for microhardness .Then GC Tooth Mousse was applied as remineralizing gel for 7 & 14 & Research Institute, days and then again subjected for microhardness test. Results: All the samples showed a decrease in the microhardness after two cycles of bleaching Address For Correspondence: which was statistically significant. After application of GC Tooth Mousse the samples showed a Dr. Amandeep Kumar (Senior Lecturer) Dept. of Conservative Dentistry & Endodontics marked increase in microhardness after seven and fourteen days. Guru Nanak Dev Dental College Conclusions: McInnes bleaching agent does decreases the enamel microhardness by causing & Research Institute, Lakhmirwala Road, enamel demineralization and GC Tooth Mousse used in the study causes an increase in the Sunam - 148028(Punjab) microhardness of bleached enamelby maintaining a high gradient of calcium and phosphate ions Email.ID : [email protected] at the enamel subsurface. Ph No : 09216913145 Submission : 11th August 2011 Key Words th Amorphous calcium phosphate, bleaching, casein phosphopeptide, McInnes bleaching solution, Accepted : 18 January 2012 Vickers hardness number. Quick Response Code Introduction The efficacy of bleaching agents is The desire to have white teeth and thus a validated by many in vitro and in vivo more pleasant smile has become an studies.7,8 nevertheless, these bleaching important esthetic need of the agents should be used only after carefully patient1 .Tooth bleaching has been evaluating the adverseeffects on dental reaching great popularity as a result of the tissues1 . In fact, the effect of esthetic demands imposed by society; it bleachingprocedures on enamel is still has been indicated for teeth discoloured controversial and needs tobe Among laboratory studies, surface by aging, trauma, endodontic treatment, elucidated9 .Increased frequency of acid microhardness measurement is a simple ingestion of colored foods and beverage, exposure tends to alter the total method to determine the mechanical tobacco, and naturally discoloured demineralization/ remineralisation properties of enamel and dentin surface teeth2 .The successful outcome of any of amounts resulting in greater amounts of and it is not only related to the loss or gain the applied modalities mainly depends on mineral loss. of the mineral content of the dental the etiology, diagnosis, and proper Although a reduction in enamel structure, but also to the composition of selection of bleaching materials and the microhardness has been reported,10,13 it the applied product and their pH values correct clinical technique3 . must be assumed that this alteration and the presence of other components in 1 The technique of bleaching or whitening reflects not only the bleaching procedure commercial bleaching agents . teeth was first described in 1877.4 but also the pH of the formulation used7 . Based on these observations the present Hydrogen peroxide was thought to be In fact, some studies have found no study was undertaken to investigate the used for the first time in 1884 and has significant differences in enamel influence of McInnes bleaching agent on since been established as the most microhardness after bleaching with enamel microhardness and subsequent effective bleaching agent because of its hydrogen peroxide in high remineralisation by CPP-ACP on unique ability to penetrate the tooth concentrations.14,15 bleached enamel. structure5 . Later it was McInnes who Recently casein phosphopeptide- reported a technique where hydrogen amorphous calcium phosphate (CPP- Materials And Methods: peroxide, hydrochloric acid and ethyl ACP) derived from cow's milk has been A total of 20 freshly extracted maxillary ether were used. This technique has been reported to reduce the demineralization anterior teeth were selected. The teeth found to be successful for bleaching the process of the tooth structure and were then cut sagittaly using diamond teeth of patients with endemic fluorosis.6 enhance the remineralisation process16 . disc and the buccal surface were

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 013 impregnated in the cold cure acrylic resin 1) First cycle of bleaching: The for statistical significance. The changes (DPI) facing upwards (Fig 1). Using the bleaching agent thus prepared was in microhardness at different times of plastic moulds the resin were made in to applied to the enamel surface using a assessment were analysed using the pellets. These specimens were then kept cotton applicator for five minutes (Fig 3). "ONE WAY ANOVA". in artificial saliva to prevent dehydration. It was then washed under deionized In this study these comparisons were The samples were then rinsed in water water, damped dry with absorbent paper done between the groups: and dabbed dry with absorbent paper and and then subjected for microhardness. 1) In the first comparison baseline was then subjected to baseline microhardness After this, the samples were stored in compared with bleaching and test using Vickers Micro Hardness Tester artificial saliva for 24 hours to prevent remineralisation cycles (Table 1). (AKASHI-MVK-H2). dehydration. 2) The next comparison was done Fig 1: Showing sectioned specimen with buccal surface 2) Second cycle of bleaching: Again between the 1st cycle and 2nd cycle impregnated in the cold cure acrylic resin facing upwards. after 24 hours, the second application of of bleaching (Table 2). bleaching agent was carried out as 3) The third comparison was done described earlier and the microhardness between the 2nd cycle of bleaching values were recorded. and cycles of remineralisation (Table Fig 3: Showing the application of McInnes Bleaching 3). agent. 4) The next comparison was done between the 1st and 2nd cycle of remineralisation (Table 4). The recorded values were then subjected to statistical analysis.

Discussion: The test specimens were placed on the The lightening of the colour of a tooth stage of tester and stabilized (Fig 2). through the application of a chemical Then area to indent was selected by agent to oxidize the organic pigmentation focusing with 10x objective lens.After in the tooth is referred to as 'Bleaching'. this the load of 100 g was applied on the Bleaching or tooth whitening dates back surface of specimen for 30 seconds, Remineralisation process to the 18th century. In early nineteenth never close to any edge of the specimen. 1) First cycle of Remineralisation: GC century, hydrogen peroxide alone and in The indentation formed was viewed and Tooth Mousse (Recaldent) was applied combination with other materials, was measured with 10x objective lens. The with cotton applicator tips on the post used as bleaching agent17 . average microhardness of the specimen bleached samples, every day for seven It was in the year 1966, that McInnes was determined from three indentations days with minimum application time of reported a technique that combined to avoid any discrepancy, since the three minutes (Fig 4). The samples were hydrochloric acid and hydrogen peroxide enamel surface has a curvature. The then washed under deionized water, to remove fluorosis stains. He used a procedure was repeated for all the twenty stored in artificial saliva for next seven solution of five parts of 30% hydrogen specimens. days and then subjected for peroxide, five parts 36% hydrochloric Fig 2: Showing the test specimen was placed on the stage microhardness test as described earlier. acid and one part diethyl ether and of Vickers Micro Hardness Tester (AKASHI-MVK-H2). 2) Second cycle of remineralisation: applied the solution with a cotton Following this, GC Tooth Mousse was wrapped toothpick to the areas of the applied for seven more days and at the teeth affected by the stain. After 10 to 15 end of fourteen days the samples were minutes the teeth were washed with water again subjected for microhardness and neutralized with a sodium testing using the same procedure as bicarbonate paste. described earlier. It has been reported18 that McInnes Fig 4: Showing the application of Remineralising gel (GC bleaching technique were specifically Tooth Mousse) recommended for the treatment of teeth exhibiting endemic dental fluorosis because of its superficial nature, easy manipulation and its quality of being less Bleaching process expensive when compared to other After recording the baseline hardness commercially available agents like values McInnes bleaching was prepared carbamide peroxide19 .In the present study using mixture of 1 ml of 36% McInnes bleaching agent was selected as hydrochloric acid (S D Fine Chem. it was commonly used in clinical set up Limited, Mumbai), 1ml of 30% hydrogen for treating dental fluorosis. peroxide (S D Fine Chem. Limited, The effects of bleaching on enamel Mumbai) and 0.2 ml of diethyl ether (S D microhardness are probably related to Fine Chem. Limited, Mumbai) which is Results: their pH, as well as alteration of the mixed in the ratio of 5:5:1. The mixture The data obtained from the following test organic matrix of enamel under the was prepared freshly in a dappen dish were subjected for statistical analysis. A chemical action of hydrogen peroxide. before each application. "P" value of 0.05 or less was considered The strong oxidising effect of hydrogen

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 014 Table 1 show that baseline microhardness values when compared with first cycle of bleaching decreased by a small margin Microhardness measurement of tooth of 0.4% which was not significant (P=0.034) and a decrease of 4% which was highly significant (P<0.001) when compared with second cycle of bleaching. But no significant difference was found when baselines microhardness values were material can be done in three different compared with remineralisation values in hardness. ways like; Knoop's hardness number(KHN), Vicker's hardness N Mean Std. Std. 95% Confidence Interval for Mean Minimum Maximum number (VHN), andBrinnel's hardness Deviation Error Lower Bound Upper Bound number(BHN).In the present study Vicker hardness number was chosen over BASELINE MICROHARDNESS 20 319.09 27.983 6.257 305.99 332.18 274 355 Knoop's hardness number because a 1ST CYCLE OF BLEACHING 20 317.88 27.897 6.238 304.82 330.93 273 354 square shape of indent obtained in VHN was easy and accurate to measure. Even 2ND CYCLE OF BLEACHING 20 293.61 22.616 5.057 283.02 304.19 267 345 the minute changes in the square shape 1ST CYCLE OF REMINERALISATION 20 314.99 27.820 6.221 301.97 328.01 271 353 indent after the test can be easily detected, whereas the Knoop hardness 2ND CYCLE OF REMINERALISATION 20 319.46 28.046 6.271 306.33 332.58 275 356 test gave a rhomboid shape indentation with opposing surfaces parallel to each Table 2 shows the comparison in the microhardness values between the first and second cycle of bleaching which showed a 3% decrease and was significant (P<0.05). other and detecting the error was difficult. N Mean Std. Std. 95% Confidence Interval for Mean Minimum Maximum The average hardness valuefor enamel is Deviation Error Lower Bound Upper Bound in the range from 270 to 350 KHN range or from 250 to 360 VHN range. In this 1ST CYCLE OF BLEACHING 20 317.88 27.597 6.238 304.82 330.93 273 354 study the microhardness values were in 2ND CYCLE OF BLEACHING 20 293.61 24.616 5.057 283.02 304.19 267 345 the range from 266.7 to 360 VHN which was within standard range. Table 3 shows 2.8% & 3.5 % increase in Vicker's hardness number and was significant (P<0.01) when the 2nd cycle of One of the factors that affect the hardness bleaching was compared with 1st and 2nd cycle of remineralisation respectively measurement was the specimen's preparation, because any tilt or not flat N Mean Std. Std. 95% Confidence Interval for Mean Minimum Maximum surface would yield a too large an indentation and thus a smaller Vickers's Deviation Error Lower Bound Upper Bound hardness measurement. Hence three 2ND CYCLE OF BLEACHING 20 293.61 22.616 5.057 283.02 304.19 267 345 indentations were made to avoid any operational bias, then average of these 1ST CYCLE OF REMINERALISATION 20 314.99 27.820 6.221 301.97 328.01 271 353 indentations were taken for statistical 2ND CYCLE OF REMINERALISATION 20 319.46 28.046 6.271 306.33 332.58 275 356 analysis. Various techniques have been followed to Table 4 showed an increase in the VHN by 1% and was significant (P<0.05) when comparison was done between first and neutralize the effect of bleaching; the use second cycle of remineralisation of baking soda, prophylactic paste containingfluoride, APF gel and use of N Mean Std. Std. 95% Confidence Interval for Mean Minimum Maximum copious amount of water23 . In the present Deviation Error Lower Bound Upper Bound study GC Tooth Mousse has been used, which is commercially available Casein 1ST CYCLE OF REMINERALISATION 20 314.99 28.520 6.221 301.97 328.01 271 353 Phosphopeptide (CPP), stabilized 2ND CYCLE OF REMINERALISATION 20 319.46 27.416 6.271 306.33 332.58 275 356 amorphous calcium phosphate (ACP) product24 . GC Tooth Mousse was developed by Prof peroxide on the organic matrix of teeth significant. Reynolds at the University of Melbourne plays a predominant role in the When the bleaching cycle was repeated 25 in 1998 .CPP stabilizes ACP and forms 10,12 after 24 hours (the second cycle of alterations observed after bleaching . Nano complexes with ACP at the tooth bleaching) there was significant Hydrogen peroxide as diffuses through surface thereby providing a reservoir of reduction in the VHN, which shows 4% the enamel and dentin releases free calcium and phosphate ions which decrease in the microhardness, which radicals, reactive oxygen molecules and favours mineralization.CPP also buffers was significant. hydrogen peroxide ions that converts the pH of plaque, depresses Artificial saliva was used for storing the long chained dark colored chromophores demineralisation and enhances specimens in between the bleaching in to light colored chromophores. This remineralisation which also results in the effect can probably be increased by low cycles, because it is believed that 26 anticariogenic property of CPP-ACP . pH of the bleaching agent, causing artificial saliva contributed to a slight subsequent alterations in the mineral increase in the microhardness, after 21 The values obtained after the application composition, decreasing enamel and demineralisation . of remineralizing solution (second cycle 20 The amount of demineralisation of dentin microhardness . of remineralisation) showed an increase enamel by bleaching was assessed by All the samples used in the study showed in VHN by 1%. microhardness tester. Microhardness test no change in the microhardness Although most of the remineralizing was selected mainly because it was immediately after first cycle of solutions were supersaturated with bleaching. Around 0.4% reduction in the economical compared to other tests and 22 respect to amorphous and crystalline microhardness was seen which was not was easily available . calcium phosphate phases, the solutions

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 015 which were stabilised by the CPP-ACP, bleaching system on the integrity of 18. McEnoy SA. Chemical agents' for such as in GC Tooth Mousse, the enamel and dentine Journal of removing intrinsic stains from vital spontaneous precipitation of calcium Dentistry 32(7) 581-590. teeth, I: Technique development. phosphate did not occur and thus the 8. Papathanasiou A, Kastali S, Perry RD Quintessence Int. 1989;20:323-8. longer the duration of solution in contact &Kugel G (2002) Clinical evaluation 19. Chen JH, Xu JW, Shing CX. with the teeth, the better was the of a 35% hydrogen peroxide in-office Decomposition rate of Hydrogen remineralisation27 . whitening system Compendium of Peroxide bleaching agent under According to manufacturer's instructions Continuing Education in Dentistry various chemical and physical for the maximum benefit the solutions of 23(4) 335-344. condition. J Prosthet Dent. GC Tooth Mousse should be left on the 9. de Oliveira R, PaesLeme AF 1993;69:46-8. tooth surface as long as possible. Hence &Giannini M (2005) Effect of 20. Borges AB, Yui KCK, Avila TC'D, in the present study the excess GC Tooth carbamide peroxide bleaching gel Takahashi CL, Torres CRG, Borges Mousse was wiped off after three minutes containing calcium or fluoride on ALS: Influence of remineralizing leaving the residues on the samples and human enamel surface gels on bleached enamel then stored in artificial saliva. microhardness Brazilian Dental microhardness in different time Journal 16(2) 103-106. intervals. Oper. Dent Conclusions: 10. Seghi RR &Denry I (1992) Effects of 2010;35(2):180-186. From the above study it can be concluded external bleaching on indentation and 21. Chow LC, Takagi S, Carey CM, Sieck that abrasion characteristics of human BA: Remineralisation effects of a ?McInnes bleaching agent does enamel invitro Journal of Dental two- solution fluoride mouthrinse: decreases the microhardness of Research 71(6) 1340-1344. An in situ study.J Dent Res 2000; enamel by causing enamel 11. Attin T, Kocabiyik M, Buchalla W, 79(4):991-995. demineralisation. Hannig C & Becker K (2003) 22. White DJ, Faller RV, Bowman WD. ?GC Tooth Mousse used in the study Susceptibility of enamel surfaces to Demineralization and causes an increase in the demineralizationnafter application of remineralization evaluation microhardness of bleached enamel by fluoridated carbamide peroxide techniques--added considerations. J maintaining high gradient of calcium gels.Caries Research 37(2) 93-99. Dent Res. 1992;71:929-33. and phosphate ions at the enamel 12. Pinto CF, Oliveira R, Cavalli V 23. Lopes GC, Bonissoni L, Baratieri subsurface. &Giannini M (2004) Peroxide LN, Vieira LC, Monteiro S Jr: Effect bleaching agent effects on enamel of bleaching agents on the hardness Refrences: surface microhardness, roughness and morphology of enamel. J 1. Ameri H, Ghavamnasiri M, Akram A: and morphology.Brazilian Oral EsthetRestor Dent 2002;14(1):24-30. Effect of different bleaching time Research 18(4) 306-311. 24. Araujo EM, Baratieri LN, Vieira LC, intervals on fracture toughness of 13. Lewinstein I, Fuhrer N, Churaru N Ritter AV: In situ effect of 10% enamel. J Cons Dent 2011;14(1):73- &Cardash H (2004) Effect of carbamide peroxide on 75. different peroxide bleaching microhardness of human 2. Camargo SEA, Valera MC, Camargo regimens and subsequent fluoridation enamel:function of time. J CHR, Mancini MNG, Manezes MM: on the hardness of human enamel and EsthetRestor Dent 2003;15(3):166- Penetration of 38% Hydrogen dentin.Journal of Prosthetic Dentistry 173. Peroxide into the PulpChamber in 92(4) 337-342. 25. Shen P, Cai F, Nowicki A, Vincent J, Bovine and Human Teeth Submitted 14. Park HJ, Kwon TY, Nam SH, Kim HJ, Reynolds EC: Remineralisation of to Office Bleach Technique. J Kim KH & Kim YJ (2004) Changes enamel subsurface lesions by sugar- Endod2007;33(9):1074-1077. in bovine enamel after treatment with free chewing gum containing casein 3. Watts A, Addy M: Tooth a 30% hydrogen peroxide bleaching phosphopeptide-amorphous calcium discoloration and staining: A review agent.Dental Materials Journal 23(4) phosphate. J Dent Res of the literature. Br Dent 517-521. 2001;80(12):2066-2070. J.2001;190(6):309-316. 15. Sulieman M, Addy M, MacDonald E 26. Reynolds EC, Cain CJ, Webber FL, 4. Suleiman M, Addy M, Macdonald E, & Rees JS (2004) Theeffect of Black CL, Riley PE, Johnson IH, Rees JS: The bleaching depth of a hydrogen peroxide concentration on Perich JW: Anticariogenicity of 35% hydrogen peroxide based in- the outcome of tooth whitening: An in calcium phosphate complexes of office product: A study in vitro. J Dent vitro study.Journal of Dentistry 32(4) tryptic casein phosphopeptide in the 2005;33(1):33-40. 295-299. rat. J Dent Res 1995;74(6):1272-1279. 5. Goldstein R, Garber D: Complete 16. Panich M, Poolthong S: The effect of 27. Spalding M, Taveira LA, de Assis Dental Bleaching. casein phosphopeptide-amorphous GF: Scanning electron microscopy Chicago,Quintessence, 1991; pp. 2, calcium phosphate and a Cola soft study of dental enamel surface 12, 75, 94.McEnoy SA. drink on In vitro Enamel Hardness. J exposed to 35% hydrogen peroxide: 6. Chemical agents' for removing Am Dent Assoc 2009;140:455-460. Alone, with saliva, and with intrinsic stains from vital teeth, I: 17. VimalSikri: Tooth discoloration and 10%carbamide peroxide. J Technique development. bleaching. Textbook of operative EsthetRestor Dent 2003;15(3):154- Quintessence Int. 1989;20:323-8. dentistry 2ndedi. 164. 7. Sulieman M, Addy M, Macdonald E & Rees JS (2004) A safety study in Source of Support : Nill, Conflict of Interest : None declared vitro for the effects of an in-office

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 016 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Train yourself to work without Pain - 1 Archana Nagpal 1 Professor & Head Department of Prosthodontics Maintenance of Musculoskeletal Health in Himachal Dental College Clinical Practice. Sundernagar, Distt Mandi (H.P.) Address For Correspondence: Abstract Dr. Archana Nagpal Professor & Head Musculoskeletal disorders are on a rise in dentistry. Extended working hours, prolonged standing Department of Prosthodontics or unsupported sitting, bad postures, improper work habits and instruments that are difficult to Himachal Dental College handle etc. are some factors that contribute to this problem. As result certain nerve and muscle Sundernagar, Distt Mandi (H.P.) problems may arise that could prevent dentists from providing highest quality of service and st threaten their professional careers. This article elaborates some tips to improve posture and Submission : 21 August 2011 explains certain stretching exercises that can be performed during breaks to prevent strain injuries Accepted : 17th January 2012 during work.

Key Words Quick Response Code Musculoskeletal injuries, Posture, stretching exercises, Dentistry.

Repetitive strain injuries are on a rise in vessels, cause excessive strain on dentistry. The positions in which dentists muscles, and cause wear and tear on the repeatedly put themselves through their joint structures. So working with good work, place them at great risk for posture is very important. developing musculoskeletal disorders. comfortable posture. Generally Majority of dentists and dental hygienists Tips For Working With Good Posture1 patients should be placed in a semi experience some type of musculoskeletal 1. One must work close to his/ her body. supine position for mandibular pain in their shoulders and neck, hand and The dentist's chair must be positioned procedures and a supine position for wrists, lower back, forearms and elbows. close to the patient to minimize maxillary procedures. These problems decrease work forward bending thus reducing stress 7. The work place should not be too cold performance, job satisfaction and affect on the back, shoulders and arms. because this will decrease circulation their professional careers. Very little 2. Always try to maintain erect posture and blood flow to the extrimities attention is given on impact of dental with feet flat on the floor. aggrevating the previously existing work on development of nerve and 3. Alternate work positions between problems. muscle pathologies. To protect their own sitting, standing and side of the health, dentists should seek out and patient. This allows certain muscles Certain Exercises That Can Be receive education about musculoskeletal to relax while shifting stress onto Performed During Short Breaks2 health, and injury prevention during other muscles and increasing Longer work periods without breaks can work. The purpose of this article is to circulation. lead to musculoskeletal disorders. Quick discuss various postural strategies and 4. Height of dentist's chair and patient's stretch exercises can be performed in and stretching and strengthening techniques chair should be adjusted to a out of operatory and can be incorporated during breaks to ensure long term comfortable level. If the dentist's into daily routine that facilitates balanced comfort, efficiency and ease in dental chair is too low and patient's chair is musculoskeletal health. These exercises practice. too high, it causes the dentist to raise can be performed easily while anesthesia his shoulders and leads to neck is taking effect or while wearing gloves The Importance Of Posture problems and pinched nerves. If the .Some such exercises are as follows. Proper posture is important to perform position is other way round excessive A. Neck and shoulder combination work effectively and avoid chronic injury bending of neck and wrists leads to - With the elbow at shoulder height and at during work. Some improper postures neck and wrist problems. 90O angle, gently pull the arm across the that are taken by dentists are working 5. Light adjustment should be proper so front of the body with opposite arm. Look with neck tilted to one side, elevated that one does not have to strain his over the shoulder being stretched and shoulders, excessive twisting, too much neck to see inside the patient's mouth. hold for two to four breathing cycles. forward bending and working in same 6. If the chair can be adjusted into a Repeat with the other side. position for more than half an hour. These horizontal reclining position, it B. The untwister - with the knees positions put pressure on nerves and allows the dentist to work in a more wider than the shoulder width, bend to the

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 017 discontinue stretching if it increases pain. ?Perform stretches in both directions. ?Hold the stretches to 2-4 breathing cycles. ?Slowly release the stretch and return to a neutral zone. ?Begin the exercises gradually, starting with minimum number of repetitions.

In addition, aerobic exercises should be performed 3-4 times a week for atleast twenty minutes. Various stress management techniques like breathing techniques, massage, meditation or yoga can be practiced at home.

Conclusion Work related pain is common among dental professionals. This problem can be managed by using a multi factorial approach that includes preventive education, postural and positioning strategies, proper selection and use of ergonomic equipment and frequent breaks with stretching and postural strengthening techniques. It is important that dentist incorporate these strategies into practice to facilitate musculoskeletal health that will enable longer, healthier careers; increase productivity, provide safer workplace and prevent musculoskeletal disorders

Refrences 1. Graham Colin . Ergonomics in dentistry ; 2002 . 2. Valachi Bethany, Valachi Keith . Preventing musculoskeletal disorders in clinical dentistry. J Am Dent.asoc . 2003 ; 134 : 1604 -1612.

left side, resting full body weight through and down squeezing the shoulder blades the left elbows on the left knee. Stretch downward and together. Hold for long the right arm overhead and look towards breathing Cycle. Repeat five times. the ceiling. Hold for two or four breath cycles. Repeat on the other side. Safety Tips During Streches2 C. Upper trapezius stretch- anchor To avoid injury, following points must be the right hand behind the seat of the kept in mind: operator chair, gently bring the left ear ?Avoid stretches in painful range and towards the left armpit. Hold for a two to four breathing cycles. Repeat on other side. D. Downward squeeze- assume a neutral head posture(ears over the shoulders) do not let the head move forward throughout the exercise. Lift the Source of Support : Nill, Conflict of Interest : None declared chest upwards, position the arms at sides with fingers pointing upwards and palms facing forwards. Roll the shoulders back

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 018 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 The Authenticity Of Use Of Gingival Crevicular 1 Harinder Gupta 2 Ruchika Arora Blood As An Early Indicator Of Elevated 3 Monika Kamboj

Systemic Blood Glucose Levels In 1 Professor And Head 2,3 MDS Student Undiagnosed Diabetes Mellitus Patients Dept. Of Periodontics Govt. Dental College And Hospital, Amritsar.

Abstract Background & Objectives : The field of periodontal medicine can help in early detection of certain Address For Correspondence: chronic systemic diseases like diabetes mellitus in a more easy and simplified manner. Diabetes Dr. Ruchika Arora, MDS Student, mellitus is undiagnosed in approximately ½ of the patients actually suffering from the disease. In Dept. Of Periodontics, Govt. Dental College & Hospital, Amritsar, Punjab. addition, the prevalence of DM is more than twice as high as in patients with periodontitis when Email ID : [email protected] compared to periodontally healthy subjects. Thus, a high number of patients with periodontitis may have undiagnosed DM. The purpose of the present study was to evaluate whether blood oozing from gingival crevice during routine periodontal examination can be used for determining glucose levels. Submission : 24th September 2011 Methods : In the present study 50 patients( 23 diabetic and 27 non-diabetic) with bleeding on Accepted : 19th January 2012 probing were selected. Blood oozing from the gingival crevices of anterior teeth following periodontal probing was collected with a glucose self-monitoring device (one touch ultra 2, Johnson & johnson) and the blood glucose levels were measured. At the same time, capillary finger-stick blood was taken for glucometric analysis. Quick Response Code Results : The patient's blood glucose values ranged from 69 mg/dl to 374 mg/dl. The comparison between gingival crevicular blood, finger-prick blood showed a very strong correlation with an r value of 0.988 ( p < 0.001) Conclusion : The data from this study has shown that GCB collected during diagnostic periodontal examination can be an excellent source of blood for glucometric analysis.

Key Words DM, gingival crevicular blood, capillary finger prick blood.

Introduction periodontally healthy patients. Thus, a Department of Periodontics, Numerous advances in preventive high number of patients with Government Dental College & Hospital, medicine have provided methods for periodontitis may have undiagnosed Amritsar, Punjab. The study was detecting serious chronic diseases which DM3 . performed randomly on a total of fifty presently threaten our public health. patients including 26 males and 24 Today's clinician must direct his efforts to The ability to collect gingival crevicular females with evident bleeding on the “gray” areas of undiagnosed blood (GCB) for glucose measurement probing. asymptomatic disease as well as to the using readily available glucometers that The following criteria were considered treatment of existing disease. The early measure glucose in a few seconds seems for the selection of subjects: detection of subclinical disease by to be a good method of screening diabetic advanced screening procedures is patients. Several studies3,4,6,7,8 in the past Selection Criteria making considerable progress in the field have reported significant correlation 1. Patients with evident bleeding on of preventive medicine to reduce the between GCB & CFB (capillary finger- probing. nonstop progression of certain chronic stick blood) but few fail to accept this diseases. The field of periodontal correlation5 . So, the aim of our study is to Exclusion Criteria medicine can also help in early detection evaluate the authenticity of use of 1. Patients with requirement for of certain chronic systemic diseases like gingival crevicular blood as an early antibiotic premedication. diabetes mellitus in a more easy and indicator of elevated systemic blood 2. Patients with disorder that was simplified manner1 . Diabetes mellitus is glucose levels in diabetes mellitus accompanied by an abnormally low 1 undiagnosed in approximately /2 of the patients. or high haematocrit .For example, patients actually suffering from the Polycythaemia Vera, anaemia, and disease. The prevalence of DM patients is Material And Methods dialysis. more than 2 times as high in patients with For this study, subjects were selected 3. Patients with intake of substances that periodontitis when compared to randomly from the general OPD of the interfere with the coagulation system for example, Coumarin derivatives,

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 019 Non-steroidal anti-inflammatory to be diabetic by our measurements low amount of blood necessary to drugs or Heparin. were aware of their diabetic status. perform the analysis. Moreover, the 4. Sites with suppuration. The diabetic status of the unaware 8 technique described is more familiar and patients was further confirmed by less traumatic to the patient than a finger Periodontal examination included intravenous laboratory method of puncture4 . measurement of probing depth, glucose measurement which is attachment level, and bleeding on considered as the gold standard for blood The strong correlation obtained in the probing. A site with more profuse glucose measurements. present study on comparison between the bleeding was chosen for collecting the various blood glucose measurements gingival crevice blood (GCB) sample on The patients were further divided into indicates the feasibility of using the anterior segment of the mouth. The two groups- periodontal sulcular blood as an area was isolated with cotton rolls to alternative to the FP blood in accordance prevent saliva contamination and dried Group I- Diabetic group (n=23) and to the previous studies. On analysis of our with compressed air. Probing was Group II- Non-Diabetic group (n=27) study, finger prick capillary blood repeated until a sufficient amount of and intra group analysis was done. glucose showed a slightly higher mean blood appeared in the gingival crevice. value than gingival crevicular blood The one touch ultra 2, Johnson & Johnson On comparison of gingival crevicular glucose mean value, may be due to was used according to the manufacturer's blood glucose and finger-prick blood contamination of GCF which dilutes the recommendations. Immediately after glucose measurements of Group I glucose concentration producing lower measuring glucose levels in GCB, a patients, the Pearson's correlation measurements in GCB. capillary fingerstick blood (CFB) sample coefficient showed r-value = 0.977 and a was drawn from the index finger using a P-level <0.001. Conclusion disposable sterile lancet. Within the limitations of this study, the On comparison of gingival crevicular following conclusion can be made that Statistical analysis using Pearson's blood glucose measurements and finger- GCB collected during diagnostic correlation coefficient was performed to prick blood glucose measurements of the periodontal examination may be an assess the correlation between the Group II patients, the Pearson's excellent source of blood for glucometric glucose measurements in the gingival correlation coefficient showed r-value = analysis. The technique is safe, easy to blood samples and those obtained by 0.875 and a P-level of <0.001. perform, and comfortable for the patient finger puncture. Paired t-test was and therefore, helps to increase the performed to test the significance of the Discussion frequency of diagnosing diabetes during difference in glucose level between the Since periodontal inflammation with or routine periodontal therapy which gingival and finger readings. without complication factor of DM is provides a more objective indicator for known to produce ample extravasate of referral to physicians than traditional Results blood during diagnostic periodontal methods. Thus, the dentist may increase The range of the gingival crevicular examination (Ervasti 1985)2 no extra his importance as a member of the health blood glucose measurements varied from procedure, e.g. finger puncture with a team by participating in the search for 69mg/dl to 374 mg/dl, with a mean value sharp lancet is necessary to obtain blood undiagnosed asymptomatic DM. of 154.7 mg/dl and a standard deviation for glucometric analysis. Even in the case of 85.77mg/dl. of very low gingival crevicular bleeding, References a glucose measurement is possible with 1. Stein GM, Nebbia AA. A chairside The range of the finger-prick blood the use of self monitoring device (Ultra method of diabetic screening with glucose measurements varied from 77 Touch 2,Johnson & Johnson), due to the gingival blood. Oral Surg Oral Med mg/dl to 372 mg/dl, with a mean value of 157.4 mg/dl and a standard deviation of 84.93 mg/dl.

On comparison of gingival crevicular blood glucose and finger-prick blood Table 2 shows the comparison in the microhardness values between the first and second cycle of glucose measurements, finger prick bleaching which showed a 3% decrease and was significant (P<0.05). capillary blood glucose showed a higher mean value (157.4 mg/dl) than gingival Sulcular Blood Finger Blood Comparison Correlation crevicular blood glucose mean Overall (n=50) value(154.7 mg/dl) and showed r = 154.70 ± 85.77 157.48 ± 84.93 t = 1.469; r = 0.988; 0.988; p < 0.001, thus giving statistically p = 0.148NS p < 0.001* significant results. Diabetics (n = 23) 224.52 ± 82.29 230.30 ± 75.10 t = 1.505; r = 0.977;

On analysis of the glucose p = 0.146NS p < 0.001* measurements of the randomly Non-Diabetics (n= 27) included 50 patients, 23 patients were 95.22 ± 12.13 95.44 ± 11.50 t = 0.194; r = 0.875; found to be diabetic and 27 patients p = 0.847NS p < 0.001* were non diabetic. And surprisingly, only 15 patients out of the 23 diagnosed

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 020 Oral Pathol 1969; 27: 607-612. 2. Ervasti T, Knuuttila M, Pohjamo L, Haukipuro K. Relation between control of diabetes and gingival bleeding. J Periodontol 1985; 56: 154-57. 3. Parker RC, Repley JW, Isley W. Gingival Crevicular Blood for assessment of blood glucose in diabetic patients. J Periodontal 1993; 64: 666-672. 4. Beikler T, Kuczek A, Petersilka G, Flemming TF. In-dental-office screening for diabetes mellitus using gingival crevicular blood. J Clin Periodontol 2002;29: 216-218. 5. Muller HP, Behbehani E. Methods for measuring agreement: glucose levels in gingival crevice blood. Clin Oral Invest 2005; 9: 65-69. 6. Khader YS, Judeh A, Rayyan M. Screening for type 2 diabetes mellitus using gingival crevicular blood. Int J Dent Hygiene 2006; 4: 179-182. 7. Ardakani MR, Moeintaghavi A, Haerian A, Ardakani MA. Correlation between levels of sulcular and capillary blood glucose. J Contemp Dent Pract. 2009; 10: 10- 17. 8. Strauss SM, Wheeler AJ, Russell SL, Gluzman R. The Potential use of gingival crevicular blood for measuring glucose to screen for diabetes: An Examination based on characteristics of the blood collection site. J Periodontal 2009; 80: 907-914.

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

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 021 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Chronic Periodontitis And Oxidative Stress - A 1 Abdul Samad Aziz 2 M. G. Kalekar Biochemical Study 3 T. Benjamin 4 A. N. Suryakar Abstract 5 Milsee Mol J. P Periodontitis is a known inflammatory disease of the peridontium; the tissue that surrounds and supports the teeth. Periodontitis may be associated with oxidative stress. The aim of the study was 1 Ph. D Student to evaluate and compare the biochemical oxidative stress markers in patients with chronic 2 Associate Professor periodontitis and healthy controls. The biochemical parameters used in the study were total Department of Biochemistry, 3 Head antioxidant capacity (TAOC), antioxidant enzymes like RBC- superoxide dismutase (RBC-SOD), Department of Dentistry, glutathione peroxidase (GPx). Vitamin C a water soluble antioxidant, Malondialdehyde (MDA) a Grant Medical College and marker of oxidative stress, C - reactive protein (CRP) an inflammatory marker is also taken into Sir J J Group of Hospitals, Mumbai,Maharashtra consideration for the study. The obtained results suggest that oxidative stress is induced in chronic 4 Registrar periodontitis. As compared to healthy controls the levels of CRP, MDA and RBC-SOD were Maharashtra University of Health Sciences, significantly higher (p<0.001) and those of TAOC, GPx and vitamin C were significantly lower Nashik, Maharashtra (p<0.001) in patients with chronic periodontitis. 5 Asst. Prof in Biochemistry Department of Biotechnology, Sinhgad College of Science, Key Words Ambegaon (Bk), Pune, Maharashtra chronic periodontitis, oxidative stress, biochemical markers, total antioxidant capacity, antioxidant enzymes, malondialdehyde Address For Correspondence: Mr. Abdul Samad Aziz, Ph. D Student, Department of Biochemistry, Grant Medical College and Sir J J Group of Hospitals, Mumbai, Maharashtra Mobile No : +919823375529 Introduction: antioxidants (AOs) that prevent or limit [email protected] Oral health is an important aspect of oxidative tissue injury caused by ROS Submission : 21st September 2011 overall health status of an individual. [6]. AOs may be enzymes such as th Teeth and their supporting (periodontal) superoxide dismutase (SOD), catalase Accepted : 17 January 2012 structures are of importance to oral (CAT), glutathione peroxidase (GPx), Quick Response Code health. Periodontitis is an inflammatory glutathione reductase (GR), high disease of the peridontium, which affects molecular weight proteins such as the supporting tissues of the teeth [1]. The albumin, ceruloplasmin, transferrin, low human oral cavity is colonized by a molecular weight water soluble number of microbes, especially bacteria. antioxidants such as ascorbic acid, uric Often, bacteria and host cells form a acid etc and low molecular weight water commensal relationship which is insoluble antioxidants such as beneficial for both, but under certain tochopherol, carotenoids, bilirubin etc. conditions (increased mass or AOs overall, act at different levels of pathogenicity, reduced host immune action such as prevention, interception Materials and Methods: response), disease may occur. Specific and repair damage caused by ROS. In a bacteria induce the release of cytokines normal healthy human body the Study group: which increase the number of defense generation of free radicals or pro- A total of 60 subjects: 30 patients with cells and their activation [2, 3]. Reactive oxidants is effectively kept in check at chronic periodontitis (19 males and 11 oxygen species (ROS) such as various levels by antioxidant defense females, with a mean age of 41.6 ± 6.4) superoxide anion, hydroxyl radical, mechanism. However, when it gets and 30 healthy controls (19 males and 11 nitrous oxide and hydrogen peroxides are exposed to adverse physico-chemical, females, with a mean age of 39.6 ± 8.4) produced via the bacteria- host mediated environmental or pathological agents, were referred to the Department of pathway, stimulating this delicately maintained balance Dentistry, Grant Medical College, polymorphonuclear leucocytes (PMNL) (antioxidant: oxidant) shifts in favor of Mumbai. The patients in the study group to produce superoxide radicals via pro-oxidants, resulting in oxidative stress were otherwise healthy, with no history “respiratory burst”. This result in [7, 8 and 9]. of major illness and consumption of increased ROS concentration leading to antioxidants, antibiotics, anti oxidative damage to periodontal tissues The present study tries to evaluate and inflammatory or any other drugs for at with an impaired circulating antioxidant: compare some biochemical oxidative least six months. Subjects having past oxidant balance [4, 5]. stress markers in peripheral blood of illness and undergoing any treatment, patients with chronic periodontitis and smokers, alcoholics, pregnant and All mammalian cells contain healthy controls. lactating women were excluded from the

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 022 study. All the individuals had a minimum method, obtained from Randox Table 1: Clinical parameters: p values for mean ± SD of 20 teeth present. The individuals in the Laboratories (U. K). GPx catalyses obtained by Mann-Whitney U test control group were from the same oxidation of glutathione by cumene Clinical Parameters Chronic Healthy p geographical region with good oral hydroperoxide. The oxidized glutathione health. is reduced by glutathione reductase and Periodontitis Controls values The study was undertaken as per the the decrease in absorbance was measured (n=30) (n=30) approval of the Institutional Ethics at 340 nm [14]. Committee of Grant Medical College and Gingival Index (GI) 2.38 ± 0.49 0.68 ± 0.12 0.001 Sir J. J. Group of Hospitals, Mumbai. A The serum vitamin C content was Plaque Index (PI) 2.25 ± 0.53 0.45 ± 0.44 0.001 written informed consent was obtained measured using the dinitro phenyl from all the subjects enrolled for the hydrazine (DNPH) method. In strong Papillary bleeding Index 2.56 ± 0.37 0.85 ± 0.89 0.001 study. acidic medium, oxidized ascorbic acid (PBI) reacts with 2, 4 DNPH to form a red Clinical measurements: coloured complex which was measured Clinical Attachment Loss 7.68 ± 0.97 1.83 ± 0.31 0.001 The periodontal status of all individuals at 500 nm [15]. (CAL) was evaluated by measurement of gingival index (GI) as developed by Loe The serum MDA was estimated using H and Silness J , plaque index (PI) as thiobarbituric acid method. A pink described by Silness P and Loe H, colored complex is obtained whose papillary bleeding index (PBI) developed absorbance was measured at 530 nm [16]. by Muhlemann HR [10] and clinical attachment loss (CAL). CAL was The serum CRP was measured by the measured on six sites of each tooth latex turbidity method using the kit Table 2: Biochemical parameters: p values for mean ± SD (mesial, median and distal points at obtained from Spinreact (Spain). The obtained by Mann-Whitney U test buccal and palatal aspects). The change in absorbance was measured at Biochemical Chronic Healthy p individual scores were compared on a 540 nm [17]. scale for characterization of periodontitis Markers Periodontitis Controls values as slight, moderate or severe [11]. All Statistical Analysis: (n=30) clinical measurements were evaluated by The measured values for the clinical (n=30) a single investigator. parameters and biochemical markers TAOC (µM/L) 824.83 ± 79.5 913.17 ± 67.3 0.001 were subjected to statistical analysis. The Sample collection: values were expressed as mean± SD. The RBC-SOD (U/g Hb) 527.60 ± 83.4 292.43 ± 37.8 0.001 A total of 4 ml venous blood was p values for mean ± SD were obtained by GPx (U/g Hb) 8.27 ± 1.24 13.71 ± 1.42 0.001 collected in disposable syringe. Of this, 1 Mann-Whitney U test. p value less than ml heparinised blood was used for 0.05 is considered to be statistically Vitamin C (mg %) 0.44 ± 0.07 0.63 ± 0.07 0.001 analysis of RBC-SOD, blood GPx and significant. MDA (nM/ml) 4.10 ± 0.39 2.02 ± 0.25 0.001 plasma TAOC. The remaining 3ml of blood was allowed to stand at room Observations and Results: CRP (mg/L) 3.35 ± 0.43 1.85 ± 0.29 0.001 temperature for 30 min and later centrifuged to obtain serum, which was Clinical measurements: used for the analysis of Vitamin C, MDA The values of clinical measurements are and CRP. listed in Table 1. All clinical parameter scores (mean ± SD) were significantly Biochemical studies: higher (p<0.001) in chronic periodontitis

The plasma TAOC was measured by the patients compared to healthy controls. Graphs: Comparison between the different biochemical Ferric Reducing Ability of Plasma oxidative stress markers in chronic periodontitis and healthy (FRAP) assay [12]. The reaction Biochemical studies: controls (a) TAOC (µM/L), (b) RBC-SOD (U/g Hb), (c) GPx measures antioxidant reduction of The values of biochemical parameters (U/g Hb), (d) Vitamin C (mg %) (e) MDA (nM/ml) and (f) CRP (mg/L) Fe3+TPTZ (tripyridyl triazine) to evaluated in the present study are shown Fe2+TPTZ and the change in absorbance in Table 2. The values are expressed as was measured at 593 nm. mean ± SD and were found to be significant (p<0.001) in chronic The RBC-SOD was measured using the periodontitis patients when compared to kit method, obtained from Randox healthy controls. Laboratories (U. K). 1 unit of enzyme activity was defined to cause 50% Discussion: inhibition of rate of reduction of 2, 4 - Periodontal disease has long been idophenyl 3-4 nitrophenol 5-phenyl recognized as a public health problem. tetrazolium chloride (INT) under assay Periodontitis is caused by multi factorial condition. Change in absorbance was process triggered by infection of recorded at 505 nm [13]. peridontium with Gram negative bacteria. The response of the host to most Blood GPx was also measured using kit periodontal infection is chronic (a)

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 023 with periodontitis. The significantly decreased Total Antioxidant Status (TAS), in the peripheral blood in chronic periodontitis may be one of the pathogenic mechanisms underlying the link between periodontal disease and several systemic diseases [21].

Antioxidant enzymes, superoxide dismutase (SOD) and glutathione peroxidase (GPx) provides protection within the cell against ROS. Three isoenzymes of SOD are known in (b) (f) humans, Cu-Zn- SOD found in cytoplasm and nucleus, mitochondrial Mn-SOD and extracellular Cu-Zn-SOD. inflammation. This response has both Two forms of GPx are known, classical local and systemic inflammatory cellular GPx and extracellular GPx manifestations [18]. These inflammatory (eGPx), of which eGPx serves an manifestations may lead to oxidative important antioxidant role in many stress. The present study has focused on extracellular surfaces and spaces [27]. the relationship between periodontitis The function of SOD is to remove and biochemical oxidative stress damaging ROS from the cellular markers. environment by catalyzing dismutation of two super oxide radicals to hydrogen Total antioxidant capacity (TAOC) peroxide (H2O2). GPx reduces H2O2 by reflects full spectrum of antioxidant the oxidation of reduced glutathione. In activity against various reactive oxygen contrast to our findings, Baltacioqlu E et and nitrogen radicals. The total al 2006 [23], Canakci V et al 2007 [22] antioxidant assay measures and Akalin F A et al 2008 [28] have ( C ) predominantly the low molecular weight observed significantly lower SOD chain breaking antioxidants, such as activities in chronic periodontitis urate, ascorbate, bilirubin etc. Generally, patients. low total antioxidant capacity indicates oxidative stress or increased The human periodontal ligament has susceptibility to oxidative damage [19]. shown to possess the enzyme SOD which offers biological protection against ROS. Oxidative stress is implicated in the Bacterial lipopolysaccharides also pathogenesis of periodontitis. Various stimulates superoxide release from studies have associated periodontitis gingival fibroblast, suggesting that the with TAOC. Capple IL (2007) [20], induction of SOD may represent an observed lower GCF TAOC levels in important defense mechanism of the chronic periodontitis compared to fibroblasts during inflammation [29]. In healthy controls. However, plasma the present study increased RBC-SOD TAOC has not shown significant activity in chronic periodontitis supports differences in chronic periodontitis and the above findings as part of the systemic healthy controls. The present study has (d) response. Various studies conducted by observed lowered plasma TAOC in Panjamurthy K et al 2005 [30], Wei D et patients with chronic periodontitis as al 2010 [29] and Tonque M O et al 2011 compared to healthy controls. Similar to [31] have observed higher SOD activity the present findings, various studies have in chronic periodontitis group than in observed compromised TAOC in chronic controls which is in accordance with our periodontitis compared to healthy study. controls. Konopka T et al (2007) [21] and Canakci V. et al (2007) [22] have The present study has obtained lower observed lower TAOC in saliva, gingival GPx activity in whole blood of chronic blood and peripheral blood of subjects periodontitis group than in controls. The with chronic periodontitis as compared to study conducted by Tsai CC et al 2005 the healthy control group. Similarly [32] has shown no significant change in Baltacioqlu E et al (2006) [23], Akalin FA salivary GPx in chronic periodontitis and (2009) [24], D' Aiuto F et al (2010) [25] healthy controls. Patel S P et al 2009 [4] and Abou Sulaiman et al (2010) [26] have have observed direct proportionality in (e) associated reduced antioxidant capacity GPx activity in GCF with the severity of

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 024 periodontal disease. However, consistent complement factor 1 (C1q). It has been periodontally healthy controls. J Clin with our findings Canakci V et al 2007 demonstrated that CRP levels are higher Periodontol 2005;32(3):238-43 [22], Canakci F C et al 2009 [27] and in periodontitis patients than in healthy 6. Chapple IL, Mathews JB. The role of Tonque M O et al 2011 [31] have shown subjects [41]. Studies conducted by reactive oxygen and antioxidant lower GPx activity in chronic Nadeem M et al 2009 [42], Gani DK et al species in periodontal tissue periodontitis compared to healthy 2009 [43], Thakare KS 2010 [44], and destruction. Periodontol 2000 controls. Masi S et al 2011 [45] have observed 2007;43:160-232 elevated CRP levels in chronic 7. Djordjevic VB. Free radicals in cell Vitamin C (Ascorbic acid) is a low periodontitis as compared to the control biology. Int Rev Cytol 2004;237:57- molecular weight, water soluble group, which supports our findings. 89 antioxidant. It has protective effect on 8. Valko M, Leibfritz D, Moncol J, maintaining tissue homeostasis by The balance between ROS and Cronin MT, Mazur M, Telser J. Free playing important role in collagen antioxidant defense mechanism is likely radicals and antioxidants in normal synthesis and therefore helps in to be important in periodontal physiological functions and human maintenance of structural integrity of the pathogenesis. As observed in our study, disease. Int J Biochem Cell Biol connective tissue. Vitamin C also has a patients with chronic periodontitis have 2007;39:44-84 beneficial role as radical scavenger [33]. shown higher inflammatory and 9. Maurya DK, Kumar SS, Vitamin C, through its antioxidant action, oxidative stress markers, and lowered Devasagayam TPA. Free radicals, neutralizes oxidative stress, and in doing antioxidant defense. Further studies cancer and cardiovascular disease. so may be depleted in plasma. It is based on large sample size are needed to Conference proceedings-National therefore quite possible that periodontitis establish these findings and also to reveal conference on oxidation stress and its causes lower plasma vitamin C through the mechanism of pathogenesis of complications in human health 2011 this mechanism [34]. In our study serum periodontitis at a molecular level. Jan;7-19 vitamin C level was lower in chronic 10. Soben P. Essentials of preventive and periodontitis as compared to healthy Conclusion: community dentistry. Indices in controls which was also found by Staudte The study can be concluded on the note dental epidemiology. 2nd ed. Arya H et al 2005 [35],Anwar TM 2007 [34], that, patients with chronic periodontitis Med Pubc2003;127-240 Chapple IL et al 2007 [33], Thomas B et show higher oxidative stress which is 11. John MN. 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It is a stable end product of oxidative stress markers, which may be 13. Woolliams JA, Wiener G, Anderson peroxidation of lipids by ROS. MDA is of help in clinical management of the PH, McMurray CH. Research in one of the most frequently used indicator disease. veterinary science 1983; 34:253-56 of lipid peroxidation and may be a 14. Paglia DE, Valentine WN. Studies on potential biomarker indicating oxidative References: the quantitative and qualitative stress [38]. Our finding indicates higher 1. Kinane DF. Causation and characterization of erythrocyte serum MDA level in chronic pathogenesis of periodontal disease. glutathione peroxidase. J Lab Clin periodontitis as compared to the healthy Periodontol 2000 2001;25:8-20 Med 1967;70:158-169 controls. Many researchers like Borges I 2. Marc Q, Wim T, Susan KH, Michael 15. Harold V. Carbohydrates. Practical Jr et al 2007 [39], Khalili J 2008 [40], GN. 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Cardiovascular disease and protein, which is used as an inflammatory glutathione peroxidase (eGPx) in periodontal disease: commonality marker. CRP during its role in periodontal health and disease. Arch and causation. Compendium 2004 inflammatory process binds to the Oral Biol 2009 Jun;54(6):543-48 July;25(7)Supp1:26-37 surface of pathogens and opsonises them 5. Akalin FA, Toklu E, Renda N. 19. Young IS. Measurement of total for the process of phagocytosis. CRP can Analysis of SOD activity levels in antioxidant capacity. J Clin Pathol also activate the classic complement gingival and GCF in patients with 2001;54:339 cascade by binding to 'q' factor of chronic periodontitis and 20. Chapple IL, Brock GR, Milward MR.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 025 Compromised GCF TAOC in 30.Parjamurthy K, Manoharan S, and effects of life style pattern. periodontitis: cause or effect. J Clin Ramchandran CR. Lipid Clinical chemistry 1997;43:1209-14 Periodontol 2007 Feb;34(2):103-10 peroxidation and AO status in 39. Borges I Jr, Moeira EA, Filho DW, 21. Konopka T, Krol K, Kopec W, Gerber patients with periodontitis. Cell Mol Oliveira TB, da Silva MB, Frode TS. H. Total antioxidant status and 8 - Biol Lett 2005;10(2):255-64 Proinflammatory and oxidative stress hydroxyl-2-deoxyguanosine levels in 31. Tonque MO, Ozturk O, Sutcu R, markers in patients with periodontal gingival and peripheral blood of Cryhan BM, Kilinc G, Sonmez Y et disease. Mediators Inflamm 2007; periodontitis patients. Arch Immunol al. The impact of smoking status on 2007:45794 Ther Exp 2007 Nov-Dec;55(6):417- antioxidant enzyme activity and 40. K h a l i l i J , B i l o k y t s k a H F, 22 MDA level in chronic periodontitis. J SalivarKhalili J, Bilokytska HF. 22. Canakci V, Yildrim A, Canakci CF, Periodontol 2011 Jan; (Epub ahead of Salivary MDA levels in clinically Eltas A, Cicek Y, Canakci H. Total print) healthy and periodontal diseased antioxidant capacity and antioxidant 32. Tsai CC, Chen HS, Chen SL, Ho YP, individuals. Oral Dis 2008 Nov; enzymes in serum, saliva and Ho KY, Wu YM et al. Lipid 14(8):754-60 gingival cervicular fluid of peroxidation : a possible role in the 41. Gupta SC, Jindal V, Ranbika T. CRP preeclamptic women with and induction and progression of chronic and its role in periodontitis. Indian J without periodontal disease. J periodontitis. J Periodontol Res 2005 of Dental Sciences 2011;3(1):31-32 Periodontol 2007 Aug;78(8):1602-11 Oct;40(5):378-84 42. Naddem M, Stephen L, Schibert C, 23. Baltacioqlu E, Aklain FA, Alver A, 33. Chapple LC, Milward MR, Dietrich Dacids MR. Association between Balafan F, Unsal M, Karabulut E. T. The prevalence of inflammatory periodontitis and systemic infection Total antioxidant capacity and SOD periodontitis is negatively associated in patients with ESRD. SADJ 2009 activity levels in serum and GCF fluid with serum antioxidant Nov;64(10):470-73 in post menopausal women with concentrations. J Nutr 2007 43. Gani DK, Lakshmi D, Krishnan R, chronic periodontitis. J Clin Mar;137:657-64 Emmadi P. Evaluation of CRP and Periodontol 2006 Jun;33(6):385-92 34. Anwar TM. Plasma Vitamin C is interleukins - 6 in the peripheral 24. Akalin FA, Baltacioqlu E, Alver A, Inversely Associated with blood of patients with chronic Karabulut E. Total antioxidant Periodontitis. J Evid Base Dent Pract periodontitis. J Indian Soc capacity and super oxide dismutase 2008;8:103-104 Periodontol 2009 May; 13(2):69-74 activity levels in serum and gingival 35. Staudte H, Siqusch BW, Glockmann 44. Thakare KS, Deo V, Bhongade ML. cervicular fluid in pregnant women E. Grapefruit consumption improves Evaluation of CRP serum levels in with periodontitis. J Periodontol 2009 vitamin C status in periodontitis periodontitis patients with or without Mar;80(3):457-67 patients. Br Dent J 2005 atherosclerosis. Indian J Dent Res 25. D' Aiuto F, Nibali L, Parker M, Patel Aug;199(4):213-17 2010 Jul-Sep;21(3)326:29 K, Suran T, Donos N. Oxidative 36. Thomas B, Kumari S, Ramitha K, 45. Masi S, Salpea KD, Li K, Parkar M, stress, systemic inflammation and Ashwini Kumari MB. Comparative Nibali L, Donos N et al. Oxidative sever periodontitis. J Dent Res 2010 evaluation of micronutrients in the stress, chronic inflammation and Nov;89(11):1241-46 serum of diabetes mellitus patients telomere length in patients with 26. Abou Sulaiman AE, Shehadeh RM. and healthy individuals with periodontitis. Free Radic Biol Med Assessment of total antioxidant periodontitis. J Indian Soc of 2011 Mar; 50(6):730-35 capacity and use of vitamin C in the Periodontal 2010 Jan;14(1):46-9 treatment of non smokers with 37. Van der U, Kuzmanova D, Chapple chronic periodontitis. J Periodontol IL. Micro nutritional approaches to 2010 Nov;81(11):1547-54 periodontal therapy. J Clin 27. Canakci CF, Geek Y, Yildirim A, Periodontal 2011 Sezer U, Canakci V. Increased levels March;38Supp11:142-58 8 - hydroxyl-2-deoxyguanosine and 38. Nielsen F, Mikkelson BB, Nicholson MDA and its relationship with JB, Anderson HR, Grandjean P. antioxidant enzymes in saliva of Plasma MDA as biomarker and periodontitis patients. Eur J Dent oxidative stress: reference interval 2009 Apr;3(2):100-106 28. Akalin FA, Isiksal E, Baltacioqlu E, Renda N, Karafulut E. SOD activity in gingival in type 2 diabetes mellitus patients with chronic periodontitis. Arch Oral Biol 2008 Jan;53(1):44-52 29. Wei D, Zhang XL, Wang YZ, Yang CX, Chen G. Lipid peroxidation Source of Support : Nill, Conflict of Interest : None declared level, total oxidant status and super oxide dismutase in serum, saliva and gingival cervicular fluid in chronic periodontitis patients before and after periodontal therapy. Aust Dent J 2010 Mar;55(1):70-8

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 026 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Comparison of Different Angular 1 Kavita Sachdeva, B.D.S. 2 Anil Singla, M.D.S. Measurements to Assess Sagittal Skeletal 3 Vivek Mahajan, M.D.S. 4 H.S. Jaj, M.D.S. Discrepancy - A Cephalometric Study 5 Vishal Seth, M.D.S. 6 Madhurima Nanda, B.D.S. Abstract 1 Introduction: - An accurate evaluation of sagittal jaw relationship is important in orthodontic P.G Student 2 Professor and HOD diagnosis and treatment planning. Numerous angular and linear measurements have been 3 incorporated to assess the antero-posterior jaw discrepancy between maxilla and mandible so as Senior Lecturer 4 Reader to reach the correct diagnosis. So the purpose of this study is to compare ANB angle, Wits 5 Senior Lecturer appraisal, Beta angle, YEN angle and W-angle used to measure antero-posterior dysplasia and to 6 P.G Student find out which is the most reliable amongst them. Dept of Orthodontics & Dentofacial Orthopaedics, Material and Method: - Sample comprised of 45 pre-treatment lateral cephalograms which were Himachal Dental College, Sundernagar, H.P. divided into 3 groups: Group I-Class I skeletal pattern (n=15), Group II- Class II skeletal pattern (n=15) and Group III - Class III skeletal pattern (n=15) Address For Correspondence: Dr. Kavita Sachdeva Results: - ANOVA analysis was performed and highly significant differences were found in Beta Department of Orthodontics, angle, Yen angle and W-angle in all the three Groups (Group I, Group II, and Group III). Himachal Dental College, Conclusion: - Thus it has been concluded from the study that Beta angle, Yen angle and W-angle Sunder Nagar (H.P.) are significant angles to assess the sagittal jaw relationship between maxilla and mandible. E-mail:[email protected] Ph: 09816658882 Key Words Submission : 25th September 2011 Sagittal Discrepancy, Beta Angle, YEN Angle and W-Angle Accepted : 28th April 2012

Quick Response Code Introduction measurement since that time. However, The evaluation of sagittal jaw both Down's and Riedel's methods are relationship between maxilla and subject to error due to variations in the mandible has been one of the major position of nasion which is not fixed problem in the field of orthodontics during growth, and any displacement will ,which is of prime importance in directly affect the A-B plane angle and diagnosis and treatment planning .This is ANB angle. because of rotations of jaws during 1 C in condyle which is not clearly visible growth, vertical relationships between As an alternative to ANB, Jacobson in either. Most recently introduced sagittal the jaws and reference planes, and a lack 1975 introduced Wits appraisal. It relates dysplasia indicator is YEN angle of validity of the various methods points A and B to the functional occlusal 8 1,2,3,4 introduced by Neela et al (2009). Since it proposed for their evaluation . plane. The distance between the points of measures an angle between line SM and Numerous angular and linear intersection AO and BO is measured to MG, rotation of jaw because of growth or measurements have been incorporated to describe antero-posterior relationship. In orthodontic treatment can mask true assess the sagittal discrepancy between females AO should coincide BO, basal dysplasia, similar to ANB angle. maxilla and mandible into various whereas in males BO should be 1mm cephalometric analyses which could help ahead of AO.Though Wits appraisal 9 To overcome these problems, Bhad et al the clinician to establish the most avoids point N, accurate identification of (2011) developed W-angle. It does not appropriate treatment plan. Appraisal by functional occlusal plane is not easy or depend on any unstable landmarks or linear measurements has distinct accurately reproducible, especially in dental occlusion and would be especially advantages over angular measurements mixed dentition patients. Secondly, any valuable to assess true sagittal changes in that there are fewer variables to effect change in the angulation of functional because of growth and orthodontic their accuracy and there is less error of occlusal plane, caused by either tooth treatment. So the purpose of this study is 5 eruption and dental development or measurement. to compare the various angles ANB orthodontic intervention, can profoundly angle, Wits appraisal, Beta angle, YEN 6 influence Wits appraisal. Downs in 1948 introduced the A-B plane angle and W-angle used to measure angle. Positive and negative signs were 3 antero-posterior dysplasia and to find out used to denote protrusion and retrusion of Baik and Ververidou introduced the beta which is the most reliable amongst them. mandible. A few years later Riedel7 in angle in 2004.Though, it assesses sagittal 1952 introduced ANB angle and it discrepancies, it depends on points A and Material And Method became the most commonly used B, which are difficult to locate and point This study was conducted in the

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 027 Department of Orthodontics and Fig 2 – Lateral Cephalogram showing ANB angle, Wits Dentofacial Orthopedics Himachal appraisal , Beta angle , Yen angle , W-angle Dental College, Sundernagar. It consisted of 45 pretreatment lateral cephalograms of 10 to 25 year old individuals who had never undergone orthodontic treatment which were divided into 3 groups Group I - Class I skeletal pattern group (n=15) Group II - Class II skeletal pattern group (n=15) Fig 1- Planmeca X-ray machine with model no: 2002 Group III - Class III skeletal pattern group (n=15) Discussion The following inclusion criteria was Clinicians with increasing frequency are taken for the Class I skeletal pattern treating malocclusions in conjunction group (1) ANB angle of 1° to 3°, (2) Wits with orthognathic surgery. A method of appraisal between 0 and -3 mm (3) Beta maxillomandibular assessment that angle between 27 º - 35 º degrees, and (4) provides accurate data on this Yen angle between 117 º - 123 º (5) W- relationship at an early age would be 5 angle between 51º - 56 º and pleasant highly desirable. The most popular parameter for assessing the sagittal jaw ANB Angle - Difference between SNA and SNB angle profile. Wits Appraisal - Perpendicular lines drawn from points A The following inclusion criteria was relationship remains the ANB angle, but and B to functional occlusal plane.The distance between AO taken for the Class II skeletal pattern it is affected by various factors and can and BO is measured. often be misleading.1 It has been Beta Angle – Angle measured between perpendibular line group drawn from point A to C-B line and A-B line (1) The ANB angle was above 4° (2) Wits suggested that although the apical base YEN Angle - Angle between the SM line and the M–G line appraisal greater than or equal to -1 mm relationships were constant in all W-Angle - Angle between the perpendicular line from point (3) Beta angle less than 27 º (4) Yen angle conditions, the ANB angle became either M to S–G line and the M–G line less than 117 º (5) W-angle less than 51º small or large and thus such a 10,11 without entailing some changes in other and the profile had a Class II appearance. measurement was not reliable. So one parts. Similarly, the facial skeleton and The following inclusion criteria was must consider Bjork opinion that the the dentition are functional parts of the taken for the Class III skeletal pattern human body constitutes a functional skull as a whole. It follows, therefore, that group (1) the ANB angle was less than or entity, no part of which can be varied variations in the bite will be largely equal to 1° (2) Wits appraisal less than or equal to -4 mm (3) Beta angle more than Table I- Mean, Standard Deviation and p-Valve for the Three Groups 35º (4) Yen angle more than 123 º (5) W- angle more than 56 º and the profile had a Groups N Mean Std. Deviation p-VALUE Class III appearance. Then the lateral cephalograms exposed ANB I 15 1.8462 1.67562 0.829 with jaws in centric relation, lips relaxed, and the head in the Natural head position. II 15 3.2000 1.01419 The radiographs were obtained with III 15 1.5000 1.01905 Planmeca X-ray machine with model no: 2002(fig 1). All the cephalograms were Wits Appraisal I 15 0.8182 0.60302 0.728 recorded with the same exposure II 15 1.0000 1.09545 parameters and in the same machine. These cephalograms were traced, and III 15 0.6000 0.89443 ANB, Wits appraisal, and Beta angle, Yen Beta Angle I 15 29.4000 3.81351 <0.001** angle and W-angle were measured to find the antero-posterior dysplasia and most II 15 25.9333 1.48645 reliable amongst them. (Fig 2) III 15 35.1333 1.68466

Statistical Analysis Yen Angle I 15 118.733 1.16292 <0.001** The mean, standard deviation and P value II 15 114.666 1.04654 were calculated for each parameter. ANOVA analysis was performed and III 15 125.333 1.29099 highly significant differences were found W Angle I 15 52.8667 1.30201 <0.001** in Beta angle, Yen angle and W-angle in all the three Groups (Group I, Group II, II 15 48.7333 1.03280 and Group III) (Table I) III 15 53.1333 1.08233 **Highly significant

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 028 related to cranial and facial structures."12 pre-maxilla and G- center of largest circle 100-105 The result of this study shows that the that is tangent to the internal inferior, 4. Nanda R 2005: Biomechanics and ANB angle values are not significant (p- anterior, and posterior surfaces of the esthetic strategies in clinical 0.829) among three groups. This is in mandibular symphysis and so it is not orthodontics. Elsevier, St. Louis. pp. favour of the study conducted by influenced by growth changes and can 38-73 Brown13 , Chang 11 and Jacobson1 , who easily be used in mixed dentition. But 5. Nanda R, Merrill RM : claimed that any change in the SN plane since it measures an angle between line Cephalometric assessment of sagittal would affect the ANB angle. This is also SM and MG, rotation of jaw because of relationship between maxilla and supported by Rotberg et al14 who also growth or orthodontic treatment can mandible: Am J Orthod Dentofac stated that nasion usually moves in mask true basal dysplasia, similar to Orthop 1994;105:328-44 anterior and slightly superior direction ANB angle. 6. Downs WB: Variations in facial because of the growth increments on the Our study shows that W- angle values relationships: Their significance in cranial base plane passing through sella were statistically significant (p < 0.001) treatment and prognosis: Am J and nasion. among three groups. This is also Orthod 1948;34:812-823 So when using the ANB angle, factors supported Bhad et al 9 who stated that this 7. Riedel RA: The relation of maxillary such as the patient's age, growth rotation measurement does not depend on structures to cranium in malocclusion of the jaws, vertical growth, and the unstable landmarks or the functional and in normal occlusion. Angle length of the anterior cranial base (AP occlusal plane. It uses three stable points- Orthod 1952;22:142-145 position of N) should be considered, point S, point M, and point G and the 8. Neela PK, Mascarenhas R, Husain A: which makes the interpretation of this angle is measured between a A new sagittal dysplasia indicator: the angle much more complex (Jacobson, perpendicular line from point M to the S- Yen angle. World Journal of 1975)1 . G line and M-G line. The geometry of the Orthodontics 2009;10:147-151 Our study shows that Wits values were W angle also has the advantage to remain 9. Bhad WA, Nayak S and Doshi UH: A also non-significant (p - 0.728) among relatively stable even when the jaws are new approach of assessing sagittal three groups. This is also supported by rotated or growing vertically this is dysplasia: the W angle : European Moore et al 15 and Ishikawa et al16 who because of rotation of the S-G line along Journal of Orthodontic 2011:1-5 also stated that Wits appraisal although with jaw rotation, which carries the 10.Freeman RS : Adjusting A-N-B not affected by landmarks or jaw perpendicular from point M with it. angles to reflect the effect of rotations; it still has the problem of Therefore, measurement of W angle is maxillary position : Angle Orthod correctly identifying the functional useful sagittal parameter in skeletal 1981;51:162-71 occlusal plane, which can sometimes be patterns with clockwise or 11.Chang HP: Assessment of impossible, especially in mixed counterclockwise rotation of the jaws as anteroposterior jaw relationship: Am dentition. Furthermore, changes of the well as during transitional period when J Orthod Dentofac Orthop Wits measurement throughout vertical facial growth is taking place. 1987;92:117-22 orthodontic treatment might also reflect 12. Oktay H : A comparison of ANB, changes in the functional occlusal plane Conclusion WITS,AF-BF AND APDI rather than pure sagittal changes of the It was concluded from the present study measurements : Am J Orthod jaws. that Beta angle, Yen angle and W-angle Dentofac Orthop 1991; 99: 122-8 Our study shows that Beta angle values are statistically significant angles to 13. Brown M : Eight methods of were statistically significant (p < 0.001) assess the sagittal jaw relationship analyzing a cephalograms to among three groups. This is also between maxilla and mandible. On the establish anteroposterior skeletal supported by Biak and Ververidou3 who other hand measurements such as ANB discrepancy : Br J Orthod stated that Beta angle does not depend on angle and Wits appraisal are misleading 1981:8;139-46 cranial landmarks or the functional for the assessment of antero-posterior 14. Rotberg S, Fried N, Kane J, Shapiro E occlusal plane and remain relatively discrepancy. : Predicting the " Wits appraisal from stable even when the jaws are rotated. the ANB angle : Am J Orthod Another advantage of the Beta angle is References 1980:77;636-42 that it can be used in consecutive 1. Jacobson A: The "Wits" appraisal of 15. Moore RN, DuBois LM, Boice PA, comparisons throughout orthodontic jaw disharmony. Am J Orthod 1975; Igel KA: The accuracy of measuring treatment because it reflects true changes 67: 125-138. condylion location. Am J Orthod of the sagittal relationship of the jaws, 2. Moyers RE, Bookstein FL, Guire KE: Dentofac Orthop 1989; 95: 344-347 which might be due to growth or The concept of pattern in craniofacial 16. Ishikawa H, Nakamura S, Hiroshi I, orthodontic or orthognathic intervention. growth. Am J Orthod 1979; 76: 136- and Kitazawa S: Seven parameters But it uses point A and point B, which can 148 describing anteroposterior jaw be remodelled by orthodontic treatment 3. Baik CY, Ververidou M: A new relationships: postpubertal prediction and growth. approach of assessing sagittal accuracy and interchangeability. Am Our study shows that Yen angle values discrepancies: the Beta angle. Am J J Orthod Dentofac Orthop 2000;117: were statistically significant (p < 0.001) Orthod Dentofac Orthop 2004;126: 714-720 among three groups. This is also supported by Neela et al 8 who stated that Yen angle depend on stable points S- midpoint of sella turcica, M- midpoint of Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 029 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Comparative Evaluation Of Two Forms Of 1 Rouble Kathuria 2 Nymphea Pandit Calcium Sulfate Hemihydrate For The 3 Ashish Jain 4 Deepika Bali Treatment Of Infrabony Defects. 5 Shipra Gupta 1 Junior Resident Abstract 2 Background : Calcium sulfate based bone grafting materials (CS) have been used for periodontal Professor & Head (M.D.S) Deptt Of Periodontics And Oral Implantology, reconstructive procedures. However, their fast degradation profile is a cause of concern in D.A.V. (C) Dental College & Hospital, Yamuna Nagar relatively larger defects. Particles of Nano Calcium sulfate hemihydrate (nCS) are developed to 3 Professor & Head (M.D.S) overcome this shortcoming. This study evaluates the efficacy of the two forms of calcium sulfate Department Of Periodontics, hemihydrates (CS and nCS) for the treatment of intra osseous periodontal defects. Dr. H.S. Judge Institute Of Dental Sciences & Hospital, Methods : Total of thirty sites (in 12 patients) were randomly allocated to treatment with flap surgery 4 Associate Professor (M.D.S) + CS or flap surgery + nCS. Clinical and radiographic outcomes were assessed at baseline and at Deptt Of Periodontics And Oral Implantology, D.A.V. (C) Dental College & Hospital, Yamuna Nagar 3 and 6 months post-surgery for both the groups. 5 Results : There was significant reduction in plaque index, gingival index and pocket depth in CS Associate Professor (M.D.S) Department Of Periodontics, and nCS groups at 3 months and 6 months as compared to baseline. However, these three indices Dr. H.S. Judge Institute Of Dental Sciences & Hospital, were statistically non significant after 3 months and 6 months when compared between the groups. Both CS and nCS groups showed statistically significant amount of defect fill and defect Address For Correspondence: resolution at 3 months and 6 months as compared to baseline. At 6 months, a greater percentage Dr. Shipra Gupta of defect fill and resolution was noticed in the nCS group as compared to the CS group. Department Of Periodontics, Conclusions : Both graft materials can be considered valuable options in the treatment of infrabony Dr. H.s. Judge Institute Of Dental periodontal defects. However, nCS is more effective compared to CS. The enhanced gain in defect Sciences & Hospital, Panjab University, Chandigarh, India fill and resolution of osseous defects in nCS could be attributed to its slow degradation profile that is closer to the rate of bone growth. Submission : 30th September 2011 Accepted : 27th March 2012 Key Words Periodontal disease; Bone graft; Calcium sulfate; Bone regeneration; clinical attachment loss. Quick Response Code

Introduction apatite naturally present in bone1 . Regeneration of lost supporting tissues has always been considered the ideal Medical grade calcium sulfate hemi objective of periodontal therapy. hydrate (CS) is completely synthetic, Periodontal regeneration refers to the biocompatible, biodegradable and a restoration of supporting tissues of the highly osteo conductive material. It is the teeth such as bone, cementum, and only bone graft that possesses the treatment of infrabony defects. periodontal ligament to their original haemostatic, angiogenic and barrier healthy levels before damage from membrane properties. It is an effective Materials And Methods periodontal bacteria has occurred. pharmaceutical/growth factor delivery The present study was designed as a Several bone replacement grafts have vehicle and can be used in combination single- center randomized- controlled been developed for use in periodontal with other bone graft materials2, 3 . trial. The study was conducted at therapy to support bone formation and Department of Periodontics at D.A.V defect fill. Calcium sulfate based bone Inspite of its superior properties, its fast Centenary Dental College and Hospital, grafting material has been used for 119 degradation profile is a cause of concern Yamuna Nagar, India, between April years with the first reported use of in relatively large defects. CS undergoes 2009 to February 2010. All clinical calcium sulfate from German physician degradation in 4 to 6 weeks.4 procedures were performed in Freidrich Trendlenberg in Bonn. Upon Nanocrystalline calcium sulfate was accordance with the Declaration of implantation in the body, it dissolves into developed by a patented procedure to Helsinki and the Good Clinical Practice calcium and sulfate ions. Calcium ions overcome this shortcoming §, 5 . The bone Guidelines. Each patient provided combine with phosphate ions from body graft stimulates bone regeneration in a written informed consent before fluids to form calcium phosphate. This controlled fashion. participation and ethical clearance for the serves as osseo conductive lattice of study was received from Ethical biologic apatite that stimulates bone in The present study was undertaken to: Committee, D.A.V Centenary Dental growth into the defect. This newly To evaluate clinically and College and Hospital, Yamuna Nagar. deposited material is mainly carbonated radiographically the efficacy of two hydroxyl apatite which is similar to forms of calcium sulfate (CS and nCS) in Patient and Defect Eligibility

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 030 Patients (a total of 30 sites in 12 properties of calcium sulfate and subjects, performed all pre- and post- patients)in the age group of 29- 62 years undergoes slower, controlled degradation treatment clinical and radiographic were included in the study in accordance than pure calcium sulfate. recordings using a UNC-15 graduated to the following criteria: 1) moderate to periodontal probe and a customized advanced periodontitis along with Surgical Phase. All surgeries were acrylic occlusal stents to provide radiographic evidence of infrabony performed by one periodontal surgeon reproducible testing points and insertion defect; 2) no systemic diseases that (RK). The site of surgery was axes. A customized acrylic stent was contraindicated periodontal surgery; 3) anesthetized using local anesthesia, 2% fabricated on the study cast, for each no medications affecting periodontal xylocaine with epinephrine 1:2, 00,000. patient, which was grooved in an status; 4) no pregnancy or lactation; and Intra sulcular incisions with reflection of occluso-apical direction to minimize 5) presence of 1 deep (probing depth full thickness flaps were utilized to retain variations in the direction of probing at [PD] 6mm, radiographic depth 3mm) as much soft tissue as possible in order to subsequent recordings. All the interproximal intra osseous periodontal obtain primary closure. Root and defect measurements were made from a fixed defect. Third molars and teeth with debridement were accomplished with reference point on the stent, which was degree III mobility, furcation hand instruments (Gracey Curettes). At done in accordance with the study by involvement, or inadequate endodontic the completion of surgical debridement, Orsini M et al (2008)6 . The apical margin treatment or restoration were excluded. defects were filled with the assigned graft of the customized acrylic stent was used Smokers were also excluded from this material. The graft material was emptied as the fixed reference point and the study. into a sterile dappen dish and prepared by measurements were made at the proximal adding slow set liquid drop by drop until line angle of the tooth with bony defect. Experimental Protocol it formed a paste like consistency. The Only one site representing the same Allocation. After subject selection (by paste was filled in the defect space and an deepest point of the defect was included. RK), each intraosseous defect was effort was made to avoid contamination Investigated Clinical Parameters randomly assigned to receive CS or nCS of the debrided root surface with saliva included: 1) Plaque index (Silness and (by coin toss at the time of initiation of and blood until the graft material had Loe (1964)) 7 ; 2) Gingival index (Loe surgery). The clinical procedures differed been applied. The soft tissue flap was and Silness (1963)) 8 (GI); 3) Probing only with respect to the graft material. then repositioned at the original level and Pocket depth (PD) and 4) Clinical closed with interrupted direct loop attachment level (CAL). Presurgery procedures. Each patient sutures using 3-0 silk sutures. Care was underwent a full- mouth session of taken to achieve a tension free primary Investigated Radiographic Parameters scaling and root planning using closure of flap on suturing. Surgical site were: 1) Defect depth; 2) Amount of mechanical and hand instrumentation (by was protected by applying a periodontal defect fill; 3) Percentage of defect fill; 4) RK) and received personalized oral dressing (Figure 1). Amount of defect resolution and 5) hygiene instructions. The surgical phase Percentage of defect resolution. The was delayed until the achievement of Post-Surgery Procedures. The patients intraoral periapical radiographs of each minimal residual inflammation and were directed to abstain from mechanical defect site were taken pre-operatively optimal soft tissue conditions at the oral hygiene procedures in the surgical and post-operatively using millimeter defect site. area for 2 weeks. All the subjects were grid (X-ray Mesh). All radiographs were given both routine post-operative verbal reviewed in a single reference centre by a Regenerative material used in the and written instructions. A 0.12% masked evaluator. Defect depth was study. CS (DentoGen, Orthogen, LLC, chlorhexidine mouthrinse (10 ml twice a measured as the distance between the Springfield, NJ) is an FDA approved day) was used to support plaque control. alveolar crest and the base of the defect. medical grade Calcium sulfate They were prescribed medications which Defect fill was calculated as difference hemihydrate for bone regeneration in included a non-steroidal anti- between initial and post-surgical dentistry. CS is packaged in a cup in 1g inflammatory agent (Ibuprofen 400mg radiographic bone level (distance from quantities and comes with regular set and thrice a day for 3 days) for post-operative CEJ to bottom of intrabony defect) which fast set liquid. Regular set liquid discomfort and an antibiotic Amoxicillin then helped us determine the percentage comprises of 0.9% sodium chloride / Clavulanic acid (FlemiclavTM 625 mg of the defect fill. Defect resolution was solution while fast set liquid consists of twice a day for 3 days) to prevent calculated as the difference between 4% w/v potassium sulfate solution. For infection. After 14 days, dressing, sutures initial and post-surgical defect depth, the present study regular set liquid was and any plaque present in the area was which helped us determine the added to CS to form the putty. removed. The recall appointments were percentage of defect resolution. All the scheduled at 3 months and 6 months post parameters were evaluated at baseline, at nCS (NanoGen, Orthogen, LLC, surgically for oral hygiene procedures 3 and 6 months post-surgically for all Springfield, NJ) is particles of and supra gingival plaque removal, soft sites (Figure 1). nanocrystalline calcium sulfate. This tissue evaluation, radiographic nanocrystalline bone graft material evaluation and for recording of clinical Statistical Analyses provides benefits of calcium sulfate with parameters. Subgingival scaling was A sample size of 15 (each group) was a slower degradation profile to allow for performed after completion of study at 6 estimated to achieve 80 % power to complete bone filling in large defects. months post- surgery. detect a difference of 1.0 between null Particle size of CS is 30-40µm. The hypothesis and the alternative mean. A pellets of nCS comes with a diameter of Recordings. One examiner (NP) masked statistical software program (SPSS 425-1000µm. nCS retains the desirable to the type of treatment received by the version 13.0) was used for data analysis.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 031 The statistical analysis was performed using the student t-test (paired and unpaired) for plaque index, gingival index, probing depth and clinical attachment level. Wilcoxon and Mann Whitney test was applied for defect fill, % defect fill, defect resolution and % defect resolution respectively. Mean values and standard deviations were calculated for each variable and examination interval. A) Preoperative assessment done using customized acrylic stent and UNC-15 periodontal probe. Results E) Post operative assessment of clinical parameters at six Descriptive statistics months. None of the patients were excluded from the analysis because of insufficient access or a defect morphology preventing root or defect instrumentation, or bone graft placement. Both the groups comprised of 15 sites each. All patients complied with the recall program until reevaluation. All defects were reevaluated at 3 and 6 months post- surgery.

Clinical recordings Pre- and post- surgery clinical and radiographic recordings are reported in

B) Osseous defect after debridement in relation to Table 1- 5. mandibular right first premolar (distal). The mean plaque index at baseline and F) Preoperative radiographic picture of the defect. after 3 months and 6 months post operatively for both the groups is given in Table 1. The mean difference of plaque index at 3 months and 6 months from baseline was 0.53 ± 0.26 and 0.64 ± 0.30 respectively for CS sites, and 0.46 ± 0.43 and 0.59 ± 0.19 respectively for nCS sites, both of which were highly significant (p<0.001) (Table 1) compared to baseline. However, there was no statistically significant difference in mean values of plaque index at baseline (p=0.54), at 3 months (p=0.24) and at 6 months (p=0.16) between the two groups (Table 2). C) CS placed and condensed into the osseous defect. G) Postoperative radiographic picture of the defect at three months. The mean gingival index at baseline and after 3 months and 6 months post operatively for both the groups is given in Table 1. The mean difference of gingival index at 3 months and 6 months from baseline was 0.42 ± 0.12 and 0.55 ± 0.18 respectively for CS sites and 0.42 ± 0.13 and 0.66 ± 0.21 respectively for nCS sites, both of which were highly significant (p<0.001) (Table 1) compared to baseline. However, there was no statistically significant difference in the mean values of gingival index at baseline (p=0.12), at 3 months (p=0.17)

D) Interrupted direct loop sutures given using 3-0 H) Postoperative radiographic picture of the defect at six and at 6 months (p=0.42) between the two MersilkTM. months. groups (Table 2).

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 032 Table 1: Comparison of mean values of plaque index, gingival index, pocket depth and clinical attachment level within the Table 2: Comparison of mean values of plaque index, group (paired t-test) gingival index, pocket depth and clinical attachment level at baseline, 3 months and 6 months between CS and Comparison of mean values of plaque index nCS groups (unpaired t-test)

CS nCS Comparison of mean values of plaque index

Time Mean ± SD Difference from baseline p-value Mean± SD Difference from baseline p-value CS nCS p-value

Baseline 2.03 ± 0.38 - - 2.11± 0.30 - - Baseline 2.03 ± 0.38 2.11± 0.30 -

3 months 1.50 ± 0.36 0.53 ± 0.26 <0.001 1.65±0.31 0.46±0.43 <0.001 3 months 1.50 ± 0.36 1.65±0.31 <0.001

6 months 1.39 ± 0.28 0.64 ± 0.30 <0.001 1.52±0.23 0.59±0.19 <0.001 6 months 1.39 ± 0.28 1.52±0.23 <0.001

Comparison of mean values of gingival index Comparison of mean values of gingival index

Baseline 1.90 ± 0.31 - - 2.06± 0.24 - - Baseline 1.90 ± 0.31 2.06± 0.24 -

3 months 1.48 ± 0.34 0.42 ± 0.12 <0.001 1.64±0.27 0.42±0.13 <0.001 3 months 1.48 ± 0.34 1.64±0.27 <0.001

6 months 1.35 ± 0.18 0.55 ± 0.18 <0.001 1.49±0.16 0.66±0.21 <0.001 6 months 1.35 ± 0.18 1.49±0.16 <0.001

Comparison of mean values of pocket depth Comparison of mean values of pocket depth

Baseline 8.20 ± 1.52 - - 8.00± 1.13 - - Baseline 8.20 ± 1.52 8.00± 1.13 -

3 months 5.53 ± 1.12 2.66 ± 0.82 <0.001 4.93 ±0.96 3.06±1.22 <0.001 3 months 5.53 ± 1.12 4.93 ±0.96 <0.001

6 months 2.87 ± 0.64 5.33 ± 1.29 <0.001 2.53 ±0.64 5.46±1.19 <0.001 6 months 2.87 ± 0.64 2.53 ±0.64 <0.001

Comparison of mean values of clinical attachment level Comparison of mean values of clinical attachment level

Baseline 8.60 ± 1.59 - - 8.53± 1.60 - - Baseline 8.60 ± 1.59 8.53± 1.60 -

3 months 6.07 ± 1.10 2.53 ± 0.99 <0.001 5.80 ±1.57 2.73±1.16 <0.001 3 months 6.07 ± 1.10 5.80 ±1.57 <0.001

6 months 3.40 ± 0.91 5.20 ± 1.47 <0.001 3.53± 1.06 5.00±1.20 <0.001 6 months 3.40 ± 0.91 3.53± 1.06 <0.001 p <0.001 Highly Significant NS = Non significant CS - Calcium Sulfate Hemihydrate CS - Calcium Sulfate Hemihydrate nCS - Calcium Sulfate Hemihydrate- nanocrystalline form nCS - Calcium Sulfate Hemihydrate- nanocrystalline form

Table 3: Comparison of mean values of defect resolution and defect fill (Wilcoxon test) Table 4: Comparison of mean values of defect resolution and defect fill at 3 months and 6 months between CS and nCS group (Mann Whitney test) Comparison of mean values of defect resolution

CS nCS Comparison of mean values of defect resolution

Time Mean ± SD Difference from baseline p-value Mean ±SD Difference from baseline p-value CS nCS p-value

Baseline 3.90 ± 1.50 - - 4.43±1.36 - - Baseline 3.90 ± 1.50 4.43±1.36 0.19 (NS)

3 months 0.87 ± 0.44 3.03± 1.43 <0.001 1.50 ±1.40 2.93 ±1.49 <0.001 3 months 0.87 ± 0.44 1.50 ±1.40 0.13 (NS)

6 months 1.23 ± 0.56 2.67± 1.32 <0.001 2.23± 1.32 2.20± 1.49 <0.001 6 months 1.23 ± 0.56 2.23± 1.32 0.003 (HS)

Comparison of mean values of defect fill Comparison of mean values of amount of defect fill

Baseline 9.56 ± 1.56 - - 9.37±2.29 - - Baseline 9.56 ± 1.56 9.37±2.29 0.69 (NS)

3 months 1.00 ± 0.53 8.56± 1.50 <0.001 1.67 ±1.43 7.70±2.30 <0.001 3 months 1.00 ± 0.53 1.67 ±1.43 0.12 (NS)

6 months 2.03 ± 1.46 7.53± 1.75 <0.001 2.60± 1.42 6.77± 2.17 <0.001 6 months 2.03 ± 1.46 2.60± 1.42 0.11 (NS) p<0.001 Highly significant HS = Highly significant; NS = Non significant CS - Calcium Sulfate Hemihydrate CS - Calcium Sulfate Hemihydrate nCS - Calcium Sulfate Hemihydrate- nanocrystalline form nCS - Calcium Sulfate Hemihydrate- nanocrystalline form

The mean pocket depth at baseline and baseline was 2.66 ± 0.82 and 5.33 ± 1.29 months (Table 1) compared to baseline. after 3 months and 6 months post respectively for CS sites, and 3.06 ± 1.22 However, there was no statistically operatively for both the groups is given in and 5.46 ± 1.19 respectively for nCS significant difference in mean values of Table 1. The mean difference of pocket sites, both of which were highly PD at baseline (p=0.69), at 3 months depth at 3 months and 6 months from significant (p<0.001), both at 3 and 6 (p=0.13) and at 6 months (p=0.17),

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 033 Table 5: Comparison of mean percentage of defect The mean percentage of defect fill from procedures, calcium sulfate is one of the resolution and defect fill at 3 months and 6 months between CS and nCS group (Mann Whitney test) baseline to 3 months and 6 months post first bone substitutes used in orthopedics surgery was 10.44 ± 4.86 and 20.94 ± and dentistry because of its beneficial 13.82 respectively for CS sites and 17.65 properties6 . Comparison of mean percentage of defect resolution ± 12.23 and 27.81 ± 12.60 respectively Calcium sulfate (CS) is a well-tolerated, CS nCS p-value for nCS sites (Table 5). There was no biodegradable, osteoconductive bone statistically significant mean percentage graft substitute and is a reasonable 3 months 23.43 ± 12.48 33.74 ± 23.80 0.45 (NS) of defect fill at 3 months (p=0.08) and 6 alternative to autogenous bone graft. 6 months 32.86 ± 13.95 52.02 ± 22.34 0.016 (S) months (p=0.06) for CS and nCS sites After being implanted into the bone (Table 5). defect, calcium sulfate undergoes Comparison of mean values of amount of defect fill degradation to calcium and sulfate ions. 3 months 10.44 ± 4.86 17.65 ± 12.23 0.08 (NS) The mean defect depth at baseline was Calcium ions combine with phosphate 3.90 ± 1.50 whereas the amount of defect ions from body fluids to form calcium 6 months 20.94 ± 13.82 27.81 ± 12.60 0.06 (NS) resolution at 3 and 6 months post phosphate, which provides an NS = Non significant; S= Significant operatively was 0.87 ± 0.44 and 1.23 ± osteoconductive surface which CS – Calcium Sulfate Hemihydrate 0.56 respectively for CS sites. The mean stimulates the recruitment of osteoblasts nCS - Calcium Sulfate Hemihydrate- nanocrystalline form defect depth at baseline was 4.43 ± 1.36 and development of new bone in the whereas the amount of defect resolution defect. As calcium sulfate undergoes at 3 and 6 months postoperatively were degradation in the body, there is a local between the two groups (Table 2). 1.50 ± 1.40 and 2.23 ± 1.32 respectively decrease in pH. This pH drop results in for nCS sites (Table 3). There was demineralization of defect walls The mean CAL at baseline and after 3 statistically no significant difference in releasing bone growth factors which months and 6 months post operatively for the mean values at baseline (p=0.19), and stimulate the formation and development both the groups is given in Table 1. The at 3 months (0.13) but statistically of new bone. mean difference of clinical attachment significant difference at 6 months (0.003) level at 3 and 6 months from baseline was between the two groups (Table 4). While it has been used for more than a 2.53 ± 0.99 and 5.20 ± 1.47 respectively century, certain of its advantages have for CS sites and 2.73 ± 1.16 and 5.00 ± The mean difference of defect resolution become apparent only in the past decade. 1.20 respectively for nCS sites both of at 3 months and 6 months from baseline It has been shown to serve as guided which were highly significant (p<0.001) was 3.03 ± 1.43 and 2.67 ± 1.32 tissue regeneration barrier membrane on both at 3 and 6 months (Table 1) respectively for CS sites and 2.93 ± 1.49 its own11 . Pecora and colleagues (1997)12 compared to baseline. However, there and 2.20 ± 1.49 respectively for nCS concluded that it works as a barrier was no statistically significant difference sites, both of which were highly membrane by excluding growth of in mean values of CAL at baseline significant (p<0.001) both at 3 and 6 connective tissue and allowing bone (p=0.91), at 3 months (p=0.59) and at 6 months (Table 3) compared to baseline. regeneration. Recently, calcium sulfate months (p=0.71) between the two groups was also observed to possess angiogenic (Table 2). 13 The mean percentage of defect resolution properties. Strocchi et al (2002) from baseline to 3 months and 6 months demonstrated that more blood vessels Radiographic Recordings post surgery was 23.43 ± 12.48 and 32.86 grew into the defects filled with calcium The mean defect measurement at ± 13.95 respectively for CS sites & 33.74 sulfate than those filled with autograft. It baseline was 9.56 ± 1.56 whereas the ± 23.80 and 52.02 ± 22.34 respectively can effectively be used as a drug delivery amount of defect fill at 3 and 6 months for nCS sites. There was statistically vehicle. Several drugs like Tobramycin post operatively was 1.00 ± 0.53 and 2.03 3 significant difference in mean percentage (Beardmore et al in 2005) , Simvastatin ± 1.46 respectively for CS sites (Table 3). of defect resolution at 6 months (p=0.16) (Nyan et al in 2007)14 and Daptomycin The mean defect measurement at and non significant difference at 3 15 baseline was 9.37 ± 2.29 whereas the (Webb et al in 2008) have been months (p=0.45) for the two groups delivered locally through calcium amounts of defect fill at 3 and 6 months (Table 4, 5). postoperatively were 1.67 ± 1.43 and sulfate. 2.60 ± 1.42 respectively for nCS sites Discussion However, calcium sulfate (CS) dissolves (Table 3). The mean difference of defect Periodontal tissue regeneration of fill at 3 months and 6 months from rapidly from the outer surface inwards at intrabony defects has been demonstrated rate as high as 1 mm per week (it is baseline was 8.56 ± 1.50 and 7.53 ± 1.75 by the use of different therapeutic respectively for CS sites, and 7.70 ± 2.30 usually completely degraded in 4 modalities. Various bone grafts have been weeks).4 At times, its degradation and 6.77 ± 2.17 respectively for nCS shown to be effective in treating sites, both of which were highly outpaces the rate of new bone growth into periodontal disease. Trombelli et al the defect. To overcome this weakness, a significant (p<0.001) both at 3 and 6 9 10 (2002) and Reynolds et al (2003) in nanocrystalline calcium sulfate (nCS) months (Table 3) compared to baseline. their systematic reviews summarized that There was statistically no significant particles based bone graft was developed. bone replacement grafts and bone Particles of nCS consist of densely difference in the mean values at baseline substitutes were significantly more (p=0.69), at 3 months (p=0.12) and at 6 packed grains of calcium sulfate in effective than open flap debridement in nanocrystalline form. nCS particles months (p=0.11) between the two groups improving attachment levels and in (Table 4). degrade in 12 to 14 weeks compared to reducing probing depth. Among the standard CS, which degrade in 4 to 6 different materials used in regenerative

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 034 weeks. This material encourages robust was 0.87 mm and 1.23 mm respectively regeneration22, 23, 24 . bone growth and finds applications in for CS sites which was statistically various dental bone defects (intrabony significant. The mean amount of defect Keeping in view the small sample size of defects, extraction sockets, sinus lifts, resolution from baseline to 3 and 6 the present study it is recommended that root perforations and apicoectomies) 4. months was 1.50 mm and 2.23 mm further studies employing large study respectively for nCS sites which was also populations and longer evaluation time The present study was undertaken to statistically significant (Table 3). There periods with frequent radiographic evaluate two forms of calcium sulfate was no statistically significant difference examination need to be conducted to (CS and nCS). in the mean amount of defect resolution analyze maximum potential of calcium at 3 months but was significant at 6 sulfate hemihydrate in regenerative This study showed statistically months between the two groups (Table periodontics. significant improvement in plaque and 4). The mean percentage of defect gingival indices at both follow up visits, resolution at 3 months and 6 months in Conclusions when compared to the baseline levels CS sites was 23.43% and 32.86% and The present study was conducted to (Table 1). There was no statistically 33.74% and 52.02% for nCS sites which evaluate the efficacy of two forms of significant difference in mean values of was statistically significant at 6 months calcium sulfate hemihydrate for the plaque index or gingival index at (Table 5). These results are in treatment of infra bony defects. Clinical baseline, at 3 months and at 6 months consistency with the study done by Couri and radiographic evaluation was carried between the two groups (Table 2). This CJ et al (2002)19. This is consistent with out at baseline, 3 months and 6 months was consistent with the studies conducted the observation that calcium sulfate for both the groups (CS and nCS). by Kim et al (1998)16 , Stein JM et al completely degrades in 4 to 5 weeks, The following conclusions were drawn (2009)17 . The reduction of plaque and whereas particles of nanocrystalline from the present clinical study: gingival scores could be attributed to the calcium sulfate show very little proper oral hygiene and patient degradation at 4 weeks and takes up to 12 1. There was significant reduction in compliance. to 14 weeks for complete degradation. plaque index, gingival index and pocket depth in CS and nCS groups at For the differences between the time The results of present study showed that 3 months and 6 months as compared points within each group, probing depth calcium sulfate (CS and nCS) improves to baseline. and clinical attachment level showed the healing outcomes vis-à-vis probing 2. There was no statistically difference statistically significant reduction (Table depth reduction and gain in clinical in mean values of plaque index, 1). There was no statistically significant attachment level. Better gingival index and pocket depth at 3 difference in mean values of pocket depth biocompatibility, excellent handling months and 6 months between the or CAL at baseline, at 3 months and at 6 properties, comparatively low cost, two groups. months between the two groups (Table angiogenicity, barrier membrane and 3. The gain in mean values of clinical 2). These findings are in agreement with hemostatic properties are the explicit attachment level at 3 months and 6 the results of Orsini M et al (2001)18, benefits of using calcium sulfate months were statistically significant Couri CJ et al (2002)19 and Paolontonio hemihydrates. nCS exhibited better as compared to baseline, however, the M et al (2008)11. Levy et al (2002) stated defect fill and defect resolution than CS. gain in clinical attachment level was that reduction in pocket depth by surgical No adverse effect or tissue response was statistically non significant after 3 means may be important in achieving observed with both the graft materials. months and 6 months when compared sustained periodontal stability20 . between the groups. Defect fill and defect resolutions are the 4. Both CS and nCS groups showed The mean amount of defect fill from main outcomes that are usually reported statistically significant amount of 21 baseline to 3 months and 6 months was by regenerative studies. While defect defect fill and defect resolution at 3 1.00 mm and 2.03 mm respectively for fill takes into account only the changes at months and 6 months as compared to CS sites which was statistically the base of the defect; defect resolution baseline. significant. The mean amount of defect takes into account the changes in alveolar 5. A greater percentage of defect fill and fill from baseline to 3 and 6 months was crest that may occur with regenerative resolution was noticed in nCS group. 1.67 mm and 2.60 mm respectively for therapy in addition to fill of the defect at 6. Both graft materials can be nCS sites which was also statistically the base. Thus, it may be interpreted that considered valuable options in the significant (Table 3) compared to defect resolution is a better parameter. treatment of infra bony periodontal baseline. There was no statistically The most reliable outcome for assessing defects. However, based on the significant difference in the mean amount periodontal regeneration is histology. results, nCS is more effective then of defect fill at 3 months and 6 months Due to ethical considerations, patient CS. between the two groups (Table 4). The management limitations such as surgical 7. The enhanced gain in defect fill and mean percentage of defect fill at 3 months re-entry and patient morbidity, no resolution of osseous defects in nCS and 6 months in CS sites was 10.44% and histological evaluation was made to could be attributed to its slow 20.94% respectively and 17.65% and establish proof of periodontal degradation profile that matches the 27.81% for nCS sites respectively (Table regeneration. Based on the histological rate of bone growth. 5). evidence from human and animal trials, it is worth assuming that the clinical Acknowledgments The mean amount of defect resolution improvements following calcium sulfate The bone graft materials used in the study from baseline to 3 months and 6 months treatment represents true periodontal (DentoGen and NanoGen) were provided

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 035 by Orthogen LLC. The authors report no al. Surgical treatment of periodontal bioabsorbable membranes plus conflicts of interest related to this study. intrabony defects with calcium autogenous bone graft in the sulfate implant and barrier versus treatment of intrabony periodontal References collagen barrier or open flap defects: A split mouth study. J 1. Mamidwar S, Ricci JL, Harold A. debridement alone: A 12 month Periodontol. 2001; 72: 296-302. Bone regeneration with calcium randomized control clinical trial. J 19. Couri CJ, Maze GI, Hinkson DW, sulfate based bone grafts. Inside Periodontol. 2008; 79:1886-93. Dawson DV. Medical grade calcium Dentistry. 2006; 2:1-7. 12. Pecora G, Andreana S, Margarone JE, sulfate hemihydrate versus expanded 2. Orthogencorp.com [homepage on the Covani U, Sottosanti JS. Bone polytetrafluoroethylene in the internet]. New Jersey:Orthogen regeneration with a calcium sulfate treatment of mandibular class II LLC;2008. Available from: barrier. Oral Surg Oral Med Oral furcations. J Periodontol. 2002; 73: http://www.orthogencorp.com/CS/ Pathol Oral Radiol Endod. 1997; 1352-9. properties.html. 84:424-9. 20. Levy RM, Giannobile WV, Feres M, 3. Beardmore AA, Brooks DE, Wenke 13. Strocchi R, Orsini G, Iezzi G, Scarano Haffajee AD, Smith C, Socransky SS. JC, Thomas DB. Effectiveness of A, Rubini C, Pecora G et al. Bone The effect of apically repositioned local antibiotic delivery with an regeneration with calcium sulfate: flap surgery on clinical parameters osteoinductive and osteoconductive Evidence for increased angiogenesis and the composition of the bone graft substitute. J Bone Joint in rabbits. J Oral Implant. 2002; 28: subgingival microbiota: A 12-Month Surg Am.2005; 87:107-12. 43-8. Data. Int J Periodontics Restorative 4. Ricci JL, Weiner MJ, Iorio DD, 14. Nyan M, Sato D, Oda M, Machida T, Dent. 2002 June; 22: 209-19. Mamidwar S, Alexander H. Kobayashi H, Nakamura T et al. Bone 21. Stavropoulos A, Karring T. Guided Evaluation of timed release calcium formation with the combination of tissue regeneration combined with a sulfate (CS-TR) bone graft simvastatin and calcium sulfate in deproteinized bovine bone mineral substitutes. Microsc Microanal. critical sized rat calvarial defect. J (Bio-Oss) in the treatment of 2005; 11:1256-7. Pharmacol Sci. 2007; 104:384-6. intrabony periodontal defects: 6-year 5. Orthogencorp.com [homepage on the 15. Webb ND, McCanless JD, Courtney results from a randomized-controlled internet]. New Jersey: Orthogen HS, Bungardner JD, Haggard WO. clinical trial. J Clin Periodontol. LLC; 2008. Available from: Daptomycin eluted from calcium 2010; 37: 200-10. http://www.orthogencorp.com/rd/ sulfate appears effective against 22. Ruhaimi AKA. Effect of adding CScr.html. staphylococcus. Clin Orthop Relat resorbable calcium sulphate to 6. Orsini M, Orsini G, Benlloch D, Res. 2008; 466:1383-7. grafting materials on early bone Aranda JJ, Mariano S. Long term 16. Kim CK, Chai JK, Cho KS, Moon IS, regeneration in osseous defects in clinical results on the use of bone Choi SH, Sottosanti JS et al. rabbits. Int J Oral Maxillofac replacement grafts in the treatment of Periodontal repair in intrabony Implants. 2000; 15:859-64. intrabony periodontal defects. defects treated with a calcium sulfate 23. Maeda ST, Bramante CM, Taga R, Comparison of the use of autogenous implant and calcium sulfate barrier. J Garcia RB, Moraes IG, Bernadineli bone graft plus calcium sulfate to Periodontol. 1998; 69: 1317-24. N. Evaluation of surgical cavities autogenous bone graft covered with a 17. Stein JM, Fickl S, Yekta SS, Hoischen filled with three types of calcium bioabsorbable membrane. J U, Ocklenburg C, Smeets R. Clinical sulfate. J Appl Oral Sci. 2007; Periodontol. 2008; 79:1630-7. evaluation of a biphasic calcium 15:416-19. 7. Loe H. The gingival index, the plaque composite grafting material in the 24. Silveira RL, Machado RA, Silveira index and the retention index treatment of human periodontal CRS, Oliveira RB. Bone repair systems. J Periodontol. 1967; 38 intrabony defects: A 12- month process in calvarial defects using (suppl): 610-6. randomized controlled clinical trial. J bioactive glass and calcium sulfate 8. Loe H, Silness J. Periodontal disease Periodontol. 2009; 80: 1774-82. barrier. Acta Cirurgica Brasileira. in pregnancy. I. Prevalence and 18. Orsini M, Orsini G, Benlloch D, 2008; 23:322-8. severity. Acta Odontol Scand. 1963; Aranda JJ, Lazaro P, Sanz M et al. 21: 533-51. Comparison of calcium sulfate and 9. Trombelli L, Heitz-Mayfield LJ, autogenous bone graft to Needleman I, Moles D, Scabbia A. A systematic review of graft materials and biological agents for periodontal intraosseous defects. 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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 036 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Original Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Evaluation Of Antimicrobial Activity Of Root 1 Sharma D K 2 Sachdev V Canal Irrigants-An In Vitro Study 3 Sharma N 1 Assistant Prof. Dept. of Microbiology Abstract 2 Principal & Prof. The aim of this in vitro study was to determine the antimicrobial efficacy of Sodium hypochlorite, Dept. of Peadodontics chlorhexidine and hydrogen peroxideas root canal irrigants. Patients visiting in the dept of 3 Assist. Prof. conservative dentistry and paedodontics were included in this study. Results were as follows: The Department of Oral Medicine and Radiology most abundant bacteria was S. aureus (95%), followed by S. pyogenes (80%), P. Himachal Dental College, aeruginosa(30%), Micrococci(20%), E.coli (15%), and Candida albicans(10%). Zone of inhibition Sunder Nagar, Himachal Pradesh by different irrigants was compared using impregnated filter paper disc. S. aureus showed 27mm Address For Correspondence: zone of inhibition with 0.2% CHX which was followed by 26.0mm for Micrococci , 23.0mm for S. Dr. Devender K. Sharma pyogenes , 13.0mm for P. aeruginosa, 13.0mm for C. albicans &7.0mm for E. coli . No zone of Assistant Prof. inhibition was observed around where normal saline was used as control. The results of these Dept. of Microbiology measurements reveled that 0.2%Chlorhexidine (CHX) is best among all the irrigants used in root Himachal Dental College, canal treatment . The normal saline which was used as control did not show any antimicrobial Sunder Nagar, Himachal Pradesh Phone No +91-94180-71129 effect. Email ID : [email protected] th Key Words Submission : 20 September 2011 Root canal, Enodontics, CHX, Irrigants Accepted : 17th March 2012

Quick Response Code Clinical Significance conducted to determine the efficacy of Clinical significance of this study is the antimicrobial activity of the irrigants, estimate antimicrobial efficacy of these namely sodium hypochlorite, hydrogen root canal irrigants for successful and peroxide, and chlorhexidine against uneventful root canal treatment. commonly isolated aerobic and anaerobic organisms from root canal Introduction infections. Bacteria and their byproducts are considered as the major etiological Materials & Methods mirror, tweezer. factors for endodontic diseases. The Patients, visiting Department of ?Sterile absorbant paper points. various microorganisms isolated from Conservative dentistry and Peadodontics ?Culture medium like Nutrient agar, the infected root canals are gram positive dentistry during this period, with the MacConkey agar, Blood agar, Potato and gram negative aerobes, obligatory proven history of root canals exposure dextrose agar and Muller -Hinton anaerobes and yeast Abirami CP et.al were included in the study. agar. (1999). There has always been a strong ?0.2% chlorhexidine (CHX), 2.5% correlation between the basic sciences of Criteria for inclusion of the patients: Sod. hypochlorite (NaOCl), 3% microbiology and the clinical science of Patients with following symptoms and hydrogen peroxide (H2O2), sterile endodontics. The microbial flora of the criteria were included in this study. physiological normal saline. root canal system is polymicrobial. ?Patients with history of toothache and Mainly facultative anaerobes and / or swelling for 2-3 days. Methods obligatory anaerobes. The success of ?Patients showing clinical signs and Root canal access opening in the teeth endodontic treatment is directly symptoms with radiographic was prepared with the help from influenced by the elimination of evidence of root canal exposure. endodontologist. After gaining the microorganisms from infective root adequate access to the canal, sterile paper canals. Irrigant solutions are essential Exclusion criteria: points were placed in the canal for few during root canal preparation because of ?Patients with previous history of root seconds. After some time paper points their help in cleaning the root canal, canal treatment were excluded from were removed with the help of a sterile lubricate the files, flush out debris, kill the study. forceps and inoculated in the nutrient bacteria, and dissolve tissue without broth. The test tubes incubated at 370 C damaging the priapical tissues. The Material Used: for 24 hrs. Development of turbidity in selection of ideal irrigants depends upon ?A pair of sterile disposable gloves and the medium indicated growth of its antibacterial action Eracan E et.al disposable mouth masks. microorganisms. The turbid culture (2006) . Therefore this study was ?Stainless steel kidney tray, mouth suspensions were subcultured on

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 037 Table: 1 Showing means of diameter (in mm) of inhibition zones by irrigants using agar diffusion test

Irrigants 0.2% Chlorhexidine 3% Hydrogen Peroxide 2.5% Sodium Normal

Isolates (CHX) (H2O2) Hypochlorite (NaOCl) Saline

Staphylococcus aureus 27.0 35.0 13.0 0

Streptococcus pyogenes 23.0 20.0 12.0 0

Pseudomonas aeruginosa 13.0 10.0 9.0 0

Escherichia coli 7.0 5.0 6.0 0

Candida albicans 13.0 7.0 19.0 0

Fig.1 showing whatman filter paper discs impregnated Micrococci 26.0 21.0 11.0 0 with four irrigants viz: 0.2 % Chlorhexidine (CHX), 3.0 % hydrogen peroxide ( H2O2), 2.5 % sodium hypochlorite ( NaOCl) and normal saline. Nutrient agar, MacConkey agar, Blood discs. This was followed by 21.0 mm, agar and Potato dextrose agar. Each plate 10.0mm, 7.0mm, for Micrococci, was incubated at 370C for 24-48 hrs and Streptococcus pyogenes, Pseudomonas after incubation plates were observed for aeruginosa, Candida albicans and colonies characteristics. Escherichia coli respectively.

Results For Staphylococcus aureus 35.0 mm The most abundant was Staphylococcus zone of inhibition was observed with 3%

aureus which was isolated from all but H2 O 2 where as 27.0 mm with 0.2% one patient, thus accounting for 95% of Chlorhexidine and 13.0 mm for 2.5% root canal infections. This was followed NaOCl. But widest zone of inhibition for by Streptococcus pyogenes which was Staphylococcus aureus was observed found in 16 samples 80%, Pseudomonas with 0.2% Chlorhexidine. Similarly aeruginosa 30% occurrence while 0.2% Chlorhexidine showed widest zone Micrococci 20%, Escherichia coli 15% of inhibition for Pseudomonas and Candida albican 10% . Only one aeruginosa as well as for Escherichia coli patient was found to infected with and Micrococci. Streptococcus pyogenes alone, all others were multiply infected. Incidence of Summary & Conclusion occurrence (%) of these organisms . The Success of endodontics treatment is Fig.2 Showing zone of inhibtion by irrigants on muller- hinton agar negatively influenced by the presence of Zone of inhibition: zone of inhibition by microorganisms within the root canal different irrigants was compared using system. The studies have shown the impregnated filter paper discs. relationship between the development of Staphylococcus aureus showed 27.0 mm apical periodontitis and colonization of zone of inhibition with the 0.2% pulpal space by bacteria. Apical Chlorhexidine impregnated paper disc. periodontitis is an inflammatory process This was followed by zone of of the periradicular region and is initiated inhibition(26.0mm) for Micrococci, and sustained by endodontics infection (23.0 mm) for Streptococcus pyogenes, Zerella JA et.al (2006). The control and (13.0 mm ) for Pseudomonas aeruginosa, the elimination of microorganisms are (13.0 mm) for Candida and (7.0 mm ) for very important during endodontics Escherichia coli . treatment because of their role in pulpal and perapical diseases. Therefore this For 2.5% NaOCl 19.0mm zone of study was carried out to find the efficacy inhibition was observed for Candida of various root canal irrrigants (0.2%

albicans followed by (13.0 mm) for CHX, 2.5% NaOCl, 3% H2 O 2 ). Staphylococcus aureus, (11.0 mm) for Micrococci, (12.0 mm) for Streptococcus Study conducted by Oztan MD et.al Fig.3 showing incidance of infection of root canal pyogenes, (9.0 mm) for Pseudomonas (2006). has shown that in primary bacterial isolates aeruginosa and (6.0 mm) for Escherichia endodontic infections, micro flora coli. consists mostly of anerobes. However, in case of failed endodontics treatment the Largest zone of inhibition i.e. 35.0 mm intracanal flora is different and was observed around Staphylococcus facultative anaerobes may predominate. aureus when 3% H2 O 2 was used in paper These results are in concordance to our

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 038 study in which the predominate efficacious root canal irrigant as BPFDA, Zaia AA. Teixeira FB organisms isolated were facultative compared to the NaOCl. So the results of (2005) . In vitro assessment of the anaerobes. present study indicate that 0.2% immediate and prolonged Chlorhexidine is very effective antimicrobial action of chlorhexidine Mechanical instrumentation- associated antimicrobial endodontics irrigant. These gel as an endodontic irrigants against irrigation has been considered to play a results are almost similar to the study Enterococcus faecalis. Oral Surg Oral key role to the success of endodontics conducted by Abirami and Subba Rao Med Oral Pathol Oral Radiol Endod. treatment. Sodium hypochlorite, owing (1999) which has showed that 0.2% 99: 768-72. to its powerful germicidal and chlorhexidine and 3% H2 O 2 are superior 5. Eracan E, Dulgergil T, Yavuz I (2006) bactericidal properties is still the most in antimicrobial activity against all the . The effects of antibacterial solution frequently used root canal irrigants microorganisms. on microorganisms isolated from Bystorm A & Sundqvist G (1983). infected root canals IN VIVO. Discussion Biotechnol& Biotechnol.Eq. 20 : 1. Chlorhexidine gluconate is a cationic Present study has high lightened the 6. Oztan MD, Kiyan M, Gerceker D biguanide that combines to the cell wall polymicrobial nature of root canal (2006). Antimicrobial effect, in vitro of the bacteria and causes the leakage of infection and importance of obligate and gutta-percha pointscontaining root intracellular components.At low facultative microorganisms in root canal canal medications against yeast and concentration of CHX small molecular infection. Furthermore this study has also Enterococcus faecalis. Oral Surg Oral weight substances will leak out resulting correlated the effectiveness of various Med Oral Pathol Oral RadiolEndod. in a bacteriostatic effect. At higher root canal irrigants in endodontology. 102(3) : 410-416. concentration CHX has bactericidal 7. Tripathi KD. Essentials of medical effect owing to precipitation and Our study has shown the effectiveness of pharmacology. Fifth edition. Page coagulation of cytoplasm, probably sod. hypochlorite as root canal irrigant 805-806. caused by protein cross linking Dametto against some common root canal 8. Vianna ME, Berber VB, Ferraz CCR FR et.al (2005). pathogens. But overall effectiveness of (2004). In vitro evaluation of the CHX has proven to be better than NaOCl antimicrobial activity of

The antimicrobial activity of sodium and H2 O 2 . Large scale studies are required chlorhexidine and sodium hypochlorite depends upon the to further refine issues related to the hypochlorite. Oral Surg Oral Med concentration of undissociated effectiveness of various root canal Oral Pathol Oral RadiolEndod. 97: hypochlorous acid in solution. The irrigants in endodontology. 79-84. hypochlorous acid exerts its germicidal 9. Zamany A, Larz SW (2003) . The effect by an oxidative action on sulfydryl Bibliography effect of chlorhexidine as an groups of bacterial enzymes as essential 1. Abirami CP, Subba Rao CV (1999). endodontic disinfectant. Oral Surg enzymes are inhibited, important Evaluation of the antimicrobial Oral Med Oral Pathol Oral Radiol metabolic reactions are disrupted activities of root canal irrigants: an in Endod . 96: 578-81. resulting in the death of bacterial cell vitro study.Endodontology - Journal 10. Zerella JA, Fouad AF, Larz SW Baumgartner JC & Cuenin PR (1992) . of Indian Endodontic Society. 2:27- (2005) . Effectiveness of calcium 29. hydroxide and chlorhexidine 3% H2 O 2 when used as irrigant, it 2. Baumgartner JC, Cuenin PR (1992) . gluconate mixture as disinfectant liberates nascent oxygen which oxidizes Efficacy of several concentrations of during treatment of failed endodontic necrotic matters and bacteria. Catalysts sodium hypochlorite for root canal cases. Oral Surg Oral Med Oral present in the tissue speeds irrigation. J Endod. 18: 605-12. Pathol Oral RadiolEndod. 100 : 756- decomposition resulting in foaming- 3. Bystorm A, Sundqvist G (1983). 61. helps in loosening the debris (Tripathi Bacteriological evaluation of the KD). effect of 0.5%sodium hypochlorite in endodontics therapy. Oral Surg Oral In our study 0.2% Chlorhexidine showed Med Oral Pathol Oral RadiolEndod. better antimicrobial effect against all the 55: 307-12. organisms tested as compared to the other 4. Dametto FR, Ferraz CCR, Gomes irrigants used. This is a contradictory to the study conducted by Vianna ME et.al. (2004) in which 5.25 % NaOCl used as irrigant showed the better results as compared to the 0.2% CHX gel. The Source of Support : Nill, Conflict of Interest : None declared reason for this contradiction can be due to the higher concentration (5.25 %) of NaOCl used in this study as compared to the 2.5% NaOCl used in our study.

But the results of our study are in concordance with the study conducted by Dametto FR et.al (2005) in which 0.2% CHX gel was proved to be more

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 039 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Glove Type Silicone Finger Prosthesis - A Case 1 Laxman Singh Kaira 2 Vishal Katna Report 1 PG Student, Department of Prosthodontics, Darshan Dental College And Hospital, Loyara, Udaipur - Rajasthan Abstract 2 Finger deformities affect aesthetics and function of hand severely compromising and also cause Senior Lecturer Department of Prosthodontics psychological disturbances. This clinical report describes the fabrication of a silicone glove type Himachal Dental College, Sundernagar HP finger prosthesis for a 30 years old male patient with missing upper 1/3 rd part of middle finger of left hand after injury at work. The glove type finger prosthesis was retained by a vaccum effect on Address For Correspondence: Dr. Laxman Singh stump. The glove type finger prosthesis offered psychological ,functional and rehabilitative 47 A Vijay Colony, New Cantt Road advantages for the patient restoring the natural appearance with the prosthesis. This prosthesis Dehradoon, Uttranchal also eliminated the trauma generated by dysfunction and represented an efficient psychological Ph:9929578916,9549375516 therapy. Email:[email protected]

th Key Words Submission : 24 March 2011 th Glove type finger prosthesis,Silicone,Amputee Accepted : 10 February 2012

Quick Response Code Introduction Rajasthan for the replacement of the Finger or partial finger amputations are missing upper 1\3 rd part of middle finger the most frequently encountered forms of of left hand . His chief complaint was loss partial hand loss . The most common of grip and ugly appearance. History causes of these amputations are traumatic reveals that the amputations occurred at injuries ,congenital absences or the upper 1\3 rd part of middle finger 6 malformations which may present years back. He told about the injury. He clinical challenges. Finger absence works as a labourer in building thumb apart , without stretching (Figure causes loss of grasp, security and marked construction and while breaking big 1). psychological trauma. stones he got injury in middle finger and Beasley has noted that individuals who index finger . After trauma upper 1/3 part keep their hands inside pockets due to of middle finger get amputed and index embarrassment over appearance are as finger was disfigured. The surrounding functionally disabled as a forequarter area appeared to be normal with no signs (scalpulothoracic) amputee.1 of any inflammation . After clinical A precisely fitting prosthesis can improve evaluation of the defect it was concluded function by restoring normal length , that the amputed finger was acceptable protecting a sensitive stump, maintaining for prosthetic rehabilitation . An sensitivity through a thin lamina and informed consent was taken from the transmitting pressure and position sense patient before starting the treatment to for activities such as writing or typing. ensure his willingness and co-operation. Figure 1 : Pretreatment Photographs Of Both Hands The gentle ,constant pressure of an This patient was convinced for silicone elastomer prosthesis can help rehabilitation of missing upper 1/3 rd part Preparation Of Models desensitize and protect the injured of middle finger with glove type finger The impressions were then poured in tip.Individuals who desire finger prosthesis. dental stone (kalabhai dental pvt ltd) replacement usually have high using vibrator to avoid voids and the expectations for the appearance of the Procedure working casts of both hands were prostheses.2 Here ,the prosthetic Making of Impression : The patient hands retrieved. Wax Pattern Fabrication and management of a male patient with were lubricated with petroleum jelly to Try in - A donor was selected finding the amputed middle finger was presented prevent the impression material from same age ,sex and build as the patient and with less expensive and easily available sticking to the amputed site. Two big an putty impression of the left hand was silicone material. cardboa rd boxes were used for making made . The impression was poured in the impressions of both the right and left molten wax (modelling wax) and after Case Report hand using irreversible hydrocolloid cooling, the wax pattern was retrieved. A 30 year old male patient was reported to impression material. The patient was The necessary modifications were made the Department of Prosthodontics, instructed to keep the hands in normal at chair side. The wax try in was done in Darshan Dental College Udaipur, resting position along with fingers and the patient finger. During try in stage ,the

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 040 fit, stability and seating of the wax pattern Once the final prosthesis was retrieved on which a standard digital prosthesis were evaluated along with the shape and ,the flash was trimmed using a sharp attaches securely by means of an size of the pattern (Figure 2). blade . osseointegrated implant placed on Fitting and instructions intramedullary canal of residual bone of Slight extrinsic staining was done for the amputed digit.3 exact matching of the shade.Though the In a study by Manurangsee et al, acrylic fit of the prosthesis was quite satisfactory resin prostheses were fabricated and artificial rings was placed to hide the firmly attached to the abutments using margins of the prosthesis(Figure 5 & 6). hexagonal magnetic suprastructure system.4 Lundborget al rehabilitated 3 patients with traumatic thumb amputations with implant retained silicone thumb prosthesis.5 Advantage of intrinsic colouration is Figure 2 : Model With Wax Pattern increased service life of prosthesis. Nail bed preparation Disfigured index finger can be corrected An undercut was created beneath the only by plastic surgery and not by cuticle margin that would function to prosthetic means. Hence glove type retain the prefabricated artificial nail finger prosthesis was fabricated only for within the wax pattern. The nail was Figure 4 : Packing Of Silicone Material In Mould middle finger. shaped according to the nail of the natural Conclusion fingers. A convenient and affordable method of Flasking and Dewaxing of Pattern prosthetic rehabilitation of an amputed Putty wash technique was used to make finger with room temperature impression of amputed stump and was vulcanising silicone material has been poured in die stone. The pattern was presented.The custom made glove type transferred on the model and flasked to finger prosthesis is esthetically enhance the accuracy at the stage of acceptable and comfortable in patients shade matching such that the dorsal and with amputed fingers ,resulting in the palmer aspects of the finger were psychological improvement and separable, separating medium is applied Figure 5 : Glove Type Finger Prosthesis Dorsal View personality.Patient was highly satisfied between the two pours. After dewaxing with this prosthesis in terms of retention ,the mould is allowed to cool (Figure 3). ,function and esthetics. The morale of the patient was also boosted to a great extent. References 1. Beasley R J general consideration in managing upper limb amputation orthop clinics of northamerica 1981:12;4 ,743-749. Figure 6 : Glove Type Prosthesis Palmer View 2. John W Michael ,Horst Bucknor - Patient was demonstrated about the use Journal of prosthodontics and and maintenance of the prosthesis. orthoptics 1994,vol 6,nu 1, 10-15. Patient was instructed not to expose the 3. Cemal Aydin, Secil Karakora, prosthesis to high temperatures, and Handan Yilmaz et al -The use of Figure 3 : Dewaxing Of Wax Pattern sunlight and not to smoke as it stains the dental implants to retain thumb Colour matching prosthesis yellow. prosthese: a short term evaluation of 2 Shade matching was done using natural cases , Int J Prosthodont daylight. The best time for this procedure Discussion 2008;21:138-140. was between 11 am to 1 pm .The room Currently many traumatically amputed 4. M a n u r a n g s e e P , temperature vulcanising silicone(M P digits can be saved by microsurgical IssariyawutC,Chatuthong V et al- SAI mumbai) was used to matched replantation or osseointegrated digital Osseointegrated prosthesis: an intrinsically with the dorsal and palmer prosthesis .In some cases, however alternative method for finger surface of finger. It is essential to carry reconstruction is contraindicated or reconstruction. J Hand out this procedure in front of the patient patient economic conditions preclude surg(Am)2000;25:86-92. so as to gain approval. such treatment options. Prosthetic 5. LundborgG ,BranemarkPL, Rosen b Packing of Mould replacement of fingers can be satisfactory et al- Osseointegrated thumb Cyanoacrylate was painted to the in patients who have atleast 1.5 cm of prostheses: a concept for fixation of artificial nail .Vaseline was applied to the residual stump. The osseointegrated digit prosthetic devices,J hand Surg mould. Mould was packed with silicone digital prosthesis is an alternate 1996;21:216-221. (Figure 4). The material was allowed to technique for patients with short stump bench cured overnight . Finishing of prosthesis Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 041 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Gingival Depigmentation In Children: A Case 1 Manjul Mehra 2 Rashu Grover Report 3 Sunil Gupta 4 Gunmeen Sadana Abstract 1,2 Senior Lecturer, In recent years, there is an increasing need for esthetics and growing cosmetic demands for a 3 Professor, pleasing smile in many individuals. In particular, parents are more conscious of the black or dark 4 Professor And Head, pigmentation patches on the facial aspects of the gingiva of their child, which may be strikingly Dept Of Pedodontics And Preventive Dentistry, Sri Guru Ram Dass Institue Of apparent during smiling and speaking. Till date very little literature has been published regarding clinical methods of treatment of pigmented gingiva in children. A case is reported here in which a Dental Sciences And Research, Amritsar simple and effective surgical depigmentation was performed without the use of any sophisticated Address For Correspondence: instruments or apparatus. Dr. Manjul Mehra(M.D.S.) Senior Lecturer, Dept Of Pedodontics And Preventive Dentistry, Key Words Sri Guru Ram Dass Institue Of Glove type finger prosthesis,Silicone,Amputee Dental Sciences And Research, Amritsar, 143001 Punjab India Phone Number : 08146133366 E-mail Address : [email protected] Introduction acceptable results along with patient's Submission : 12th July 2011 Hyperpigmentation of the gingiva is satisfaction. Accepted : 19th January 2012 caused by excessive melanin deposition by the melanocytes mainly located in the Case report Quick Response Code basal and suprabasal cell layers of the A 9-year-old male child visited epithelium [1]. Several local and Department of Pedodontics, Sri Guru systemic factors cause melanin Ram Das Institute of Dental Sciences pigmentation, including physiological or And Research, along with his parents racial pigmentation, smokers melanosis, with the concern of his unaesthetic pigmented nevus, melanotic macula, anterior gingival pigmentation and his Addison disease, Peuutz-Jeghers malalligned teeth. On examination, the syndrome, HIV infection and drugs such patient had a very high smile line that handle with a No.15 blade and a high as minocycline and anti- malarial revealed the deeply pigmented gingiva speed hand piece with diamond bur were drugs[2]. It has been observed that there on the labial surface of both maxillary used to remove the pigmented layer (Fig. is positive correlation between gingival and mandibular arches. The color of his 2). pigmentation in children and parental gingiva was dark to black (Fig. 1). smoking, this pigmentation may be induced by the stimulation of melanocytes by stimuli present in tobacco smoke such as nicotine and benzopyrene [3]. The hyperpigmentation of the gingiva is benign in most cases, and is not a medical concern. However, it may cause esthetic problems for some individuals, Fig.2 : Immediately after surgery of the maxillary anterior especially those who have gummy Fig 1 : Pre-operative photograph showing pigmented gingiva smile[4]. Gingival depigmentation is a Pressure was applied with sterile gauze periodontal plastic surgical procedure soaked in local anesthetic agent to control whereby the gingival hyperpigmentation The patient had a mixed dentition period hemorrhage during the procedure. After is removed or reduced by various with maxillary right central incisor in removing the entire pigmented techniques. The first and foremost cross bite. Depigmentation procedure epithelium along with a thin layer of indication for depigmentation is patient was planned only in maxillary arch along connective tissue with the scalpel, demand for improved esthetics. with anterior inclined plane for abrasion with diamond bur was done to The present case report, describes a correction of cross bite. get the physiological contour of the simple and effective surgical A scalpel surgery with bur abrasion was gingiva, the exposed surface was depigmentation technique that does not planned to perform the depigmentation. irrigated with saline. It is recommended require sophisticated instruments or Following the administration of local to use the largest size diamond apparatus yet yields esthetically anaesthetic solution, A Bard Parker

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 042 bur(diameter of ball 2mm or 2.5mm) Cryotherapy is a method of tissue Among the mentioned techniques, we because small burs do not smoothen destruction by rapid freezing. The found the scalpel and abrasion technique surfaces easily and have a tendency to cytoplasm of the cells freeze leading to relatively simple and versatile and it make small pits in the area to be denaturation of proteins and cell death. required minimum time and effort. No corrected. Care must be exercised to use This procedure does not require the use of sophisticated and expensive feather-light brushing strokes to remove local anesthesia, is relatively a painless armamentarium were required, only the pigmented areas without holding the procedure and has shown to produce blade and bur were sufficient. The bur in one place. All the remnants of the excellent results.However it is followed procedure essentially involves surgical melanin pigment or pigmented areas of by considerable swelling and it is also removal of gingival epithelium along the epithelium should be completely accompanied by increased soft tissue with a layer of the underlying connective removed to prevent possible relapse of destruction as the depth of penetration tissue and allowing the denuded the problem. Surgical area was covered cannot be controlled [6]. connective tissue to heal by secondary with a periodontal pack and post- Recently, a laser has been used to ablate intention. The new epithelium that forms operative instructions were given. cells containing and producing the is devoid of melanin pigmentation . Analgesic was prescribed for the melanin pigment. This has the However, scalpel surgery may cause management of pain. After one week, the advantages of easy handling, short unpleasant bleeding during and after the pack was removed and the surgical area treatment time, hemostasis and operation, and it is necessary to cover the was examined. The healing was decontamination and sterilization effects exposed lamina propria with periodontal uneventful without any post surgical .The Nd:YAG laser produces invisible, dressing for 7 to 10 days [13]. complications. The gingiva became pink near-infrared light with a wavelength of Though the initial result of the and healthy within 5 weeks after ablation. 1,064 nm. Because the Nd:YAG laser has depigmentation surgery is highly At 9 month follow up, there was no rays that have an affinity for melanin or encouraging, repigmentation is a recurrence of gingival other dark pigments, it works more common problem. The exact mechanism hyperpigmentation (Fig 3). The patient efficiently when the beam is applied of repigmentation is not understand, but and his parents were very impressed with under the presence of a pigment . No according to migration theory, active such a pleasing aesthetic outcome. significant side effects of scarring, or melanocytes from the adjacent textural or pigmentary changes have been pigmented tissue migrate to treated areas, reported and the incidence of causing repigmentation [14].Dummett hypopigmentation has been reported as and Bolden observed partial recurrence lower than that by other types of of hyperpigmentation in 6 out of 8 lasers[7]. Hyuj-Jin et al found both the patients after gingivectomy at 1 to 4 Nd:YAG laser and the high speed rotary months[1],where as Permutter and Tal et instrument seem to be effective in the al did not observe repigmentation until 20 esthetic treatment of gingival melanin months after cryosurgical hyperpigmentation[8]. G Berk et al depigmentation[15] .No recurrence of Fig.3 : 9 month post operative showing pink and firm pointed out that Er,Cr:YSCG Laser was a hyperpigmentation was found in any of gingiva good and safe choice for removal of the 4 patients treated by Atsawasuwan et pigmented gingiva without local al at 11 to 13 months after gingival Discussion anesthesia[9]. But this approach needs depigmentation using Nd:YAG In recent years, there is an increasing expensive and sophisticated equipment Laser[10] . Sameer A .Mokeem observed need for esthetics and growing cosmetic that is not available commonly at all no repigmentation occurring in any of demands for a pleasing smile in many places and makes the treatment very the three patients treated with surgical individuals. In particular, parents are expensive . abrasion after 18 months[16]. more conscious of the black or dark Free gingival grafting is quite an In the present case, repigmentation was pigmentation patches on the facial invasive and extensive procedure and has not observed during a short follow up aspects of the gingiva of their child, not been advised for depigmentation period (9 month). However, long -term which may be strikingly apparent during procedures routinely. but it has the observation are required to determine the smiling and speaking. Till date very little disadvantage of a second surgical site, efficacy of depigmentation in children. In literature has been published regarding additional discomfort and poor tissue future, even if gingival repigmentation clinical methods of treatment of color matching at the recipient site [11]. occurs in this patient, the same procedure pigmented gingiva in children. Different Bone denudation procedure is again an could be repeated in the same region. treatment modalities have been used for invasive method not used for the obvious The timing of doing depigmentation this procedure in adults. The selection of reasons of bone loss and the discomfort procedure in children is not clear in the a technique for depigmentation of the involved in the procedure for the patient. literature. However, personal experience gingiva should be based on clinical Gingival depigmentation has been has found that delay is not necessary as experience, patient's affordability and attempted by displacing the flap (push the children are conscious about their individual preferences. back technique), by Kon et al and have dental esthetic appearance and that of the Electrosurgery requires more expertise reported that melanocytes may lose their other children. than scalpel surgery. Prolonged or ability transiently to produce and transfer The depigmentation procedure was repeated application of current to tissue the pigment to the keratinocytes, but successful and both the patient and his induces heat accumulation and undesired return to normal much faster than do parents were satisfied with the result and tissue destruction [5] melanocytes observed after most important ,his self esteem has gingivectomy or other procedures[12] improved . Thus, we conclude that

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 043 depigmentation of hyperpigmented Microscopic Study in Humans. Int J. of the gingiva following. gingiva by scalpel surgery with bur Periodont RestDent,13:85-92,1993. Injury.JPeriodontology 1986;57:48- abrasion is simple, easy to perform, cost 13. Almas K, Sadiq W: Surgical 50 effective and above all provides Treatment of Melanin- Pigmented 16. Sameer A .Mokeem .Management of minimum discomfort to the patient with Gingiva: An Esthetic Approach. gingival hyperpigmentation by esthetically pleasing results. Indian Journal of Dental Research, surgical abrasion -Report of three 2002; 13( 2): 70-73. cases .Saudi dental Journal References 14. Begamaschi O, Kon S, Doine AI, 2006;18:3:162-165. 1. Dummett CO. Overview of normal Ruben MP. Melanin repigmentation oral pigmentations, J Indiana Dent after gingivectomy: A five year Assoc 1980;59(3):13-18. clinical and transmission Electron 2. Cicek Y, Ertas U. The normal and Microscopic Study in Humans. Int pathological pigmentation of oral Journal of Periodontics & Restorative mucous membrane: a review. J Dentistry, 1993;13(1):85-92 Contemp Dent Pract 2003 Aug 15. Perimutter S.Tai H ,Repigmentation 15;4(3):76-86. 3. Hanioka T, Tanaka K, Ojima M, Yuuki K. Association of melanin Source of Support : Nill, Conflict of Interest : None declared pigmentation in the gingiva of children with parents who smoke. Pediatrics 2005 Aug;116(2):186-90. 4. Hoexter DL. Periodontal aesthetics to enhance a smile. Dent Today 1999;18(5): 78-81. Information For Authors 5. Gnanasekhar JD, Al Duwairi YS. Elecrosurgery in Dentistry. Manuscripts must be prepared in accordance with "Uniform requirements for Manuscripts submitted to Quintessence Int 1998;29:649-54. Biomedical Journal" developed by International Committee of Medical Journal Editors (October 2001). The 6. Yeh CJ. Cryosurgical treatment of uniform requirements and specific requirement of Indian Journal of Dental Sciences are summarised below. melanin-pigmented gingiva. Oral Before sending a manuscript contributors are requested to check for the latest instructions available. Surg Oral Med Oral Pathol Oral The Editorial Process Radiol Endod 1998;86:660-3. The manuscripts will be reviewed for possible publication with the understanding that they are being submitted 7. Goldstein A, White JM, Pick RM. to one journal at a time and have not been published, simultaneously submitted, or already accepted for Clinical applications of the Nd:YAG publication elsewhere. laser. In: Miserendino L, Pick RM, The Editors review all submitted manuscripts initially. Manuscripts with insufficient originality, serious editors. Lasers in dentistry. Chicago: scientific flaws, or absence of importance of message are rejected. The journal will not return the unaccepted Quintessence Publishing Co.; 1995. manuscripts. p. 199-216. Other manuscripts are sent to two or more expert reviewers without revealing the identity of the authors to the 8. Hyuk-jin Ko,Jin-Woo Park ,Jo- reviewers. Within a period of eight to ten weeks, the contributors will be informed about the reviewers' comments and acceptance/rejection of manuscript. Articles accepted would be copy edited for grammar, Young Suh.Esthetic treatment of punctuation, print style, and format. Page proofs will be sent to the first author, which has to be returned within gingival melanin hyperpigmentation five days. Correction received after that period may not be included. All manuscripts received are duly with a Nd:YAG Laser and high speed acknowledged. rotary instrument:comparative case report.J Periodontal Implant Sci Types of Manuscripts and word limits 2010;40:201-205. Original research articles 9. G.Berk, K.Atici, N.Berk : Treatment Randomised controlled trials, intervention studies, studies of screening and diagnostic test, outcome studies, of Gingival Pigmentation with cost effectiveness analyses, case-control series, and surveys with high response rate. Up to 2500 words excluding references and abstract. Er,Cr:YSGG Laser.J Oral Laser Short Communication Application 2009;5:249-253. Up to 1000 words excluding references and abstract and up to 8 references. A short communication contains 10. Atsawasuwan P, Greethong K, only a short report of the case (only pertinent details) and a short discussion and references upto a maximum Nimmanon V. Treatment of Gingival of 8. Number of figures should be restricted to a maximum of 6. hyperpigmentation for esthetic Case reports purposes by Nd: YAG laser: Report of Only New / interesting / very rare cases can be reported. Cases with clinical significance or implications will be 4 cases. J Periodontol 2000;71:315- given priority, whereas, mere reporting of a rare case may not be considered. Up to 2000 words excluding 321. references and abstract and up to 10 references. Review articles 11. Tamizi M, Taheri M. Treatment os Systemic critical assessments of literature and data sources. Up to 3500 words excluding references and severe physiologic gingival abstract. pigmentation with free gingival Letter to the Editor autograft. Quintessence Int. Should be short, decisive observation. They should not be preliminary observations that need a later paper for 1996;27(8):555-8. validation. Up to 400 words and 4 references. 12. Kon S, Bergamaschi 0. Dome Al. Announcements of conferences, meetings, courses, awards, and other items likely to be of interest to the Ruben MP. Melanin Repigmentation readers should be submitted with the name and address of the person from whom additional information can after Gingivectomy: A 5-Year be obtained. Up to 100 words. Clinical and Transmission Electron

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 044 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Cemento - Ossifying Fibroma - A Case Report 1 Sudhakara Reddy.K 2 Girish Rao. S 1 PostGraduate Resident Abstract 2 Professor & Head The cemento-ossifying fibroma is a central neoplasm of bone as well as periodontium affecting the Dept of Oral & Maxillofacial Surgery, jaws and other craniofacial bones. They commonly affect adults between the third and fourth RV Dental College, Bangalore decade of life and manifest as slow-growing, assymptomatic, intraosseous masses. An accurate Address For Correspondence: diagnosis requires careful clinical, radiological and histological correlation in order to make an Dr. Sudhakara Reddy.K optimal treatment and an excellent outcome. They are insensitive to radiotherapy and recurrences PostGraduate Resident are uncommon. Surgical enucleation or resection is the treatment of choice. Dept of Oral & Maxillofacial Surgery RV Dental College & Hospital, This article reports a case of 35 years old male who came to us with the history of swelling in the JP Nagar, Bangalore maxillary anterior region that was asymptomatic except in causing disfigurement. Clinically, there Phone : +91-08026658411 was an expansion of the buccal plate but not the lingual plate of the anterior part of maxillary Mobile No: +919845198455 alveolar region. The covering mucosa was normal and there was no tenderness or parasthesia. E-mail: [email protected] Radiographically, well-defined radiolucent area present between the permanent maxillary central [email protected] incisors flecked with multiple small radiopacities. Surgical excision under local anesthesia was th Submission : 24 August 2011 done, followed by primary closure. The patient was asymptomatic in the 3 years of periodic follow th up. Accepted : 10 March 2012

Quick Response Code Key Words Cemento-ossifying fibroma, fibro-osseous lesions, ossifying fibroma, Cementifying fibroma

Introduction been reported as high as 5:14 . Most often, Cemento - Ossifying Fibroma otherwise it is located in the gingival papilla called as Cementifying fibroma or between adjacent teeth. Because of the Ossifying fibroma is a relatively rare close proximity and similarity to the tumor which is classified under Fibro- periodontal ligament tissue have led to linear one and therefore the lesions grow osseous tumors. WHO defined it as the assumption that they are of by expansion equally in all directions and demarcated or rarely, encapsulated periodontal tissue origin thus the term present as a round tumor mass usually. neoplasm consisting of fibrous tissue periodontoma some times is applied but 5 containing varying amounts of this theory remains unexplained Histological Features mineralized material resembling bone The mandible is more commonly Histologically, Cemento-ossifying and/or cementum. They can arise from involved than the maxilla. The lesion is fibromas are well circumscribed, any part of the facial skeleton and skull generally asymptomatic until the growth occasionally encapsulated, consisting of with over 70 per cent of cases arising in produces a noticeable swelling and mild cellular fibrous tissues and thin isolated 1 the Head and neck region. Cases involve deformity; trabeculae of bones. The bone may show mainly the mandible and maxilla but osteoblastic rimming and spherical occasionally, reported in the orbitofrontal Radiographic Features deposits of calcified material, which are bone, nasopharynx, paranasal sinuses The Cemento - Ossifying Fibroma relatively acellular resembling and skull base. presents as a well defined unilocular or cementum. As the lesion matures, the multilocular lesion with smooth islands of cementum increase in number, The first description of a variant of contours. The maturity of the lesion will enlarge, and ultimately coalesce. ossifying fibroma, was given by Menzel determine the degree of radio opacity. In 2 in 1872, calling it a cemento-ossifying the initial stage, it appears as a Treatment fibroma, in a 35-year-old woman with a radiolucent lesion with no evidence of The lesion, which is usually well long-standing large tumor of the internal radio opacities. As the tumor circumscribed and and this facilitates its mandible. It is a reactive gingival lesion matures, there is increasing calcification extirpation from the surrounding bone, that is believed to arise from cells of the so that the radiolucent area becomes should be excised. Recurrence is rare. periodontal ligament 3 or periosteum. flecked with opacities until ultimately the lesion appears as an extremely Case Presentation Clinical Features radiopaque mass. Nevertheless, majority A 35 yrs old male patient has been This tumor is more common in young and of the lesions demonstrate varying referred to our unit for the swelling on his middle-aged adults. There is a marked degrees of radiolucency. There is a gums in the upper front region of the predilection for the female sex, which has centrifugal growth pattern rather than a mouth (Figure 1). The medical, social

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 045 and family histories were unremarkable. examination was done and showed Hb: Surgical excision was planned under 12 gm%; TLC: 12900/mm 3 ; DLC: local anesthesia. Crevicular with neutrophils 65%, lymphocytes 27%, releasing incision (Figure 4) given eosinophils 2%, and basophils and extending from canine to canine. monocytes 0%. The erythrocyte Extraction of 21, and 22 done. Complete sedimentation rate was 24 mm at 1 h, excision of the mass done. (Figure 5.1 & bleeding time was 2.55 min, and clotting 5.2) time 6.35 min.

Radiographically, the orthopantomograph (Figure 3.1)

Figure 4: Incision exposing the lesion

Figure 1: Pre operative profile Figure 3.1: OPG

Patient noticed small swelling 6 yrs back showed a large radiolucent lesion with .Initially it was 2-3mm and gradually patchy mineralization extending from the increase to present size. Swelling was lateral incisor region to the opposite side non-tender. On local examination, there incisor region. The lesion was well is a noticeable swelling of 4×3cm extra demarcated with sclerotic border and orally on the anterior maxilla pushing the heterogeneous in contrast. The lesion Figure 5.1: Excisional Lesion upper lip outward. Intraorally, Single extended mesiodistally from the area of diffused pale pink swelling in labial lateral incisor region to the opposite side gingiva in relation to 11, 21, and 22 incisor area and superioinferiorly from extending superiorly from the depth of 3mm below the pyriform aperture to the vestibule to the gingival margin the apices of upper anterior teeth. No obliterating vestibule. (Figure 2) evidence of cortical erosion was noticed, though difficult to judge in orthopantomograph view. An occlusal view radiograph (Figure 3.2)

Figure 5.2: Residual Area

Bone graft taken from the symphysis region has been placed in the defect Figure 2: Pre operative Intra orally followed by primary closure of the wound with 3-0 silk sutures. (Figure 6.1 Surface is smooth and shiny. Blood Figure 3.2: Occlusal View & 6.2) The excised mass was sent to the vessels are seen on the superior surface of revealed a well-defined radiolucent area pathology department for this to the swelling. On palpation labial swelling present between the permanent maxillary pathological examination which is non-tender, bony hard in consistency central incisors, with displacement of confirmed the diagnosis as cemento- non fluctuant, fixed to underlying tissues, incisors posteriorly and to either side ossifying fibroma. Antibiotics and anti- non compressible and non pulsative. towards the canines. The region was inflammatory agents were continued for There was an expansion of the buccal flecked with multiple small the next 1 week. Alternate sutures were plate but not the lingual plate of the radiopacities.The radiographic removed on the fifth postoperative day anterior part of maxillary alveolar region. differential diagnosis included and the remaining sutures on the seventh Teeth 21, 22 are tender on percussion, odontogenic keratocyst, odontogenic postoperative day. Patient was followed Teeth 21 was grade-II mobility, and Teeth myxoma, cemento-ossifying fibroma, up for 3 years post operatively and 22 was Grade -III mobility. Periodontal focal cemento-osseous dysplasia and showed good result. (Figure 7) pockets measuring 1cm in length present central giant cell granuloma. in distal aspect of 22. Routine blood

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 046 cementoossifying fibromas are The recommended treatment of the asymptomatic until they cause central cementoossifying fibroma is expansion. Thus, they are generally not excision. Central cemento ossifying diagnosed until the tumor has had time to fibromas usually "shell out" easily at produce calcifications. They are typically surgery, but maxillary central well-defined, solitary radiolucencies cementoossifying fibromas are more with scattered radiopaque foci. They difficult to remove completely than maintain a spherical shape, expand the mandibular central cementoossifying Figure 6.1: Bone Graft In Place surrounding cortical bone without fibromas. This may be attributable to the cortical perforation, and may cause tooth difference in bone character between the divergence. mandible and maxilla and to the available space for expansion in the maxillary Pathologic examination of the central sinus. cementoossifying fibroma shows a Recurrence has been reported in as many proliferation of irregularly shaped as 16-28% 7of patients with mandibular calcifications within a hypercellular central cementoossifying fibromas. fibrous connective tissue stroma. The calcifications are extremely variable in References: appearance and represent various stages 1. Cemento-ossifying fibroma with of bone and cementum deposition. mandibular fracture. Case report in a Histologic differentiation between young patient Australian Dental Figure 6.2: Closure osteoid and cementum is difficult. In Journal 1998;43:(4):229-33 some cases, most of the calcified 2. Su L, Weathers DR, Waldron CA. fragments are immature cementum, with Distinguishing features of local basophilic coloration on hematoxylin cementoosseous dysplasia and and eosin-stained sections. cementoossifying fibromas. I A pathologic spectrum of 316 cases. The radiographic appearance is Oral Med Oral Pathol Oral Surg invariably a mixture of radiolucency 1997; 84: 301-309. followed by more radiopacity which 3. Kramer IRH, Pindborg JJ, Shear M. means the tumor was undergoing Neoplasm and other lesions related to maturation and that ossification phase bone. In: WHO. Histologic typing of Figure 7: Post Operative accounting for the increased density. odontogenic tumors. Berlin. Springer-Verlag;1992. p.28-31 The differential diagnosis includes other 4. Eversole LR, Leider AS, Nelson Discussion lesions that contain radiopacities within a K.Ossifying fibroma: a The cemento-ossifying fibroma is a well-defined radiolucent mass: clinicopathologic study of sixty-four benign osseous tumor that commonly osteosarcoma, fibrous dysplasia, cases. Oral Surg Oral Med Oral affects adults of middle age, 30-40 years. odontogenic cysts, squamous cell Pathol. 1985; 60:505-11 It may present as small radiolucent areas carcinomas, calcifying odontogenic cysts 5. Vlachou S, Terzakis G, close to the apices of teeth that could be (Gorlin cysts), and calcifying epithelial Doundoulakis G, Barbati C, mistaken for periodontal pathology. odontogenic tumors (Pindborg tumors). Papazoglou G. Ossifying fibroma of What is common in both cases is the lack The well-defined border of the central the temporal bone. J Laryngol Otol. of symptoms and non-specific cementoossifying fibroma helps 2001; 115:654-6. radiolucency (the absence of intra- differentiate it from the aggressive 6. Kuta AJ, Worley MacDonald, lesional calcifications). sarcomas and carcinomas. Fibrous Kaugars GE. Central dysplasia has a characteristic "ground Cementoossifying fibroma of the They are composed of varying amounts glass" appearance not seen in the central maxillary sinus: A review of six cases. of cementum, bone, and fibrous tissue. cementoossifying fibroma. The AJNR 1995; 16: 1282-1286 The name central cementoossifying radiologic differentiation of central 7. Buchner A, Ficarra G, Hansen LS: fibroma is used because there is a cementoossifying fibroma from Gorlin Peripheral odontogenic fibroma. Oral spectrum of fibroosseous lesions that cysts and Pindborg tumors is difficult; the Surg Oral Med Oral Pathol 1987 Oct; arise from the periodontal ligament, final diagnosis is based on histologic 64(4): 432-8 ranging from those with only deposition appearance. Pindborg tumors have a high of cementum to those with only association with impacted teeth . deposition of bone.

Central cementoossifying fibromas occur more frequently in women than in Source of Support : Nill, Conflict of Interest : None declared men. They arise in the mandible in 62% to 89% of patients, 77% occurring in the premolar region. Most are diagnosed between 20 and 40 years of age6 . Central

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 047 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Multiple Bilateral Talon Cusps: A Report Of 1 Paras Mull J 2 Syed Nabeel Three Cases 3 Usha Hegde 4 Gazala Danish Abstract 1 MDS, Consultant Endodontist Talon cusp is an uncommon dental anomaly presenting as an accessory cusp-like structure 2 BDS, Director, Smile Makers Clinic projecting from the lingual or facial surface of anterior teeth in both the primary and permanent 3 MDS, Consultant, dentition. It can occur unilaterally or bilaterally. Three cases with multiple bilateral talons cusp in Oral and Maxillofacial Pathologist 4 upper anterior teeth in patients of south Indian origin with no apparent association to any syndrome MDS, Consultant, have been presented. The cases presented here were not associated with other dental Oral and Maxillofacial Diagnostician and Radiologist Smile Maker Clinics, Mysore, Karnataka, India abnormalities or syndromes. The talons cusp in these cases did not interfere with esthetics or function. Clinical and radiographic characteristics of this developmental anomaly and the modes Address For Correspondence: Dr. Paras mull J, Consultant Endodontist of treatment are described. Multiple dental anomalies like talons cusp should be reviewed Smile Maker Clinics, #187, 2nd Stage, MG Road carefully, since they could be a cause of functional and esthetic problems, and could be associated 2nd Main, Udayagiri, Mysore-570 019 Karnataka. with syndromes. Phone: +919844453444, 9845106626 Email: [email protected] Key Words Submission : 21th October 2011 Talon cusp, Accessory cusp, Multiple Talons cusps, Bilateral Accepted : 12th March 2012

Quick Response Code Introduction Case 1 The talon cusp is an uncommon dental A 40-year-old male patient reported to anomaly manifesting as an accessory our practice with a chief complaint of cusp-like structure, projecting from the food lodgement in his upper left back lingual or facial surface of anterior teeth tooth. The patient's medical and family of either dentition.1 It was first described histories were insignificant. Intra-oral by WH Mitchell in 1892, and was named examination revealed the presence of as "Talon cusp" by Mellor and Ripa in proximal caries in maxillary left first Intra-oral periapical radiograph showed a 1970 because of its resemblance in shape molar. Examination also revealed cusp- radiopaque V-shaped area superimposing to an eagle's talon.2 like projections on palatal surface of the normal tooth structure, but varying in maxillary anteriors. The cusp-like extension. (Figure 2) Other dental The etiopathogenesis is multifactorial, structure extended from the cemento- anomalies noted were exaggerated cusp and is thought to be polygenetic with enamel junction to halfway to the incisal of Carabelli bilaterally. some environmental influences. Talon edge for central incisors (11,21) and less cusp may occur as an isolated entity or in than halfway for lateral incisors.(12,22) association with syndromes.3,4,5 Hattab et Small tubercle-like projections were seen al have classified talon cusp as True talon from the cingula of both the (Type I), Semitalon (Type II) and Trace canines.(13,23) (Figure 1) Based on talon (Type III), based on the degree of Hattab's classification, maxillary incisors formation and extension.3 showed Type II talons cusp and the canines Type III talon cusp. Clinically it can pose esthetic and functional problems to the patient.3,6 Talon cusp affects both sexes and commonly is unilateral, but one fifth of Figure 2: Case 1. Periapical radiograph of maxillary 7 anterior teeth. Talons cusp reveals as a V-shaped the cases are bilateral. radiopaque structure superimposing over the normal structures. The objective of this paper is to report three cases with multiple bilateral talons cusp in upper anterior teeth in patients of Case 2 south Indian origin with no apparent A 25-year-old male patient with a association to any syndrome. Figure 1: Case 1. Intra-oral photograph of maxillary arch complaint of decay in his lower left back showing Type II Talons cusp on four incisors (12,11,21,22) tooth reported to our practice. The and Type III Talons cusp on both canines (13,23) Case Description patient's medical and family histories

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 048 were insignificant. Intra-oral Discussion bilaterally. Solitary tooth involvement is examination revealed the presence of The talon cusp can now be defined as an the most common finding, but bilateral occlusal caries on mandibular left first uncommon dental anomaly manifesting and multiple involvement is not molar. Examination also revealed cusp- as an accessory cusp-like structure, infrequent.4 One-fifth of the cases like projections on palatal surfaces of all projecting from the lingual or facial showed bilateral distribution of the talon maxillary anterior teeth, extending from surface of anterior teeth of either cusp.3 Danker et al found 65% of the cemento-enamel junction to halfway dentition.1,8 bilateral occurrence in radiographic to the incisal edge for central incisors and study of 15000 anterior teeth.4 less than halfway for lateral incisors and All reported talon cusps in primary teeth canines. (Figure 3) Based on Hattab's affected the maxillary central incisors, There are cases in which both maxillary classification, maxillary central incisors while in the permanent dentition permanent incisors exhibit this anomaly. showed Type II talons cusp and lateral maxillary lateral incisor was most In other cases, both lateral incisors or the incisors and the canines showed Type III frequently involved (55%), followed by canines are involved.4 Bilateral talon talon cusp. These accessory cusp-like central incisors (33%) and canines (4%).4 cusps were seen in 30% of the patients of structures did not interfere with esthetic jordonian population, whereas 70% of or functional impairment. Intraoral Prevalence of less than 1 % to those with talon cusps exhibited periapical radiograph were similar to the approximaterly 8 % has been reported.4 unilateral talon cusps.9 De Sousa et al. previous case. The variation in talon cusp prevalence described an unusual case of bilateral could be explained by variation of the talon cusp associated with dens condition among different nations, or invaginatus.11 Vardhan and shanmugam variation in the samples examined, or reported a rare case of bilateral talon cusp examination criteria. 9 on maxillary cental incisors and laterals with dens invaginatus.12 Soares et al The etiology of this anomaly is largely reported a case of bilateral bifid talon unknown. It may occur as a result of cusps on the palatal aspect of maxillary 13 Figure 3: Case 2. Intra-oral photograph of maxillary arch outward folding of the inner enamel permanent incisors. Hegde et al showing Type II Talons cusp on central incisors (11,21) epithelial cells (precursors of reported a very rare case of bilateral and Type III Talons cusp on both canines (12,13,22,23) ameloblasts) and a transient focal labial talon cusps on permanent hyperplasia of the mesenchymal dental maxillary central incisors. 14 papilla (precursors of odontoblasts).6 Case 3 Increased localized external pressure on a Sarraf-shirazi et al reported occurrence of A 20-year-old male patient walked in our tooth germ during morphodifferentiation multiple talon cusps in three siblings of a practice with a complain of discoloured stage may result in either outfolding of family and suggested that genetic teeth. Medical and family history was 15 the dental lamina as in the case of talon inheritance may be a causative factor. non-contributory. Examination revealed cusp and shoveling or infolding of the Talon cusp may present a number of brown discoloration due to poor oral 3 lamina as in dens invaginatus. problems both to the patient and the hygiene and mild generalised enamel clinician. They include compromised hypoplasia. Examination also revealed Another possible cause of the condition esthetics, occlusal interferences, cusp-like projections on palatal surfaces that is discussed is hyperproductivity of displacement of affected tooth, carious of maxillary lateral incisors, extending the anterior segment of the dental developmental grooves, pulpal necrosis from the cemento-enamel junction to 10 lamina. Bilateral distribution of talon and periapical pathosis, periodontal halfway to the incisal edge. (Figure 4) cusp in some cases, its association with problems due to excessive occlusal The accessory cusp-like structures did other dental abnormalities, talon cusp forces, advanced attrition leading to pulp not interfere with esthetic or functional occurring in family members, twins, exposure, irritation of the tongue during impairment. Intra-oral periapical offsprings from consanguineous speech and mastication, interference with radiograph suggested findings similar to marriages and in some genetic tongue space, problems in breastfeeding, the previous cases. The clinical and syndromes support genetic etiology of accidental cusp fracture and radiographic features suggested the 6,7,10 3,6,13 the condition. temporomandibular joint pain. clinical diagnosis of Type II talons cusp. The talon cusp was associated with caries However, sporadic occurrences of this Treatment may differ depending on each in relation to right lateral incisor. abnormality probably are induced by case. Small talon cusps are usually trauma or other localized insults affecting asymptomatic, necessitating no the tooth germ. Therefore control of the treatment. However, large, prominent complex processes of dental and separated talon cusps require development appears to be definitive treatment with respect to multifactorial. It is primarily polygenetic esthetics, occlusion, periodontal and 7 with some environmental influence. carious problems.3 Histologically, it is composed of normal enamel and dentin and it may or may not Deep non-carious grooves and fissures contain pulpal tissue.8 should be cleaned of debris and plaque Figure 4: Case 3. Intra-oral photograph of maxillary arch and prophylactically sealed with fissure showing Type II Talons cusp on Lateral incisors (12,22) Talons cusp can occur unilaterally or sealant. If grooves are carious, the lesion

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 049 should be eradicated and the cavity filled evaginatus of anterior teeth. B. Talon Cusp: A Literature Review with glass ionomer restorative material.3 Literature review and radiographic and Case Report. Acta Stomatol survey of 15,000 teeth. Oral Surg Croat 2006; 40(2):169-74. In case of premature contact and occlusal Oral Med Oral Pathol Oral Radiol 11. de Sousa SM, Tavano SM, Bramante interference, the anomalous cusp should Endod 1996;81(4):472-75. CM. Unusual case of bilateral talon be reduced. If the treatment needs the 5. Abbott PV. Labial and palatal "talon cusp associated with dens removal of a substantial portion of the cusps" on the same tooth: A case invaginatus. Int Endod J cusp, then reduction should be gradual report. Oral Surg Oral Med Oral 1999;32(6):494-98. and on consecutive visits at 6-8 weeks Pathol Oral Radiol Endod 12.Vardhan TH and Subramanyam S . intervals to allow deposition of reparative 1998;85(6):726-30. Dens evaginatus and dens dentin and pulp obliteration within the 6. Hattab FN, Yassin OM, al-Nimri KS. invaginatus in all maxillary incisors: extension. Following each grinding Talon cusp-clinical significance and Report of a case. Quintessence Int procedure, the tooth surface should be management: Case reports. 2010; 41(2): 105-107. treated with a desensitizing agent, Quintessence Int 1995;26(2):115-20. 13.Soares AB, de Araujo JJ, de Sousa preferably fluoride varnish.3,5 However, it 7. Segura JJ, Jimenez-Rubio A. Talon SM, Veronezi MC. Bilateral talon is desirable to evaluate and treat the talon cusp affecting permanent maxillary cusp: Case report. Quintessence Int cusp soon after eruption to avoid further lateral incisors in 2 family members. 2001;32(4):283-86. clinical problems Oral Surg Oral Med Oral Pathol Oral 14.Hegde KV, Poonacha KS, Sujan SG. Radiol Endod 1999;88(1):90-92. Bilateral Labial Talon Cusps on In all the three cases discussed above the 8. Gungor HC, Altay N, Kaymaz FF. Permanent Maxillary Central talons cusp did not interfere with esthetic, Pulpal tissue in bilateral talon cusps Incisors: Report of a Rare Case. Acta or functional impairment. However, oral of primary central incisors: report of a Stomatol Croat 2010; 44(2):120-122. prophylaxis and removal of caries and case. Oral Surg Oral Med Oral Pathol 15.Sarraf-shirazi A, Rezaiefar M, restoration with Glass ionomer cement Oral Radiol Endod. 2000;89(2):231- Forghani M. A Rare Case of Multiple was carried out in the taloned teeth in case 5. Talon Cusps in Three Siblings. Braz 3. The patients were made aware of the 9. Hamasha AA and Safadi RA. Dent J 2010; 21(5): 463-466. anomaly and were advised for regular Pevelance of talon cusp in Jordanian routine follow-up. permanent teeth: a radiographic study. BMC Oral Health 2010;10:6 Conclusion 10.Dumancic J, Kaic Z, Tolj M, Jankovic Three cases of multiple talon cusps occurring bilaterally have been presented and the clinical implications discussed. Source of Support : Nill, Conflict of Interest : None declared Clinical variations of talon cusp include those of location, shape, size, structure and number. Talon cusps occur in a wide Information For Authors variety of world populations and most often are identified in the clinical setting. Authorship criteria The importance of recognition of talon All persons designated as authors should qualify for authorship, and all those who qualify should be listed. cusp lies in the information that it may be Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. One or more authors should take responsibility for the integrity of the work as a whole, useful in identification of syndromes from inception to published article. The name and order of the authors cannot be changed once the article is associated with it. Early diagnosis could provisionally accepted. also result in minimizing the local problems such as, caries, periodontal Authorship credit should be based only on diseases and malocclusion. Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; References Drafting the article or revising it critically for important intellectual content; and Final approval of the version to be published. 1. Siraci E, Cem Gungor H, Taner B, Conditions 1, 2, and 3 must all be met. Acquisition of funding, the collection of data, or general supervision of Cehreli ZC. Buccal and palatal talon the research group, by themselves, do not justify authorship. cusps with pulp extensions on a The order of authorship on the byline should be a joint decision of the co-authors. Authors should be prepared supernumerary primary tooth. to explain the order in which authors are listed. Once submitted the order cannot be changed without written Dentomaxillofac Radiol consent of all the authors. 2006;35(6):469-72. For a study carried out in a single institute, the number of authors should not exceed six. For a case-report and 2. Mellor JK, Ripa LW. Talon cusp: A for a review article, the number of authors should not exceed four. For short communication, the number of clinically significant anomaly. Oral authors should not be more than three. A justification should be included, if the number of authors exceeds Surg 1970;29:225-28. these limits. Only those who have done substantial work in a particular field can write a review article. A short summary of 3. Hattab FN, Yassin OM, al-Nimri KS. the work done by the authors (s) in the field of review should accompany the manuscript. The journal expects Talon cusp in permanent dentition the authors to give post-publication updates on the subject of review. The update should be brief, covering the associated with other dental advances in the field after the publication of article and should be sent as letter to editor, as and when major anomalies: Review of literature and development occur in the field. reports of seven cases. ASDC J Dent Child 1996;63(5):368-76. 4. Dankner E, Harari D, Rotstein I. Dens

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 050 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Management Of Microtia In A Low Resource 1 Sajani Ramachandran 2 Prof Zile Singh Set Up 1 Assistant Professor, Department of Dentistry 2 Prof. & Head Dept Of Community Medicine Abstract Pondicherry Institute Of Medical Sciences

Microtia, the most common congenital auricular defect can be managed surgically and Pondicherry. prosthodontically. A silicon based auricular prosthesis was fabricated at a very low cost for a Address For Correspondence: patient who could not afford expensive treatment but eager to have his defect corrected. Dr. Sajani Ramachandran MDS Assistant Professor Department of Dentistry Key Words Pondicherry Institute Of Medical Sciences, Auricular,prosthesis,silicone ,low cost prosthesis,microtia Pondicherry Email Id : [email protected] Phone No : +919894136826 Submission : 24th September 2011 th Introduction: Accepted : 07 March 2012 Auricular defects may be congenital or acquired and they are the second most Quick Response Code common craniofacial malformation after cleft lip and cleft palate. The most common congenital auricular defect is microtia.It is a congenital deformity of the pinna, which can be unilateral or bilateral and occurs in about one out of 8,000 - 10,000 births. In unilateral microtia ,the right ear is most typically were made on the patients skin .These affected. It is usually associated with Figure1: Unilateral Microtia marks on the skin were transferred with atresia of the external auditory canal. the impression and was seen on the The classic occurant usually seen in working cast (figure 2). The co- microtia is comma shaped with upper correction as option which he could not [1] ordinates helped in proper orientation portion containing a small cartilage . take because of its prohibitive cost.He over the defect while making a new ear was eager to have a prosthetic form. Impression was made with the Surgical correction or prosthetic replacement of the missing parts of the patient lying on his side in a supine rehabilitation are the two options ear but was at the same time concerned position. The defect was isolated and the available for correction of auricular about his ability to finance such a adjacent hair covered with defects.Some patients do not prefer procedure. petrolatum.The patients skin was boxed surgical intervention and may not be able to the circumscribed outline with a collar to afford the very expensive silicone Challenge: of wax. Impression was made with materials used for prosthetic Apart from the aesthetic and the physical irreversible hydrocolloid material rehabilitation.Fabrication of a silicone aspect, here, we had to contend with the prothesis for a patient who wanted a cost fact that this patient,as eager as he was to effecticve but aesthetically acceptable have his defect corrected would be prosthesis is described here. helped only if the prosthesis was done at a bare minimum cost.The fabrication of ear Case History: prosthesis is a challenging maxillofacial A 23 year old male patient reported to the replacement procedure as it involves PIMS ,Pondicherry rural health centre dealing with severe undercuts and under the community medicine pronounced convolutions of ear surface. department with a microtia of the left ear [2] (figure 1). The patient, a fisherman by profession wanted to know if the repair Clinical Procedure could be done with out involving The area around the ear was outlined with an indelible pencil. Co-ordinates of the surgery.He had earlier consulted many Figure2: Working Cast With The Markings Transferred centres before and was offered surgical vertical and horizontal axes of the ear

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 051 (Alginate,Ruthenium Dental Products Pvt Ltd) with 50% more water to improve its flow properties and facilitate impression procedure. A backing with quick setting plaster (Dental grade plaster of paris,Ramaraju surgical co.Rajapalayam India) was done to provide support to impression. Gauze was used to unite the impression materiel to plaster backing. Material was allowed to set and then removed and was inspected for inaccuracies and working Figure4: Wax Pattern Contoured To The Working Cast Figure6: Prosthesis Retained With An Adhesive cast was poured. The impression of the contralateral ear was also made similarly patient with the silicon material (multisil and cast was obtained .The impression RTV, SP Sai Biomed Mumbai, India) and Care Of Prosthesis of donor ear was used to obtain accurate the adhesive(Proskin,Technomed India Patient was advised to keep skin surface pattern . The advantage of using Pvt Ltd,New Delhi,India) applied on his clean and free of natural oil secretion to matching donor ear impressionwas that it forearm and the patient was recalled increase proper adhesion of appliance. has a natural appearance and is time after 48 hours to check for any allergic Removing old adhesive from skin and saving.[3] manifestation. Skin tones were selected prosthesis before applying a thin layer of with different color tabs made of silicon. adhesive to periphery of prosthesis An individual with similar proportioned The coloring was done by artist's oil should be done . The patient was also ear was selected. Ear mould was created color(Camel artist's oil colour, Camlin given a spectacle in order to camouflage by boxing and impression was made Ltd,Mumbai,India) using empirical trial the borders of the prosthesis. with irreversible hydrocolloid after and error method. placing cotton in the external acoustic Discussion: meatus .Once the impression was Processing There are 4 grades of microtia obtained, molten modelling wax (Hiflex The wax ear was invested in a three part Grade I: A slightly small ear with ,Prevest Dentpro Ltd) was poured into ear mould and after dewaxing ,silicon identifiable structures and a mould and solidified wax form was material was filled in the mould after small but present external ear removed and the contour and size was coloring the material to the appropriate canal. adjusted according to the contralateral shade. Grade II: A partial or hemi ear with a ear .Tissue surface of wax form was closed off or stenotic external softened and with the marked co- The processing was done (figure5). The ear canal producing a ordinates it was seated on the defect area prosthesis was retrieved from the mould conductive hearing loss. of the working cast. The wax pattern was and cleaned and was retained by using Grade III: Absence of the external ear checked for symmetry by placing over medical adhesive to the residual tissue with a small peanut vestigeal the patient's defect site (figure 3). present (Figure6). Facial prosthesis may structure and an absence of the Surface details were applied on the wax be retained by mechanical means or by external ear canal and ear pattern. Entire surface was stippled to using adhesives. Facial prosthetic drum match the skin texture of the adhesives are commonly dispensed as Grade IV: Absence of ear or anotia. The patient.Stippling was made more pastes, liquids which may be paintable or most common type is [6] prominent as some details could be lost spray ons and double sided tapes. Studies gradeIII. during processing. The margins were done earlier have found that prosthetic thinned and blended to the adjacent skin. adhesives have good wettability, fast There are two main treatments possible in The residual margin camouflaged the drying, adhesive to skin, clean off easily microtia-surgical reconstruction or [4] part of the anterior margin .(figure4) and adhesive to silicone . Adhesives auricular prosthesis.Rehabilitation with a require practice and precision of the prosthetic ear matched to the wearer to obtain correct initial placement contralateral ear provides a better of the prosthesis[5] morphologic result.[7]

The surgical reconstruction of ear results in morphology that is less similar to opposite ear because of its complex nature and is considered to be one of the most demanding challenges for a plastic surgeon. Prosthesis fabrication on the other hand is the most conservative method of correcting ear deformity4 Figure3: Wax Pattern Tried On The Patient For Assessing Symmetry The age at which the outer ear surgery can be done depends on the technique. A patch allergy test was done for the Figure5: Prosthesis After Processing Earliest age at which surgery can be

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 052 attempted is at 3. The different options treatments are unaffordable to most auricular prosthesis.J Am Acad for auricular reconstruction are patients .An alternative cost effective Dermatol,2000;43:687-690. but at same time aesthetically acceptable 6. Tanner PB, Mobley SR, External 1. Rib graft reconstruction-since the treatment materials are necessary so that Auricular and facial prosthesis. A implant is patients own living many of the patients who do not come collaborative effort of the cartilage, the ear continues to grow as forward for treatment can be targeted for reconstructive surgeon and the child does.This is preferred after rehabilitation. anaplastologist Auricular surgery age six so that rib is large enough to aesthetic and reconstructive facial provide the donor material necessary. References: plastic surgery North Am 2006, 14( 2) 2. Reconstruction of ear using Med por 1. Pos willo D. The pathogenesis of the :137-145 polyethylene plastic implant. first and second branchial arch 7. Russel R Wang, carl Andres, 3. Ear prosthesis: .Prosthetic ears syndrome.Oral surgery ,Oral hemifacial microsomia and treatment appear very realistic and require few medicine, Oral pathology,1973; 35: options for auricular replacement, A minutes of daily care. They are made 302-28. review of the literature. J prosthet of silicone which is colored to match 2. Kenneth & Brown ,Fabrication of ear dent 1999,82:197-204 the individual color of the skin and prosthesis. J Prosthet dent 1969 8. John Beumer III, Thomas A Curtis, attached using adhesives or implants ;21:670-76 Mark T , Maxillofacial rehabilitation to which magnets or bar clips are 3. James C lemmon, Mark S Chambers, in prosthodontic and surgical used. The optional age to start Peggy J Wesley and Jack W Martin, condition. Ishiyako pub; Euro wearing a prosthesis is 6-9 years.[8] Technique for fabricating a mirror American Inc.1996. image prosthetic ear. J Prosthet dent 9. Ting Jao, Fuquiang Zhan, Huing Now new techniques are being used for 1996; 75:292-93. ,Design and fabrication of auricular creating auricular prosthesis with a 4. John F wolfardt, Victor Tain, M Gary prosthesis by CAD/CAM system ,Int computer aided design /manufacture. faulkner, Narasimha Prasad, J prosth 2004; 17:460-4 (CAD-CAM System ).[9] Mechanical behavior of three maxillo facial prosthetic adhesive system. A Conclusion pilot project.J Prosthet dent 1992; 68: Inspite of all the latest technologies and 943-9. techniques being available many of these 5. David F Butler ,Gregory G Gion,Ronald R Rapini .Silicone

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

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 053 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Reinvigorate Lives Through Prosthodontics In 1 Paul Simon 2 Jayashree Mohan Bilateral Complete Maxillectomy Patient- A 3 Surendran. S 4 Sunantha. S Case Report 5 Neeraj Sharma 1 Professor Abstract 2 Professor and Head Fewer fields of dentistry offer more challenges to the technical skills and ingenuity or greater 3,4 PG students satisfaction, than the successful rehabilitation of function and esthetics. Prosthetics play an active Department of Prosthodontics, role in rehabilitation and reinvigorates the patients with facial disfigurement and reducing Vinayaka mission’s Dental College & Hospital 5 physiological and psychological trauma to them. Senior Lecturer Department of Prosthodontics, A patient reported to our institution with total absence of maxilla which was due to bilateral Seema Dental College and Hospital, Rishikesh maxillectomy done due to carcinoma involving the right and left maxilla and left maxillary sinus . On examination extra-orally there was mid-facial deficiency and intra-orally complete maxillectomy Address For Correspondence: was done and nasal septum and aperture were visualized, partially edentulous mandibular arch Dr. Paul Simon was present. Such defects can be efficiently rehabilitated with modern techniques and materials. Professor, Department of Prosthodontics, Definitive prosthesis includes hollow bulb maxillary obturator. Vinayaka mission’s Dental College & Hospital Salem

th Key Words Submission : 26 August 2011 complete bilateral maxillectomy, hollow bulb obturator, soft liners Accepted : 27th March 2012 Quick Response Code

Introduction These patients also experience problems Extensive bilateral midfacial defects like seepage of nasal secretions into the involving the upper jaw, palate, and sinus oral cavity, poor lip seal, xerostomia, presents a reconstructive challenge (Wang, R.R., 1997) exophthalmoses, and (Panje, W.R., H.E. Hetherington, 1995). diplopia (Panje, W.R., H.E. Bilateral complete maxillectomy is a Hetherington, 1995). Complete relatively uncommon surgical procedure rehabilitation of a bilateral maxillectomy obturator which was not retentive and resulting in devastating effects on the patient can be achieved using a patient had difficulty in speech and cosmetic, functional, and psychological multidisciplinary team approach deglutation. The patient’s medical aspects of a patient’s life (Sjowall, L., C. involving both surgical and prosthetic history revealed that he had undergone a Lindqvist, 1992). Prosthetic restorations personnel. surgical intervention for adenocystic have become the preferred method for the Factors influencing the prognosis of carcinoma involving the right and left rehabilitation of complex mid-facial prosthetic reconstruction in these maxilla and left maxillary sinus. The defects like the bilateral maxillectomy. patients are the size of the defect, resection of bilateral maxilla was done. They allow rapid, single stage availability of hard and soft tissues in the On extra-oral examination partial reconstruction which is important since defect area to provide support for the zygomectomy was done , the face improvement in the quality of life is of prosthesis, (Des Jardins, R.P.,1978) appeared asymmetrical and had mid- paramount concern, for many of these proximity of vital structures, patient facial deficiency.(fig .1). Intra-orally the patients surgery may be only palliative attitude, temperament, systemic nasal septum and lateral wall of the nose (Johnson, J.T., M.A. Armani, 1983). Post conditions, and the patient’s ability to could be visualised ( f i g . 2 ) . surgical prosthetic rehabilitation of adapt to the prosthesis (Brown, K.E., Orthopantamogram (OPG) (fig.3) also complete maxillectomy patients is a 1970).rehabilitation of a bilateral shows absence of maxilla . This type of subject seldom discussed in the literature maxillectomy patient can be achieved resection presents a difficult situation (Sjowall, L., C. Lindqvist, 1992). Many using a multidisciplinary team approach mechanically for obturator fabrication. of these patients show poor prosthetic involving both surgical and prosthetic The upward and outward direction of the prognosis due to lack of a stable personnel. mandibular closure will tend to force the underlying bed of supportive hard tissue prosthesis in that direction rotating for stability and retention of the Case Report: around the most anterior rests. The force prosthesis. A 56-year-old male patient reported to of gravity will tend to dislodge the Bilateral maxillectomy affects a variety the department of prosthodontics of obturator in a downward direction of functions like mastication, speech, Vinayaka mission’s dental college and rotating around a fulcrum through the olfactory, and gustatory sensations. hospital for replacement of his existing most posterior rest . But in this particular

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 001 case there was no posterior rest and so engaging the undercuts wherever possible is necessary to resist these two distinct dislodging tendencies.

Figure 7

Figure 4

Figure 1

Figure 8

Figure 5 the bulb portion of the obturator is generally hollowed after it has been Figure 2 Wax try-in was done and the denture was processed into acrylic resin. Weight fabricated(fig.6). Palatal surface of the reduction is especially important when denture was reduced to about 2mm the obturator prosthesis is suspended thickness in order to reduce the weight of without bony or posterior tooth support the prosthesis(fig.7). Then the prosthesis on the defect side, as is the case with most was tried in the patients. We found a maxillary resection prostheses. A hollow compromised retention because during maxillary obturator may reduce the the process of denture fabrication few of weight of the prosthesis by up to 33%, the undercuts had to blocked out for the depending upon the size of the maxillary Figure 3 denture to be retrieved from the cast . defect. In order to give the palatal feel for Procedure: Patient may be uncomfortable with the the patient hollow bulb was fabricated In order to fabricate the obturator rigid denture base in those fragile areas of with the lost salt technique and checked preliminary impression was made with nasal septum and may cause soreness as for buoyancy(fig.9). The final prosthesis the low fusing impression compound well. In order to improve the retention was delivered to the patient and patient material. As the impression compound is soft reliner ( Ufi gel P, voco) was used in had better appearance and phonation and rigid, irreversible hydrocolloid material the tissue surface in the defect areas comfort. Depending upon the nature of is used to record the defective areas i.e (fig.8). Once the soft relining was done the defect, movement of the obturator nasal septum and undercuts around it. A the denture had a better retention and the varies and creates soreness and special tray was fabricated . The nasal patient was comfortable . discomfort for the patient. These pressure aperture was blocked and Secondary To reduce the weight of the prosthesis, sores are adjusted at the post insertion impression was made with the putty (poly and subsequent follow-up appointments. vinyl siloxane) elastomeric impression Optimal outcome of the obturator material. Light body elastomeric prosthesis depends on the successful impression material was used to record integration of the prosthesis with the the finer details of the defect area (fig.4). patient’s oral functions plus Master cast was made(fig.5). In this psychological acceptance of the particular case neither any remaining obturator by the patient. Firmly retained teeth nor ridge was present for the prosthesis can provide the patient with retention of the prosthesis through clasps psychological support during the difficult , only undercuts helps in this case. period after maxillectomy.

The occlusal rims for maxillary and Discussion mandibular arch were fabricated. Jaw In dentate patients, primary retention, relation was done. Articulation was done. Figure 6 support, and stability of an obturator

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 001 base provides maximum support, Ital.2010 Feb;30(1):33-9 retention, and stability for a maxillofacial 3. Lethaus B,Lie N,de Beef F,Kessler prosthetic patient and additional steps of P,de Baat C,Verdonck HW. Surgical relining the record base with silicone and prosthetic reconstructions in resilient materials can be avoided. But in patients with maxillectomy. J Oral this case the undercuts extends into to Rehabil. 2010 Feb;37(2):138-42. fragile region into which the rigid denture 4. Laney WR. Maxillofacial prosthetics: base can’t be extended. Thus the soft Postgraduate Dental Handbook reliners should be used in such cases. Series, Volume 4. PSG Publishing Company Littleton, Massacheusetts Summary 1979. The pre-surgical treatment planning is of 5. Rahn AO, Goldman BM, Parr GR. great importance not only for the patient Prosthodontic principles in surgical but also for the success of the surgical planning for maxillary and procedure and prosthesis. In different mandibular resection patients. J clinical scenarios whether in partially Prosthet Dent 1979;42:429-33. Figure 9 dentate and/or edentulous patients both 6. Marunick MJ, Harrison R, Beumer J. depend on the number and distribution of hard and soft tissues are essentially Prosthodontic rehabilitation of remaining teeth . Engagement of soft required for the fabrication of a stable and midfacial defects. J Prosthet Dent tissue undercuts including the scar band functional prosthesis. During 1985;54:553-60. at the skin graft-mucosal junction, may prosthodontic rehabilitation the support 7. Yazdanie N and Manderson RD. also play a significant role particularly in can be gained from within the defect and Prosthetic management and edentulous patients. Wide surgical remaining structures. Retention can be rehabilitation of an extensive resections for the control of malignancies achieved from the non-resected tissue, intraoral and facial defect. Int J frequently result in a small number of scars and bony undercuts by Prosthodont 1989;2:550-4. remaining or no teeth with complete conventional and unconventional means. 8. Yamamoto Y. Mid-facial resection of ridge. In this case scar bands, reconstruction after maxillectomy. soft tissue undercuts serve as abutments References Int J Clin Oncol. 2005 for the obturator and are subjected to 1. Taylor TD. Clinical Maxillofacial Aug;10(4):218-22. constant, non-axial, cantilever forces. Prosthetics. Quintessence Publishing 9. Ali A, Patton DW, Fardy MJ. The skin graft-mucosal junction scar Co. Illinois, USA. 2000. pg 85,105. Prosthodontic rehabilitation in the band will also stretch out over time and 2. Tirelli G,Rizzo R,Biasatto M,Di maxilla following treatment of oral become ineffective in helping to retain Lenarda R,Argenti B,Gatto A,Bullo cancer. Dental update 1994; :282-6. the obturator. F.Obturator prostheses Structural durability is mandatory for followingpalatal resection:clinical longevity of the prosthesis. In these cases. Acta Otorhinolaryngol patients, chewing function is not confined due to the lack of support on the Source of Support : Nill, Conflict of Interest : None declared surgical defect side. The bulb portion of the obturator is designed so that the 3D configuration of congruous vertical and Information For Authors horizontal walls offset crack development and fracture propagation. Preparation of the Manuscript Tensile stress accumulation developing The manuscripts should be typed in A4 size (212 × 297 mm) paper, with margins of 25 mm (1 inch) from all along the midline of conventional the four sides. Use 1.5 spacing throughout. Number pages consecutively, beginning with the title page. The complete dentures resulting in fatigue language should be British English. fracture . Title Page : The title page should carry A stable record base is critical for recording an accurate maxilla- Type of manuscript mandibular relationship and in The title of the article, which should be concise, but informative; evaluation of the esthetics and phonetics Running title or short title not more than 50 characters; of the wax try-in prosthesis. The fit and Name of the authors (the way it should appear in the journal), with his or her highest academic degree(s) and institutional affiliation; The name of the department(s) and institution(s) to which the work should be stability of the record base for an attributed; The name, address, phone numbers, facsimile numbers, and e-mail address of the contributor obturator, however, is often responsible for correspondence about the manuscript; The total number of pages, total number of compromised because of the size of the photographs and word counts separately for abstract and for the text (excluding the references and abstract). surgical defect and is further Source(s) of support in the form of grants, equipment, drugs, or all of these; and If the manuscript was compounded by the need to block out presented as part at a meeting, the organisation, place, and exact date on which it was read. undercuts and by under-extended Abstract Page borders. Conventional record bases can The second page should carry the full title of the manuscript and an abstract (of no more than 150 words for rotate into the defects when attempting case reports, brief reports and 250 words for original articles). The abstract should be structured and state the the centric relation record, resulting in an Context (Background), Aims, Settings and Design, Methods and Material, Statistical analysis used, Results and Conclusions. Below the abstract should provide 3 to 10 key word. inaccurate record. A processed record

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 001 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Systemic Lupus Erythematosus - A Diagnostic 1 Harpreet Singh Grover 2 Nidha Gaba Dilemma! 3 Shailly Luthra 1 Professor & HOD Abstract Deptt of Periodontics & Oral Implantology Systemic lupus erythematosus is an autoimmune disorder which usually affects the females. It is a S.G.T. Dental College Hospital & Research Institute clinically heterogeneous disease, and is characterized by presence of auto antibodies directed Gurgaon, Haryana. against nuclear antigens. It can present with multisystem involvement. The oral lesions can 2 Ex.Senior Lecturer, Deptt.of Oral Medicine & Radiology, present as ulcers or discoid lesions. They can mimic a number of other lesions. Diagnosis is based on the signs and symptoms, investigations and serological examination. Steroids form the first line Desh Bhagat Dental College & Hospital Muktsar (Punjab) of therapy. Malignant potential is rare. 3 B.D.S., Post Graduate Student, Deptt of Periodontics & Oral Implantology Key Words S.G.T. Dental College Hospital & Research Institute Systemic lupus erythematosus,Auto immune disorder,Discoid lesions. Gurgaon, Haryana. Address For Correspondence: Dr. Shailly Luthra, Flat No-1004, Antariksh Greens, Doordarshan Welfare Organisation, Introduction point ulcers on the lower labial mucosa Plot no-8, Sector 45. Lupus erythematosus (LE) is a and left buccal mucosa. They gradually Gurgaon, Haryana Tel: 08800235100 connective tissue disease including increased in size and involved the upper Email: [email protected] Discoid Lupus Erythematosus (DLE) and lower labial mucosa, hard palate, and Submission : 16th September 2011 and Systemic lupus erythematosus left buccal mucosa. She visited dentist Accepted : 14th March 2012 (SLE)1 . Discoid lupus erythematosus, where she was advised Nitragel for the less aggressive form of LE is a chronic, local application on the same. The lesions scarring, atrophy producing aggravated on the application of Quick Response Code photosensitive dermatosis. It rarely (5%) medication. They were extremely painful progresses to SLE. It is most commonly and associated burning sensation was seen in middle aged women. The clinical present even on taking normal foods. Her manifestations include the appearance of past medical history revealed that she discoid lesions solely on the skin, most was asthmatic since 16 years and was on commonly on the face, scalp, oral medication - Asthalin inhaler mucous membrane, chest, back and (salbutamol-100mg). She used to take extremities2 . Systemic lupus one to two puffs per day according to the erythematosus is a clinically need. She had skin lesions one year back oval in shape, soft in consistency, tender heterogeneous, autoimmune disease which started as erythmatous rashes on and palpable. characterized by the production of auto the face and gradually involving the back antibodies. It usually occurs in the and lower part of neck. She visited a Extra oral examination revealed diffuse postmenopausal females. It has got a dermatologist and was advised Tab brownish black pigmentation involving multisystem clinical presentation with .Kenacort (4mg) and Clobetasolgel the malar region bilaterally involving the the involvement of dermatological, (0.05%). She also gave the history of nasolabial fold region, whole length of hematological, renal, neural, and oral blood transfusion on three separate the nose, philtrum region, and chin and involvement. Oral lesions can be either in occasions since one year. She extending till the upper part of the neck. It the form of discoid lesions or ulcers. 1 complained of joint pains especially knee was interspersed with isolated areas of Extremely vigilant examination and & ankle joints pains for which she had depigmentation and annular erythmatous necessary investigations are required for visited a specialist and was found to be areas. Similar lesions were evident in the the accurate diagnosis. Steroids form the Rheumatoid factor negative. Her mid clavicular region and also the whole main line of treatment. menstrual history was normal. General back region. The lesions were non tender physical examination of the patient on palpation. Fissuring was evident Case Report revealed a moderately build and bilaterally at the corner of mouth. Blood A 40 year female patient came to the nourished patient with all vital signs encrustations were evident involving the department with the chief complaint of within the normal limits. vermillion zone region of the upper and ulcers in the oral cavity since 15 days. Conjunctivalpallor was evident.Lymph the lower lip. There was loss of History of present illness revealed that Node examinationrevealed solitary, distinction of the vermillion border of the the ulcers started 15 days back as tiny pin bilateral submandibular lymph nodes lower lip. On palpation the lesions were measuring approx 1.5 X 1.5 cms in size,

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 057 extremely tender and bled on minor marked improvement in the signs and provocation. Intraorally bilaterally symptoms. There was significant diffuse erythematous lesions were reduction in the buccal mucosal lesions. present on the right and the left buccal The skin lesions also showed signs of mucosa. Diffuse erythematous lesions remission. She was advised to continue were evident involving the entire palate. the intraoral topical medication as well as They were interspersed with few white topical application for the skin surface. keratotic lacy lesions. The lesions were After 1 month the patient reported with extremely painful. Gingival complete healing of the palatal lesions. inflammation was present. Hard tissue Mild erythematous lesions were evident examination revealed full complement of on the lower labial mucosa and right and maxillary and mandibular dentition. left buccal mucosa. There was significant Figure 4 - Lesions Involving The Back Region reduction in the burning sensation during Considering the history, mode of onset of her second visit after 1.5months. Patient the lesions, clinical appearance of the is still under follow up. lesions we arrived at the provisional diagnosis of oral manifestation of systemic lupus erythematosus. The differential diagnosis ofErythema multiformae, Stomatitis veneneta and Pemphigus vulgaris were considered. Hemogram revealed reduced values of hemoglobin, white blood cells and platelet counts. ESR was raised. Peripheral blood smear report revealed microcytic hypochromic anemia with leucopenia and thrombocytopenia. Figure 5 - Lesions Involving The Lips. Random blood sugar levels were within the normal limits. Blood urea was 40 mg% and albumin was detected in the urine examination.Pulmonary function tests revealed pleuritis and severe chest congestion. PEFR (peak expiratory flow Figure 1- Frontal View Of The Patient rate) was reduced. Anti-nuclear antibodies (ANA) were negative however LE cell preparation results was positive ,hence a final diagnosis of Systemic lupus erythematosus was made.

The treatment modality involved a regimen of drugs for the specific disease Figure 6 - Lesions Involving The Palate condition as well as for the accompanied symptoms after consultation with the physician. The regimen for this particular patient included -

Benzydyamine Hydrochloride 0.15% thrice daily, Figure 2- Lesions Involving The Chin And Upper Part Of ?Triamcinolone acetonide-0.1 %- for Neck. local application thrice daily. ?Cefadroxil250 mg b.i.d for 5 days ?60 million spores of lactobacillusb.i.d for 10 days ?I.V Deriphylline 12th hourly for 5 days ?Inj Frusemide-10mg for 15 days ?Dexamethasone sodium and neomycin sulphate(0.5%) topical application ?InjDexona 4mg for 15 days ?Ranitidine 150 mgo.d. for 7 days. Figure 7 - Follow Up After 15 Days Frontal View Of The After 15 days, the patient reported Figure 3- Lesions Involving The Midclavicular Region Patient

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 058 neutrophils, immune complex deposits & hospitalized patient with SLE would be at complement C3a,C4a ,C5a6 . Later stages great risk of acquiring pneumonia.9 Chest have macrophage infiltrations which are pain warrants a detailed workup to rule involved in healing5. out pulmonary embolism and myocardial infarction, especially in those who test Genetic factors & specific genetic loci positive for antiphospholipid antibodies.7 (HLA-DR, HLA-DQ, C-RP) are also Two well-known cardiac features of SLE important for the pathogenesis of SLE4 . are pericarditis and endocarditis. Patients Environmental factors like exposure to with SLE are at increased risk of U-V light (photosensitivity), drugs atherosclerosis. Chronic inflammation (pharmacogenetics) & infections ( with and the use of corticosteroids contribute Epstein barr virus) also precipitate the to this risk. Gastrointestinal involvement development of SLE7 . 1 most commonly results in non-specific abdominal pain and dyspepsia Hepato- Figure 8 - Follow Up After 1 Month Healed Lesion Clinical features of SLE are diverse and splenomegaly can come and go with Involving Lower Lip And Mucosa. include1 disease activity. Mesenteric vasculitis is very rare, but can be life threatening, Constitution Features like fatigue, especially if it leads to perforation. weight loss, fever etc. Various vascular manifestations- Renal Diseases or Lupus Nephritis Raynaud's phenomenon, occur causing affects 30% of the patients and is the most the classical triphasic colour change. dangerous, life threatening complication. The clinical differential diagnosis Neuropsychiatric Lupus includes includes Apthous ulcers, Erythema headache, depressions, seizures and multiformae, Lichen planus, Stomatitis psychosis. Migraines are also more venenata, Stomatitis medicamentosa, prevalent in these patients. Seborrheic dermatitis, actinic keratosis and fixed drug eruptions5 . Diagnosis is Musculoskeletal Disease includes - based on clinical examination, laboratory Myalgia & Arthralgia.Arthralgia is examination and Immunological tests. In asymmetric and migratory is often the 1997 American College of Figure 9 - Follow Up After 1 Month Healed Lesions On The earliest manifestation. The joints of the Rheumatology gave the diagnostic Palate hands are most often affected. The criteria for SLE in which 4 out of 11 arthritis is moderately painful and symptoms occurring either serially or in nondestructive. Deformities observed are succession confirm SLE. These are 5 Discussion usually due to tendon inflammation ?Malar Rash SLE is a chronic multifactorial prototypic (Jaccoud'sArthropathy), rather than ?Discoid rash autoimmune disease characterized by the degeneration. ?Photosensitivity presence of auto antibodies directed ?Oral Ulcers against nuclear antigens.This disease Dermal involvement in lupus includes ?Arthritis commonly affects young women of child malar and discoid rashes and generalized ?Serositis bearing age with aFemale: Male ratio of photosentivity. Alopecia also results due ?Renal Disorder 12:1 within the age group of 15-45yr and to hair follicle plugging with keratin Oral ?Neurological Disorder ? ratio of 2:1 inchildren or elderly3 . lesions such as desquamative gingivitis, Hematological Disorder marginal gingivitis or erosive mucosal ?Immunological Disorder ? The clinical heterogeneity of this disease lesions have been reported in up to 40% Antinuclear Antibody is mirrored by its complex of patients. Patients with advanced cases etiopathogenesis. In presence of of SLE may have features of Sjögren's If a diagnosis of SLE is suspected, then appropriate antigens SLE develops due to syndrome, such as dry eyes, mouth and the most useful preliminary testing formation of soluble immune complexes skin. includes a complete blood count with mainly composed of IgG& IgM4 differential white blood cell counts. This Haematological features include following a pattern of type III count will reveal chronic anemia that is normocytic normochromic anaemia, hypersentivity reaction triggered by normocytic-normochromic with thrombocytopaenia (sometimes, but endogenous antigens which can be thrombocytopenia and notalways associated with 6,7 generalised or organ specific. Because of lymphocytopenia. antiphospholipid antibodies) the size of the immune complexes &its andleukopaenia. Pleuritis, causing chest known affinity organs like kidneys, Other disease-specific tests for 5 pain, cough and breathlessness is the lungs, joints are the target sites . autoantibodies like antinuclear most common pulmonary manifestation antibodies,anti-double stranded-DNA, of SLE8 . Pleural effusions and Tissue damage is caused primarily by anti-Smith antibody, anti RO-(SSA), parenchymal damage often lead to platelets & neutrophils, lesions contain anti-phospholipidantibody,and pneumonitis. Subsequently, a

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 059 complement, C3, C4levels1 . CurrOpinImmunol2004; 16(6):794- Chronic renal failure because of SLE will 800. Treatment of SLE is based on prevention, influence the choice or dosage of 5. Albilia JB, Lam DK,Clokie CML, reversal of inflammation, maintaining medications prescribed by dentist Sándor CKB, Systemic Lupus states of re-mission and alleviation of .Patients suffering from chronic renal Erythematosus: A Review for symptoms.Treatment plan includesthe failure is often on dialysis. Dental surgery Dentists. JCDA, 2007; 73:823-828 use of protective sunglasses, protective should be planned one day after dialysis 6. Cervera R, Khamashta MA, Font J, clothing and Sunscreen treatment to ensure elimination of Sebastiani GD, Gil A, Lavilla P, et al. (SPF>15)5 .Various medicinal therapies adminis-tered medications and their by- Systemic lupus erythematosus: include- Non-steroidal anti- products1 . clinical and immunologic patterns of inflammatory drugs, cyclooxygenase-2 disease expression in a cohort of selective inhibitors and For patients with neuropsychiatric 1,000 patients. The European antimalarialswhich are generally symptoms the dentist's role is paramount Working Party and Systemic Lupus effective for musculoskeletal complaints to rule out odontogenic, Erythematosus. Medicine and mild serositis5 , 1 0 . Systemic temporomandibular joint and associated (Baltimore) 1993; 72:113-24. corticosteroids, such as prednisone, are myofascial sources of pain1. Patients on 7. Estes D, Christian CL. The natural reserved for patients with morbid long-term corticosteroids may require history of systemic lupus symptoms associated with significant supplemental dosing on the day of a erythematosus by prospective organ involvement, particularly renal, potentially stressful dentoalveolar analysis. Medicine (Baltimore) 1971; central nervous system and systemic surgery5 . 50: 85-95. vascular diseases10 . The dosage of 8. Paran D, Fireman E, Elkayam O: corticosteroid is progressively tapered as Conclusion Pulmonary disease in systemic lupus signs and symptoms resolve. However, Lupus is like a puzzle, with genetics, erythematosus and the some patients may require a maintenance gender, and the environment being antiphospholpid syndrome. dose to remain in remission.10 important pieces of the puzzle which Autoimmun Rev 2004, 3:70-75. when fit together result in this 9. Fessler BJ, Boumpas DT. Severe Perioperative Management by the autoimmune malady. A multidisciplinary major organ involvement in systemic Dentist 5,9,1 approach to medical consultation and lupus erythematosus. Diagnosis and Dentists must enforce preventive dental appropriate referrals ensures management. Rheum Dis Clin North care and monitor patients with SLE comprehensive medical and dental Am 1995; 21; 1:81-98. closely for head and neck infections management of patients with SLE. 10. Fessler BJ, Alarcon GS, McGwin G because they are predisposed to severe (1982) Jr, Roseman J, Bastian HM, Friedman infections. These infections are often AW, et al. Systemic lupus silent and difficult to detect because of References erythematosus in three ethnic groups: anabsence of pain and 1. Manson JJ, RahmanA . Systemic XVI. Association of swelling.Thorough clinical examination Lupus Erythematosus. Orphanet J hydroxychloroquine use with is required to avoid overlooking Rare Dis. 2006; 1:6. reduced risk of damage accrual. infections. Infections can progress 2. ChandraSekhar .P, Suvarna M, Arthritis Rheum 2005; 52; 5:1473- rapidly in patients with SLE because of ArvindBabu.R.S , Anuradha.C , 80. disease or therapy-related Shamala R., Reddy .B.V.R- Lupus immunosuppression. Most patients with erythematosus - A report of 3 cases, J SLE can have a superimposed OrofacSci, 2010; 2: 30-35. antiphospholipid antibody syndrome that 3. Susan M. Lupus Update: Perspective predisposes them to thromboembolic and Clinical Pearls. Cleveland Clinic events, such as arterial and venous Journal of Medicine 2009; 76: 137- thrombosis, pulmonary embolism, stroke 42. and myocardial infarction9 . It is therefore 4. Nath SK, Kilpatrick J, Harley JB. important to document whether these Genetics of human systemic lupus patients are managed with erythematosus: the emerging picture. anticoagulation therapy, aspirin or warfarin before dental surgery. Recent laboratory tests may be indicated preoperatively to determine platelet count, prothrombin time and the international normalized ratio (INR) for Source of Support : Nill, Conflict of Interest : None declared blood clotting time. Local measures for maintaining hemostasis may also be required. Antibiotic prophylaxis before bacteremia-associated dental and oral surgical interventions is required to prevent infectious endocarditis in SLE patients with valvular damage1 .

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 060 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Treatment Of Gingival Hyperpigmentation With 1 Anurag Aggarwal 2 Deepak Bala Diode Laser - An Esthetic Approach 3 Saryu Arora 4 Manpreet S Walia Abstract 5 Sunil Malhan Excessive gingival display and gingival hyperpigmentation are major concerns for a large number 1 M.D.S. (Reader) of patients visiting the dentist. Melanin hyperpigmentation usually does not present a medical Deptt of Conservative Dentistry problem, but patients usually complain of dark gums as unaesthetic. This problem is aggravated in National Dental College & Hospital, Derabassi patients with a "gummy smile" or excessive gingival display while smiling. Esthetic periodontal 2 Post Graduate Student plastic surgery is especially rewarding in such individuals with compromised esthetics. This case Deptt of Periodontology & Oral Implantology M. M College of Dental Sciences & Research report represents correction of gingival hyperpigmentation by laser ablation using diode laser with 3 satisfactory and pleasant results. M.D.S. (Senior Lecturer) Deptt. of Prosthodontics Key Words Swami Devi Dayal Hospital & Dental College Gingival hyperpigmentation, Gingival depigmentation, Repigmentation 4 M.D.S. (Professor and Head) Deptt. of Prosthodontics H.S. Judge institute of Dental Sciences & Hospital 5 M.D.S (Professor and Head) Introduction cryosurgical techniques but the results Deptt of Conservative Dentistry & Endodontics In today's dental practice esthetics has are almost similar but not stable for long Desh Bhagat Dental college, Muktsar 4 become a significant aspect and term . Address For Correspondence: clinicians are more concerned of Dr. Anurag Aggarwal Now day's most accepted painless, M.D.S. (Senior Lecturer) achieving acceptable gingival esthetics bloodless, effective, pleasant and reliable Department of Conservative Dentistry as well as addressing biologic and technique used for the removal of Swami Devi Dayal Hospital and Dental College, Golpura, Panchkula, India. functional problems. The color of the gingival depigmentation is by mean of Mobile No: +91-9815288381 gingiva plays an important role in overall diode lasers. E mail: [email protected] esthetics but the principles and the Following case report presents the Submission : 24th August 2011 techniques of the management of the management of gingival melanin Accepted : 12th April 2012 problems associated with gingival hyperpigmentation with diode laser melanin hyperpigmentation are still not exclusively for esthetic purposes Quick Response Code fully established. providing excellent outcome. Gingival melanin hyperpigmentation is usually encountered in African, Eastasian Case report & Hispanic ethnicity1,2 as well as in Patient of age 22 years reported to the certain medical conditions such as department with a chief complaint of endocrine disturbance, Albright's having unaesthetic, diffuse, dark-brown syndrome, malignant melanoma, to black gingival discoloration in the antimalarial therapy, Peutz-Jeghers labial aspect of the maxilla and mandible. was taken before the procedure. Laser syndrome, trauma, hemochromatosis, Patient requested for cosmetic therapy safety precautions were taken during the neurofibromatosis and chronic which will improve the esthetics on procedure. pulmonary disease3 . It varies from smiling. In general the skin pigmentation individual to individual but directly correlates with gingival pigmentation but Surgical Procedure:- relates to melanoblastic activity. in this specific patient the gingival ?The surgical site was anesthetized by Melanin hyperpigmentation usually does melanin hyperpigmentation was local infiltration with 2% lignocaine not present as a medical problem as it is observed that moderately predominated containing 1:80000 adrenaline. often physiological rather than over skin pigmentation. Patient's clinical ?Laser beam was activated at 2.5 W pathological but patients may complaint & medical history revealed physiologic using brush technique in focused mode of "black gums" which may pose esthetic gingival melanin hyperpigmentation. i.e. continuous movement of the beam problem & embarrassment especially in Patient's gingiva was found clinically with approximately 20% to 30% overlaps patients with a ''gummy smile'' or healthy & free from any visible clinical of the laser spots. Lasing time differed excessive gingival display while smiling inflammation thus taking into according to the degree of pigmentation, or talking. Gingival depigmentation is a consideration the patient's chief the pigmented surface treated, and the periodontal plastic surgical procedure complaint, laser assisted gingival epithelial thickness. The beam was whereby the gingival hyperpigmentation depigmentation procedure was planned. initially delivered along the is removed or reduced by various Whole procedure was explained verbally mucogingival junction, moving towards techniques such as mechanical, surgical, to the patient in simple and clear the free gingival margin. The papillary chemical, electrosurgical, and language and written informed consent edges and the free gingival margins were

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 061 initially left untouched to avoid with a focused Nd:YAG laser beam using morphological deformations. During the brush technique after the procedure. lasing, the gingiva was covered with Although the fenestration healed charred layer that was easily removed by uneventfully with the defocused beam, it wet gauze. A burning smell typical to the was more time-consuming8 . procedure was reduced or eliminated by In the present case report no power suction evacuation. No repigmentation occurred in treated periodontal dressing was given. patient till one year follow up. ?The entire gingival surface that required treatment was lased in a single Conclusion session. Present case report concluded that the ?Patient was instructed to avoid trauma management of gingival melanin to the treated gingiva and refrain from 3 Month Post Operation hyperpigmentation with diode laser is a acidic and hot food for one week. safe and effective procedure providing ?The patient was reevaluated 10 days excellent esthetic outcome at one year and 3 months after the last lasing session. follow up. The results were pleasing to Evaluation included clinical examination the patient which is the ultimate goal of and comparative clinical photographs any therapy. Following laser ablation the (Fig 1-5). gingiva healed uneventfully and completely regenerated with no infection, pain, swelling, or scarring. So to conclude that depigmentation with laser can be used as successful procedure.

1 Year Post Operation References 1. Fry L, Almyeda JR. The incidence of The results were very pleasing and the buccal pigmentation in caucasoids gingival appearance was satisfactory 2 to and negroids in Britain. Brit J 4 weeks after treatment. Patient did not Dermatol 1968; 80(4): 244-7. needed any rest or experienced any 2. Tamizi M, Taheri M. Treatment of Pre Operation interruption in performing normal severe physiologic gingival activities. During the 1 year follow-up, pigmentation with free gingival no signs of repigmentation were autograft. Quintessence Int 1996; observed. 27(8): 555-60. 3. Leston JM et al. Oral mucosa: Discussion variation from normalicy, part II. Recently, laser ablation has been Cutis 2002; 69(3): 215-7. recognized as an effective, pleasant and 4. Roshna T, Nandakumar K. Anterior reliable technique. It is preferred over esthetic gingival depigmentation and other techniques by many clinicians. crown lengthening: Report of a case. J When laser energy interacts with biologic Contemp Dent Pract 2005; 15: 139- tissue, the effect is influenced by the 47. emitted wavelength, laser energy, and 5. Ishikawa I, Aoki A, Takasaki AA. During Surgery time of exposure and rate of movement of Potential applications of the fiber tip across the target tissue. Erbium:YAG laser in periodontics. J Actually the absorption of laser energy in Periodontal Res 2004; 39: 275-85. the tissue is the key element of laser- 6. Schuller DE. Use of the laser in the tissue interaction. Pain reduction, intra- oral cavity. Otolaryngol Clin North and postoperatively, and rapid wound Am 1990; 23: 31-42. healing are important advantages of laser 7. Tal H, Oegiesser D, Tal M. Gingival use5 . In this present case report, patient Depigmentation by Erbium: YAG reported absence of pain intraoperatively, Laser: Clinical Observations and postoperatively which may be due to the Patient Responses. J Periodontol sealing of the ends of the sensory nerve 6. 2003; 74: 1660-7. Here the brush technique with a 8. Atsawasuwan P, Greethong K, defocused beam was used as used by Tal Nimmanon V. Treatment of gingival Post Operation H et al 2003 which seems to be safe and hyperpigmentation for esthetic effective7 . However Atsawasuwan et al purposes by Nd: YAG laser: Report of Results 2000 described gingival fenestration 4 cases. J Periodontol 2000; 71: 315- No discomfort, teeth sensitivity, pain or resulting in bone exposure up to 4 weeks 21. bleeding complications were found intra or postoperatively. Therefore no antibiotics or analgesics were prescribed. Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 062 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Role Of Cryosurgery In The Management Of 1 Ravi Narula 2 Bhavna Malik Benign And Premalignant Lesions Of The 1 M.D.S. Professor 2 Post Graduate Student Maxillofacial Region Department of Oral & Maxillofacial Surgery Guru Nanak Dev Dental College & Research Institute, Sunam Distt. Sangrur - 148028 Abstract Thirty four patients with age ranging from 2 to 68 years visiting the outpatient department of Guru Address For Correspondence: Nanak Dev Dental College and Research Institute, Sunam were selected at random. The Dr. Ravi Narula cryosurgical procedure was performed on 10 cases of lichen planus, 8 cases of mucocele, 4 cases 10 A Defence Colony, Stadium Road, of leukoplakia, 3 cases of pyogenic granuloma,4 cases of ranula, 2 cases of giant cell lesions,1 Patiala-147001, Punjab, India Telephone No:- 91-9815037127 case each of epulis fissuratum, hemangioma and fibroma. Ascon type of cryosurgical apparatus Email: [email protected] employing nitrous oxide(temperature -60 to -190o C) as a refrigerant was used in this study. Freeze thaw cycles each of one and a half minute freeze and 3 minute thaw at overlapping sites were Submission : 14th November 2011 sufficient for all the cases of leukoplakia. All the cases of leukoplakia were treated in single session Accepted : 26th April 2012 of cryosurgical procedure. Epulis fissuratum required double freeze thaw cycles each of 2 minutes freeze and four minutes thaw. All the lesions of mucocele were treated in single session and each lesion required double freeze-thaw cycle of one minute freeze and two-minutes thaw. All cases of Quick Response Code ranula required only a single session. Two cases of lichen planus and one case of mucocele showed recurrence. All cases showed normal healing between second to fourth week postoperatively after last cryo-application except one case of epulis fissuratum showed reduction in size but incomplete healing. The results of treatment of various lesions managed by cryosurgery support, the clinical contention that cryosurgery has earned a place on the armamentarium of maxillofacial surgery. Key Words cryosurgery, freeze-thaw, premalignant lesions, hyperplastic lesions, mucocele, ranula

Introduction investigate the role of cryosurgery in cryogen and Joule Thompson .Here, the Cryosurgery is the method of deliberate various mucosal lesions such as escape of pressurized gas through a destruction of tissues by controlled leukoplakia, hemangiomas, mucoceles, narrow orifice results in internal work cooling. James Arnott (1851) was first to pannulas, lichenplanus, granulomatous being performed as the gas expands, report on the therapeutic use low and hyperplastic lesions. leading to the extraction of heat from the temperature in malignant disease by local environment. These instruments means of salt /ice mixture applied to Methods produce a temperature at the probe breast neoplasm. The unique properties 21 male patients and 13 female patients surface of about -70 degree centigrade of cryosurgery were recognized before suffering from different benign and pre- (nitrous oxide). Ascon type of the turn of this century and since then use malignant lesions of the maxillofacial cryosurgical apparatus operating on of cold and removal of tissue by freezing region were diagnosed on the basis of Joule-Thompson principle was used in has been utilized in various field of detailed history and histopathological this study. medicine with an aim of destroying and examination, wherever required. Two cryoprobes were used depending removing unwanted tissues. Its success Routine laboratory hematological upon the size and location of the lesions. has paralled the development of investigations and complete urine A disc was used for larger surface lesion. cryosurgical apparatus and its future examinations were carried out pre- To speed the cooling rate, the probe was progress may also reflect the kind of new operatively to rule out any systemic precooled before application to the technologies that are currently being disorder. After thorough assessment, the tissues by letting the gas flow through the developed. patients were subjected to cryosurgical probe for 5-7 seconds prior to application The oral mucosa is particularly well procedure. to the tissues. Once freezing began, the suited to the application of the cryoprobe The available apparatus may be classified probe was fixed in place by ice formation because it is moist and does not require a into open and closed systems. Open and was not moved until thaw began. coupling medium. Healing of the oral systems involve the direct application to Large lesions were managed by multiple mucosa after cryotherapy is relatively superficial lesions . overlapping applications till the entire uncomplicated by infection or pain The three main types of closed system are disease area was frozen. although swelling is sometimes thermo-electric which operates by Peltier For mucoceles and lichen planus a single pronounced. effect, evaporative sytem which depends freeze thaw cycle of sixty seconds freeze The study was designed so as to on controlled evaporation of liquid was applied .For leukoplakias and

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 063 hemangiomas double freeze thaw cycles the palate. Three cases of pyogenic of one and a half to two minutes each granuloma involved the maxillary were employed .For ranulas, double gingiva. Single case of hemangioma freeze thaw cycle of one and a half minute involved buccal mucosa. All the four each was employed. cases of ranula involved floor of mouth For granulomatous and fibrous lesions (Fig.1) ,the freezing was extended beyond two minutes with double freeze thaw cycle at Cryosurgical procedure varied each session . A slow thaw of 2-5 minutes depending on the lesion involved was observed in all the instances. .Cryosurgical procedures includes the For deep lesions, pressure was applied to Leukoplakia-Pre-Operatively following three important aspects: depress the probe to increase the depth of 1. Number of cycles given the ice ball. For superficial lesions either 2. Duration of each cycle probe was placed gently or slight traction 3. Number of sessions required was applied. The lesion after treatment It is seen that double freeze thaw cycles of with cryosurgery was left as such and each one and a half minute freeze and 3 following drugs were prescribed. minute thaw at overlapping sites were A NSAID -Ibuprofen 600mg orally, eight sufficient for all the four cases of hourly for three days. leukoplakia and were treated in single A mouthwash to combat the smell of session of cryosurgical procedure.(fig.1) necrotic tissue -Chlorhexidine mouth Granulomatous and hyperplastic lesions wash twice daily. A topically applicable which included three cases of pyogenic local anesthetic such as benzocaine (to be Ice ball formed granuloma and one case of fibroma used if required) ,required double freeze thaw cycles each Patients were called on 1st,7th, 15th of 2 minutes freeze and four minutes postoperative days for check up with a thaw. Two sessions of cryosurgical follow up period of three to six months. procedure were required for each lesion. Postoperative findings such as pain, All the lesions of mucocele were treated swelling, numbness, trismus and any in single session and each lesion required other complications were observed and double freeze-thaw cycle of one minute recorded. freeze and two minutes thaw. Single case of hemangioma required Results: double freeze thaw cycle of one and half The distribution of lesions treated with Post-Operatively minutes freeze and three minutes thaw. cryosurgery according to the type of All the cases of lichen planus required lesion and site of occurrence in the oral double freeze thaw cycle of one and a half cavity are shown in Table 1. minutes freeze and 3 minutes thaw It is evident that all the cases of lichen depending upon the size of lesion, the planus involved the buccal mucosa .Out number of sessions required range from of the four cases of leukoplakia, two two to three. involved the lower lip, one buccal All the cases of ranula required only a vestibule and one buccal mucosa. All the single session. Double freeze thaw cycles cases of mucocele except one involved of two minutes freeze and four minutes lower lip. One case of mucocele involved Sloughing and necrosis thaw were needed for each lesion (Fig.2) Two cases of giant cell epulis which were Table 1 : Distribution Of Lesions Treated With Cryosurgery According To Site treated with combined surgical and cryosurgical approach required double Sr. Lesions freeze thaw cycle of two minutes freeze and four minutes thaw.Single session was Lichen Planus Leukoplakia Mucocele Ranula Granulomatous Hemangioma Giant Cell Epulis needed for each lesion. Hyperplastic Lesion Lesions Fissuratum Single case of epulis fissuratum was

1. 3 1

2. 10 1 1

3. 2 7 1

4. 1

5. 1

6. 4

7. 1 1

10 4 8 4 4 1 2 1 Ranula-Pre-Operatively

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 064 neoplasms(Emmings et al,1967)18 . lesion.Cryotherapy emerged as a It is concluded from above mentioned alternative modality in the present studies that within its limitations study.All the cases except one showed ,cryosurgery is an effective, simple, good results with minimum of predictable, relatively self limiting and postoperative complications.One case safe method for almost all types of oral recurred after one month and was treated lesions.As it causes necrosis and by marsupilization. sloughing as part of treatment ,delayed The treatment of ranula ranges from healing is an inherent problem with this complex excision of gland to a simple technique else,it is free from marsuplisation.However,surgery in the complications such as pain,haemorrhage floor of the mouth is asssociated with a Ice Ball Formed ,infection,inadvertant damage to risk of injury to wharton's duct and to adjacent structures ,or scar formation that lingual nerve ,profuse bleeding due to are seen with knife excision or rich blood supply and high risk of electrosurgery. infetion due to loose areolar tissue in In the present study ,four cases of various spaces in this region.All the cases leukoplakia were treated.Healing was of ranula in this study showed complete completed by two to three weeks after the ablation .Mild to moderate postoperative last application.No postoperative pain and swelling was seen.Mild complications were observed except transient paresthesia was reported in one mild pain and swelling.The results are in of the cases.Thus cryosurgical procedure conformity with those of Sako et al is a good preference in the treatment of (1972) ,Poswillo(1974) and Vercellino ranulas.These results are in confirmity (1980) who also reported a successful with the reports of Marvin E.Chapin 14 Post-Operatively treatment of leukoplakia with (1976) ,who have successfully treated cryosurgery. ranulas with cryotherapy. The management of oral hemangiomas is Lichen planus is basically a skin given three sessions of cryosurgical required in those cases where disease.Mutiple etiological factors have procedure consisting of double freeze spontaneous remission do not occur or been suggested including thaw cycles of 2 minutes each.Lesion was that occur in older individuals.These infection,trauma,stress,immunologic reduced in size but not completely lesions are treated by surgery,radiation factors,hypertension and contact allergy eradicated and had to be treated by therapy,sclerosing agents injected into to certain metals.It is present in oral surgical excision. thhe lesions,compression,selective cavity in various forms sucreticular, embolization and cryotherapy.Surgical papular, bullus, erosive and plaque Discussion removal is difficult because of like.Many treatment modalities have Cryosurgery is a successful mode of uncontrollable haemorrhage during the been proposed for this disease which therapy for the conditions which have procedure.Radiation therapy has its own includes topical steroids,laser traditionally presented problems in the disadvantages such as xerostomia, therapy,antifungal mouth washes management such as osteoradionecrosis and malignant ,surgical excision and cryosurgery. leukoplakia,vascular malformation and changes of benign tissue. In the present study, all the patients of certain extensive surface lesions like Other modalities such as sclerosing lichen planus treated with cryotherapy lichen planus. agents and compression require long responded with good results. Pain and The technique of freezing has been used duration of treatment consisting of burning sensation disappeared with to treat hemangiomas by Chapin M.E.et multiple injections at 6-8 weeks intervals complete healing within four weeks. 1 2 al(1976) , Hartman p.k.et al (1984) and and even then, results are However, recurrence occurred in two 3 Haim Tal et al (1992) . unpredictable.Selective embolization cases, in first case after one year and in Applications of selected freezing have pose high risks of CVAs. However, the other after 6 months postoperatively. been employed to treat leukoplakia and cryotherapy appears to be a simple,safe But the period of remission of this hyperkeratosis by Emmings et al(1967), and predictable method of treatment. troublesome disease was significant. Sako et al(1969),Gongloff r.k.et al In the present study,one case of Moreover, cryoapplication can be easily (1980)6 and Ishida C.E.(1998)7 . With the hemangioma present on buccal mucosa repeated without any harm to patient. advancement in cryosurgical technique was treated in one sitting with excellent Therefore, cryosurgery is a good and equipment,it was utilized in results.These results are in confirmity treatment modality atleast a palliative pyogenic granuloma, angioma, fibroma, with those of Poswillo D.E. (1971)15 , therapy for oral lesions of lichen planus. keratoacanthoma. Sankodi(1979)8 , Haim Tal (1992)3 who These results are in confirmty with Bekke Lichen planus was treated with reported successful treatment of and Baart(1979)16 ,Sonkodi(1979)8 who cryotherapy with good results by Sankodi hemangiomas with cryotherapy..W employed cryosurgery to treat lichen 8 I.(1979) ,Bekke J.P.H.et al(1979),Loitz Mucoceles are benign cystic lesions planus with good results. G.A.(1986) and Ishida.C.E.(1998)7 which frequently occur on lower In the hyperplastic and granulomatous Cryosurgery was also used to treat lip.Trauma to the minor salivary glands lesions , pyogenic granulomas , trigeminal neuralgia (Barnard J.D.W. et play a significant role in etiopathogenesis fibroepithelial polyps, fibromas and al,1979;Zakrzewska J.M., 1986, of these cysts.High rates of recurrence some papilloma constitute the most 1988,1991)1 0 , s 1 1 , 1 2 salivary gland was reported after surgical excision of the prevalent lesions of the oral cavity. These

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 065 tumors and tumor like lesions that appear equipment and use of liquid nitrogen, this 95-101 on the tongue ,gingiva, oral vestibule mode of therapy appears to have 9. Loitz GA and O'Leary JP. Erosive ,floor of mouth and lips are generally the promising role in the management of lichen planus of tongue treated by result of inflammatory and hyperplastic locally aggressive and recurrent lesions. oral surgery. J. Oral Maxillofac reactions to local,chronic irritative Thus, its simplicity in application and the Surg.1986; 44: 580-82 factors. Conventional surgical excision absence of postoperative infection, 10. Barnard JDW, Lloyd JW and Glynm and suturing remain the popular contraction, scarring and little or no CJ. Cryosurgery in the treatment of treatment of choice of these lesions. In recurrence makes cryosurgery a highly intractable facial pain. Br. J. Oral the present study ,three cases of pyogenic useful method in treating various Surg.1978-79; 16: 135-42 granuloma and one case of fibroma conditions of oral cavity. 11. ZakrZewska JM, Nally EF and Flint showed good results. SR. Cryotherapy in the management Irregular irritative hyperplastic lesions of Refrences of paroxysmal trigeminal neuralgia. the sulcus, associated with chronic 1. Chapin ME. Cryosurgery with J. Maxillofac. Surg.1986; 14: 5-7 irritation from denture flanges , can be nitrous oxide: Report of cases. J. Oral 12. ZakrZewska JM, Nally EF. The role managed effectively by cryosurgery. Surg. 1976; 34: 717-21 of cryosurgery(cryoanalgesia) in the Simple excision in these circumstances 2. HartmanPK, Verne D and Davis RG. management of paroxysmal leads to loss of sulcus depth, which may Cryosurgical removal of a large trigeminal neuralgia .A six year necessitate a more radical approach to the hemangioma. Oral Surg., Oral Med., experience. Br. J. Oral Surg.1998; problem ,such as vestibuloplasty. Oral Path.1984; 58(3):280-82 26(1): 18-25 Necrosis of the hyperplastic tissue may 3. Haim Tal. Cryosurgical treatment of 13.Leopard PJ and poswillo DE. be achieved with minimal alteration of hemangiomas of lip. Oral Surg., Oral Practical cryosurgery for oral lesions. sulcus depth by cryosurgery. Though Med., Oral Path. 1992; 73:650-54 Br. Dent. J. 1974; 136: 185-96 cryosurgery is a good modality of 4. Emmings FG, Mirdza, Georgew G Jr. 14. Vercellino V, Magnani G, Goia F, treatment for epulis fissuratum as it Freezing the mandible without Gandolfo S. Our clinical experience maintains the sulcus depth but it has its excision. J. Oral Surg. 1966; 24:145- with the cryosurgery of oral lesions of limitation.Small lesions can be easily 54 odontostomatologic interest. 1980; treated but in large lesions, treatment 5. Leopard PJ. Cryosurgery and its 29(4): 252-258 with cryosurgery is very long and not application to oral surgery. Br. J. Oral 15. Poswillo DE. A comparative study of predictable. Surg.1975; 13: 128-52 the effects of electro-surgery and Two cases of peripheral giant tumor were 6. Gongloff RK, Samit AM, Greene Jr cryosurgery in the management of treated in the present study with surgical GW, Innco GF Gage AA. benign oral lesions. Br. J.Oral excision and cryotherapy. Cryotherapy Cryosurgical management of benign Surg.1971; 9: 1-7 included double freeze thaw cycle with 2 and dysplastic intraoral lesions. J. 16. Bekke JPH and Baart JA. Six years minutes freeze. Both cases showed good Oral Surg. 1980; 38: 671-76 with cryosurgery in the oral cavity. result. Though peripheral giant cell 7. Ishida CE, Ramos-e-Silva M. 1979; 8: 251-270 granuloma has low recurrence rate but Cryosurgery in oral lesions. Int. J. the use of cryosurgery ensures the Dermatol.1998; 37(4): 283-85 complete eradication of lesion. 8. Sonkodi I. Cryosurgery in Stomato- With the recent development of better oncology. Int. J. Oral Surg. 1979; 8:

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 066 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Idiopathic Non-syndromic Oligodontia In 1 Deepak Kumar Gupta 2 Meet Kamal Permanent Dentition - A Case Report 3 Harmesh Sharma 4 Shally Gupta Abstract 1 Professor Tooth agenesis is a common developmental anomaly that appears in 2.2-10% of the general Deptt of Orthodontics & Dentofacial Orthopedics population (excluding agenesis of third molars). Congenital tooth agenesis can be either MM College of Dental Sciences & Research, Hypodontia (agenesis of fewer than six teeth excluding third molars) or Oligodontia (agenesis of MM University, Mullana, Ambala. 2 more than six teeth excluding third molars). Oligodontia can occur either as an isolated condition Professor and HOD Deptt of Oral Pathology & Microbiology (non-syndromic oligodontia) or it can be associated with cleft lip\palate and other genetic Gian Sagar Dental College and Hospital, syndromes (syndromic oligodontia). The exact aetiology of Oligodontia is unknown. The Ram Nagar,Rajpura. management includes various procedures like the restorative, surgical and orthodontic to improve 3 Demonstrator, Deptt of Periodontics the aesthetics and function. The present article reports a case of Oligodontia where in seven Govt. Dental College and Hospital, Patiala. permanent teeth excluding the third molars were missing in a non-syndromic 15 years old female 4 Professor and HOD patient. Deptt of Oral Pathology & Microbiology Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Chandigarh. Key Words Address For Correspondence: Oligodontia, Hypodontia, Non -syndromic, Congenital, Tooth agenesis. Dr. Deepak Kumar Gupta House No: 910 FF, Sector -9, Panchkula, Haryana-134109 Phone no: (0) 9417270593, E-mail: [email protected] Introduction: epithelium th Agenesis of some teeth is referred to as 3) Failure of initiation of the underlying Submission : 04 August 2011 th hypodontia which is preferable to term mesenchyme. Accepted : 06 March 2012 partial anodontia. Anodontia, which implies complete failure of the teeth to Characteristic dental symptoms Quick Response Code develop, is a rare condition. The term associated are reduced number of teeth, Oligodontia is sometimes used when reduction in tooth size, anomalies of only a few teeth are present.1 Stewart tooth form, and delayed eruption. The states; Oligodontia is the agenesis of absence of teeth in young patients can numerous teeth (more than 6 teeth) cause aesthetic, functional, and excluding the third molars. Various psychological problems particularly if terminologies are used to describe the the teeth of the anterior region are congenital absence of teeth in the involved .2, 3 deciduous and permanent dentition. Hypodontia is used to describe the Case Report: trauma to the anterior segment. absence of one or few teeth, oligodontia A 15 year old female patient reported to a According to the past dental history given is used for agenesis of numerous teeth private clinic, with a chief complaint of by the patient's mother, the permanent and anodontia is the extreme of missing teeth in the lower front tooth teeth in the mandibular anterior region oligodontia where there is total absence region. The intra oral examination did not erupt after the exfoliation of the of any dental structure.2 The condition showed the presence of following primary teeth. Patient was healthy with such as Oligodontia is often associated permanent teeth i.e. 16 , 12 ,11 and 21, no relevant medical and family history with specific syndrome &/or severe 22,24,25,26 in the maxillary arch and suspecting congenital absence of the systemic abnormalities, whereas 34,35,36 37, 44, 45,46 in the mandibular permanent teeth .An OPG was taken anodontia is commonly seen in severe arch. The teeth clinically absent which showed congenital absence of cases of ectodermal dysplasia.2, 3 were15,14,13,23, 31,32, 33, 41,42,43 in 15,31,32,33,41,42,43 and tooth # 13 both the arches. Retained primary teeth ,14,23 were impacted as seen in Fig[5]. The cause for congenital absence of teeth were 54, 55 and root stump of 72, as seen The third molar buds in both the arches could be due to any of the following in Fig [1 to 4 ]. were also absent. A complete medical reasons: examination was done to rule out any 1) physical obstruction or disruption of The examination of soft tissues revealed systemic abnormality. Haematological the dental lamina, no significant abnormality. The dentition and biochemical findings were found to 2) space limitation, and functional of the parents and sibling were normal. be within limits. abnormalities of the dental There was no history of any infection or

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 067 Fig.2 Maxillary cast teeth present 16,E,D,12,11,21,22,24,25,26

Fig 1. Teeth present in upper arch are 16, E, D, 12, 11,21,22,24, 25 and 26

Fig.4 Mandibular cast with Permanent teeth present 37,36,35,34, 44, 45, 46 and the teeth in the anterior segment are missing

Based on above findings the case was diagnosed as Idiopathic Non- Fig.3 Teeth missing in the lower anterior region 31, 32, 33, 41, 42, and 43, Syndromic Oligodontia in Permanent also note the root stump of 72, i. e. Left lower B Dentition. The line of treatment planned for the above reported case was extraction of mobile deciduous teeth/root stump, orthodontic tooth movement to correct class II malocclusion and a removable partial prosthetic appliance as our patient is in adolescent age group .The patient is to be monitored every six months to determine the need to refit or remake of removable partial prosthetic appliance. Implants are recommended only for missing anterior teeth and fixed prosthesis latter on in life after the complete growth of the jaw bones.

Discussion: A tooth is said to be congenitally missing if it has not erupted in the oral cavity and is not visible in radiograph.4 When describing the phenomenon of Fig 5. OPG shows absence of the tooth buds for 15,31,32,33,41,42,43, also note the complete absence of third molars congenitally missing teeth the term most buds frequently used is Hypodontia.5

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 068 Hypodontia is an anomaly that may result ?Oral facial digital syndrome diagnosed at an early stage so that the in dental malpositioning, periodontal type1[OFD1] effect of psychological distress can be damage, lack of development of ?Witkop tooth-nail syndrome minimized. maxillary and mandibular bone height ?Fried syndrome and also shows a significant effect on ?Hair-nail-skin-teeth dysplasia References: psychological and aesthetic development ?Rieger syndrome 1. Hartsfield Jr. Acquired and of an individual.5 ?Down's syndrome Developmental Disturbances of the ?Wolf-Hirschorn syndrome teeth and associated oral structures. Hypodontia and Oligodontia are either ?Marshall's syndrome In: Mc Donald RE, Avery DR, Dean isolated /non syndromic or syndromic i.e. ?Hemifacial microsomia and recessive JA, eds. Dentistry for the Child and associated with some syndrome. In incisor hypodontia 7,8 Adolescent. 8th ed. St Louis: CV recent years the following definitions Mosby Co; 2004:103-147. have been used : In this modern world, hypodontia is often 2. Stewart RE, Witkop Jr CJ, Bixler D. ?Hypodontia: 1 to 6 teeth missing encountered by the dental practitioners. The dentition and anomalies of tooth (excluding the third molars) Hence the use of OPG is recommended, size, form, structure, and eruption. In: ?Oligodontia : more than 6 teeth together with clinical /systemic Stewart RE, Barber TK, Troutman missing (excluding) the third molars examination for the detection or KC, Wei SHY, eds. Pediatric ?Anodontia :complete absence of confirmation of dental development and Dentistry: Scientific Foundations of teeth5,6 coming to the diagnosis of hypodontia / Clinical Procedures. 1st ed. St Louis: Oligodontia. CV Mosby Co; 1982:87-109. Several factors like hereditary, trauma , 3. Gorlin RJ, Cerrenka J, Moller K, infection to the developing tooth bud , In our case we reported seven permanent Horribin M, Witcop CJ. Oligodontia, overdose of radiation ,systemic teeth missing excluding the third molars. taurodontia and sparse hair growth. conditions like rickets and syphilis The patient was ruled out for being Birth defects 1975; II. 2:39. ,several intrauterine disturbances, associated with any syndrome and 4. White SC, Pharoah MJ.Oral metabolic disorders and idiopathic systemic disorder. Thus, congenital lack radiology principles and factors have been proposed as of more than six permanent teeth without interpretations. In: White SC (ed). aetiological factors for Oligodontia. It any systemic disorder or syndrome was Dental anomalies .St Louis, PA: can occur either as a single entity or in suggestive of Idiopathic Non Syndromic Mosby, 2000 pp305-306. association with some syndrome.7 Oligodontia in Permanent Dentition. 5. Arte S. Phenotypic and genotypic features of familial hypodontia . Oligodontia and hypodontia are Conclusion: Academic dissertation. Institue of associated with dental anomalies like The missing teeth, abnormal occlusion or dentistry, University of Helsinki, delayed formation or eruption of teeth, altered facial appearance may cause 2001 reduction in tooth size and form , psychological distress in some or all 6. Silva Meza R. Radiographic malposition of teeth (ectopic maxillary patients. In the above presented case the assessment of congenitally missing canines and ectopic eruption of other patient presented with a class II teeth in orthodontic patients. Int J teeth),infra positioning of primary malocclusion which seem more due to a Paediatr Dent 2003; 13:112-116 molars, teeth with short roots , retrognathic mandible than a prognathic 7. Shipla,Thomas AM and Joshi JL. taurodontism , rotation of premolars and maxilla. Now whether the retrognathism Idiopathic Oligodontia in Primary or maxillary lateral incisors , enamel of mandible is caused by under Dentition: CaseReport and Review of hypoplasia , hypo calcification, development of mandible due to missing Literature.J Clin Pediatr Dent 2007; dentinogenesis imperfect, speech tooth buds in anterior region of mandible 32(1): 65-68 impairment and deep bite all of which can (since presence/absence of teeth 8. B.Cakur,S.Dagistan and M Bilge have a physiological and psychosocial stimulates/retards the growth of jaw bone .Nonsyndrromic Oligodontia in impact on the individual.7,8 respectively) or it is a general Permanent Dentition:Three Siblings. manifestation in line with the usual class The Internet Journal of dental Dental manifestations are seen in several II malocclusion patients need further Science.2006 Volume 3 Number 2 syndromes along with malformations of investigation. Depending upon the extent other organs: of the severity, orthodontist teams up ?Isolated cleft lip/palate with prosthodontist in treating such ?Pierre Robin sequence cases. Thus such cases should be ?Van der Woude syndrome ?MSX1 ?Hypohidrotic Ectodremal Dysplasia [EDA or HED] ?Ectodactyly - Ectodermal dysplasia - Source of Support : Nill, Conflict of Interest : None declared cleft syndrome[EEC] ?Cleft lip palate ectodermal dysplasia [CLPED1] ?IP, Bloch - Sulzberger syndrome ?Hypohidrotic ectodermal dysplasia and immune deficiency [HED-ID]

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 069 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Peripheral Ossifying Fibroma - A Case Report 1 Hemant Batra 2 Neeraj Sharma 3 Anubha Gulati Abstract 4 Peripheral ossifying fibroma (POF) is one of the several common reactive hyperplastic lesions of Sheeba Mohindra the gingiva. It arises from the gingival corium, periosteum, and periodontal ligament. Commonly 1 Prof & HOD, Dept.of Oral & Maxillofacial Surgery used synonyms for POF include calcifying fibroblastic granuloma, peripheral fibroma with 2 Sr. Asst.Prof, Dept.of Oral Medicine & Radiology calcification, peripheral cementifying fibroma, and calcifying or ossifying fibrous epulis. This article 3, 4 Assoc. Prof, Dept Of Oral Pathology Dr. HSJ Institute Of Dental Sciences presents a case of peripheral ossifying fibroma in a 55-year-old female along with the clinical, histopathologic, and radiographic features and treatment details. Panjab University, Chandigarh Address For Correspondence: Key Words Dr. Hemant Batra peripheral ossifying fibroma, gingival enlargement, fibroma Prof And Hod Dept. Of Oral And Maxillofacial Surgery Dr. HSJ Institute Of Dental Sciences Panjab University Chandigarh Introduction Email: [email protected] The peripheral ossifying fibroma(POF) Submission : 24th December 2011 is a common gingival lesion manifesting Accepted : 14th April 2012 as a localized gingival enlargement typically measuring less than 1.5 cm at its Quick Response Code greatest dimensions. It varies from pale pink to cherry red in color, can be either pedunculated or sessile and is typically located in the interdental papilla region.1,2,3 It is more common in the young women. The majority of lesions occur during a person's second decade, with a 4 declining incidence in later years. The bone involvement. Incidentally, an lesion may cause a separation of the impacted mesiodens could be seen on the adjacent teeth, and occasionally minimal radiographs. (Figure 2) Clinically, bone resorption can be seen beneath the 5 differential diagnoses for the growth lesion. were pyogenic granuloma, peripheral Figure 1. Intra-oral view showing a sessile growth arising odontogenic fibroma, fibroma, and Case Report from the gingiva of maxillary left central and lateral peripheral giant cell granuloma. A A 55 years old female patient reported to incisors. the department of oral medicine and radiology with an exophytic growth in the oral cavity which has been gradually increasing since the past three months. The swelling started as a small nodule. The patient did not give any significant medical history. Intraoral examination revealed poor oral hygiene and neglected dental condition. A well-demarcated, non-tender, firm, focal, sessile nodular growth arising from the gingiva of the maxillary left central and lateral incisors was seen. The oval-shaped mass was 1.5 cm x 2 cm in size, with a reddish pink color, smooth surface, and distinct edges. (Figure 1) Bleeding on probing was noted. An intraoral periapical radiograph and orthopantomogram of the maxillary central incisors showed no underlying Figure 2. Orthopantomogral showing no underlying bone involvement. An impacted mesiodens is seen.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 070 provisional diagnosis of pyogenic connective tissue. Chronic irritation of granuloma was made for the gingival the periosteal and the periodontal growth. membrane causes metaplasia of the Under local anesthesia, the lesion was connective tissue and resultant initiation completely excised. (Figure 3) The of formation of bone or dystrophic excisional biopsy was submitted for calcification.12 There are three types of histological analysis. The histo mineralized tissue in the POF: dystrophic pathological examination of the lesion calcification, bone (woven or lamellar), revealed the prominent area of highly and cementum- like material. The cellular fibrous connective tissue dystrophic calcification is most prevalent showing collagen fibers and proliferating in ulcerated lesions.4 Ossification or plump fibroblasts, and focal areas of Figure 5. Round to ovoid cementum like calcifications calcification may not be evident in all seen. H-E staining X40. round to ovoid calcifications. The cases, particularly in the earlier stages of covering stratified squamous epithelium considered to be the irritants causing its lesional growth. was parakeratinized with focal areas of growth.7 Factors such as a high female It is suggested that there is no absolute acanthosis. The underlying connective predilection and a peak occurrence in the histological distinction between bone tissue was infiltrated with inflammatory second decade of life also suggest of and cementum, and as the so-called cells and showed few dilated blood hormonal influences.8 Sixty percent of cementum-like globules of calcification vessels engorged with red blood cells. the lesions occur in the maxilla, with are seen in fibro-osseous lesions in all (Figure 4 and 5) The diagnosis was POF more than 50% occurring in the incisor- membrane bones, it is unrealistic to according to both clinical and canine region.9,10 The associated teeth are separate the ossifying and cementifying histopathological patterns. A five-month usually not mobile. lesions and it is speculated that the fibro- postsurgical follow-up showed no Roentgenographically, in a vast majority osseous lesions might represent stages in evidence of recurrence. of cases there is no apparent underlying the evolution of a single disease process bone involvement visible. On rare passing through the stages of fibrous dysplasia to ossifying fibroma to occasions, there appears to be superficial 14 erosion of bone.11 Radiopaque foci of cementoid lesions. calcifications have been reported to be After the elimination of the local scattered in the central area of the lesion, etiological factors like plaque, calculus, but not all lesions demonstrate ill fitting dentures and poor quality radiographic calcifications.12 A minor restorations, local surgical excision of adjustment of exposure settings POF is the preferred treatment. Excision (decrease of kilovolt peak; increase of should include the periodontal ligament milliampere) is recommended for and the periosteum at the base of the showing the tiny radiopaque foci. lesion in order to reduce the chances of Figure 3. Excised tissue. The clinical features are not sufficient for recurrence. However, total excision of the diagnosis of POF because there are the lesion in the maxillary anterior region other conditions that may have similar can result in an unsightly gingival defect unless appropriate efforts are taken to clinical appearances and clinical courses 1 such as pyogenic granuloma and repair the periosteal defects. Various peripheral giant cell granuloma. different surgical techniques like lateral Therefore biopsy and histopathological sliding flap of full thickness or partial examination is required for definitive thickness, subepithelial connective tissue diagnosis. graft, or coronally positioned flap may be In the present case the findings except for used to manage this defect and minimize patient esthetic concerns. Recurrence age correlated the general characteristics 14,15 and there was no underlying bone rates of 8-20% have been reported. The recovery of our patient was Figure 4. Histopathological picture showing fibrous involvement. The patient had poor oral connective tissue covered with stratified squamous hygiene, which probably contributed uneventful and is on regular follow-up. epithelium. with etiopathogeny of the POF. Considerable confusion has prevailed in Conclusion the nomenclature of POF with various In conclusion, a slowly growing soft- Discussion synonyms being used such as peripheral tissue mass in the anterior oral cavity The POF occurs almost exclusively on cementifying fibroma, ossifying fibro- should raise a suspicion of a reactive the free margin of the gingiva and usually epithelial polyp, peripheral fibroma with gingival lesion such as POF. It is a benign involves the interdental papilla. The fact osteogenesis, peripheral fibroma with fibro-osseous lesion with significant that the lesion emerges from the cementogenesis, peripheral fibroma growth potential. Histopathological periodontal ligament and is not seen in with calcification, calcifying or ossifying examination is essential for accurate edentulous areas suggests its origin to be fibrous epulis and calcifying fibroblastic diagnosis. Once diagnosed, POF should the connective tissue elements of the 13 be treated by total excision to prevent 6 granuloma. periodontal ligament. Dental calculus, Histopathologically, the lesions show recurrence. plaque, dental appliances, ill-fitting excessive proliferation of mature fibrous crowns, and rough restorations are References

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 071 Kfir Y, Buchner A, Hansen LS: Reactive maxillofacial pathology: a rationae Philladelphia, PA: W.B. Saunders Co; lesions of the gingiva. A for diagnosis and 2006:113-308. clinicopathological study of 741 cases. J treatment.Quintessence pubishing, 12. Kendrick F, Waggoner WF. Periodontol 51:655, 1980 Illinois 2003:25 Managing a peripheral ossifying 7. Gardner DG: The peripheral fibroma. J dent Child 1996;63:135- 1. Walters JD, Will JK, Hatfield RD, odontogenic fibroma: An attempt at 138. Cacchillo DA, and Raabe DA. classification. Oral Surg Oral Med 13. Kumar SK, Ram S, Jorgensen MG, et Excision and repair of the peripheral Oral Pathol 1982;54:40-48. al. Multicentric peripheral ossifying ossifying fibroma: a report of 3 cases. 8. Kenney JN, Kaugars GE, Abbey LM. fibroma. J Oral Sci. 2006;48(4):239- J Periodontol 2001;72(7):939-944. Comparison between the peripheral 243. 2. Neville, et al. Text book of oral and ossifying fibroma and peripheral 14. Langdon JD, Rapidis AD, Patel MF. maxillofacial Pathology. 2nd ed. odontogenic fibroma. J Oral Ossifying Fibroma-One Disease or West philadelphia:Saunders 2004.p. Maxillofac Surg. 1989;47(4):378- Six? An Analysis of 39 Fibro- 451-452. 382. Osseous Lesions of the Jaws. Br J 3. Martin S. Greenberge, et al. Burket's 9. Buchner A, Hansen LS: The Oral Surg 1976;14:1-11. Oral medicine. 11th edn. Hamilton: histomorphologic spectrum of 15. Kenney JN, Kaugars GE, Abbey LM. BC Decker Inc, 2008:133-134. peripheral ossifying fibroma. Oral Comparison between the peripheral 4. Buchner A, Hansen LS. The Surg Oral Med Oral Pathol ossifying fibroma and peripheral histomorphologic spectrum of 1987;63:452-461. odontogenic fibroma. J Oral peripheral ossifying fibroma. Oral 10. Poon C, Kwan P, Chao S. Giant Maxillofac Surg 1989;47:378-82. Surg Oral Med Oral Pathol. peripheral ossifying fibroma of the 16. Cuisa ZE, Brannon RB. Peripheral 1987;63(4):452-461. maxilla: Report of a case. J Oral ossifying fibroma: A clinical 5. Norman K. Wood, Paul W. Goaz. Maxillofac Surg 1995;53:695-8. evaluation of 134 pediatric cases. Differential Diagnosis of Oral and 11. Rajendran R. Benign and malignant Pediatr Dent 2001;23:245-8. Maxillofacial Lesions. 5th edn. St tumors of oral cavity. In: Shafer WG , Louis: Mosby, 2006:143-144. Hine MK, Levy BM. Shafer's 6. Marx RE, Stern D. Oral and Textbook of Oral Pathology. 5th ed.

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 072 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Cone Beam Computed Tomography: Third Eye 1 Neha Vaidya 2 Amarnath G S In Diagnosis And Treatment Planning 3 B C Muddugangadhar 1 Post Graduate Student Abstract 2 Professor & Head Computerized tomography (CT)-based dental imaging for implant planning and surgical guidance 3 Reader carries both restorative information for implant positioning, as far as trajectory and distribution, and Deptt. of Prosthodontics M R Ambedkar Dental College & Hospital radiographic information, as far as depth and proximity to critical anatomic landmarks such as the mandibular canal, maxillary sinus, and adjacent teeth. Computed tomography imaging, also Cline Road, Cooke Town, Bangalore - 560005 referred to as a computed axial tomography (CAT) scan, involves the use of rotating x-ray equipment, combined with a digital computer, to obtain images of the body. Using CT imaging, Address For Correspondence: cross sectional images of body organs and tissues can be produced. Other imaging techniques Dr. Neha vaidya are much more limited in the types of images they can provide. Cone Beam Computed Dept. of Prosthodontics tomography (CBCT) is a compact, faster and safer version of the regular CT. Through the use of a M R Ambedkar Dental College & Hospital Cline Road, Cooke Town, Bangalore - 560005 cone shaped X-Ray beam, the size of the scanner, radiation dosage and time needed for scanning E mail - [email protected] are all dramatically reduced. This review discuss in detail the principles of the Cone Beam th computed tomography and its applications in the field of implantology. Submission : 5 December 2011 Accepted : 4th April 2012 Key Words Computed Tomography, Cone Beam Computed Tomography, Imaging Techniques Quick Response Code

Introduction successful outcomes in dental implant There has been a rapid increase in the treatment and CT-based dental imaging, number of practitioners involved in coupled with surgical template guidance, implant placement, including specialists is unknown and awaits discovery through and general practioners with different large prospective clinical trials. levels of expertise. Although the However, using CT-based dental imaging significance of accurate planning and together with surgical template guidance Exploration of CBCT technologies for surgical guidance as it pertains to critical is becoming a reliable procedure based use in radiation therapy guidance began anatomic landmarks such as the on a series of recent preliminary clinical in 1992, followed by integration of the mandibular canal, maxillary sinus, and studies and case reports.1 - 4 The first CBCT imaging system into the adjacent teeth cannot be overstated when development of advanced imaging in gantry of a linear accelerator in 1999. The reviewing imaging modalities for the recent years is breathtaking. Dentistry, as first CBCT system became commercially preoperative assessment of the dental a whole, still needs some time to adapt to available for oro-maxillofacial imaging implant site, many conflicting variables this rapid development in imaging. With in 2001 (NewTom QR DVT 9000; need to be considered. The amount of the vastly improved diagnostic ability Quantitative Radiology, Verona, Italy. information provided, its accuracy, and from CBCT, the treatment outcome Commercially available CBCT systems its applicability need to be weighed becomes highly predictable. The quality for oro-maxillofacial imaging include the against cost, convenience, availability, of all dental patient care will be enhanced CB MercuRay and CB Throne (Hitachi radiation dose, and expertise required to by it. One thing is sure: the change has Medical, Kashiwi-shi, Chiba-ken, produce and read the output of each just begun. Japan), 3D Accuitomo products (J. modality. Currently there are a number of Morita Manufacturing, Kyoto, Japan), software systems that analyze History and iCAT (Xoran Technologies, Ann computerized tomography (CT) scans to CBCT was first adapted for potential Arbor, Mich; and Imaging Sciences aid in planning surgery and produce the clinical use in 1982 at the Mayo Clinic International, Hatfield, Pa). (Fig 1) physical surgical drilling template Biodynamics Research Laboratory5 . Similar systems designed for point-of- guides. These templates are computer Initial interest focused primarily on service head and neck imaging have also manufactured in such a way that they applications in angiography in which recently become available (MiniCAT, identically match the location, trajectory, soft-tissue resolution could be sacrificed Xoran Technologies; 3D Accuitomo and and depth of the planned implant. As the in favor of high temporal and spatial- 3D Accuitomo 170, J Morita dental practitioner places the implants, resolving capabilities. Since that time, Manufacturing; ILUMA Cone Beam CT, the templates stabilize the drilling by several CBCT systems have been IMTEC, Ardmore, Okla and GE restricting the degrees of freedom of the developed for use both in the Healthcare, Chalfont St. Giles, UK). The drill trajectory and depth. The interventional suite and for general principle of CBCT is based on a fixed x- quantitative relationship between applications in CT angiography.6,7 ray source and detector with a rotating

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 073 structures and the mandible.10-13 A relatively low patient dose for dedicated maxillofacial scans is a potentially attractive feature of CBCT imaging. An effective dose in the broad range of 13-498 µSv can be expected, with most scans falling between 30 and 80 µSv, depending on exposure parameters. In comparison, CT with similar parameters delivers 860 µSv.14,15 Image quality can vary considerably with dose; images acquired with higher radiation exposure often produce superior image quality.

CBCT Benefits & Applications ?Evaluation of the jaw bones to assess the position of the nerves in the lower jaw, and the sinuses and nose in the upper jaw.(Fig 3) ?Evaluation of the bone for implant placement. (Fig 4) Figure 1: Some currently available CBCT scan devices: New Tom 9000 Volumetric Imaging Device and J. Morita's 3D Accuitomo cone-beam CT ?Evaluation of abnormalities (pathology) in or affecting the bones (Fig 5) ?Evaluation of the hard tissue (bones) of the tempro-mandibular joint (Fig 6) ?Evaluate extent of alveolar ridge resorption ?Assessment of relevant structures prior to orthodontic treatment such as the presence and position of impacted canine and third molar teeth ?Assessing symmetry of the face (cephalometrics) (Fig 7) ?Assessing the airway space (sleep apnea) ?To permit 3D reconstructions of the bones or the fabrication of a Biomodel of the face and jaws ?Assessing the mandibular nerve prior to the removal of impacted teeth, especially the lower wisdom teeth

CBCT Versus Dental X-ray

Figure2. In cone beam computed tomography, a cone-shaped x-ray beam irradiates a patient's jaw. The transmitted x- Cone beam images provide undistorted rays are detected by a sensor. The data is then sent to a computer and reconstructed into 3-D images by software. or accurate dimensional views of the jaws. Panoramic images, by contrast, are gantry.(Fig 2) been outsourced to medical CT scanners has begun to take place in dental offices. Oro-Maxillofacial Imaging Early dedicated CBCT scanners for Advanced cross-sectional imaging dental use were characterized by Mozzo techniques such as CT are used in Oro- et al8 and Arai et al9 in the late 1990s. maxillofacial imaging to solve complex Since then, more commercial models diagnostic and treatment-planning have become available, inciting research problems, such as those encountered in in many fields of dentistry and oral and craniofacial fractures, endosseous maxillofacial surgery. To date, multiple dental-implant planning, and ex vivo studies have attempted to orthodontics, among others. With the establish the ability of CBCT images to Figure 3: Visualization of the intimate relation of the advent of CBCT technology, cross- accurately reproduce the geometric mandibular canal and an impacted wisdom tooth, imaged sectional imaging that had previously dimensions of the maxillofacial with the Scanora 3D.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 074 coronal, sagittal, and panoramic views, a ?The lower cost of the machine may be panoramic film provides an image of passed on to the patient in the form of only one dimension, namely a mesio- lower fees distal or antero-posterior perspective. ?Both jaws can be imaged at the same Further, in a panoramic image all the time (depending on the specific cone structures between the x-ray tube and the beam machine) image detector are superimposed on one ?Radiation dose is considerably less another. With CT it is possible to separate than with a medical CT. out the various structures, for example, the left condyle from the right one. Imaging Modalities In Dental Implant Figure 4: Tomographic cone-beam computed tomographic Placement images analyzed with iCAT software CBCT Compared to Tomography Implantologists have long appreciated Unlike panoramic radiography, plain- the value of 3- dimensional imaging. film tomography, if performed with the Conventional CT scans are used to assess appropriate equipment, does not result in the osseous dimensions, bone density, distortion. Like panoramic radiography, and alveolar height, especially when however, it does result in magnification, multiple implants are planned. Locating the degree of which differs from landmarks and anatomy such as the manufacturer to manufacturer. Plain-film inferior alveolar canal, maxillary sinus, tomography provides direct (as opposed and mental foramen occurs more to reconstructed) cross-sectional, sagittal accurately with a CT scan. The use of the and coronal views. The disadvantage of third dimension has improved the clinical plain-film tomography is that it requires success of implants and their associated much more chair time than CT. It can thus prostheses, and led to more accurate and be especially difficult to do on patients aesthetic outcomes.16,17 With CBCT Figure 5: Folicular dentigerous cyst in the right mandible who are unable to sit or hold still for a technology both the cost and effective associated with an impacted tooth, imaged with the period of time. Cone beam CT, on the radiation dose can be reduced. CBCT has Scanora 3D other hand, can be performed within a 10- been in use in implant therapy and may be 40 second range, depending on the region employed in orthodontics for the clinical being imaged and on the desired quality assessment of bone graft quality of the image. Cone beam CT also following alveolar surgery in patients provides stronger indication of bone with cleft lip and palate. The images quality. produced provide more precise evaluation of the alveolus. This CBCT Versus CT technology can help the clinician ?Cost of equipment is approximately determine if the patient should be 3-5 times less than traditional restored or if teeth should be moved Figure 6: Patient with flattening in the temporomandibular Medical CT joint, imaged with the NewTom 3G. orthodontically into the repaired ?The equipment is substantially lighter alveolus. Anatomic structures such as the and smaller. inferior alveolar nerve, maxillary sinus, ?Cone beam CTs have better spatial mental foramen, and adjacent roots are resolution (i.e. smaller pixels) easily visible using CBCT . The CBCT ?No special electrical requirements image also allows for precise needed measurement of distance, area, and ?No floor strengthening required volume. Using these features, clinicians ?The room does not need to be cooled can feel confident in the treatment ?Very easy to operate and to maintain; planning for sinus lifts, ridge little technician training is required augmentations, extractions, and implant ?Some cone beam manufacturers and placements. vendors are dedicated to the dental Before implant placement and during Figure 7: A patient with deviation in the face in the right side, imaged with the NewTom market. This makes for a greater treatment planning, the implant clinician appreciation of the dentist 's needs must be able to measure the height and both magnified and distorted. ?In the majority of cone beam CTs the width of the alveolar process to ensure Magnification by itself is not a problem, patient is seated, as compared with adequate bone and to select appropriately as long as one knows or can calculate the lying down in a medical CT unit. sized implants. In addition, the clinician magnification factor. Distortion, on the This, together with the open design of must know the precise location of the other hand, is the unequal magnification the cone beam CTs virtually mandibular canal (injury to the of different parts of the same image. Due eliminates claustrophobia and greatly neurovascular bundle within the canal to distortion panoramic images are enhances patient comfort and can result in facial paresthesia) and the notoriously unreliable to use for making acceptance. The upright position is maxillary sinuses (perforation of the measurements.16 also thought by many to provide a sinuses creates the possibility of antral In addition, while CT images can provide more realistic picture of condylar infections and increases the likelihood of cross-sectional (bucco-lingual), axial, positions during a TMJ examination implant failure). Multiple views of the

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 075 proposed implant site should be taken, tissues. Research on this technology is imaging. This technology is not without which often require the use of different still preliminary, without prospective controversy, and further research is imaging procedures. Various studies that convincingly demonstrate its required to establish informed radiographic modalities are available to benefit compared with conventional CT. recommendations about its appropriate the clinician, including intraoral films Both in medical and oral and use in a clinical setting. (i.e., periapical and occlusal maxillofacial imaging in dentistry, radiographs), panoramic radiographs, CBCT has been largely adopted as an References cephalometric radiographs, plain office-based service. This is a usage 1. Siessegger M, Schneider BT, (conventional) tomography, computed model purported to expedite patient Mischkowski RA, et al. Use of an tomography (CT), cone beam CT, digital diagnosis and treatment while image-guided navigation system in subtraction radiography, and magnetic simultaneously reducing costs, providing dental implant surgery in resonance imaging. one-step management with fewer billed anatomically complex operation Cross-sectional imaging techniques can visits and no radiologist consultation sites. J Craniomaxillofac Surg. be an invaluable tool during preoperative fees. Point-of-service imaging and other 2001;29:276-281. planning for complicated endosseous self-referral services, however, have 2. Fortin T, Champleboux G, Bianchi S, dental implantation procedures.1 9 been widely criticized for encouraging Buatois H, Coudert JL. Precision of Conventional linear tomography and CT overuse and directly inflating medical transfer of preoperative planning for have traditionally been used in costs. The belief that financial incentives oral implants based on cone-beam presurgical imaging, though the former undermine the clinical decision-making CT-scan images through a robotic has overlain ghosting artifacts and the process has been the basis for it's drilling machine. Clin Oral Implants latter has relatively high radiation criticism. The advent of CBCT Res. 2002;13: 651-656. exposure and cost.20 technologies has also fueled the 3. Tardieu PB, Vrielinck L, Escolano E. Practitioners have begun using office- controversy surrounding office-based Computer-assisted implant based CBCT scanners in preoperative imaging, which is usually performed and placement, a case report: treatment of imaging for implant procedures, interpreted by non-radiologists often the mandible. Int J Oral Maxillofac capitalizing on availability and low without the accreditation, training, or Implants. 2003;18: 599-604. dosing requirements. licensure afforded by the radiology 4. Vrielinck L, Politis C, Schepers S, community. Pauwels M, Naert I. Image-based Limitations of CBCT Imaging planning and clinical validation of While there has been enormous interest, Conclusions zygoma and pterygoid implant current CBCT technology has limitations Outcomes assessment in this area of placement in patients with severe related to the "cone beam" projection dentistry is difficult, primarily due to bias bone atrophy using customized drill geometry, detector sensitivity and and variability in clinical research. guides: preliminary results from a contrast resolution. These parameters Observed differences can be due to prospective clinical followup study. create an inherent image "noise" that differences among investigators and/or Int J Oral Maxillofac Surg. 2003; reduces image clarity such that current interest groups rather than differences in 32:7-14. systems are unable to record soft tissue the treatments. Furthermore, once cost- 5. Robb RA. The dynamic spatial contrast at the relatively low dosages to-benefit analyses are conducted, the reconstructor: an x-ray video- applied for maxillofacial imaging. increase in cost associated with CT-based fluoroscopic CT scanner for dynamic Another factor that impairs CBCT image implant planning and computer volume imaging of moving organs. quality is image artifact such as streaking, fabrication of surgical templates must be IEEE Trans Med Imaging 1982;1:22- shading, rings and distortion. Streaking justified from a consumer perspective 33 and shading artifacts due to high areas of (i.e., the value associated with the 6. Fahrig R, Fox AJ, Lownie S, et al. Use attenuation (such as metallic increased safety and predictability of of a C-arm system to generate true restorations) and inherent spatial dental implants). It helps the clinician to three-dimensional computed resolution may limit adequate safely and predictably transfer the rotational angiograms: preliminary in visualization of structures in the dento- optimal-implant trajectory and distances vitro and in vivo results. AJNR Am J alveolar region. from the adjacent tooth and mandibular Neuroradiol 1997;18:1507-14 nerve to the patient's mouth. The final 7. Saint-Fe´lix D, Trousset Y, Picard C, Controversies restoration becomes functional and et al. In vivo evaluation of a new As with any emerging imaging esthetic. It does not compromise adjacent system for 3D computerized technology, use of CBCT scanners has teeth or anatomic structures, yet was well angiography. Phys Med Biol been the subject of criticism as well as accepted by the patient. CBCT is an 1994;39:583-95 acclaim21 . The technology itself is limited emerging CT technology, which has 8. Mozzo P, Procacci C, Tacconi A, et by lack of user experience and what is potential applications for imaging of al.Anew volumetric CT machine for currently a relatively small body of high-contrast structures in the head and dentalimaging based on the cone- related literature. The point-of-service neck as well as maxillofacial regions. beam technique: preliminary results. operational model that dominates Preliminary research suggests that high- Eur Radiol 1998;8:1558-64 diagnostic head and neck CBCT imaging spatial-resolution images can be obtained 9. Arai Y, Tammisalo E, Iwai K, et al. practices has also drawn criticism. with comparatively low patient dose. To Development of a compact computed Because of the low radiation dose, CBCT date, the most researched applications for tomographic apparatus for dental use. can only provide bony detail and is head and neck CBCT are in sinus, middle Dentomaxillofac Radiol unable to provide images of the soft and inner ear implant, and maxillofacial 1999;28:245-48

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 076 10. Lascala CA, Panella J, Marques MM. 14. L u d l o w J B , I v a n o v i c M . tomography- based dental imaging Analysis of the accuracy of linear Comparative dosimetry of dental for implant planning and surgical measurements obtained by cone CBCT devices and 64-slice CT for guidance, Part 1: Single implant in the beam computed tomography (CBCT- oral and maxillofacial radiology. Oral mandibular molar region. J Oral NewTom). Dentomaxillofac Radiol Surg Oral Med Oral Pathol Oral Implantol. 2006;32:77-81. 2004;33:291-94 Radiol Endod 2008;106:106 -14. 19. Tyndall DA, Brooks SL. Selection 11. Mischkowski RA, Pulsfort R, Ritter Epub 2008 May 27 criteria for dental implant site L, et al. Geometric accuracy of a 15. Schulze D, Heiland M, Thurmann H, imaging: a position paper of the newlydeveloped cone-beam device et al. Radiation exposure during American Academy of Oral and for maxillofacial imaging. Oral Surg midfacial imaging using 4- and 16- Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol slice computed tomography, cone Oral Med Oral Pathol Oral Radiol Endod 2007;104:551-59. Epub 2007 beam computed tomography systems Endod 2000;89:630-37 Jul 5 and conventional radiography. 20. Lofthag-Hansen S, Gro¨ndahl K, 12. Lagrave`re MO, Carey J, Toogood Dentomaxillofac Radiol 2004;33:83- Ekestubbe A. Cone-beam CT for RW, et al. Three-dimensional 86 preoperative implant planning in the accuracy ofmeasurements made with 16. Serman NJ. Pitfalls of panoramic posterior mandible: visibility of software on cone-beam computed radiology in implant surgery. Ann anatomic landmarks. Clin Implant tomography images. Am J Orthod Dent 1989;48:13-16. Dent Relat Res 2008 Sep 9. Dentofacial Orthop 2008;134:112-16 17. Hatcher DC, Dial C, Mayorga C. 21.A.C. Miracle, S.K. Mukherji, 13. Kumar V, Ludlow JB, Mol A, et al. Cone beam CT for pre-surgical Conebeam CT of the Head and Neck, Comparison of conventional and assessment of implant sites. J Calif Part 2:Clinical Applications, Aug cone beam CT synthesized Dent Assoc.2003;31:825-833. 2009Am J Neuroradiol 30:1285-92 cephalograms. Dentomaxillofac 18. Almog DM, LaMar J, LaMar FR, et Radiol 2007;36:263-69 al. Cone beam computerized

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

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 077 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Mcinnes Solution - A Phoenix Solution In 1 Nidhi Aggarwal 2 Ravi Kapur Dentistry - The Case Series 3 Seema Nayyar 4 Jyotika Jain Abstract 5 Angelique This survey presents clinical cases in which vital bleaching modality with McInnes Solution have been used to successfully treat discolored teeth. 1 Reader 2 Principal History: Patients came to Department of Conservative Dentistry and Endodontics with discolored 3 vital teeth demanding appreciable esthetic outcome and prime importance was given to the Professor 4 PG Final Year Student conservation of the tooth structure. 5 PG Final Year Student Findings: Mild to moderate stains present on teeth. MM College of Research and Dental Sciences Treatment Plan: 25 patients were selected with mild to moderate enamel fluorosis. Freshly MM University (Mullana-Ambala) prepared McInnes solution was used on the upper and lower anteriors for acquiring esthetic Address For Correspondence: change in the shade of the teeth. Pre and post-operative pictures were taken. After completion of Dr. Nidhi Aggarwal the treatment, each patient was given a separate performa with 8 factors to be assessed with Aggarwal Orthopaedic Centre, scores and a grading system to evaluate the bleaching procedure with McInnes solution. Agarsen Chownk, Jagadhri Yamunagar (Haryana) Outcome: The grading criteria on an average with all cases show excellent results. The success of Ph: +91-9416025150 this study explored the successful usage of McInnes solution alone in day to day clinical practice Submission : 15th December 2011 which emerges hereby as a phoenix solution in today's dental practice which had been completely Accepted : 14th April 2012 forgotten with latest tooth whitening modalities. Key Words Quick Response Code Smile, Esthetics, Cosmetic, Bleaching

Introduction dentistry has generated more interest in “You can only hold a smile for so long, bleaching as patients are asking for after that it's just teeth.” - Chuck whiter and more beautiful teeth and do Palahniuk. Smiles are instinctive, a not want their teeth to be cut down. It is a universal sign of friendliness. Smile is a conservative method of treating dentition major expression of emotions like discolored by ingested substances, to achieve appreciable aesthetics. happiness, love and excitement. fluorosis, or other causes .There have Esthetics: Appreciative of, responsive to, been tremendous advancements in or zealous about the beautiful; having a bleaching materials and techniques to sense of beauty or fine culture.It can provide more natural and life-like enhance personal and professional solutions to aesthetic issues with relationships and inspire others in many discolored teeth either intrinsic or ways. Yet too often, our teeth deny us the extrinsic. My study is for the use of Mc benefits of a beautiful smile. They ruin Innes solution in clinical practice which What is McInnes Solution? (Figure 1) the looks through discoloration. It's a is completely forgotten in spite of that it 5 Parts 35% hydrogen peroxide- physical handicap and put a badimpact conserves the tooth structure as bleaches the enamel upon person's self-image, self- compared to other modalities. It is one of 5 Parts 30% hydrochloric acid-etches confidence and physical attraction.Our the most documented clinical techniques the enamel society tends to dislike yellowing of teeth in dentistry and yet for reasons unknown, 1 Part diethyl ether- removes the facial that comes with age or the various it has escaped the acceptance that it debris intrinsic stains that occur deserves in day to day clinical developmentally.The color of the teeth is practice.The successful outcome of this This case series surveyed the various in?uenced by a combination of their solution mainly depends on the patient- aspects of McInnes solution emphasizing intrinsic color and the presence of any related factors: the patient's needs, age, on advantages of this solution in today's extrinsic stains that may form on the expectations and affordability. The domain of dental bleaching. tooth surface.The desire to have white clinician-related factors include the teeth and thus a more pleasant smile has availability of bleaching materials and a Complete Care - Assessment & become an important esthetic need of thorough knowledge of the material Diagnosis patients today .Cosmetic or aesthetic science, including methodologies and Before bleaching procedure, it should dentistry can help us to achieve whatever techniques involved.A step-wise follow a comprehensive examination, it is we see in the mirror of our mind's approach to treatment is promoted to record taking, diagnosis and custom eye.The current trend toward cosmetic encourage the most conservative solution treatment plan. Once it has been

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 078 Table I Assessment Performa After Bleaching With McInnes Solution Inclusion Criteria Exclusion Criteria Name Of The Patient: Place of Birth / Residence: Absence of Restorations on anterior teeth Previous bleeching treatment Age: Sex: Absence of tooth sensitivity - stimulated sensitivity using air syringe Tooth sensitivity or history of treatment of tooth sensitivity Occupation: Chief Complaint: Patients between 21-28 years of age Patients with periodontal diseases Factors Assessed: College students - for an easy follow up Tetracycline stains

Smokers Factors Variables Grading Patient

Patients unable to attend the follow up appointments Assessed Grading

Pregnant women 1. Esthetics Excellent 1 determined what the patients want and to the patients to assess the immediate Enhanced Satisfactory 2 what exact conditions are, they can be results. Non Satisfactory 3 given choices for cosmetic care that meet theirdesires in a personalized way. Case 1 2. Comfort Very - Comfortable 1 During Comfortable 2 Case Reports Chief Complaint:Patients reported to Treatment Uncomfortable 3 the Department of Conservative 3. Chair side Short Duration 1 Dentistry and Endodontics with: 1. Discolored anterior teeth demanding time per Average Duration 2

appreciable esthetic outcome. patient Long Duration 3 2. Prime importance was given to the PRE-OPERATIVE POST-OPERATIVE conservation of tooth structure. Case 2 4. Postoperative Absent 1

Sensitivity Mild-Moderate 2 Case Selection:With the inclusion and exclusion criteria (Table 1), after taking Severe 3 the informed consent, 25 patients 5. Duration of Immediate 1 selected with mild to moderate enamel fluorosis according to Dean's Fluorosis Treatment 2 Visits 2 Index. >2 Visits 3 PRE-OPERATIVE POST-OPERATIVE Treatment Protocol: 6. Cost Affordable 1 Patients informed about the diagnosis, Case 3 the approximate treatment time and Effectiveness Expensive 2 number of sittings.Pre -operative pictures Very Expensive 3 were taken. Oral prophylaxis done judiciously with pumice paste to remove 7. Latrogenic None 1 the surface stains. Coating ofbuccal and Complications (Lips, Slight 2 palatal gingiva, lips and mucosa was done with ora-base. Application of Gingival, Mucosal Burns) Moderate-Severe 3 rubber dam was done. (Figure 2) PRE-OPERATIVE POST-OPERATIVE 8. Reversible No Reversal 1 After completion of the treatment:Each patient was given a separate performa Discoloration Slight Reversal 2 (Table 3) with 8 factors to be assessed after 6 Months Reappearance 3 with scores 1/2/3 + A self -analytic grading system (table 4) to evaluate the Grading System: Scoring (Table 4) bleaching procedure with McInnes solution. 1-8 Excellent Table 3 9-16 Appreciable Grading System: Scoring (Table 4) Results/Outcome:The grading criteria 17-24 Worse Figure 2 on an average with all cases show Isolated teeth were rubbed with freshly APPRECIABLE RESULTS. (9 - 16 Although a wide arena of esthetic prepared McInnes solution for 5 minutes Scoring). restorative materials are available to us at 1 minute intervals each. Then it was Discussion:The record made out from today for the management of discolored copiously irrigated with normal saline. patient's analytical score system anterior teeth, bleaching with Mc Innes Rubber dam was removed. Polishing was perfectly gives a picture that McInnes Solution still remains a viable done with polishing paste. Post - solution can be well accepted for clinical option.Definitely bleaching with operative pictures were taken and shown day to day practice as bleaching solution. McInnes solution is simple, inexpensive,

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 079 provides the advantage of continuing the safety of the bleaching technique must treatment or terminating the bleaching evaluate not only the product, but also the process at any time. It is a fast process delivery method and treatment time. that the results are evident even after a The success of my study explored the single visit. Many patients prefer successful usage of McInnes solution bleaching by the dental professional alone in day to day clinical practice because it requires less active which emerges hereby as a phoenix The factors assessed can be summarized as: participation on their part. solution in today's dental practice which The role of McInnes solution as a had been completely forgotten with latest gives instant results, not dependent on bleaching agent is fully justified. But tooth whitening modalities. patient's compliance as other office based with the increasing esthetic demand, procedures, no heat is required to activate patient demands for enhanced esthetic References the bleaching solution, no dehydration of procedures like composite veneering, 1. I A Pretty, R P Ellwood, P A Brunton, the tooth occurs with no damage to the laminates, crowns etc. A Aminian. Vital tooth bleaching in pulp. Bleaching with McInnes solution is bit dental practice: 1. Professional The solution also allows individuals with technique sensitive, as it is a chemical, bleaching. Dent Update 2006; normal range dentition to whiten their acidic in nature. So, precision on a part of 33:288-304 teeth to meet cosmetic demands. dentist is important.Some patients report 2. Watts A, Addy M. Tooth Bleaching with this solution a metallic taste sensation immediately discolouration and staining: A review isesthetically pleasing and minimally after bleaching; however, this normally of literature BDJ 2001, 190 (6): 309- invasive option for young patients rather disappears after few hours. Tooth 316 than a complete coronal coverage. It can sensitivity, if this has occurred, the 3. Garber and Goldstein - Complete be successfully carried out at various patient should be reassured that this is a dental bleaching 1995; 5th Edition; times. The successful outcome depends common side effect and will disappear Quintessence Publications mainly on the etiology, correct diagnosis after bleaching. Patients should be 4. Tam L. Vital tooth bleaching review and proper selection of bleaching reassured that the side effects are minor and current status. JCDA 1992; 58(8): technique. It requires less chair-time, and transient and will disappear after the 654-63 safe, more comfortable for the completion of treatment. 5. Goldstein C.E., Garber D.A. patients;impart tremendous patient Bleaching of vital teeth: state of art. satisfaction as the results are immediate. Conclusion Quintessence Publications 20 (10): The solution is useful for the removal of Bleaching techniques that have been 729-737, 1989 stains throughout the arch or even shown to be relatively and reasonably 6. Arens D. Role of bleaching in treating specific areas of a single tooth safe and effective, both in current usage aesthetics, DCNA 33(2): 319-336, (such as in some types of fluorosis). The and over time should be accepted as a 1989 dentist is in complete control of the reasonable treatment option,knowing the process throughout treatment. This risks and benefits. Effectiveness and

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 080 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Restoration Of Post-surgical 1 Gursharan Singh 2 Nishtha Madan Hemimaxillectomy Defect With The Help Of A 1,2 Reader Deptt of Prosthodontics Hollow Bulb Obturator. Bhojia Dental College & Hospital, Baddi Teh: Nalagarh, Distt. Solan HP Abstract Address For Correspondence: Restoration of maxillary defects with the help of obturatorsrestores mastication, speech, Dr. Gursharan Singh, deglutition, facial contours and dental appearance. To achieve the above, comprehensive Reader, Dept of Prosthodontics treatment planning and application of sound physiological design principles for Removable Partial Bhojia Dental College & Hospital, Budh (Baddi) - 173205, Teh Nalagarh, HP Dentures are essential. Tel (M) - 09872628508 The failures in this area can be due to the lack of acceptance by the patient or inefficiency of E-mail:[email protected] prosthesis itself. The rehabilitation of acquired maxillary defects should be aimed at reducing th such failures by careful treatment planning and designing of the prosthesis. Present case report Submission : 14 November 2011 describes measures undertaken during treatment ofa post-surgical hemimaxillectomy defect with Accepted : 18th March 2012 the help of a hollow bulb obturator. Quick Response Code Key Words Hollow bulb obturator, acquired maxillary defect, hemimaxillectomy

Introduction Patients also experience seepage of nasal A large number of patients with secretions into the oral cavity, poor lip surgically resected maxillas report to seal, xerostomia, exophthalmos and Department of Prosthodontics of various diplopia. Acceptance of the new A 36 years old male patient reported to Hospitals for prosthodontic prosthesis is always a slow and difficult the Department of Prosthodontics, rehabilitation. Such rehabilitation is process. Patient education plays an Bhojia Dental College and often a challenging experience for both important role in the rehabilitation Hospital,Baddi with chief complaint of a the operator as well as the patient. The process. large gap due to missing teeth and a role of both prosthodontists and surgeons portion of the upper jaw bone on the right has been clearly established. Post- Aramany proposed a defect classification side [Fig 1]. His medical history revealed surgical experience of the patient is system that presents differences of that hemi-maxillectomy was performed 2 physically challenging mechanics in 6 classes that are years back due to a growth in the andpsychologically demoralizing recognized for prosthetic design of an maxillary sinus. .1 Maxillary jaw resection often leads to obturator framework for partially impairment in appearance, mastication, edentulous cases.3,4 A definitive obturator Facial asymmetry due to collapsed right speech, deglutition and self-image, has two components, a metallic maxillary region was seen during extra impacting the quality of life of patients so framework and an acrylic resin obturator oral examination.Intraoral examination afflicted. Speech of such patients is bulb. unintelligible.2 The metallic framework stabilizes Main objective of prosthetic obturation is anticipated cantilever forces along closure of the maxillary defect and fulcrum line whereas the remaining teeth separation of the oral cavity from sino- and the palate provide stability to the nasal cavities. In addition obturator prosthesis during mastication and restores function and esthetics, preserves speech.5,6 The intimate contact of the the associated structures and contribute obturator bulb with soft tissues lining the to the patient's perception of improved defect not only stabilizes the prosthesis quality of life. A successful prosthetic but also minimizes nasal leakage and design to enable prosthesis function hyper-nasal speech. properly utilizes remaining palate and dentition to maximize retention, support and stability of the obturator. Case Report Figure 1 : Intra Oral View Of The Defect

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 081 obtained was picked up in the stock tray using putty polyvinyl siloxane impression material.

The master cast was obtained from the above impression of the maxillary arch. [Figure 6].

The arbitrary block out of master cast was done and 2 mm thickness of wax build up done to provide adequate thickness of Figure 2 : Inside View of Hollow Obturator Figure 6 : Post Insersion View of The Patient heat cure acrylic resin for strength of the obturator and for construction of hollow bulb obturator portion [Fig 2]. revealed the loss of the alveolar ridge with teeth, hard and soft palate, anterior The hollow obturator was fabricated in wall of maxillary sinus and considerable heat cure acrylic resin comprising main portion of the nasal septum. The defect body and lid, which were joined later on was classified underAramany class II, as with self-polymerizing acrylic resin. the dentition and the alveolar bone were removed along the midline. The The master cast was then duplicated and individual had been wearing an ill-fitting refractory cast was obtained on which acrylic obturator for the past 1 year. wax-up for metal framework was done. Lower jaw and dentition was intact. The pattern was cast in cobalt - chrome The primary aim of the treatment was alloy. After finishing and polishing, a Figure 3 : Try in of Cast Metal Framework toseparate sino-nasal and oral cavities to metal try in of the framework was done aid in articulation, deglutition, [Fig 3 & 4]. restoration of mid facial contour and improvement of masticatory function. Wax bite block was fabricated on the It was decided to fabricatethe prosthesis metal meshwork portion ofthe denture in two phases. Firstly the construction of base framework overlying the defect the hollow bulb obturator followed by site[Fig 4]. removable cast partial denture providing support to it. A jaw relation record was made and casts mounted on asemi adjustable articulator for the teeth arrangement. Procedure After the try in, the denture was Impressions of the upper and lower jaws processed in heat cure acrylic were made with irreversible hydrocolloid resin[Figure 5]. impression material in stock tray after blocking out the undercuts in the defect The hollow bulb obturator shell and the area with petrolatum-laden gauze pieces. denture were joined using auto Figure 5 : Palatal View of Obturator Diagnostic casts were obtained. polymerizing acrylic resin. Maxillary diagnostic cast was surveyed Obturator prosthesis was placed inside and necessary block out was carried the mouth. Patient's speech showed out.The defect was outlined and special immediate remarkable improvement. tray was fabricated on the diagnostic cast using auto polymerizing acrylic resin. The post insertion follow up and the Rest seats were prepared on theteeth 24, patient care were carried out at the 25 and 26. [Fig 2 & 4] prescribed intervals of time. Patient was extremely comfortable with the prosthesis when review examination The defect was border molded to record was carried out. [Figure 6] the functional anatomy of buccal and labial tissues surrounding the defect. To make the final impression, gross extent of the defect was recorded using putty Discussion material and light body addition Comprehensive treatment planning is polyvinyl siloxane impression material. necessary to meet objectives for patients with complex rehabilitative needs, hence it is necessary to facilitate and coordinate Figure 4 : Cast Frame Ready for Jaw Relation Record The impression of the defect thus treatment planning among surgeons and

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 082 prosthodontists. designed to reduce the stresses intelligibility following transmitted to the abutment teeth while prosthodontics obturation of A range of options is available to the retaining the obturator in place. The bulb surgically acquired maxillary defect. surgeons and prosthodontists for portion was made hollow so as to J Prosthet Dent 1979;32:87-96. palatomaxillary reconstruction as well as minimize the weight of the obturator. 3. Aramany MA. Basic principles of prosthodontic rehabilitation. This improved cantilever mechanism of obturator design for partially suspension and avoided stresses on the edentulous patients. Part A maxillectomy defect in a vertical supporting structures.8 The closed hollow 1:classification. J Prosthet Dent orientation has a more profound effect on obturator prosthesis can prevent fluid and 1978;40:554-7. prosthetic stability. food collection, reduce air space and 4. Aramany MA. Basic principles of allow for maximum extension.9 The obturator design for partially The most important factor for the buccal wall of the nasal extension was edentulous patients. Part II: design stabilization of obturator prosthesis is extended superiorly to help resist principles. J Prosthet Dent favourable distribution of force during rotational forces on the abutment teeth. 1978;40:656-62. mastication and function. The Increasing the height of lateral wall of 5. Brown KE. Peripheral consideration engagement of structures within the obturator above the scar band created a in improving obturator retention. J defect diminishes the counterproductive longer lever arm from the point of ProsthetDent1968; 20:176-81 lever forces placed on the rotation leading to less vertical 6. Schwartzman B,Caputo A, Beumer J. obturatorleading to better support, displacement. Obturator stability was Occlusal force transfer by removable stability and retention of the prosthesis, enhanced by maximum extension in all partial denture designs for a radical and thus increasing its success.7 directions.10 maxillectomy. J Prosthet Dent 1985;54:397- 403. The obturator planned for the patient 7. Devin JO, Daniel B, Mark U. consisted of two components; a metallic Summary Prosthodontic guidelines for surgical framework and an acrylic resin obturator Fabrication of a functional maxillofacial reconstruction of the maxilla: A bulb. prosthesis requires full application of the classification system of defects. J clinician's knowledge and experience Prosthet Dent 2001;86:352-63. The framework was designed by based on the sound knowledge of 8. Ronald P.DesJardius. Obturator selecting the most suitable components to principles of RPD design along-with a prosthesis design for acquired resist the various forces acting on the specific treatment plan.The technique maxillectomy defects. Prosthet Dent prosthesis without applying undue stress presented allows application of sound 1978;39:424 - 35 on the remaining teeth and soft tissue prosthodontic principles and judicious 9. Barry HH, Carl FD. Fabrication of a structures. The important considerations design providing effective restoration of closed hollow obturator. J Prosthet in designing of the framework were the function and esthetics in a case involving Dent 2004;91:383-5. size and the location of the defect as they post-surgicalmaxillectomy defect and its 10. Brown KE. Clinical considerations in relate to the remaining palate and rehabilitation with a hollow obturator. improving obturatortreatment dentition. Maximum support was .Prosthet Dent 1970; 24 : 461-6 planned through utilization of full palatal coverage. Preservation of teeth or part of References the residual ridge across the midline 1. Didier M. New surgical obturator greatly improved obturator stability. prosthesis for hemi maxillectomy Tissue ward movement was resisted by patients. J Prosthet Dent placement of multiple occlusal rests. 1993;69:520-3. Retainers and bracing components were 2. Majid AA. Weinberg B. Speech

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 083 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Radiographic And Surgical Guide Fabrication 1 Satpreet Singh Bhasin 2 Monika Makkar For An Implant Retained Mandibular Over 3 Neeta Pasricha 4 Venus Sidana Denture 1 Senior Lecturer 2,4 Professor 3 Abstract Professor & Head Deptt. of Prosthodontics, This case report describesthe use of patient's complete denture prosthesis as radiographicguide National Dental College, after incorporation of radio opaquemedium to optimize information from computed tomography Dera Bassi. Punjab scans for implant placement. This article also provides a step by step procedure for duplicating complete dentureprosthesis to be used as surgical stentfor mandibular implant supported over Address For Correspondence: denture. Dr. Satpreet Singh Bhasin, Senior lecturer Key Words Deptt. of Prosthodontics, National Dental College, stent,implantology, hydrocolloid Dera Bassi. Punjab Email ID : [email protected] Submission : 27th August 2011 Introduction Surgical stent provides communication Accepted : 14th April 2012 Successful implant treatment is directly between the surgeon and restoring Quick Response Code related to achieving integration and dentist, so that the implant is placed at the restoring hard and soft supporting ideal position and angulations The structures for esthetics and function [1] .Itis purpose of stent is to preview the necessary for the clinician to visualize the definitive restoration and its relationship final prosthetic result before implant to adjacent structures, to communicate placement and to have thorough the restoration planned by the understanding of the surgical and Prosthodontist to the surgeon, to reduce prosthodontic phases of treatment to osteotomy and to locate healing screws at [2] [3] achieve a predictable outcome .This the time of second stage surgery . conventional complete dentures for desire of predictable results led to maxilla and an implant retained development of prosthetically guided This article features a method of using overdenture for mandibular arch. implantology. Despite significant existing mandibular complete prosthesis advances in devices and techniques, as radiographic stent and a duplicated For diagnostic preoperative evaluation, placing dental implants in a correct denture as a surgical template. patient existing denture was used as position still remains a challenge. Advantages of the technique are twofold: aradiographic guide. The desired implant Diagnostic casts, probing depths and it is cost effectiveand makes use of locations were marked on existing panoramic radiography can lead to equipment and materials commonly denture at five positions.In the transverse unpredictable results as they do not give found in dental clinics. plane, it corresponds to the interproximal three-dimensional (3-D) radiographic area between the mandibular central information required for correct Case Report [1] incisors,between canine and first positioning and orientation of implant . A 54 year old male patient reported to premolar and as well as fifth site being in Moreover, implant supported prosthesis Department of Prosthodontics with requires determination of final prosthesis complaint of loose mandibular during treatment planning stage. Thus for denture.Clinical and radiographic a successful implant supported prosthesis examination revealed adequate maxillary the Prosthodontist should plan the bone height and anteriormandibular implant position in accordance with ridge resorption. Evaluation of existing accurate mesiodistal and buccolingual dentures revealed adequate extensions location, angulation with residual bone with fair amount of retention and stability and correct implant orientation. To along with satisfactory position of achieve these objectives dental CT scan denture teeth. A treatment plan was imaging in conjunction with prepared after a standard protocol that radiographic guide (stent) with took into consideration patient's desires, radiopaque marker should be used. treatment alternatives and treatment Fig 1 : Gutta Percha Markers Placed At Proposed Implant costs. The plan included fabrication of Sites On The Existing Mandibular Denture

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 084 Fig 5 : Duplicated Denture While Retrieving From The Flask

Fig 2 : Denta Scan With Radiographic Markers

between the first two sites ,on both sides ( Figure 1). Gutta-percha cones were used as radio opaque markers to the mandibular denture to assess the anatomy of proposed implant sites in the denta scan. Denta scan was taken with complete denture acting as radiographic guide in patients mouth (Figure 2,3). After analyzing the denta scan, three implants in mandibular anterior region were planned for the present case.

For the fabrication of surgical guide template, the patient's mandibular Fig 6 : Duplicated Denture denture was duplicated in duplicating flask by using irreversible hydrocolloid (Figure4). The mandibular denture was stabilized by wax stopper corresponding to access holes in duplicating flask. Irreversible hydrocolloid was used to invest the denture in the flask.After the setting of hydrocolloid, the denture was taken out of the flask. Auto polymerizing acrylic resin was then poured through access holes in the mold and flask was then bench pressed. The mandibular denture wasretrieved from the flask after 30 minute (Figure5) and thereafter finishing and polishing was done ( Figure6,7). This duplicate denture was modified for surgery by creating window Fig 7 : Duplicated Denture like openings at the proposed implant sites to be used as surgical guide template

Fig 8 : Duplicated Denture As Surgical Guide Template Intraorally Fig 3 : Denta Scan With Radiographic Markers Fig 4 : Self Cure Resin Poured In Duplicating Flask

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 085 (Figure8). The interproximal positions satisfaction for the patients[5] . solve these problems.Using a template of gutta-percha were taken as the ,the accuracy of the proposed direction of reference positions. The foremost advantage of the stent used implant placement is as close to 5 in this case is its surgical ease, simplicity, degree[7] . Discussion precise accuracy and low cost. It can be The ability to restore an edentulous arch fabricated with minimum laboratory References with endosteal implants revolutionized procedures which are used in routine 1. Edward M. Armet. Implant treatment dentistry. This resulted in a paradigm dental practice. On the other hand, the planning using patient acceptance shift and opened up numerous fixed type screw retained implant stents prosthesis, radiographic record base approaches to restore edentulous arches. which are fabricated with the help of CT and surgical templatePart 1 As implant dentistry is evolving towards and CAD/CAM technology are very :Presurgical phase. Implant Dent accelerated treatment protocols, with costly and require more time and 1997 ;6:193-`197 immediate or delayedfunctional and laboratory procedures. 2. McCall ra rosenfeld AL. Influence of nonfunctional loading, the importance of residual ridge resorption pattern on presurgical planning becomes In the present case,the stent was made implant fixture placement and tooth paramount. Theparadigm for restorative- after duplication of the existing position Part II Presurgical driven implant placement works best mandibular denture by using irreversible determination of prosthesis type and when templates are used to hydrocolloid,duplicating flask and self design. Int J Periodont Rest Dent transferinformation from the desired plan cure acrylic resin. The use of the 1992:12:33-51. to the surgical reality. The advent of mentioned materials and equipment 3. Gregori M. Kurtzman, Douglas computed tomography (CT)imagingand made it a verycost effective,quick and Dompkowski.Simplifying Implant surgical templates allow for clinically easy technique of fabricating surgical Surgical Stents for the Partially significant improvements in guide template Edentulous Arch .Inside Dentistry accuracy,time efficiency and reduction in .July/ August 2009,Vol 5,Issue 7. surgical error. Summary 4. Arun M.L .Optimal placement of There is no substitute for thorough osseointegrated implants. J.Cand This patient was a long term denture diagnosis and treatment planning and Dent Asso. 1990; 56(9):8736. wearer with complaint of poorly fitting meticulous surgical and prosthetic 5. U S Pal, Pooran Chand, Neeraj K lower denture. After thorough clinical treatment for success of implant Dhiman,Singh R K, Vimlesh Kumar. and radiographic examination ,it was supported prosthesis. Proper utilization Role of Surgical Stents in decided to support the mandibular of surgical and radiographic stents is one determining the positions of denture with implants. The denta scan is of the most important aspects of pre implants. National Journal of mandatory for such patients which gives surgical phase.The stent facilitates the Maxillofacial Surgery, 2010; 1: 20- a 3-dimensional picture of alveolar bone. accurate placement of implants in 23. Radio opaque Guttapercha markers optimal positions where sufficient bone 6. Naitoh M, Arji E,Okumara S, Onsaki placed in the existing mandibular is present. In cases with insufficient bone, C, Kurita K, Ishigomi T. The use of denture, helped to assess the anatomy of stent may help in making a strategic multiplaner reformatted bone at the proposed implant sites in the alteration of chosen implant site[6] . The computerized Tomographyin the patients via the dentascan. use of radiographicstentseither derived surgical prosthodontic planning of from existing prosthesis or from implant placement. Clin Oral Surgical guide stent is useful for diagnostic wax ups is essential. The Implants Res. 2000;11:409-14. determining the location and direction for incorporation of suitable radiographic 7. Adrian ED, Ivanhoe JR, Krantz fixture installment and can also be used markers provide both the surgeon and WA.Trajectory surgical guide stent during second stage surgical procedure to the prosthodontist with reference points for implant placement. J Prosthet identify the position of buried fixture as to determine the available bone at Dent 1992; 67: 687-91. ideally as possible in relation to residual theexact spatial location of surgical alveolar ridge[4] . implant sites[7] .

The stents fabricated with the radiopaque The anterior mandible often shows markers provide radiographic as well as progressive ridge resorption in the period clinical ease for optimum implant of edentulousness. Surgical stents help to installation. Along with all these advantages, they also provide liberty to flapless implant placement. The drill holes can directly be made through the stent, so the implant surgery may become less traumatic (with the preservation of Source of Support : Nill, Conflict of Interest : None declared soft tissue including the gingival margins of adjacent teeth and the interdental papilla) with decreased operative time .This results in accelerated post-surgical healing, fewer post-operative complications and increased comfort and

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 086 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Case Report All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Periodontal Plastic Surgery For Alveolar Ridge 1 Ashish Agarwal 2 Hirak S. Bhattacharya Augmentation: A Case Report 3 Mini S. Semi 1 BDS, MDS, FICDRO, Senior Lecturer 2 Professor Abstract 3 Reconstruction of alveolar ridge deficiency for cosmetic, functional, and cleansibility requirements Reader Department of Periodontics is a major challenge for reconstructive Periodontist. No single procedure is well suited to overcome Institute of Dental Sciences, Bareilly, India this kind of problem. This article reviews ridge augmentation using subepithelial connective tissue graft combined with bone graft for correction of alveolar ridge collapse in maxillary anterior region. Address For Correspondence: The objective of this article is to update the knowledge associated with various soft tissue Dr. Ashish Agarwal augmentation procedures and techniques. Senior Lecturer, Department of Periodontics Institute of Dental Sciences, Bareilly, India Contact no: 09453442418 Key Words Email id: [email protected] periodontal plastic surgery, alveolar ridge augmentation, alveolar ridge defects. Submission : 27th August 2011 Accepted : 14th April 2012

Quick Response Code Introduction documented in the management of Resorption of alveolar ridge, a common residual ridge deformities. The technique physiological finding after tooth loss, that have been used for this purpose are often requires periodontal corrective Roll flap procedure4 , Pouch graft surgery before prosthetic, and implant procedure 5 , onlay epithelialized grafts 6 , placement.1 Especially in the anterior interpositional graft technique7 , and visible region ridge collapse leads to combined onlay interpositional graft8 unacceptable structural, functional and procedure. above all esthetic compromises. From a morphologic standpoint, Seibert In this case report we augmented a classified ridge deformities into three alveolar ridge by the pouch technique types according to the vertical and using subepithelial connective tissue horizontal defect components2 graft combined with bone graft.

1. Class I defect Case Report ?Buccolingual loss of tissue contour A 45 Years female patient reported in the with a normal apicocoronal height. Department of Periodontics, Institute of 2. Class II defect Dental Sciences, Bareilly, with a ? Apicocoronal loss of tissue with complain for unaesthetic tooth site. She Fig. 1 - Facial View Of Class I Alveolar Ridge Defect normal buccolingual contour. stated that following removal of upper 3. Class III defect left central incisor, the site healed with a ?A combination of buccolingual and deep notch in the gums. Intraoral apicocoronal loss. examination revealed a mild to moderate buccolingual ridge deficiency in missing Later, Allen et al.3 introduced severity as a tooth region, leading to the diagnosis of classification criterion in the evaluation class I alveolar ridge defect (Fig. 1, 2). of alveolar deformities. Severity is Patient had no systemic abnormality. On classified as- discussing the condition and findings, ?Mild deformity < 3mm she agreed for soft tissue ridge ?Moderate deformity 3 - 6mm augmentation procedure followed by ?Severe deformity > 6mm prosthetic replacement. Thorough Fig. 2 - Occlusal View Of Class I Alveolar Ridge Defect scaling and root planning was given to Ridge augmentation is a valuable the patient for removal of the local debris, After administering local anesthesia, periodontal plastic surgery procedure for and patient appointed for surgical phase incision was given for pouch formation correction of ridge defects for esthetic after 1 months. on the alveolar crest in the buccal side of purpose. Soft tissue ridge augmentation involved area (Fig. 3). This pouch was using palatal grafts have been thoroughly Surgical Procedure extended in the apical aspect of alveolar

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 087 and no decreased in tissue volume was noticed (Fig. 9, 10). The patient was instructed to maintain proper oral hygiene and referred to Prosthodontist for prosthetic requirements.

Discussion A deform ridge may result from tooth extractions, sever periodontal disease, abscess formations, etc.1 The deformity Fig. 7 - Connective Tissue And Suturing Fig. 3 - Pouch Formation In Involved Site that exits in the ridge is directly related to the volume of the root structure and associated bone that is missing or has been destroyed. Several soft tissue augmentation techniques have been developed to reestablish natural appearing soft tissue architecture. The following factors should be determined prior to the initiation of therapy- ?Volume of tissue required to eliminate the ridge deformity ?Type of graft procedure to be used ?Timing of various treatment Fig. 8 - Uneventful Healing After Surgery procedure Fig. 4 - Site Of Connective Tissue Harvesting ?Problem with tissue discolorations and matching tissue color.

Roll flap technique involves the preparation of a de-epithelialized connective tissue pedicle graft, which is subsequently secured in a subepithelial pouch for deformity correction. This procedure is used for small to moderate class I ridge defects in localized area. A Fig. 9 - After 21 Days, Uneventful Healing depithelialized palatal connective tissue pedicle flap removed from the adjacent site of collapse ridge, and tucked into the buccal gingival pouch. A pouch is made Fig. 5 - Subepithelial Connective Tissue in the supraperiosteal connective tissue at the labial surface of the ridge. The result of this procedure may be satisfactory but technique may not be convenient due to anatomic considerations and finite tissue thickness.4 Pouch graft procedure is used for class I type alveolar ridge deformity. For this type of augmentation a subepithelial pouch is prepared in the area of the ridge Fig. 10 - Increase In Buccolingual Width After 3 Months deformity, into which a free graft of connective tissue is placed and molded to create the desired contour of the ridge. Fig. 6 - Bone Graft In Pouch (DFDBA) (Fig. 6, 7). After suturing, the We have used bone graft (DFDBA) site was covered with periodontal pack. combined with connective tissue Postoperative antibiotics, analgesics, and harvesting for the pouch technique. ridge for adequate depth with the help of 0.12% chlorhexidine mouth rinse for 7 Connective tissue grafts give excellent periosteal elevator. Subepithelial days were prescribed to prevent any color match of the surrounding tissue, and due to good blood supply they are connective tissue graft was harvested postoperative discomfort. After 7 days, 5 from the palatal aspect of left second periodontal pack, and sutures were well received by the recipient site. premolar region (Fig.4,5). This removed. The surgical site was found to Onlay graft are epithelialized free graft, connective tissue graft transferred to the heal without any complication (Fig. 8). which following placement, receive their preformed pouch that was filled with At 21 days, and 3 months postoperative nutrition from the de-epithelialized decalcified freeze dried bone allograft follow-ups, there is uneventful healing, connective tissue of the recipient site. This type of graft is use for large class II

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 088 and III defects. If necessary, grafting can Different surgical techniques have shown 453. be repeated at 2-3 months intervals to acceptable esthetic outcome. 3. Allen EP, Gainza CS, Farthing GG, gradually increase the ridge height. Nevertheless, many of these results are Newbold DA. Improved technique Onlay graft maintains their epithelium case reports or series, and outcome are for localized ridge augmentation. A over the connective tissue. The graft is mainly related to skill of the operator. report of 21 cases. J Periodontal. secured with its connective tissue base in Generally the published cases show short 1985;56:195-199. contact with de-epithelialized recipient term results. Long term stability of the 4. Scharf DR, Tarnow DP. Modified roll site. Significant ridge correction can be regenerated tissues should be proven in technique for localized alveolar ridge achieved by this technique, but due to longitudinal studies. augmentation. Int J Periodontics color difference between from palatal Restorative Dent. 1992:12:415-425. and gingival tissue, it may create Conclusion 5. Langer B, Calanga L. the unpleasant esthetic results. 6 This article demonstrates the correction subepithelial connective tissue graft. Interpositional grafts are used to correct of an unaesthetic ridge deformity using J Prosthet Dent. 1980;44:363-367. class I, and mild to moderate class I and II pouch technique. The pouch method 6. Seibert JS. Reconstruction of defects. The surgical procedure requires provided adequate volume to establish deformed, partially edentulous the use a thick, wedge shape connective natural appearing soft tissue architecture. ridges, using full thickness onlay tissue graft. This graft is then inserted in This technique facilitates the ease of graft grafts. Part I. Technique and wound the recipient bed, creates similar to the placement and aesthetic result. healing.Compend Contin Educ Dent. pouch procedures by means of partial 1983;4:437-453. thickness dissection. The graft is References 7. Seibert JS. Treatment of moderate sutured, leaving the epithelial surface at 1. Schropp L, Wenzel A, Kostopoulos L, localized alveolar ridge defects: the level of surrounding tissue. 7 et al. Bone healing and soft tissue preventive and reconstructive Combined onlay interpositional graft contour changes following single- concepts in therapy. Dental Clinica of attempt to maximize the benefits of onlay tooth extraction: a clinical and North America 1993a;37,265-280. epithelialized graft and subepithelial radiographic 12-month prospective 8. Seibert JS, Louis JV. Soft tissue ridge connective tissue graft. This type of study. Int J Periodontics Restorative ridge augmentation utilizing a augmentation is mainly used for class III Dent. 2003;23:313-323. combination onlay interpositional ridge defects. The submerged connective 2. Seibert JS. Reconstruction of graft procedure: a case report. Int J tissue section of the interpositional graft deformed, partially edentulous Periodontics Restorative Dent. aids in the revascularization of the onlay ridges, using full thickness onlay 1996;16;310-321. section of the graft, thereby gaining a grafts: I. Technique and wound greater percentage of success of the healing. Compendium of continuing overall graft.8 education in general dentistry 4,437-

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 089 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 "A Journey Of Thousand Miles Begins With A 1 Mythri H. 2 Ananda S R. Single Step" - An Adage For Incremental Dental 3 Chandu G. N. 1 Senior lecturer, Dept of Community Dentistry, Care Sree Siddhartha Dental College, Tumkur, Karnataka-572107, India. 2 Senior Lecturer, Dept of Community Dentistry, Abstract Hasanamba Dental College, Hassan, Karnataka - 572107, India. Although, most oral diseases are preventable, not all individuals and communities benefit fully 3 Prof. and Head, Dept of Community Dentistry, from the available preventive measures. In such cases, most frequently children make one of the College of Dental Sciences, Davangere, important groups of community, as they are future citizens. To be a healthy citizen of a country one Karnataka-577 004, India. should have healthy habits. To learn healthy oral habits, requires active participation of the Address For Correspondence: learners. The school based dental health programmes provide the best opportunity to reach the Dr. Mythri H. 1 largest number of children at a time. And incremental dental care is one such method to deliver a Senior lecturer, priority dental care for children. Department of Community Dentistry, Sree Siddhartha Dental College, Tumkur, Karnataka-572107, India. Key Words Phone No. : 08162206451 Incremental dental care, maintenance care, school based dental health programmes Fax No. : 08162275536 Mobile No. : 9886950367 E-mail : [email protected] Submission : 17th September 2011 Accepted : 14th February 2012

Introduction: The statistics of dental need: Quick Response Code In the context of WHO, aim of “health for A startling statistic revealed that more all by 2000”, the global status for than 80% of dental decay was found in children, should be that 50% of children 25% of population.3 Moreover, these between the ages of 5 and 6 years will be children are from lower - income free of dental caries and at 12 years of age households, ethnic minorities and many they should have 3 or fewer decayed, times have special needs. missing or filled teeth. One of the methods by which the dental surgeon can a. Over 5 % of 5 to 9 year olds have at approach a community is the assignment least one cavity or filling, by age 17, Many issues has proven that delivery of of a dental surgeon or dental committee the percentage has increased to 78%. dental care in the US is ineffective in for school children. The school is the b. 25% of the children have not seen a providing care to all segments of the most logical and practical place to dentist before entering kindergarten.4 population.5 implement large scale school dental health programmes.2 The consequences of this widespread The search for effective strategies to deal problem are alarming. More than half with prevention and treatment of oral History: (57%) of parents report unmet dental disease hence focuses on children as a In 1885 William Fisher published a paper needs of their children.5 natural target population. entitled “compulsory attention to teeth of school children”. Following this, British Unfortunately the children who most Treatment is not the answer to solving Dental Association appointed a need dental care are not receiving it. This children's oral health problems; rather committee to investigate child dental raised the concept of dental public primary prevention is the key. This gave health. health.6 raise to the concept of Incremental Dental Care. In 1898, School Dentists Society was DENTAL CARE DELIVERY formed in London. SYSTEM IN THE UNITED STATES Definition:7 “Even though the U.S spends twice as It may be defined as “Periodic care so In 1907, George Cunningham in England much per person as any other developed spaced that increments of dental proposed a method of delivering priority country on health care, it fails to provide disease are treated at the earliest time dental care to a group of children, known universal coverage for all its citizens.” - consistent with proper diagnosis and as incremental care.1 Carole Simpson quotes. operating efficiency, in such a way that there is no accumulation of dental

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 090 Limitations: Financing which has been customary in Vehicles of dental the United States, along with dental care manpower limitations, the programme usually terminates about the fourth grade (age 10) and is almost never carried through the high school period.12

Federal or central Non governmental State: Common Controlling factors: private practice clinics, schools The recent drop in childhood dental caries and higher costs per child per year above that age level, in both average and stress areas.12

Disadvantages: 6 needs beyond the minimum”. were established for follow up of those The foremost one is that operative children failing to return the cards. After dentistry is more time consuming on a Aim: one week, project personnel return to the piece meal basis. The others are, It's a rational approach on annual basis to schools and collect the cards, which are the dental problems and a plan for life then reviewed by the eligibility clerk.10 long dental care. It aims at prevention and 1] Attention to deciduous teeth: maintenance as the programme starts at Enrollment of the provider population: Few dentists will deny the an early age. It provides a complete oral Unlike the child population, the provider importance of the deciduous teeth, but examination during early child hood. population remains relatively stable from conversely, few will assign them a value year to year. The initial enrollment as great as that of permanent dentition. Why deciduous teeth have to be taken procedure was accomplished by Where priority decisions must be made care? voluntary basis and has to accept usual, the permanent teeth deserve top listing. The early loss of the temporary molars, customary and reasonable fee and they causes forward drifting of the first were asked to indicate how many permanent molars in the lower and the children they could accommodate and 2] Psychology and changing patterns upper arches which necessitates what days and what hours of the week of modern family: extraction of caries-free premolars in they would accept the children. Along No longer do children move those areas.8 with this the participating dentists should steadily from the habits taught them by prefile their fees. their parents during childhood into Method: similar adult habits of their own. One of These programmes are “gotten off the After the geographical distribution of the the good features of teen-age rebellion is ground” by taking the youngest available providers and recipients was analyzed, an the responsibility young people feel for group the first year and carrying it examination form is completed; this developing their own ways of life. forward in subsequent years as far as provides base-line data on the oral health Healthy habits and many other matters funds permit, each year adding a new status of the population. When a child's must therefore be taught directly to the class of children at the next earliest treatment is completed, the provider teenagers. They must be reconvinced in available age until an entire child submits a form including a record of all terms of their own new motivation that population is being served to as high an treatment that they received.10 teeth are worth keeping and that age as available resources permit. Six incremental care is the best way to assure year olds or the first year of the children Advantages11 : this. Teenagers can be reached by reason in school are a convenient way to reach 1. Ideal pattern of care where incidence much better than younger children. They them and then reaching back to pick up of new dental diseases are expected have social motivation, not only in four and five year olds, while maintaining each year. relation to their personal lives, but the six year olds when they become seven 2. Initial cost is less. usually toward the community as a year olds and so on.9 3. Man hour for initial care is less. whole. 4. Lesions of caries are treated well Enrollment of the patient population: before there is a chance for pulp This is accomplished in cooperation with involvement. 3] Increasing likely hood of the educational agencies in the area. On 5. Periodontal disease is intercepted interruption in children's dental entering the first grade, each child is at/near the beginning. health programmes: provided an enrollment card to be 6. Topical and other measures can be In the social groups where completed by the parent or guardian and maintained on a regular basis. systematic health care is easiest to attain, returned to the school. 7. Bills for dental service are equalized programme breaks occur because of and regularly spaced. rising divorce rates and increasing Instructions were provided to the 8. Child develops the habit of visiting mobility of the average American family. principal and each teacher before the the dentist periodically. Children are far more often involved in distribution of the cards, and procedures broken homes today and are more often moved with their families around the

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 091 country in such a way as to interrupt attack continues, incremental 17years of age. J Dent Res. 1996: 75: programmes for dental maintenance care. maintenance care may not be indicated at 631 - 641. least for extremely young children. 4. Norman O Harris, Primary preventive Emphasis might be shifted to preventive dentistry. 6th Edition, 2004. 4] Inertia toward the seeking of private visits beginning in early teenage when 5. Christine N Nathe, Dental Public dental care: periodontal disease begins its subtle Health, contemporary practice for the Lambert and Freeman, in a attack. 13 dental hygienists. study of high school children in 6. Dunning J M, Principles of Dental Brookline, Massachusetts, have Conclusion: Public Health. 4th Edition, 1986. observed that those children who Incremental Dental Care, a type of 7. Soben Peter. Essentials of Preventive received dental care on an incremental maintenance care was an old concept and and Community Dentistry. 3rd basis till fourth grade in school were in it is similar to “weather” - a lot of people Edition, 2006. significantly poorer dental condition talk about it, but nobody does anything 8. Graham turner, Organization in the later on than were those children of a about it. Actually, a lot has been done school dental service. British dental similar in4come level who had received about the weather. We measure it much journal, December 21, 1971:561 - care elsewhere. There is a sound basis to more accurately now than we did a 565. argue that given limited resources, young generation ago with the aid of computers. 9. David F Striffler, Wesley O Young, children should not be the sole focus of This accurate forecasts can better prepare Brian A Burt, Dentistry, dental programmes, but that teenagers should be us for the changes in the weather if can't practice and the community. 3rd given at least equal consideration. change the weather.14 Edition. 10. Gene P Lewis, G. Fox Monroe, Children's incremental dental care Summary: Similarly, if we identify the needy, program: an overview of the In any event, if one accepts the thesis that treatment providers, financing source southeast Tennessee-northwest routine appropriate care over a lifetime and use modern data processing Georgia project. JADA, Vol 88, April will decrease the cost of restorative care techniques to collect and study the 1974,789 - 794. and perhaps subsequent endodontic and information, we can better understand 11. Joseph John .Textbook of Preventive prosthodontic care, one might logically many factors involved, perhaps make and Community Dentistry. accept the argument that an incremental better predictions, and make better 12. Aubrey Sheiham, Impact of dental dental care should be the choice when a decisions about the allocation of treatment on the incidence of dental dental health care programme is being resources to solve the problems in health caries in children and adults. recommended for a group of children. care. Community Dent Oral Epidemiol 1997: 25; 104 - 112. 13. David F Striffler, Wesley O Young, There are others who argue that a As Leninist road to universal health care Brian A Burt, Dentistry, dental graduated incremental approach is much says - “things have to get worse before practice and the community. 3rd more logical way of proceeding, they get better”,15 in spite of some Edition. particularly when introducing with limitations and with certain 14. Clifton E Crandell, Comprehensive limited resources available. It allows the disadvantages, incremental dental care Care in Dentistry, postgraduate dental programme to start on a limited scale, can be implemented as “Whoever wants handbook series, Volume 3, 1979. expand gradually, and be phased in with to reach a distant goal must take small 15. Incremental versus Wholesale Health no large backlog of needs in eligible steps initially.” Care Reform, Economist view, children at any one time. This approach A u g u s t 2 6 , has not always been accepted by some 2006.http://economistsview.typepad. thoughtful analysts of the procedure. References: com/economistsview/2006/08/incre 1. Hiremeth S S. Text Book of mental_or_.html dated on 16/7/09. Preventive and Community The careful pencil-and-paper analysis Dentistry. 1st Edition, 2007. with what limited data were available led 2. Satish Chandra, Shaleen Chandra. to the following finding; that although Textbook of Community Dentistry. not backed by a project of prospective 1st edition, 2000. research, the annual “front end” costs of 3. Kaste L M, R H Selwitz, R J an incremental programme [that is, Oldakowski et al, Coronal caries in routine examination, radiographs, the primary and permanent dentition prophylaxes, reinforcement of patient of children and adolescents 1 - education, and application of any preventive procedures that might be indicated] added up to considerably more than the costs of the accumulated restorative care. Source of Support : Nill, Conflict of Interest : None declared

Certainly if the downward trend in caries

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 092 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 "3D Imaging Using Laser Scanner In Oral And 1 Gajendra Veeraraghavan 1 Lecturer, Dept of Oral Medicine Craniofacial Region - An Overview” Faculty of Dentistry, Zliten Misurata University

Address For Correspondence: Abstract Dr Gajendra Veeraraghavan In recent past, medical imaging has generated variety of techniques. One of these initially Lecturer, Dept of Oral Medicine, developed is Laser surface scanning. In this article, the technology of 3D laser surface scanning is Oral Diagnosis and Radiology described and applications in Oral & craniofacial region are reported. Advantages of this imaging Faculty of Dentistry, Zliten modality are discussed. Misurata University Post Box No 694, Libya Mob -00218-914779937 Email - [email protected] Key Words Laser, Scanning, Three Dimensional Imaging Submission : 17th September 2011 Accepted : 14th February 2012

Over the past various attempts have been data is obtained by moving a digitizing Quick Response Code made to measure the dimensions of face. the cursor along the anatomical features Attempts were also done to simulate the in the radiograph. This technique is time results of surgery on face and jaws and to consuming, of limited accuracy, and only predict facial change following surgery. gives a representation of predicted outcome in the midline. The method does In the past direct measurements using not provide an analysis in three classical methods of physical dimensions.5 anthropology like those using standard anthropometric tools such as sliding Previous approaches to obtaining three calipers, spreading calipers, soft tape and dimensional facial data included anatomy is recorded by the camera with a protractor have been used to access the computerized tomography (CT) and the use of mirrors and is sent to computer facial asymmetry. These measurements (MRI). However, the resolution of facial and can be retrieved at a later date for can be prone to inaccuracies. The structures is limited by the separation of further analysis. The hard copy of the commonest sources of error in CT scans. In addition soft tissue laser graph can be printed in full colour or antropometry are due to improper resolution is poor. Both MRI and CT black and white in any required view1 identification of landmarks, inadequate scans also produce distorted facial (Fig 1). measuring equipment and improper reconstruction because artifacts are measuring techniques1 . generated by metallic objects such as fillings in teeth. Finally, neither CT nor Morphoanalysis has been used in an MRI Provide the natural photographic attempt to reconstruct the facial form in appearance of the texture of the facial three dimensions by superimposition of surface.6 radiographic and photographic material, but the method did not gain wide All the above mentioned approaches acceptance.2,3 Later stereoradiographic have their limitations, both in radiation techniques with metallic implants was dose and in their ability to measure used to study the growth of children with accurately the face and skull in three congenital anomalies or deformities. dimensions. To overcome these Again this technique is limited in its difficulties a laser scanning has been application as metallic markers need to designed. be placed surgically before the recording is made, and there is a cumulative Laser scanning Technique radiation dose to the child.4 Further Patient sits in a rotating chair, opposing technique has been developed to use a camera. A non hazardous line of helium- computer to predict facial form using two neon laser light is projected on the face Fig 1 - Laser Scanning Technique dimensional lateral skull radiograph. The while the chair is rotated. The distorted laser light reflecting the subjects facial

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 093 accuracy of the laser scanning in the The faceting technique is not suitable for Assessment of Optimal scanning study by Ramieri et al appears to be high applications to the complicated surfaces conditions. when compared to CT Scans.11 of the skull. The skull, therefore treated as The Frankfort horizontal plane be a series of volume elements, called parallel of the patient and the frontal view Discussion voxels. Several methods can be used to axial plane perpendicular, to the true I.J Coward et al (1997) carried out Laser display voxels, most frequently used is horizontal plane for a reproducible three scanning on ears and face. And concluded Octree encoding (Meagher, 1982)13 . The dimensional laser graph. Best scanning that the siting of the landmarks in a image principle is to define a three dimensional quality was obtained when the subject captured by this technique has been array of cubical array. was centred in the scanner working shown to be in accurate in identifying volume.9 landmarks of ears and face and suggested Surgical simulation may be performed that if landmarks can be consistently sited interactively on the skull by selecting Artefacts on a laser scan image, they would then be volumes of interest which may be Factors that generated artifacts was able to be used to calculate dimensions of repositioned, removed, rotated or added conducted empirically and revealed that an ear and its location on face.1 to, then redisplayed in any chosen the most relevant aspects during scanning orientation. Models for predicting the were the laboratory environment, facial Moss J P et al (1987) described the use of behaviour of the soft tissue after the surface conditions and motion artifacts. a specially designed no contact laser alteration of the underlying bone scanning system and CT for studying structure are being developed to give The precautions required to reduce the changes in the facial form and its some indication of the effect of surgery artifacts were- completely darkening the relationship to changes in the supporting on facial appearance. The graphics room, removing or masking any object in bone structure after facial surgery. It is techniques described enable the patient to the room that had a reflective surface. All shown that realistic images may be be presented with a picture of the effects the situations that modify the skin texture produced from these data sets using of surgery on face in three dimensions and alter refraction (ie sweat, hydration computer graphics techniques to give the before surgery is undertaken. It is also a or creams) appeared a possible cause of images a solid 3D appearance. The valuable asset to the surgeon who is able artifacts in the acquired data. Carefully images may then be used for planning to identify and view the morphology of cleaned facial skin and climate control surgery and to provide the patient with a the bone within the maxilla or the base of were thus required for the examination. prediction of facial appearance after the skull to determine the areas where surgery.12 surgical intervention is necessary. An The most common source of artifacts was accurate method of measuring and subject motion during the time required Patch work in the form of triangles or visualizing the face and skull in three to complete digitization. Motion may facets from CT or Laser contoured data dimensions has been described, and its affect a part of the face, most commonly from CT use in the treatment of the patients with owing to eye movements or facial congenital facial deformity has been expressions, or it may affect the whole reported.12 head because of trembling of neck musculature. In all subjects, the best Reliability of a 3D surface scanner for examinations were obtained when the Computer graphics techniques orthodontic applications. patient was allowed to keep the head in a Budi Kusnoto et al (2002) assessed the natural relaxed position; forcing head reliability of generating 3D object flexion or extension exacerbated reconstruction using the Minolta VIVID trembling.9 700 3D surface laser scanner. Accuracy & Reproducibility were tested on a Evaluation of scanning errors. Image is shaded and illuminated to geometrical calibrated cylinder, a dental The accuracy of scanning was +/- provide realism (Fig 2) study model and a plaster facial model. 0.65mm. The development of a specific Tests were conducted at varying protocol resulted in a mean scanning distances between object and scanner. In error of 1-1.2mm and a recording error of calibrated cylinder tests, spatial distance 0.3-0.4mm on repeated scans of human measurement was accurate to 0.5mm (+/- subjects.9 0.1mm) in vertical dimension & 0.3mm (+/-0.3mm) in horizontal dimension. In Precision and Accuracy study model test molar width was The reported precision of the laser accurate to 0.2mm and palatal vault depth scanner has been assessed as 0.6-2mm on could be measured to 0.7mm. For facial plaster head models depending on the use model, an accuracy of 1.9+/-0.8mm was of Prelabelled landmarks.10 Accuracy for obtained. These findings suggest that the point localization on human subjects, in surface scanner has great research comparison with direct anthropometric potential because of accuracy and ease of measurements was determined to be with use. Treatment changes, growth, surgical in 1.5 mm for only one third of the most Fig 2 - Image Formed Using Laser simulations and many other orthodontic commonly used measures, and unreliable applications can be approached 3 (>2mm) for the other two thirds. The dimensionally with this device.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 094 human face. Many more applications are reproducibility of the head position The self corrected mechanism of the laser possible in studying facial soft tissue for a laser scan using a novel scanner in adjusting for image distortion growth, functional facial muscle morphometric analysis for gives flexibility for clinical research. The movements, dental casts, arch form and orthognathic surgery. Int. J. Oral software can be used to merge images head shape. Hence, laser scanning has to Maxillofac surg 2000; 29: 86-90. taken from different perspectives, thus be studied and all possibilities for the 9. Ramieri GA, Spada MC, Nasi A, eliminating undercuts. Interestingly due various research techniques to yet be Tavolaccini A, Vezzetti E, Tornincara to laser beam spread, it was found that the explored. S, Bianchi SD, Verse L. smaller the object, the more accurate Reconstruction of facial morphology measurements. For craniofacial Bibliography from Laser Scanned Data Part 1; anomalies, various studies could be 1. Coward TJ, Watson RM, Scott BJJ. Reliability of technique. performed regarding cleft lip repair, Laser scanning for the identification Dentomaxillofacial Radiology 2006; asymmetric facial growth, change of of repeatable landmarks of ears and 35:158-164. head shape& nasal molding procedures.14 face. British Journal of Plastic 10. Bush K, Antonyshyn O Three Surgery. 1997; 50:308-314. dimensional facial anthropometry Advantages 2. Rabey GP, Craniofacial using a laser surface scanner, One of the major benefits of this system is morphanalysis. Proceedings of the Validation of technique. Plast the facility to manipulate the image in Royal Society of Medicine. 1971; Reconstr Surg 1996; 98:226-35. three dimensions. Thus, one can rotate 64:103-111. 11. Aung SC, Ngim RC, Lee ST. the image on the computer screen in any 3. Rabey GP, Current Principles of Evaluation of the laser scanner as a direction and angle and select points on a morphanalysis and their implications surface measuring tool and its standard or customized reference plane.8 in oral surgery Practice. British accuracy compared with direct facial journal of Oral surgery 1977; 15: 97- anthropometric measurements. Br J All anatomical landmarks and facial 134. Plast Surg 1995; 48: 551-558. structures are recorded with in 0.5mm, 4. Rune B, Sarnas KV, Selvik G. 12. Moss JP, Linney AD, Grindord SR, which meets the current clinical Roentgen stereometry with the aid of Arridge SR, Clifton JS. Three requirements of accuracy and metallic implants in hemifacial dimensional visualization of the face reproducibility for orthognathic surgery microsomia. American journal of and skull using computerized assessment and treatment planning12 .The Orthodontics 1982; 81: 65-70. tomography and laser scanning method can be repeated without danger to 5. Harradine NW, Birnie DJ techniques. European Journal of the patient and has high spatial resolution Computerised prediction of the Orthodontics 1987; 9:247-253. and does not involve contact with the results of orthognathic surgery. 13. Meagher D. Geometric modeling patients face. It can therefore be used for Journal of Maxillofacial Surgery using Octree encoding. Comput longitudinal studies of soft tissue changes 1985; 13: 237-245. Graph Image Poc 1982; 19:129-147. in growing individuals and following 6. Hoenhen KH, Hanson WA. 14. Kusnoto B, Evans CA. Reliability of surgery. This information is used together Interactive 3 D Segmentation of MRI 3D Surface laser scanner for with a low dose CT scan to provide & CT volumes using morphological Orthodontic applications. Am J information on the bone structure and its operations. J Comput Assist Tomogr Orthod Dentofacial Orthop 2002; relationship to the soft tissue. This 1992; 16: 285-294. 122:342-8. method also provides realistic three 7. Ayoub AF, Siebert P, Moos KF, Wray 15. Girod S, Keeve E, Girod B. Advances dimensional imaging of the face and D, Urquart C, Niblett TB. A vision - in interactive craniofacial surgery skull.15 based three dimensional capture planning by 3D simulation and system for maxillofacial assessment visualization. Int J Oral Maxillofac Conclusion and surgical planning. British journal Surg 1995; 24:120-5 Three dimensional surface digitization of Oral & Maxillofacial Surgery. through laser scanners offers excellent 1998; 36: 353-357. possibilities for objective analysis of the 8. Soncul M, Bamber MA. The

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 095 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 An Insight into Tooth Factors Affecting 1 Suchetha A 2 Rashmi Heralgi Periodontium 3 Apoorva SM 4 Rohit Prasad 5 Abstract Bharwani Ashit G Several conditions exist around teeth that may predispose the periodontium to disease. These 1 Professor and Head, Dept of Periodontics situations may occur as a result of the condition or position of teeth or as a result of tooth treatment. DAPM RV Dental College, Bangalore In certain cases these tooth-related factors may contribute to the initiation of periodontal disease. 2 Assistant Professor, Dept of Periodontics While the etiology of periodontal disease is bacterial, factors that enhance bacterial accumulation Al-Ameen Dental College, Bijapur 3 Senior Lecturer or allow the ingress of bacteria into the periodontium should be considered in the classification and 4, 5 diagnosis of periodontal diseases. This is because many times these tooth-related issues can PG Student Dept of Periodontics cause site-specific problems that require treatment in an otherwise intact periodontium. Several DAPM RV Dental College, Bangalore factors related to tooth/root anatomy, have been associated with gingival inflammation, attachment loss, and bone loss. These factors will be discussed in this review, as they relate to Address For Correspondence: their potential to promote damage to the periodontium. Dr Rohit Prasad, PG Student, Dept of Periodontics, DAPM RV Dental College Key Words CA 37, 24th main, JP Nagar 1st Phase Periodontitis, Palato-gingival groove, Furcation, Cervical Enamel Projections Bangalore-560078, Karnataka Email: [email protected] Mobile : +91-9886074038 Submission : 27th July 2011 th Introduction: detection may prevent any future Accepted : 18 January 2012 Periodontitis is initiated and perpetuated attachment loss.2 by a small group of predominantly Quick Response Code microaerophilic bacteria that colonize the subgingival area. Antigens, virulence I. Tooth Related Factors factors and invading bacteria comprise a) Tooth position the microbial challenge. Inflammation b) Open contacts and immune response mounted by the c) Marginal ridges host to the microbial challenge results in production of cytokines, eicosanoids and II. Cementum Related Factors other inflammatory mediators which a) Cemental tears perpetuate the response and mediate connective tissue and bone destruction. III.Root Related Factors malocclusion in the etiology of All these events are influenced by disease a) Root surface area periodontal disease.3 modifiers which can be either local or b) Root grooves In a review, two studies have found a systemic. Local etiologic factors are c) Root trunk length correlation between periodontal disease defined as factors that influence d) Furcation and malocclusion. However, other periodontal health status locally but exert e) Bifurcation ridges studies have failed to show a relationship no systemic effect. These may be f) Cervical enamel projections between periodontal disease and anatomic as well as local iatrogenic g) Enamel pearls 1 malocclusion. One reason for the factor. h) Root concavities conflicting reports is that there is no i) Root proximity satisfactory index to measure Inherent anatomic and morphologic malocclusion. The consensus at present is features of the teeth have significant Tooth Position: that crowding of teeth is one of the most impact on the etiology of local The position or inclination of teeth can be important factor of malocclusion with periodontal disease and management and factors that predispose the periodontium relation to periodontal disease.4 prognosis of the involved tooth or teeth. to plaque accumulation and subsequent These lead to functional and structural loss of attachment. While studies show Most of the studies dealing with changes in dento-gingival junction, that areas of periodontium adjacent to malocclusion and periodontal disease are increasing its susceptibility to destructive malaligned teeth can be maintained in a cross sectional studies often comprising challenge of periodontal pathogens. They state of health, in situations where teenagers or young adults. An adverse thus contribute to the site specific nature meticulous oral hygiene is not practiced, effect of malocclusion on periodontal of periodontal disease. Awareness of periodontal disease can occur. There have health may, in any case not manifest itself potential anatomic variations and early been conflicted reports on the role of until mature age. At times, however it

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 001 may be difficult to distinguish between Various reports have been published on reduced due to potential bacterial cause and effect, since periodontitis may the importance of marginal ridge invasion and colonization.14 Cemental in itself have caused malocclusion for relationships. It was stated that it is tear may have the potential to initiate an example increased overjet and spacing of important for adjacent marginal ridges to aseptic, rapid, site specific periodontal teeth. Longitudinal studies from be of some heights.1 3 Several breakdown in a non infected childhood to adulthood in subjects with investigators noted that uneven ridges is a environment. A complete separation of persistent trails of malocclusion may significant predisposing factor in the fragment with subsequent therefore provide more valid periodontal disease, however, uneven sequestration can elicit symptoms information.5 In teeth adjacent to an marginal ridges of contiguous posterior comparable to acute periodontitis.1 edentulous site when the tooth migrates teeth are of less importance than the or tips mesially, the tipped surface of the presence and extent of plaque and Root surface area: teeth can become inaccessible for self calculus deposits in determining Root surface area, a product of length and performed oral hygiene. This can lead to periodontal health status.12 circumference of roots, is an important attachment and bone loss at these sites.6 factor in the treatment of the In most studies a strong correlation exists It can be concluded that marginal ridge periodontally involved teeth. Total root between teeth positioned facially to the discrepancy may not be a significant risk surface area may vary from 154 mm2 for dental arch and recession defects. One factor for development of periodontal the maxillary mandibular central incisor might assume from these data that disease; however, if a marginal ridge to 433 mm2 for the maxillary 1st molar malalignment, tooth brush trauma and discrepancy leads to an open contact, .The root surface area of the canines is the calculus play more than just a casual role there may be damage to the second largest in the dentition surpassed in causation of gingival recession.7 periodontium.13 only by that of molars. This large area of root surface and the position in the dental Open Contacts: Cemental Tears: arch anterior or to the muscles of Several investigations have found open The phenomenon of cemental tear has mastication, make the canines, contacts to be modifying factor for been observed both within unexposed mechanically well suited to with stand periodontal disease. In a study by Blieden and exposed cementum. The tear or the forces of mastication.16 et al. it was reported that the percentage fracture can either occur as a complete of diseased papillae in the areas with separation along the cemento- dentinal Root surface area is important because weak proximal contact was consistently border or as a partial split within the small losses of attachment height caused higher than that found in the areas of good cementum following one of its by inflammatory periodontal disease or contact.3 Similarly a number of studies incremental lines. The detachment in gains of attachment following reported a positive association between unexposed cementum has been related to periodontal therapy affect a significant open contacts and presence of acute trauma from occlusion.14 Extracted portion of the total support of the tooth. A periodontal disease.8,9 . Whereas another teeth with cemental tear have been study was conducted to study linear study reported that the significance of examined to determine whether the variations of root surface area in 1mm open contacts on periodontal disease is presence and extent of attachment loss on increments from CEJ to the furcation area very minimal.10 the surface having this defect differ from and reached maximum dimensions at the that on the opposite, intact side of the level of root separations; approximately Though conflicting reports are present root. The results revealed a significantly 38% of total RSA located within 2mm of linking open contacts with periodontal greater loss attachment on cemental tear root separation. Coronal one half of the disease, Consensus report by 1999 surfaces than on the opposite intact site. root length accounted for 60% of total International World Workshop for Histological examination further RSA. Presence of concavities and other classification of periodontal disease and indicated that the split between the root root convolutions seen in furcation area conditions has classified open contacts and the fragment most likely occurs also increase the RSA in furcation area.17 under anatomic tooth factors that along the cemento dentinal border.15 predispose/modify periodontal disease.3 Root Grooves: One might assume from these data that There are few reports regarding cemental Root grooves are developmental malalignment, tooth brush trauma tears. One of the case report suggested the anomalies in which an infolding of the calculus play more than just a casual role cemental tear fracture could be caused by inner enamel epithelium and Hertwigs in causation of gingival recession.11 occlusal trauma.15 In another report, two epithelial root sheath (HERS) creates a kinds of cemental tears were reported. It groove on the tooth surface.2 Such Marginal Ridges: was suggested that fragments of morphological features compromise Marginal Ridges may exhibit 3 types of cementum could be detached by root patient's self care, favour accumulation variations planning or during surgery and of plaque, calculus and food debris. They 1) Uneven in height uneventful healing could be obtained, the facilitate plaque growth and later provide 2) They may not meet at the contact process of aging in addition to continuous anaerobic condition for bacterial area because of rotation or occlusal strain may lead to this problem.15 selection and proliferation. They cause malposition of teeth Depending upon the location, these patients inaccessibility to routine oral 3) Faulty marginal ridge and factures may or may not be followed by hygiene procedures and they also sluiceway form (because of repair. If a cemental tear becomes complicate restorative procedures.2 restoration or grinding).12 exposed, or has a close proximity to oral Various types of root grooves have been cavity. The likelihood for repair is described 16, 18, 19

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 001 i) Proximal root grooves treatment.20 A literature review by Hou et furcation. Therefore horizontal ii) Palatal / lingual grooves al., indicated that prognosis is poor or attachment loss leading to furcation iii) Labial cervical vertical grooves hopeless for deeper grooves that invasion compromises the root trunk, terminate further apically on the root. It resulting in the loss of one third of the i) Proximal root grooves- was suggested that meticulous scaling total periodontal support.2 2 The These morphological features occur and root planning, and flap operations, significance of root trunk is related to more frequently in mandibular anterior with or without odontoplasty, can both prognosis and treatment of tooth. A teeth and maxillary premolar, such maintain periodontal health in teeth with molar with a short root trunk is more concavities are wider in maxillary than in PRGs in motivated patients who are vulnerable to furcation involvement but mandibular teeth and are more prone to capable of maintaining effective plaque has a better prognosis after treatment be exposed early in destructive disease control.21 since less periodontal destruction has process.1 A study was conducted on presumably occurred. Alternatively a extracted teeth to determine whether the iii) Labial cervical vertical furcation involved molar with a long root periodontal attachment loss was groove(LCVG)- trunk and short roots may not be a significantly different for root surfaces It starts on the cervical enamel and candidate for root resection, since these with and without proximal root grooves. extends to the radicular surface and teeth lose more periodontal support with For incisors and premolars, a significant resembles a furrow and has also been furcation invasion.19 greater loss of attachment was described as notch. This furrow gradually demonstrated on grooved than on non- grows deeper in apical direction and may Furcation: grooved surfaces. For premolars, the occasionally run throughout the root Furcation areas present some of the difference in loss of attachment between surface. It is assumed that this greatest challenge to the success of grooved and non-grooved surfaces was malformation is a developmental periodontal therapy. The anatomy of consistently higher than for incisors and anomaly in which an infolding of the furcation favors retention of bacterial decrease in the effect of root groove with enamel organ and Hertwigs epithelial deposits and makes periodontal increasing attachment was not seen. root sheath creates a groove on the labial debridement as well as oral hygiene These differences between the two surface of permanent maxillary procedures difficult.19 groups are presumably related to incisors.18 variation in root groove morphology. Periodontal pockets in furcation areas of While incisors generally display shallow The presence of LCVG may exacerbate multi-rooted teeth offer particular “U” shaped groove that sometimes some clinical aberrations such as esthetic difficulties with respect to debridement, disappears apically, premolars typically deficiency on gingival marginal contour, due to limited accessibility through the show a more “V” shaped groove which accumulation of plaque and furcation entrances as well as the persists towards the apical area. Thus not consequently gingival pocket with bone complexity of the root anatomy. only the presence of root groove, but also loss, as well as failures in endodontic and Progression of the destructive their morphology influences periodontal periodontal treatment18 . Most LCVGs are periodontitis lesions into the furcation disease progress.20 mild and often difficult to detect. region of the multi-rooted teeth is However severe LCVG will result in promoted to a large extent by the ii) Palatoradicular Groove / more gingival irregularity. LCVG's with morphology of the root complex with its Distolingual Groove / Developmental moderate grade of severity were found to macroscopical and microscopical radicular anamoly / Radicular lingual be 5 times more susceptible to partial structures.23 groove- coverage of the gingival margin and 6 These morphological defects are times more prone to irregular gingival Several morphologic factors related to associated with maxillary central and/or coverage than LCVG with mild grade of the furcations and roots contribute to the lateral incisors. These grooves usually severity. This and the increase in the etiology and compromised prognosis of begin in central fossa, cross the cingulum sulcus depth in LCVG incisors are the furcation involved teeth. These and extend apically for various distances adverse predispositions for periodontal factors include root trunk length, and direction. The prevalence of this sequelae, calling for cautious oral furcation entrance width, root separation, anatomic root characteristic has been hygiene maintenance18 . root surface area, root concavities, reported to be 0.5% on a subject basis. cervical enamel projections, bifurcation Most palatogingival grooves (93.8%) are Root grooves significantly enhance the ridges & enamel pearls.24 detected in maxillary lateral incisor teeth loss of periodontal attachment. Such and 58% extend more than 5mm apical to grooves may compromise the patients Bifurcation Ridges: CEJ1. The epithelial attachment in this self care, reduce the operator's access for Bifurcation ridges are one of the area is normally diseased, forming a adequate subgingival scaling and contributing anatomical factors in the ready pathway for the ingress of bacterial jeopardize an otherwise successful etiology and compromised prognosis of endotoxin and the formation of an periodontal treatment; therefore attention furcation involved teeth. infrabony pocket.21 should be paid to the handling of the root Two types of bifurcation ridges have grooves in prophylaxis and treatment of been described.19 A study by Leknes et al. reported periodontal disease.18, 20, 21 I) Intermediate unsuccessful attempts to treat ii) Buccal / lingual ridges periodontal lesions associated with PRG Root Trunk Length: and suggested that extraction of the Root trunk length is defined as area of the Intermediate bifurcation ridges connect involved tooth is the choice of tooth extending from CEJ to the the mesial and distal roots and are

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 001 composed primarily of cementum. Table-1 summarizes the prevalence of important anatomical factors known to affect periodontal tissues Buccal and lingual ridges are composed primarily of dentin with overlying thin Tooth Anatomic features Prevalence 2 layers of cementum. Maxillary incisors Palatal grooves 0.79-21%

A study was conducted by Hou et al. to 98% of all grooves found in lateral incisors investigate the correlation of Maxillary first bicuspids Root trunk length; avg 4-14.6mm intermediate bifurcation ridges and CEP with furcation involvement in 87 furcally Furcal concavity on palatal aspect of buccal root 62% involved mandibular molars. Their Mesial root concavities 100% results indicated that 63.2% of molars with furcation involvement had CEP's & Furcation entrance diameter <0.75mm 57% intermediate bifurcation ridge with Maxillary molars Furcation entrance diameter <0.75mm 63% mandibular first molars having greater prevalence (67.9%) than mandibular 2nd Root trunk length; averages molars (54.8%). A highly significant Mesial:3.5-4.2mm differences in clinical parameters of disease (pocket depth, CAL, plaque & Buccal:4.0-4.8mm gingival indices) was also found between Distal:3.3mm mandibular 1st & 2 nd molars with CEP's and intermediate bifurcation ridges Cervical enamel projections 32.6% 25 compared to those without. Mandibular molars Furcation entrance diameter <0.75mm 50%

In another study by Gher ME et al., the Root trunk length; averages topography of furcation of maxillary & Buccal:2.4-3.14mm mandibular molars was studied and it was found that furcation areas demonstrated Lingual:2.5-4.17mm presence of numerous intermediate Cervical enamel projections bifurcation ridges which present difficulties in proper debridement when First molars 80.4% the periodontal pocket reaches furcation Second molar 48.4% entrance and runs into the furcation area.16 Bifurcation ridges 65.5-76%

Cervical enamel projections: Cervical enamel projections are ectopic deposits of enamel apical to the level of total of 78 individuals aged 21-61 years disease at furcation.28 normal cemento-enamel junction, which with furcation involvement were may have tapering form and extend into 1 examined for the presence of CEP's. It CEP's are probably related to the more the root furcation areas. Cervical enamel was found that 67.9% of the 78 rapid progression of pocket formation projections are classified , using CEJ as a individuals had CEP's. The prevalence of because of their anatomy and location. landmark; CEP's in molars with and without The enamel covering of the CEP would furcation involvements were 82.5% and preclude an organic connective tissue Grade I - Short but distinct change in 17.5% respectively. Statistical analysis attachment, instead a hemi-desmosomal contour of CEJ extending towards the revealed a significant difference between attachment probably exists in the region furcation. periodontal furcation involvement and of the CEP, and this seems less resistant to Grade II - CEP approaches the furcation presence of CEP's. Furcation the breakdown by bacterial plaque. Once without making contract with it. involvements with CEP's were the breakdown occurs, rapid progression Grade III - CEP extends into the 26 associated with poor oral hygiene as of the disease becomes more likely furcation. measured by GI and PI.28 because the projection morphology of the cervical enamel allows the retention of Strong association have been shown for In a consensus report on tooth related the microbial plaque. In addition the the presence of CEP and furcation issues by Blieden et al., it was region's inaccessibility to the cleansing involvement based on cross sectional summarized that 15-25% of mandibular and its proximity to the furcation could evaluation of extracted teeth, in human 2 6 , 2 7 , 2 8 molars and 9-25% maxillary molars have predispose to further furcation invasion. skulls and human subject. CEP's and implicated them in periodontal Whether a cause and effect relationship Examination of 5000 extracted molars of destruction in furcation area.2 exists or not, requires more studies.1 human subjects showed a positive correlation between enamel projection 29 Although strong associations have been Enamel Pearls: and furcation involvement. found, there are no prospective studies In a review, it has been suggested that showing a cause and effect relationship enamel pearls may have same clinical A clinical study was conducted where between CEP's and development of implications as cervical enamel

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 001 projections in regards to the possible Root proximity: progression of plaque induced gingival predisposition to certain types of osseous Proximity of the roots of adjacent teeth is disease and periodontitis. defects. It has been postulated that fibers widely held as a risk factor for of the periodontal ligament could have no development of periodontal disease. References: true attachment in the areas of enamel 1. Leknes KN. The influence of pearl. The presence of enamel pearl on Root proximity may present an anatomic and iatrogenic root surface the root surface is more significant in impediment to self-performed or characteristics on bacterial and those cases in which they are connected professionally applied plaque removal, periodontal destruction: A Review. J by cemento-enamel projections to and in this way lead to enhanced gingival periodontal 1997; 68(6) :507-516. cervical enamel, rather than separated inflammation. Because the volume of 2. Matthews DC, Tabesh M. Detection from the crown by epithelial attachment connective tissue and bone is reduced in of localized tooth -related factors that and a wide zone of healthy cementum and areas where the tooth roots are in close predispose to periodontal infections. periodontal ligament. Enamel pearls and proximity, any inflammation that occurs Periodontol 2000; 2004;34:136-50 cervical enamel projections can occur on at these sites is thought to easily destroy 3. Blieden T M. Tooth related issues. the same teeth and when they do, can be this tissue. There is no scientific evidence Ann periodontal 1999;4(1): 91-7 contiguous with each other. to support this contention, however. In 4. Buckley LA. The relationship fact, a long-term study of root proximity between malocclusion and Root concavities: after orthodontic treatment showed no periodontal disease. J Periodontol Root concavities are a significant feature predisposition to more rapid periodontal 1972; 43(7): 415-7. of root configuration. The concavities breakdown. 5. Wasserman B H, Thompson RH Jr, can vary from shallow flutings, as seen on Geiger AM, Goodman SF, Pomerantz the mesial and distal surfaces of the Summary: J, Tyugeon LR, BeubeFE. canines, to deep developmental grooves Periodontitis is a multifactorial Relationship of occlusion and on the mesial surface of maxillary first infectious disease. Over the last century periodontal disease. II. Periodontal premolars. These concavities increase numerous investigators have attempted status of study population. J the attachment area and produce a root to define etiologic agents of the diseases Periodontol. 1971;42(6): 371-8. shape that is resistant to torquing forces. and it is not clear that specific bacterial 6. Silness J, Roynstrand T, Relationship Conversely, concavities can act as pathogens are the primary etiologic between alignment conditions of predisposing factors in the disease agents. Several conditions exist around teeth in anterior segments and dental process by providing a safe haven for teeth that may predispose the health. J Clin Periodontol 1985; bacterial plaque and by complication oral periodontium to disease. Diverse 12(4): 312-20. hygiene procedures. The concavities, morphologic tooth deformities found on 7. Kornman KS, Loe H. The role of local which are limited mainly to the proximal tooth/root surface such as cervical factors in the etiology of periodontal surfaces, are generally inaccessible for enamel projections, enamel pearls, molar diseases. Periodontol 2000 1993 2; cleaning with routine oral hygiene root concavities, intermediate bifurcation 83-97 procedures. Interproximal cleaning ridges, architecture of furcation 8. Jernberg GR., Bakdash MB, Keenan devices, although potentially more entrances, root fusions may adversely KM. Relationship between proximal effective than brushing, are time influence the course and the management tooth open contacts and periodontal consuming and only partially successful of periodontal disease. Position of the disease. J Periodontol 1983; 54(9): in removing bacterial plaque. This may tooth in arch and mucogingival 529-33. discourage long term compliance by deformities can also enhance bacterial 9. Koral SM, Howell T.H, Jeffcoat MK. patients in maintaining proper oral accumulation or allow ingress of bacteria Alveolar bone loss due to open hygiene.16 into periodontium. The primary goal of interproximal contacts in periodontal periodontal therapy is to produce an disease. J Periodontol 1981 ;52(8): A literature review by Bower RC et al. environment that is conducive to oral 447-50. concluded that these root concavities and health. Local etiologic factor may 10. Geiger A M, Wasserman B H, divergences make it unlikely that prevent removal of supragingival plaque Turgeon L R . Relationship of adequate root preparation by root and may even contribute to destruction of occlusion and periodontal disease. 8. planning can be achieved and straight and periodontal tissues. Thus it is crucial to be - Relationship of crowding and rigid cleaning devices (floss & wood able to recognize and when possible, spacing to periodontal destruction points) are unlikely to remove all eliminate any plaque retentive factors and gingival inflammation. J plaque.30 The cementum formed in the that could contribute to disease Periodontol 1974; 45(1):43-49. concavity, especially the more porous progression. Such factors compromise 11.Woofler C. The prevalence and cellular cementum, is likely to form a patient's self care, reduce operators etiology of gingival recession. reservoir for endotoxin on the access for subgingival scaling and Periodontal Abstr. 1969; 17(2): 45-50 periodontally involved root surface, jeopardizes otherwise successful 12. Grant, Stern , Listgarten. Treatment rendering it biologically unacceptable for periodontal treatment. In Consensus of periodontal trauma. Periodontics , attachment or approximation of soft report by World Workshop in Clinical sixth edition. C.V Mosby company tissues. These concave surfaces make Periodontics (1999) it was rightly stated 1988. both plaque removal and various that "tooth related conditions are not 13.Kepic TJ, O'Leary TJ. Role of periodontal therapeutic procedures separate disease entities". But they may marginal ridge relationship as an difficult.31 serve as localized predisposing and/or etiologic factor in periodontal modifying factors in the onset or disease. 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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 001 570-5. grooves: A risk factor in periodontal projections as an etiologic factor in 14. Haney JM, Leknes KN, Lie T, Selvig attachment loss . J Periodontol furcation involvement . J Am Dent KA, Wikesjo UM. Cemental tear 1994;65(9):859-63. Assoc 1976; 93(2) :342-5. related to rapid periodontal 21.Hou GL, Tsai CC. Relationship 27. Bissada NF, Abdelmalek RG. breakdown: A case report. J between palato-radicular grooves and Incidence of cervical enamel Periodontol 1992; 63(3):220-4. localized periodontitis. J Periodontol projections and its relationship to 15. Ishikawa I, Oda S., Hayashi J., 1993;20(9) :678-82. furcation involvement in Egyptian Arakawa S. Cervical cemental tears 22. Hou GL, Chen YM, Tsai CC, skull. J Periodontol 1973; 44(9) :583- in older patients with adult Weisgold AS. A new classification of 5. Periodontitis. Case reports. J molar furcation involvement based 28. Leib AM, Berdon JK. Furcation Periodontol 1996; 67(1) :15-20. on the root trunk and horizontal and involvements correlated with enamel 16. Gher ME, Vernino AR. Root vertical bone loss. Int J Periodontics projections from the cementoenamel morphology - clinical significance in Restorative Dent 1998; 18(3): 257- junction. J Periodontol 1967; 38(4): the pathogenesis and treatment of 65. 330-4. periodontal disease. J Am Dent Asoc 23.Svardstrom G, Wennstrom JL. 29. Shiloh J, Kopezyk R. Developmental 1980 ;101(4): 627-33. Furcation topography of the variations of tooth morphology and 17. Gher MW Jr, Dunlap RW . Linear maxillary and mandibular first periodontal disease. J Am Dent Assoc variation in root surface area of molars. J Clin Periodontol 1988; 1979;99(4): 627-630. maxillary first molar. J Periodontol 15(5) :271-5. 30. Bower RC. Furcation morphology 1985; 56(1): 39-43. 24. Santana RB, Uzel MI, Gusman H, relative to periodontal treatment. 18. Mass E, Aharoni K, Vardimon AD. Gunaydin Y, Jones JA, Leone CW. Furcation root surface morphology. J Labial-cervical-vertical groove in Morphometric analysis of the Periodontol 1979; 50(7):366-74. maxillary permanent incisors- furcation anatomy of mandibular 31. Booker BW 3rd, Loughlin DM. A prevalence, severity and affected soft molars. J Periodontol 2004; 75(6): morphologic study of the mesial root tissue. Quintessence Int 2005 ;36(4) 824-9. surface of the adolescent maxillary :281-6. 25. Hou GL, Tsai CC. Cervical enamel first bicuspid. J Periodontol 1985; 19. AL-Shammari KF, Kazor CE, Wang projection and intermediate 56(11) :666-70. HL.Molar root anatomy and bifurcational ridge correlated with management of furcation defects. J molar furcation involvements. J Clin Periodontol 2001:28(8):730-40. Periodontol 1997; 68(7): 687-93. 20. Leknes KN, Lie T, Selvig KA. Root 26. Swan RH, Hurt WC. Cervical enamel

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 001 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Biofilms In Orthodontics - Formation, 1 Vivek Mahajan 2 Anil Singla Prevention And Clinical Implication 3 H.S Jaj 4 Vishal Seth 1 Sr. Lecturer Abstract 2 Professor and HOD Dental biofilm has long been associated with tooth decay and periodontal disease. Fixed 3 Reader appliances induce continual accumulation and retention of bacterial plaque, which constitute a risk 4 Sr. Lecturer of white spot lesion development during orthodontic treatment and is usually associated with Dept. Of Orthodontics, HDC, Sundernagar enamel decalcification, enamel scarring, dental decay, and gingivitis. Moreover, orthodontic Address For Correspondence: appliances severely hamper the efficacy of toothbrushing, reduce the self-clearance by saliva, Dr. Vivek Mahajan change the composition of the oral flora, and increase the amount of oral biofilm formed and the Senior Lecturer colonization of oral surfaces by cariogenic and periodontopathogenic bacteria. These factors Department of Orthodontics, strongly complicate orthodontic treatment, and illustrate that the need for oral biofilm control is Himachal Dental College & Hospital even greater during orthodontic treatment than usual Sundernagar Dist.Mandi (H.P) Email : [email protected] Ph : 09736222587 Key Words Dental Biofilm, Plaque, Gingivitis Submission : 17th November 2011 Accepted : 18th February 2012

Introduction Composition and Mechanism of Quick Response Code The placement of orthodontic appliances Biofilm Formation on teeth not only impedes the Oral biofilms, including orthodontic maintenance of a proper oral hygiene1, 2 biofilms (oral biofilms formed on but also increases the level of cariogenic orthodonticbiomaterials during active bacteria in the oral cavity3-5 , leading to orthodontic treatment or retention serious biofilm-related side-effects such phase), are diversecommunities of as white spot lesions and gingival microorganisms on dental hard and soft inflammation6-8 , compromising facial tissues and dental biomaterials. These esthetics after an often lengthy and costly biofilms are embedded in an extracellular solid phase components including course of orthodontic treatment.The most matrix of polymers of host and microbial proteins, carbohydrates, fat, and common site for bacterial adhesion and origin, possessing complex spatial, inorganic components. The composition biofilm formation is at the bracket- heterogeneous and dynamic of orthodontic biofilms varies during the adhesive-enamel junction, an area that is structures16. Oral biofilms in general 8, 9 course of treatment. Placement of an difficult to clean by daily brushing . comprise about 80% water and 20% of orthodontic appliance increases not only Oral biofilms at this junction not only cause damage to oral hard and soft tissues but also weaken the bond strength of adhesives10-12 . Excessive adhesive around brackets especially provide a site for the rapid adhesion and growth of bacteria13 . Furthermore, the surface of an orthodontic adhesive is often rough, with a gap of around 10um at the adhesive enamel interface due to polymerization shrinkage. This provides adhering bacteria with a protected site against oral cleansing forces14, 15 . Consequently, the bracket-adhesive-enamel junction is a critical site for bacterial adhesion and biofilm formation in orthodontic patients. Fig. The development of a biofilm, depicted as a five-stage process. Stage 1: initial attachment of cells to the surface; stage 2: production of the extracellularexopolysaccharide matrix; stage 3: early development of biofilm architecture; stage 4: maturation of biofilm architecture; stage 5: dispersion of bacterialcells from the biofilm18

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 102 the amount of biofilm,but also the brackets (Eliadeset al., 1995). Therefore, Mechanical control. prevalence of cariogenic bacteria such as it might be expected that streptococci Effective manual or powered brushing mutans streptococci and lactobacilli17 adherepreferentially to metal brackets, and the use ofinterdental brushes is still which have higher surface-free energy by far the most important measure for Molecules are adsorbed to the tooth (Weerkampet al., 1985; Kilianet al. oral hygienecontrol in orthodontic surface within seconds immediately after Invivo, maxillary brackets harvested patients .The auxiliary interdental brush cleaning or following initial exposure to more S. mutansand S. sobrinusthan is helpful in removing biofilm formation the oral environment, and remain mandibular brackets22 while labial behind the wire during orthodontic functional(53). These molecules are brackets harvested more biofilm than treatment26 . Despite the fact that new derived mainly from saliva, but, in the lingual brackets23 Brackets have shown designs of general toothbrushes came on subgingival region, molecules originate the most adsorption capability of whole the market, longer brushing time and from gingival crevicular fluid. The saliva protein constituents while intra proper brushing techniques are still conditioning film alters the properties of oral elastics and springs have shown necessary for good oral hygiene in the surface, and bacteria interact directly much less affinity to salivary proteins. orthodontic patients. with the constituent molecules. Method of ligation Chemical Biofilm Control. Stoodley et al 18 described biofilm The labialenamel of teeth ligated with an A variety of chemical biofilm control formation through sequential steps in elastomeric ringmay exhibit a measuresincluding incorporation of which the initial attachment of planktonic significantly higher number ofmicro- antimicrobials in toothpastes, bacteria to a solid surface is followed by organisms in the plaque than mouthrinses, varnishes and adhesives are their subsequent proliferation and incisorsligated with steel wire (Forsberg currently used by the dental profession, accumulation in multilayer cell clusters, et al., 1991)5 . Clinical observation has including orthodontists. Chlorhexidine and the final formationof the bacterial indicated that acommon site of however, still remains the most effective community enclosed in a self-produced demineralization is at thejunction antimicrobial inreducing biofilm- polymeric matrix. Once the structure has between the bonding resin and induced iatrogenic side effects in developed, some bacteria are released theenamel, just peripheral and commonly orthodontic patients and S.mutanslevels . into the liquid medium, enabling the gingivalto the bracket base (Gwinnett Unfortunately, long-term use of biofilm to spread over the surface. and Ceen, 1979). chlorhexidine is known to stainteeth and tongue and affect taste sensation. The Factors influencing orthodontic Arch wires benefits of fluoride containing biofilm formation Complicated appliance designs with toothpastes and mouthrinses in Banding vs bonding Bandinginduced loops and auxiliary arch wirescreate preventing caries have been well more orthodontic biofilm formation areas that are difficult to clean and may establishedand besides aiding enamel ,gingival inflammation and white spot therefore enhance biofilm formation24 . remineralization, fluoride acts as a buffer lesions than bonding19 . Most biofilm was to neutralizeacids produced by bacteria located at the gingival margin, with more Retainers and suppresses their growth. band surface being covered by biofilm at Removable orthodontic retainers may the supragingival area than at the sub- attract oral biofilm andpresent new Modification of Orthodontic gingival one20 . retention sites, similar to removable Materials. acrylic plates, favoring bacterialadhesion Modification of orthodontic materials Adhesives: Excessive composite resin at and growth25 . Fixed retainers are in direct iseither aimed at reducing the the bracket-enamel-adhesive junction is contact with the enamel surface and consequences of orthodontic biofilms or prone to bacterial adhesion, especially cannot be removed for extensive cleaning at preventingbiofilm formation and since polymerization shrinkage may like removable ones. Therefore they are includes incorporation of chemicals in yield a gap with a width of up to 10 um at generallyconsidered to yield increased the adhesive or coating of bracket and the adhesive-enamel interface where biofilm formation with negative wire materials bacteria find themselves protected consequences with respect to gingival against oral cleansing forces2 1 . inflammation Clinical implications and future research Roughness of the composite surface It has been shown that surface roughness predisposes to rapid attachmentand Thus, it is conceivable that different types increases the bacterial adhesion forces, it growth of oral micro-organisms of biofilms will be formed on those would be desirable that orthodontists (Weitmannand Eames, 1975; Gwinnett orthodontic surfaces as they are of minimize the adhesive surface roughness and Ceen, 1979). constructed from various materials, their by smoothing, polishing, or varnishing elasticity and their topography varies. after bonding. This is a simple yet Brackets, Elastics and springs efficient way to reduce bacterial adhesion According to thermodynamic rules, Prevention of orthodontic Biofilm at the bracket-adhesive enamel junction. bacteria with high surface-free energy Development of orthodontic materials Orthodontic material manufacturers prefer high surface-free energy materials attracting less biofilms has been a goal might also provide additional procedures (Busscheret al., 1984; Van Dijket al., fordecades. Attempts have been made to to decrease the surface roughness of their 1987).It has been suggested that metal develop effective antimicrobial products for clinical practice.Although brackets increase bacterial adhesion adhesives toprevent orthodontic the hydrophobicities of stainless steel, because oftheir high surface energy biofilms. adhesives, and enamel were different, the compared with that of plastic and ceramic salivary conditioning film decreased this

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 103 difference significantly and there with 2008;14:183-193. Periodontol 2000 2010;55:16-35 also the bacterial adhesion forces. This 7. Willmot D. White spot lesions after 18. Stoodley P, Sauer K, Davies DG, indicates that the development of orthodontic treatment. Seminars in Costerton JW. Biofilms as complex antibacterial modification of orthodontic Orthodontics 2008;14:209-219. differentiated communities. Annu materials should always take the effects 8. Mei L, Busscher HJ, Van der Mei HC, Rev Microbiol 2002;56:187-209. of a salivary conditioning film into Chen Y, De Vries J, Ren Y. Oral 19. Boyd RL, Baumrind S. Periodontal account. As the adhesion forces of initial bacterial adhesion forces to considerations in the use of bonds or colonizers were significantly stronger biomaterial surfaces constituting the bands on molars in adolescents and than those of the more cariogenic strains, bracket-adhesive-enamel junction in adults. Angle Orthod 1992;62:117- while adhesion of initial colonizers is orthodontic treatment. Eur J Oral Sci 126. determinant for the strength of adhesion 2009;117:419-426. 20. Demling A, Demling C, Schwestka- of the overlaying biofilm structure65, 9. Sukontapatipark W, El-Agroudi MA, Polly R, Stiesch M, Heuer W. future research should be directed toward Selliseth NJ, Thunold K, Selvig KA. Influence of lingual orthodontic prevention of the adhesion of initial Bacterial colonization associated therapy on microbial parameters and colonizers.The long duration of with fixed orthodontic appliances. A periodontal status in adults. Eur J orthodontic treatments and salivary flow scanning electron microscopy study. Orthod 2009;31:638-642. in the oral cavity favor orthodontic Eur J Orthod 2001;23:475-484. 21. Sukontapatipark W, El-Agroudi MA, materials with non-leaching, long lasting 10. Guzman-Armstrong S, Chalmers J, Selliseth NJ, Thunold K, Selvig KA. bactericidal properties. The modification Warren JJ. Ask us. White spot lesions: Bacterial colonization associated of an orthodontic adhesive with a prevention and treatment. Am J with fixed orthodontic appliances. A quaternary ammonium compound Orthod Dentofacial Orthop scanning electron microscopy study. provided efficient contact-killing, with 2010;138:690-696. Eur J Orthod 2001;23:475-484. promising prospects for clinical 11. Petersilka GJ. Subgingival air- 22. Ahn SJ, Lim BS, Lee SJ. Prevalence application. Future research to enhance polishing in the treatment of of cariogenic streptococci on incisor the mechanical strength by improving the periodontal biofilm infections. brackets detected by polymerase processing conditions, i.e. curing the Periodontol 2000 2011;55:124-142. chain reaction. Am J Orthod samples at a higher temperature, or 12. Matasa CG. Microbial attack of Dentofacial Orthop 2007;131:736- adding a diacrylate to increase the density orthodontic adhesives. Am J Orthod 741. of crosslinking, would be approaches Dentofacial Orthop 1995;108:132- 23. Van der Veen MH, Attin R, worth exploring. 141. Schwestka-Polly R, Wiechmann D. 13. Holmen L, Thylstrup A, Artun J. Caries outcomes after orthodontic References Surface changes during the arrest of treatment with fixed appliances: do 1. Effectiveness of a chlorhexidine active enamel carious lesions in vivo. lingual brackets make a difference? dentifricein orthodontic patients: a A scanning electron microscope Eur J Oral Sci 2010;118:298-303. randomized-controlled trial. J study.ActaOdontolScand 24. Ogaard B. White spot lesions during ClinPeriodontol 2006;33:421-426. 1987;45:383-390. orthodontic treatment: mechanisms 2. Ogaard B, Ten Bosch JJ. Regression 14. Ahn HB, Ahn SJ, Lee SJ, Kim TW, and fluoride preventive aspects of white spot enamel lesions. A new Nahm DS. Analysis of surface Seminars in Orthodontics optical method for quantitative roughness andsurface free energy 2008;14:183-193. longitudinal evaluation in vivo. Am J characteristics of various orthodontic 25. Batoni G, Pardini M, Giannotti A, Orthod Dentofacial Orthop materials. Am J Orthod Ota F, Giuca MR, Gabriele M et al. 1994;106:238-242. DentofacialOrthop 2009;136:668- Effect of removable orthodontic 3. Pender N. Aspects of oral health in 674 appliances on oral colonisation by orthodontic patients. Br J Orthod 15. Lee SP, Lee SJ, Lim BS, Ahn SJ. mutans streptococci in children. Eur J 1986;13:95-103. Surface characteristics of orthodontic Oral Sci 2001;109:388-392. 4. Mattingly JA, Sauer GJ, Yancey JM, materials andtheir effects on adhesion 26. Ahn SJ, Lim BS, Lee YK, Nahm DS. Arnold RR. Enhancement of of mutans streptococci. Angle Orthod Quantitative determination of Streptococcus mutans colonization 2009;79:353-360. adhesion patterns of cariogenic by direct bonded orthodontic 16. Al Mulla AH, Kharsa SA, Kjellberg streptococci to various orthodontic appliances. J Dent Res H, Birkhed D. Caries risk profiles in adhesives. Angle Orthod 1983;62:1209-1211. orthodontic patients at follow-up 2006;76:869-875. 5. Forsberg CM, Brattstrom V, using Cariogram. Angle Orthod Malmberg E, Nord CE. Ligature 2009;79:323-330. wires and elastomeric rings:two 17. Marsh PD, Moter A, Devine DA. methods of ligation, and their Dental plaque biofilms: association with microbial communities, conflict and control. colonization of Streptococcus mutansand lactobacilli. Eur J Orthod 1991;13:416-420. 6. Ogaard B. White spot lesions during Source of Support : Nill, Conflict of Interest : None declared orthodontic treatment: mechanisms and fluoride preventive aspects Seminars in Orthodontics

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 104 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Orofacial Pain in Oncology Patients : 1 Maryam Kuzekanani 2 Hengameh Ashraaf Prevalence, Etiology, Differential Diagnosis, 1 Associate Prof Department of Endodontics, Management Kerman Dental School, Kerman Iran 2 Associate Professor Department of Endodontics, Abstract Shahid Beheshti School of Dentistry.Tehran Orofacial pain in cancer patients is a common complication.It happens because of the cancer itself or because of a wide range of anti-cancer treatments such as chemotherapy & radiation therapy or Address For Correspondence: both factors together..Some times this pain is very severe and doesn,t relieve after administration Dr. Maryam Kuzekanani of strong analgesic drugs.Since it intensifies through agressive anti cancer treatments such as Associate Prof Department of Endodontics, high dosages of administration chemotherapy drugs,it may end to the cease of the treatment Kerman Dental School, Kerman Iran itself,so this pain may be life threatening and can be a challenge for providing public health. The E-mail : [email protected] aim of this review of the literature paper is to describe the prevalence,etiology, physiopathology Phone NO : 0098-341-2456448 ,differential diagnosis and to give some recommendations for managing this pain as much as Mobile NO : 0098-9131416717 possible. Submission : 12th June 2011 Key Words Accepted : 08th December 2011 Orofacial, Pain, Oncology Quick Response Code

Introduction determine the incidence of orofacial pain Cancer accompanied with it,s Radical in Oncology 1 patients have reported methods of treatment is a problem high incidence of this complication . suffered by many patients all over the McCarthy & Skillings have reported world.Despite several investigations orofacial neurotoxicity and neuropathic done to clear the mysteries of this disease pain in a group of Chemo treated breast6 still it remains a great challenge in cancer patients as high as 65% up to 86 % palate and floor of the mouth.These signs providing public health. In relation to . .A more recent study in 2007 has also and symptoms of mucositis are denistry and specially to Endodontics reported the 1 incidence of this diagnosed approximately 6-10 days after peripheral neurotoxicity and neuropathic complication up to 70% in patients with starting Chemo therapy treatments .In the pain in orofacial tissues are common side cancer . patients who intake high dose effects of cancer and a wide range of anti- neutropenia-inducing chemo drugs cancer treatment plannings .Such pain Etiology specially in malignancies with epithelial the origin of which if not diagnosed and The main cause of the orofacial pain in origin hard pain is the most important7,8 not treated may affect the whole quality cancer patients is the tumor itself because symptom of this mucositis which makes of life 1 of the patient and may cause of the space occupying(87%-93%) and in patient contact with the clinical team. severe chronic to acute discomfort . Since much less numbers of the patients(17%- this pain can not be 2,3 controlled by the 21%) it happens following anti cancer Physiopathology analgesic drugs it may finally end to the treatments such as chemo and According to Clark and Saravanan in cease of the treatment itself.The radiotherapy, although these causes of 2008 approximately in 50% of all cancer neuropathic pain in Oncology patients orofacial pain1 may both at the same time patients the Orofacial pain is caused manifests as a diffuse jaw pain or be responsible for this complication completely or partly by neuropathy. The numbness and is 4,5 sensed quite .Leukemic infiltration,secondary nerve damage followed by the different from the localized tooth pain anemia, chemotherapy or radiotherapy administation of the chemo drugs may with pulpal origin.The purpose of current mucositis, post surgery pain,secondary involve sensory and motor nerves alone review of the literature paper is to infection,osteoradionecrosis or both together.The accumulation of the describe the prevalence,etiology, ,bisphosphonate related cytotoxic by products of the drugs during differential diagnosis and management of osteoradionecrosis of the jaws are some all cycles of administration leads to this this life threatening side effect of the 0f the well known causes of this orofacial complex nerve damage which is cancer and related anti cancer treatment s pain.The most common acute oral side maximum in the last cycles of such as chemo and radiation therapy. effect of cancer chemotherapy or administration so the orofacial pain in radiotherapy is oral mucositis in tissues oncology patients caused by the nerve Prevalence such as buccal and labial mucosa ,ventral damage usually appears and intensifies in All Epidemiologic researches done to and lateral aspects of the tongue ,soft the last rounds or in high dosages of

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 105 applications and in 1,2,8 resting cycles .If the pain is originated from the c,ancer: Part 2:Clinical perspectives this pain reduces or at all diminishes. mucositis ,the injury to the tissues causes and management .J Dent release of reactive oxygen species and Res2007:86:506-518 Differential Diagnosis periinflammatory cytokines . To relieve 5. Fischer D, ClasserG, Epstein Although the diffuse jaw pain or this pain in step one, non steroid J.Cancer and orofacial pain .J oral numbness in cancer patients is sensed antiinflammatory drugs and instep2 Maxillofac Clin North quite different from localized toothache weak opoid drugs and in the step 3 strong Am2008:;20:287-301 with pulpal origin , some authors in the 0p0id drugs are administered.AS it was 6. Mc Carthy GM,Skillings literature have reported that high dosage stated before in some of the patients this JR.Orofacial complications of administration of the chemotherapy orofacial pain doesn,t respond to the chemotherapy for breast cancer drugs specially cyclophosfamides may analgesic10 drugs well and at last may patients.Oral Surg Oral Med Oral cause toothache which just relieves after end to the cease of the treatment itself. Pathol1992;74:172-178 pulp extirpation .This condition may 7. Benoliel R, Eliav E.Neuropathic become a challenge for the dentist to find References orofacial pain.Oral &Maxillofacial out the etiology of the dental pain since it 1. Benoliel R, Epstein J,Eliav E,Elad S. SurgClin North Am2008;20:237-254 happens because of severe neurotoxicity Orofacial pain in cancer:part1.J Dent 8. Sharav y, Benoliel R.Orofacial pain and as a result severe neuropathy Res2007;86:491-505 and headache.1st followed by administration of the high 2. lark G.T, Saravanan R. Orofacial pain ed.Edinburgh.2008pp333-339 8,9 dosages of the chemo drugs without and neuro sensory disorders and 9. Zadic Y, Vainstein V.Cytotoxic having any dental problem. dysfunction in cancer patients.J Dent chemotherapy- Clin N Am 2008;52:183-202 inducedodontalgia.Jof Management 3. Sioka C, Kyritsis A.P. Central and Endodontics2010;36:1588-1592 In order to manage the orofacial pain in peripheral nervous system toxicity of 10. Eisenberg E,Marinangel F.Time to oncology patients first of all the clinician common chemotherapeutic modify the WHO analgesic should diagnose the etiology of pain agents.Cancer chemopharmaco ladder?Pain clinical update among multiple causes discussed 2009:63:761-767 2005;23:1-4 before.To treat this pain basically, the 4. Epstein JB, Elad S, Eliav E, Jurevic malignancy should be treated effectively R,Benoliel R.Orofacial pain in

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 106 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Management Of Oral Sub-Mucous Fibrosis : A 1 Shevale Vasant V 2 Kalra Rinku D Review 3 Shevale Vruturaj V 4 Shringarpure Milind D Abstract 1 Prof. And Head Oral Submucous fibrosis is a crippling disease affecting the oral cavity and extending upto pharynx 2 and esophagus. It is most common in the countries of south-east Asia and shows greater Lecturer 3 Lecturer predisposition towards the Indian ethnic group. Despite its prevalence and association with a 4 Professor significantly increased risk of cancer, its etiology is still not clear. It could lead to a spectrum of oral Deptt. of Oral & Maxillofacial Surgery deformities ranging from inability to open mouth, tongue depapillation, hoarseness of voice to Y.M.T. Dental College, Navi Mumbai. malignancy, which is why it has been grouped as a pre-malignant condition. A number of grading systems and management protocols to deal with this progressive disease have been published in Address For Correspondence: the literature. This paper presents a review of the prevalence, etio pathogenesis and management Dr. Vasant Shevale Flat no. 101/A, 1st Floor, of this condition. Al-Bahar Co-Op Housing Society Cadle Rd, Mahim - 400016 Key Words Phone No.: 09820088992 Oral Submucous Fibrosis (OSMF), Medical Management, Surgical Management Email ID : [email protected] Submission : 12th June 2011 Accepted : 08th December 2011

Quick Response Code Introduction: The non surgical management of such a Oral sub mucous fibrosis (OSMF) is an patient includes discontinuation of the insidious, chronic, resistant disease habit, avoidance of spicy foods, which may involve the submucosa of any medicinal measures like local steroids, part of the oral cavity and may extend placental extracts, hyaluronidase upto pharynx and esophagus. The disease injections singly or in combination and which was considered primarily a disease oral anti-oxidant supplements along with prevailing in the southern Asia and jaw opening exercises. Surgical southern Asian immigrants to other parts measures attempting at excision of (1,2) fibrous bands, coverage of resultant (7) of the world has now gained submucous fibrosis , idiopathica considerable attention world-wide. defects with skin grafts, collagen or other (8) scleroderma of the mouth , idiopathic dressing materials, buccal pad of fat, palatal fibrosis(9) The etiology of this crippling disease is local flaps, vascularised flaps, with or complex even though the actual without coronoidectomy and post- Prevalence: mechanism is obscure. The condition has operative active jaw physiotherapy have Global estimates from 1996 indicate that a multifactorial origin but is commonly been documented. (10) associated with chewing of areca nut about 2.5 million people have OSMF . (3) However, results from studies conducted (betel nut) habitually . History: (11) 0SMF has been well established in Indian in 2002 indicate that more than 5 The disease has a spectrum of medical literature since the time of million people in India have OSF (0.5 presentations ranging from, excessive Sushruta-- a renowned Indian physician percent of the Indian population). In salivation, burning sensation, absent who lived in the era 600 B.C and was addition, it is estimated that up to 20 percent of the world's population gustatory sensation and limitation of termed as 'Vidari'. It was first described in (12) mouth opening leading to difficulty in the modern literature by Schwartz in consumes betel nut in some form, so chewing, swallowing, articulation and 1952 who coined the term atrophica the prevalence of OSMF probably is poor oral hygiene and its complications. idiopathica mucosa oris to describe an higher than that noted in the published It has been associated with an increased oral fibrosing disease, he discovered in 5 literature. risk of malignancy and hence is Indian women from Kenya(5) . Joshi considered as a pre-malignant condition subsequently coined the termed oral The rate varies from 0.2-2.3% in males (4) and 1.2-4.57% in females in Indian . submucous fibrosis (OSMF) for the (13) condition in 1953(6) . communities. Oral submucous fibrosis The main aim in the treatment of is widely prevalent in all age groups and submucous fibrosis is to relieve the This condition has been referred to under across all socioeconomic strata in India. symptoms and improve the oral opening. a number of names, diffuse oral The occurrence of this condition in children is extremely rare. Youngest case

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 107 reported in the literature was a 4-year-old which arecoline is the main agent. The It manifests as a burning sensation in the girl (14) . A case of OSMF in a 12 year old alkaloid component of the betel nut mouth, intolerance to eating hot and girl was reported in 1993 and the etiology stimulates the inflammatory process (20) . spicy foods, blanching and stiffness of was traced to be the habit of chewing An initial epithelial inflammation is the oral mucosa, trismus, vesiculation, roasted areca nuts (15) . Another case of a 11 followed by fibro-elastic changes in the excessive salivation, ulceration, year old girl was reported in 2001 lamina propria (20,23) . Epithelial atrophy pigmentation change, recurrent highlighting the link between oral and collagen deposition result in the stomatitis, defective gustatory sensation, submucous fibrosis and the regular use of formation of dense fibrotic bands. dryness of the mouth , gradual stiffening areca-nut (paan) and the newer trans- Overactivity during chewing causes and reduced mobility of the soft palate cultural oral tobacco products (16) ischaemic changes. Subsequent fibrosis and tongue leading to difficulty in and scarring in the masticatory muscles swallowing and hyper nasality of voice, A sharp increase in the incidence of oral contribute further to fibrotic band hoarseness of voice (with laryngeal submucous fibrosis was noted after pan formation and trismus. These bands are involvement) and occasionally, mild masala came into the market, and the visible in the palate, buccal and labial hearing loss due to blockage of incidence continues to increase. areas and, in later stages, in the Eustachian tube (29) . Migration of endemic betel quid chewers pharyngeal and oesophageal areas. In has also made oral submucous fibrosis a vitro studies on human fibroblasts using The precancerous nature of oral public health issue in many parts of the areca extracts or chemically purified submucous fibrosis has been observed world, including the United Kingdom, arecoline support the theory of with development of slowly growing South Africa, and many Southeast Asian fibroblastic proliferation and increased squamous cell carcinoma in one-third of countries.(17) collagen formation that is also oral submucous fibrosis patients(30) . In demonstrable histologically in human southern India, 40% of oral cancer Etiopathogenesis: OSMF tissues (24) . The role of areca patients had oral submucous fibrosis(31) . A Although various factors have been alkaloids, copper in fibroblast 7.6% incidence of oral cancer in oral implicated in the development of oral proliferation and increased collagen submucous fibrosis patients has been submucous fibrosis, the exact role of any synthesis, stabilization of collagen reported in a median 10-year follow-up one of these in the development, severity structure by tannins and fibrogenic period (11) . Pindborg et al. summarized the and extent of the disease is not clear, as cytokines, genetic polymorphisms criteria in support of the precancerous the disease may still occur if none of these predisposing to OSMF, role of the nature of the disease as higher prevalence is present. collagen related genes CoL1A2, of leukoplakia among oral submucous COL3A1, CoL6A1, COL6A3 and fibrosis patients, high frequency of When the disease was first described in COL7A1 have been discussed by W.M. epithelial dysplasia, concurrent finding 1952, it was classified as an idiopathic Tilakaratne et al(25) . of oral submucous fibrosis in oral cancer disorder (5) . patients, and histologic diagnosis of A possible autoimmune basis to the carcinoma without the clinical suspicion Earlier workers correlated it with disease with demonstration of various of it(32) . hypersensitivity to capsaicin (Capsicum auto-antibodies and an association with annum and Capsicum fructescens-- an specific HLA antigens A10, DR3, DR7, The malignant transformation rate for active ingredient in chilies -- secondary and probably B7, along with haplophytic OSF is 7 to 30 percent.(1,2,33) to chronic iron and/or vitamin B complex pairs A10/DR3, B8/DR3, and A10/88, deficiencies; or exposure to cashew has been found (26) . These pairs, together The characteristic histologic features of kernel oil(4,18) . Ramanathan summarized with the presence of autoantibodies and OSMF consist of, atrophic epithelium the evidence of OSMF being a mucosal chronic inflammation of the oral mucosa, often keratinized, generally without rete change secondary to chronic iron and/or have been suggested as an autoimmune ridges, and in advanced cases it may be Vitamin B Complex deficiency. He basis of oral submucous fibrosis. ribbon-like with juxtaepithelial suggested that the disease is an Asian hyalinization and collagen of varying analogue of sideropenic dysphagia(19) . Clinical features density(31) . The most frequently affected locations in Currently, the habit of chewing areca nuts oral submucous fibrosis are the buccal Staging: (the fruit of Areca catechu plant) is mucosa and the retromolar areas. It also Pindborg et al described 4 consecutive recognized as the most important commonly involves the soft palate, stages of oral submucous fibrosis based etiologic agent in the pathogenesis of this palatal fauces, uvula, tongue, and labial on histologic findings: very early stage, condition. A number of epidemiological mucosa. It is generally believed that oral early stage, moderately advanced stage, surveys, case-series reports, large sized submucous fibrosis originates from the and advanced stage(34) . cross sectional surveys, case-control posterior part of the oral cavity and studies, cohort and intervention studies subsequently involves the anterior Khanna and Andrade in 1995 developed a provide over whelming evidence that locations(27) . A study on the regional classification system for the surgical areca nut is the main aetiological factor variations of this condition pointed out management of trismus(35) . for OSMF (7, 20-22) . Four alkaloids have that such an observation would depend ?Group I: Very early stage without been conclusively identified in on whether the areca nut juice and the mouth opening limitations with an biochemical studies, arecoline, quid are swallowed or spat out(28) . inter-incisal distance of greater than arecaidine, guvacine, guvacoline, of 35 mm.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 108 ?Group II: Early stage with an inter- habit, nutritional support and anti- without coronoidectomy, coverage of the incisal distance of 26-35 mm. oxidants, physiotherapy, raw area with skin grafts, fresh amnion, ?Group III: Moderately advanced immunomodulatory drugs(steroids) for collagen membrane, buccal pad of fat, cases with an inter-incisal distance of local/systemic application, intra-lesional local flaps or vascularised free flaps, 15-25 mm. Fibrotic bands are visible injections of steroids, hyaluronidase, followed by active post-operative jaw at the soft palate, and human placental extracts etc, either physiotherapy with anti-oxidants and pterygomandibular raphe and singly or in combination for early/milder proper nutrition and regular follow-ups to anterior pillars of fauces. form of disease and surgical measures for ensure maintenance of oral opening and ?Group IVA: Advanced stage: Trismus advanced cases with post-operative early detection of malignant changes if is severe, with an inter-incisal nutritional support and anti-oxidants any. distance of less than 15 mm and alongwith active physiotherapy to extensive fibrosis of the oral mucosa. prevent contracture at the surgical site Use of lasers for band excision also has ?Group IVB: Disease is most and recurrence. It is very essential to been documented. advanced, with premalignant and follow these patients closely in order to malignant changes throughout the prevent recurrence and to detect any Coverage of the area with fibrin glue or mucosa developing malignancy at its earliest so Absorbable Atelocollagen also is being as to manage this untoward and most tried at various institutes. Divya Mehrotra et al suggested a clinical common eventuality. grading of the disease and treatment Discussion: methods as (27) : Medical Care Oral sub mucous fibrosis is a chronic, ?Grade I: stomatitis and burning Medical treatment is symptomatic and progressive, debilitating disease, which sensation in the buccal mucosa with predominantly aimed at improving most commonly presents with burning no detection of fibres. Suggested mouth movements. The medical sensation, intolerance to hot and spicy treatment for this group is abstinence management has been summarized in the foods, difficulty in mouth opening with from habit and medicinal following table given by Auluck et al(37) poor oral hygiene and its complications. management. OSMF most commonly affects the buccal ?Grade II: symptoms of grade I, mucosa In addition, there may be palpable fibrous bands, involvement Surgical Care involvement of the retromolar areas, of soft palate, and maximum mouth Surgical treatment is indicated in patients fauces, palate, tongue, pharynx and opening 26-35 mm. Suggested with severe trismus and/or biopsy results esophagus. The condition is sometimes treatment: abstinence from habit and revealing dysplastic or neoplastic preceded by and/or associated with medicinal management. changes. Surgical modalities that have vesicle formation, but always associated ?Grade III: symptoms of grade II, been used include the following: with a juxtaepithelial inflammatory blanched oral mucosa, involvement reaction followed by a fibroelastic of tongue, and maximal mouth Simple excision of the fibrous bands, change of the lamina propria with opening 6-25 mm. Suggested excision of bands with myotomy with or epithelial atrophy, leading to stiffness of treatment: abstinence from habit and surgical management. ?Grade IV: symptoms of grade III, fibrosis of lips, and mouth opening ?5 mm. Suggested treatment: abstinence from habit and surgical management. Table 1: Treatment modality for OSF (Auluck et al., 2008).

S. M. Haider et al gave the following Treatment Treatment Details (36) staging system : Micronutrients and minerals Vitamin A, B complex, C, D and E, iron, copper, calcium, zinc, magnesium, selenium and others

Clinical and Functional Staging Milk from immunized cows 45 g milk powder twice a day for 3 months Lycopene 8 mg twice a day for 2 months Clinical Stage 1. Faucial bands only Pentoxyfilline 400 mg 3 times a day for 7 months 2. Faucial and buccal bands Interferon gamma Intralesional injection of interferon gamma (0.01- 10.0 U/mL) 3 times a day for 6 months 3. Faucial, buccal, and labial bands Steroids Submucosal injections twice a week in multiple sites for 3 months/ Topical for 3 months

Functional Stage Placental extracts A Mouth opening ? 20 mm B Mouth opening 11-19 mm Turmeric Alcoholic extracts of turmeric (3 g), turmeric oil (600 mg), turmeric oleoresin (600 mg) C Mouth opening ?10 mm daily for 3 months

Management Chymotrypsin, Chymotrypsin (5000 IU), hyaluronidase (1500 IU) and dexamethasone (4mg), The management of an OSMF patient hyaluronidase and twice weekly submucosal injections for 10 weeks depends on the degree of clinical involvement. It comprises of: dexamethasone discontinuation of areca-nut related

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 109 the oral mucosa and causing trismus and has been shown to have several potent inability to eat (33) . The underlying anti-carcinogenic and antioxidant IFN-gamma: This plays a role in the muscles and the muscles of mastication properties and has demonstrated treatment of patients with oral can also be affected. However, a more profound benefits in precancerous submucous fibrosis because of its serious complication of this disease is the lesions such as leukoplakia (43) It has been immunoregulatory effect. IFN-gamma is risk of the development of oral carcinoma found to inhibit hepatic fibrosis in rats as a known antifibrotic cytokine. IFN- (20). The precancerous nature of oral well as human fibroblast activity in vitro gamma, through its effect of altering submucous fibrosis has been observed suggesting its possible role in the collagen synthesis, appears to be a key with development of slowly growing management of oral submucous factor to the treatment of patients with squamous cell carcinoma in one-third of fibrosis(44) . Newer studies highlight the oral submucous fibrosis, and oral submucous fibrosis patients (27) . Oral benefit of this oral nutritional supplement intralesional injections of the cytokine leukoplakia occurs with a high incidence at a daily dose of 16 mg. Mouth opening may have a significant therapeutic effect among patients with submucous fibrosis. in 2 treatment arms (40 patients total) was on oral submucous fibrosis(50) . According to Pindborg's report on OSMF statistically improved in patients with in India, leukoplakia occurred in 55% oral submucous fibrosis. This effect was The surgical treatment involves excision cases (32) . slightly enhanced with the injection of of fibrous bands and forceful mouth intralesional betamethasone (two 1-mL opening resulting in a raw wound surface. The aim of treatment for this condition is ampoules of 4 mg each) twice weekly, but Relapse is common complication that to provide good release of fibrosis and the onset of effect was slightly delayed.(45) occurs after surgical release of the oral provide long term results in terms of trismus caused by OSMF. Initially maintainence of mouth opening and to Steroids: In patients with moderate oral surgeons aimed at surgical elimination of detect any developing malignant change submucous fibrosis, weekly submucosal the fibrotic bands which showed further at its earliest. intralesional injections or topical scar formation and recurrence of trismus, application of steroids may help to to prevent which, they started using Different treatment methods for oral prevent further damage. Steroid ointment various inter positional graft materials submucous fibrosis have been discussed. applied topically helps in cases with (51,52). ulcers and painful oral mucosa. Its Administration of vitamin B-complex therapeutic effects were mainly anti- Yeh carried out a surgical procedure of may relieve glossitis and cheilosis in inflammatory and appeared to have a incising the mucosa down to the muscles OSMF patients (38) . A peripheral direct healing action (46) Steroids are well from the angle of mouth to the anterior vasodilator, such as buflomedial known to act as immunosuppressive tonsillar pillar, taking care to prevent hydrochloride, affects the tissues in agents for prevention or suppression of damage to the stoma of the parotid duct, diffuse fibrosis to a noticeable degree by the fibroproductive inflammation found followed by split skin grafting into the (53) relief of the local ischemic effect (39) . in OSMF lesions, thus ameliorating this defect, with acceptable results . fibro-collagenous condition (47) Placental Pentoxifylline is a tri-substituted extracts: The rationale for using placental Canniff et al. described the procedure of methylxanthine derivative, which extract in patients with oral submucous split thickness skin grafting after bilateral increases red cell deformability, fibrosis derives from its proposed anti- temporalis myotomy or coronoidectomy leukocyte chemotaxis, antithrombin and inflammatory effect(48) , hence, preventing along with daily opening exercise and anti- plasmin activities, and more or inhibiting mucosal damage. Cessation nocturnal props for a further 4 weeks (26) . importantly to the present context, its of areca nut chewing and submucosal But the results with skin grafting have a fibrinolytic activity. Pentoxifylline administration of aqueous extract of high reoccurrence rate due to graft decreases red cell and platelet healthy human placental extract shrinkage(35,38,54) . The other limitation of aggregation, granulocyte adhesion, (Placentrex) has shown marked the split thickness skin graft is the fibrinogen levels, and whole blood improvement of the condition.(15) morbidity associated with the donor site viscosity (40) . Recent work has delineated along with maintenance of mouth pentoxifylline's ability to decrease Hyaluronidase: The use of topical opening post operatively for 7 to 10 days production of tumor necrosis factor alpha hyaluronidase has been shown to which is the most unpleasant and and reduce some of the systemic improve symptoms more quickly than uncomfortable experience for the toxicities mediated by interleukin-2 (41) . steroids alone. Hyaluronidase can also be patient(55) . The anti inflammatory and added to intralesional steroid immunomodulatory actions led to preparations. The combination of Collagen membrane is used as a subjective improvement in clinical steroids and topical hyaluronidase shows biological dressing. Shobha Nataraj et al outcome recorded in a study by R better long-term results than either agent used collagen membrane composed of Rajendran et al (42) . used alone.(49) Hyaluronidase degrades type I and type III bovine collagen (that is the hyaluronic acid matrix, actively similar to human collagen), following Lycopene: A number of studies have promoting lysis of the fibrinous excision of fibrotic bands to cover the proven that the management of coagulum as well as activating specific raw areas during initial phase of healing premalignant lesions should include plasmatic mechanisms (49,44) . Therefore, and observed that collagen membrane antioxidants along with the cessation of relief of trismus may be expected through had good adaptability to the surgical the habit. Lycopene is a powerful softening and diminishing of fibrous defect. Collagen when used to cover raw antioxidant obtained from tomatoes. It tissue. areas provides coverage for sensitive nerve endings thereby diminishing

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 110 degree of pain. The adherence of collagen improvement in mouth opening (38) . membrane is initially due to fibrin- The nasolabial flap is typically classified collagen interaction & later due to fibro as an axial pattern flap based on angular Mokal et al. advocated the use of vascular in-growth into the collagen. artery. It can be based superiorly or vascularized temporal myofascial With time, it slowly undergoes inferiorly. Kavarana and Bhatena filled pedicled flap to bring in good blood collagenolysis and is eventually the defect after sectioning of fibrous supply to the area of affected muscle and sloughed off. However, it resists bands with 2 inferiorly based nasolabial mucosa to improve its function (61) . masticatory forces for sufficient time, to flaps, with division of the pedicle after 3 allow granulation tissue to form. None of weeks, and observed average mouth A total of five patients were treated with the cases in their study showed any opening of 2.5 cm, with acceptable this technique and all of them showed adverse reaction to the collagen proving external scars (62) . Inferiorly based good mouth opening in long term follow its safety as a biological dressing (55,56,57) . nasolabial flap is a reliable, economical up. There was no donor site morbidity. option for the management of oral The incision line is well hidden in the hair The value of amniotic membranes as submucous fibrosis (63) . The advantages of bearing area. Moreover, this technique dressings for partial-thickness burns has nasolabial flap include its close releases strong muscles of mouth closure been demonstrated by Dino et al. and proximity to defect, easy closure of donor such as masseter from its origin and Colocho et al. There was no acute site & a well camouflaged scar. The temporalis from its insertion. This rejection and its application over partial- technique is easy to master and defects as procedure has its foundation on thickness defects provides for pain relief large as 6 to 7 cm can be closed. The anatomical landmarks and physiological and re-epithelialization. In patients for postoperative extra-oral scars are hidden facts and is an effective method of whom deep defects were covered by in the nasolabial fold. Minor treating oral sub mucous fibrosis (61) fresh amnion grafts, the inter-incisal complications include loss of the distance two years after surgical nasomaxillary crease and the creation of Extraoral local flaps are limited by their treatment decreased by 5-10 mm. an edematous and bulky flap. A periosteal extensibility to deeper parts of the Therefore, fresh amnion grafts would not suture can however be used to recreate defects. Free tissue transfer is hence the appear to be effective in a single layer the crease. By trimming all of the fat from preferred choice. The radial forearm free over deep buccal defects according to Lai the flap, the bulkiness can be reduced (64) . flap has been widely accepted DR et al(38) However, the nasolabial flaps cannot be extended adequately to cover the raw because of its reliability, its thin, pliable Borle and Borle reported disappointing area, and they also cause facial scars and and relatively hairless tissue results with skin grafting to cover the raw at times is hair bearing (27) characteristics and its long and sizable area and used tongue flap to cover the pedicle. It is one of the most popular flaps defect (46) However, tongue flaps were Yeh described the application of pedicled used in head and neck reconstruction. found to be bulky and required additional buccal fat pad after incision of fibrous Wei FC et al have successfully applied surgery for detachment. Bilateral tongue bands and suggested that this was a very this flap to reconstruct oral submucous flaps caused severe dysphagia and logical, convenient, and reliable fibrosis post-release defects (66) . Most disarticulation along with the risk of technique for treatment of oral donor sites were closed primarily in their postoperative aspiration(55) . Restricted submucous fibrosis (53) . The surgical series to leave only linear scars, thus the mobility of tongue was observed in the procedure is easy, less time-consuming two most common donor-site problems immediate postoperative phase, causing since the donor site is in close proximity encountered for radial forearm flaps, discomfort to the patient and difficulty in to the posterior third of the buccal defect donor-site function and cosmetic speech, which made it a less ideal and can be accessed and mobilized appearance were avoided. A bi-paddled choice(27) through the same buccal incision, which radial forearm flap from a single donor was used to release the fibrosis, without site has been also used for reconstruction Khanna and Andrade reported the causing any noticeable defect in the of bilateral buccal defects(67) . However, incidence of shrinkage, contraction, and cheek or mouth. Improvement in the the sacrifice of one of the two major rejection of split skin graft as very high, suppleness and elasticity of the buccal vessels supplying to the hand on both owing to poor oral condition, with mucosa on clinical examination were sides is still a concern, with the potential recurrence in 12 cases. Palatal island flap noted(53,55) , The graft begins to show signs risk of compromising the circulation to based on the greater palatine artery had of epithelization from 2nd week with the digits, ranging from cold intolerance been used to cover defect. This mean value of 14.73 days, so does not to gangrene change, especially in the technique, accompanied with bilateral necessitate coverage with a skin graft smokers. Free flap reconstruction has temporalis myotomy and (52,55,65), Should it fail, the consequences are proved effective for maintaining mouth coronoidectomy, was a highly effective not serious, as other options are open. opening after release of fibrosis. Two surgical procedure (35) . However, use of Buccal fat pad serves as a good substitute, independent free flaps from separate island palatal flap has limitation such as because it provides excellent function donor sites, such as bilateral forearm its involvement with fibrosis and second without deteriorating the esthetics and flaps or bilateral anterolateral thigh molar tooth extraction required for flap to the results obtained were sustained long (ALT) flaps, were traditionally required cover without tension (32, 60) term (27) . Thus Lai DR et al considered this for reconstruction. The former option as the quickest and most efficient form of sacrifices one of the two major arteries in Bilateral palatal flaps leave a large raw therapy for OSMF patients with severe the forearm. Both the options are time area on palatal bones in palate (61) . trismus to ensure long-term consuming and required two donor sites. To eliminate these disadvantages, Jung-

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 111 Ju Huang et al developed a technical has two components, fibrinogen and References modification that allows harvesting of thrombin obtained from patient's own 1. van Wyk CW, Grobler Rabie AF, two independent flaps from one ALT blood. Use of the fibrin glue is simple, Martell RW, Hammond MG.,HLA- thigh based on one descending branch of safe, cost effective, and rapid technique. antigens in oral submucous fibrosis. J the lateral circumflex femoral artery (d- Its use to cover the raw areas after Oral Pathol Med 1994;23:23-27. LCFA). With the described technique, excision of fibrous bands is being tried at 2. Maresky LS, de Waal J, Pretorius S, two teams can work simultaneously, the various institutes. van Zyl AW, Wolfaardt P., total operation time can be reduced and Epidemiology of oral precancer and one donor site can be left un-operated, Absorbable Atelocollagen Membrane cancer. S Afr Med J 1989;Suppl:18- one donor thigh scar can be concealed is available as a sterile, pliable surgical 20. more easily than bilateral donor sites porous scaffold agent made of highly 3. Pillai R, Balaram P, Reddiar KS. scarring both forearms, the sacrifice of purified type I atelocollagen derived Pathogenesis of oral submucous the d-LCFA is less critical than the from porcine skin. It is being used for fibrosis. Relationship to risk factors sacrifice of the radial artery. However, coverage of the raw areas in non-healing associated with oral cancer. Cancer since ALT flaps may be too bulky for oral and burn wounds. It shows minimal 1992;69:2011-2020. mucosa reconstruction, flap-thinning antigen reaction due to the elimination of 4. SirsatSM, KhanolkarVR. procedures, either intra-operatively telopeptides, is completely absorbable, Submucous fibrosis of the palate in during flap transfer reconstruction or highly bio-compatible and suitable for diet-preconditioned Wistar rats.The secondarily after surgery may be reconstruction of soft tissue. Its Saudi Dental Journal, Volume 1, undertaken(68) . advantages include, bleeding control and Number 2,1989 Arch Pathol stabilization of the blood clot, 1960;70:171-179. Omura and Mizoki used a newly acceleration of the wound healing 5. Schwartz J. Atrophia idiopathica developed collagen/silicone bi-layer process, provides matrix for tissue (tropica) mucosa oris. Demonstrated membrane as a mucosal substitute and ingrowths, can be cut to fit any size at the 11th International Dental reported that postoperative course was wound, soft and conformable to wound Congress, London 1952. unremarkable and that repair was site, maintains integrity in moist state, 6. Joshi SG: Submucousf ibrosis of the effective. The membrane comprised an leaves wound free of fiber. Its use in palate and pillars. Indian J outer layer of silicone and inner layer of OSMF is being tried in many institutes Otolaryngol 4:1-4, 1953. hydrothermal cross-linked composites of and long term results are awaited. 7. Lal D: Diffuse oral submucous fibrillar and denatured collagen sponge. fibrosis. J All India Dent Assoc 26:1- The membrane was placed on oral Patients suffering from this incurable, 3, 14-15, 1953. mucosal defects after removal of the chronic fibro-elastic scarring disease 8. Su JP. Idiopathic scleroderma of the outer silicone layer after 10-14 days(69) . need to be fully informed. It is essential at mouth. Report of three cases. Arch the onset of treatment to avoid raising Otolaryngol 1954; 59:330-2. Use of a KTP-532 laser release procedure expectations. Treatment needs to be 9. Rao ABN. 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CO2 laser, rather than a scalpel or a Cancer Epidemiol Biomarkers Prev technique involving multiple tiny Conclusion: 2002;11(7):646-653. incisions for surgical relief of the limited Oral submucous fibrosis is one of the 12. Gupta PC, Warnakulasuriya S. Global oral aperture, because the laser beam most poorly understood and epidemiology of areca nut usage. spontaneously sealed all blood vessels, unsatisfactorily treated diseases. The Addict Biol 2002;7(1):77-83. allowing the surgeon perfect visibility younger the age, the more rapid the 13. Aziz SR. Oral submucous fibrosis: an and accuracy in excising the fibrous progression of the disease. Because of the unusual disease. J N J Dent Assoc. tissues time55 . Furthermore, the laser significant cancer risk among these Spring 1997;68(2):17-9 excised wound heals with less patients, periodic biopsies of suspicious 14. Hayes PA: Oral submucous fibrosis in contraction and scarring than wounds left regions of the oral mucosa are essential a 4-year-old girl. Oral Surg 59:475- by surgical excisions71 . However, Lai DR for early detection and management of 78, 1985 et al38 considered it be practically high-risk oral premalignant lesions and 15. Anil S, Beena VT. Oral submucous impossible to excise all fibrous tissues in prevention of cancer. Dentists can play an fibrosis in a 12-year-old girl: case the oral cavity at one time. important role in both the education of report. Pediatr Dent. Mar-Apr patients about the perils of chewing betel 1993;15(2):120-2 Fibrin glue is a biological tissue quid and in the early diagnosis of such 16. Shah B, Lewis MA, Bedi R. Oral adhesive based on the final stage of high-risk premalignant lesions and submucous fibrosis in an 11-year-old coagulation wherein. Thrombin acting on cancer. Bangladeshi girl living in the United fibrinogen converts it into fibrin. 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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 113 submucous fibrosis. Int J Oral reconstruction using superficial Kai Kao, Wei-Chao Huang, Maxillofac Surg 1996;25:130-3. temporal fascia flap and split skin MingeHuei Cheng, Fu-Chan Wei: 54. Zhang HM Anatomical structure of graft- a new technique. Br J Plast Surg Two small flaps from one the buccal fat pad and its clinical 2005;58:1055-60. anterolateral thigh donor site for adaptations. Plast Reconstr Surg 62. Kavarana HM, Bhatena HM. Surgery bilateral buccal mucosa 2002 Jun: 109(7):2509-2518 for severe trismus in submucous reconstruction after release of 55.Shobha Nataraj 1, Yadavalli fibrosis. Br J Plast Surg 1987;40:407- submucous fibrosis and/or Guruprasad 2, Jayaprasad .N.Shetty: 9. contracture; Journal of Plastic, A Comparative Clinical Evaluation 63. Borle RM, Nimonkar PV, Rajan R: Reconstructive & Aesthetic Surgery of Buccal Fat Pad and Collagen in Extended nasolabial flaps in the (2010) 63, 440-445 Surgical Management of Oral Sub management of oral submucous 69. Omura S, Mizoki. A newly developed mucous Fibrosis. Archives of Dental fibrosis. The British journal of Oral & collagen/silicon bilayer membrane as Sciences,2011, Vol.2, Issue 2; 15-22 Maxillofacial Surgery, 2009; 47(5) a mucosal substitute-a preliminary 56. Gupta RL .Fate of collagen sheet :382-385 report. Br J Oral Maxillofac Surg cover for artificially created raw areas 64. Anisha Maria, Yogesh Sharma, Preeti 1997;35:85-91. (exptal study) Int J of Surg, vol Kaur: Use of Nasolabial Flap in the 70. Nayak DR, Mahesh SG, Aggarwal D, 40;1978 (a) 641-645 Management of Oral Submucous Pavithran P, Pujary K, Pillai S Role of 57.R .Mitchell A New Biological Fibrosis - A Clinical Study People's KTP-532 laser in management of oral Dressing for areas Denuded of Journal of Scientific Research Vol. submucous fibrosis J Laryngol Otol. Mucous membrane. Br Dent J 1983; 4(1), Jan. 2011, 28-30 2009 Apr;123(4):418-21. Epub 2008 155: 346-348 65. R. Martin Granizo Use of buccal fat 71.FRAME JW. Carbon dioxide laser 58. Dino BR, Eufemio G G , Devilla MS. pad to repair Intraoral defects: review surgery for benign oral lesions. Br Human amnion; the establishment of of 30 cases. Br J Maxillofac Surg; 35: Dent J 1985; 158; 125-8. an amnion bank and its practical 81-84, 1997 applications in surgery. J Phil Med 66. Wei FC, Chang YM, Kildal M, et al. A.K.WC 1965; 41; 890-8. Bilateral small radial forearm flaps 59. Colocho G, Graham WP, Greene A E , for the reconstruction of buccal Matheson DW, Lynch D. Human mucosa after surgical release of amniotic membrane as a physiologic submucosa fibrosis: a new, reliable wound dressing. Arch Surg 1974; approach. Plast Reconstr Surg 109; 370-3. 2001;107:1679. 60. Alexander D.Rapidis. The use of the 67. Lee JT, Cheng LF, Chen PR, et al. Buccal fat pad for Reconstruction of Bipaddled radial forearm flap for the oral defects: review of literature and reconstruction of bilateral buccal report of 15 cases.J Oral Maxillofac; defects in oral submucous fibrosis. 58:158-163, 2000. Int J Oral Maxillofac Surg 61. Mokal NJ, Raje RS, Ranade SV, 2007;36:615. Prasad JS, Thatte RL. Release of oral 68. Jung-Ju Huang, Chris Wallace, Jeng- submucous fibrosis and Yee Lin, Chung-Kan Tsao, Huang-

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©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 114 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Taurodotism: Etiology, Classification And 1 Rajesh Khanna, MDS 2 Neha Kansal, MDS Clinical Significance 3 Rajnish Kansal, MDS 4 Naresh Kumar, MDS Abstract 5 Kanwalpreet Bhullar, MDS Anatomical and morphological variations in teeth are important to be diagnosed and thus taken 1 care of during treatment. Taurodontism is a developmental disturbance of a tooth that lacks Professor Deptt of Conservative Dentistry & Endodontics constriction at the level of the cementoenamel junction (CEJ). Taurodontism, although not Gian Sagar Dental College and Hospital, common, is an important occurrence that may influence dental management of patients. So this Ram Nagar, Rajpura, Dist. Patiala, India. review outlines the classification, diagnosis and clinical importance of such uncommon taurodont 2 Senior Lecturer teeth. Deptt of Conservative Dentistry & Endodontics 3 Senior Lecturer Key Words 4 Reader taurodontism; anatomical variations; clinical significance Deptt Of Oral & Maxillofacial Surgery, Desh Bhagat Dental College And Hospital, Muktsar, Punjab (INDIA) 152026 5 3 Reader Introduction K. ; although the earliest example of Deptt of Conservative Dentistry & Endodontics Human dentition presents a variety of S G R D Institute of Dental Science & Research, taurodontism is that of the Krapina anatomical and morphological Neanderthal race, 70,000 years old Amritsar, Punjab (INDIA) variations. The anatomy of the root canal 4 Address For Correspondence: anthropological specimen . However, the Dr. Neha Kansal system dictates the conditions under term taurodontism was first introduced Deptt of Conservative Dentistry & Endodontics which root canal therapy is carried out by Sir Arthur Keith5 to describe molar Desh Bhagat Dental College & Hospital, 1 Muktsar, Punjab (INDIA) 152026 and can directly affect its prognosis . One teeth resembling those of ungulates, Contact no. +919855090055 of the most important abnormalities in particularly bulls. So, the term Fax: 911633264653 tooth morphology is taurodontism. This taurodontism comes from the Latin term Email id: [email protected] abnormality is a developmental 'tauros', which means 'bull' and the Greek Submission : 28th August 2011 disturbance of a tooth that lacks term 'odus', which means 'tooth' or 'bull Accepted : 18th February 2012 constriction at the level of the tooth'5 . cementoenamel junction (CEJ) and is Quick Response Code characterized by vertically elongated Incidence pulp chambers, apical displacement of Witkop CJ6 suggested that taurodontism the pulpal floor, and bifurcation or was found more often in people in which 2 trifurcation of the roots (Fig 1). teeth were used as tools, as more Taurodontism, although not common, is advantageous than cynodontism in an important occurrence that may people with heavy masticatory habits. It influence dental management of patients. has also been seen in Eskimos, External morphology was first used to Europeans, African Americans, and in normal, but hypertaurodontism is yet a describe those teeth that had apically white Americans7 . However, Sciulli PW8 rare entity. displaced furcation areas. It was first found no evidence of taurodontism in The teeth involved are mostly molars- described by Gorjanovic´-Kramberger prehistoric American Indians, people sometimes only a single tooth and other who must have also used their teeth times several molars in the same extensively. quadrant. Sert S. and Bayrili G.13 reported Pindborg JJ9 stated that the prevalence of a patient that had six taurodont molar taurodontism in modern man is less than teeth, 4 maxillary and two mandibular 0.1%. However, Blumberg JE et al.10 molars. Similarly, Shifman A and found it in about 2.5% of cases. Keene Buchner A14 reported that in one case, HJ11 reported hypo taurodontism in 2.8% eight teeth were taurodonts. The of cases and mesotaurodontism in 0.4% mandibular second molar is the most cases. Further, Shifman A and Chanannel prone, being involved in two third of all I12 showed hypo taurodontism in 5.2% of the cases found 12, 14 . It is reported that the cases, mesiotaurodontism in 1.0% and degree of taurodontism increases from hyper taurodontism in 0.7%. So, they the first to the third molar 2,15 . Also, suggested that taurodontism is not rare in reported that taurodontism is modern man as previously thought, infact occasionally observed in mandibular and Fig 1: Taurodontism hypotaurodontism is just variation of maxillary premolars, and even

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 115 mandibular canines and incisors15, 16 . taurodontism. Another problem Taurodontism may affect the deciduous complicating accurate assessment of or permanent dentition2,17,18,19 . The the incidence of taurodontism is the condition may be unilateral or bilateral inclusion of premolars or anteriors by and in any combination of teeth or many investigators32,23 , whereas others quadrants20 . Shifman A and Buchner A14 have questioned this inclusion33 . also reported that the majority of the Shaw JCM gave first classification ever affected teeth occurred singly. However, done for taurodonts in the year 1928, Fig 2: Classification Of Taurodontism Laatikainen T and Ranta R21 found that according to its severity34 : normal tooth- taurodontism was symmetrical in 91% of cynodont; least pronounced- the affected molar pairs. hypotaurodontism: moderate 1978 also included an index to calculate The gender distribution of the patients enlargement of the pulp chamber at the the degree of taurodontism as shown with taurodontism showed no expense of the roots; moderate - 21 radiographically. It was based on the statistically significant difference mesotaurodontism: pulp is quite large relative amount of apical displacement of except for a higher prevalence amongst and the roots short but still separate; and 17 the pulp chamber floor. As per their females in a Chinese population . most severe- hypertaurodontism: index, taurodontism is present if the prismatic or cylindrical forms where the distance from the lowest point at the Etiology pulp chamber nearly reaches the apex and occlusal end of the pulp chamber (A) The etiology of taurodontism is unclear. then breaks up (Fig 2). This classification to the highest point at the apical end of It is thought to be caused by the failure of is usually preferred but it is not an the chamber (B) divided by the distance Hertwig's epithelial sheath diaphragm to objective analysis. 11 (b) from A to the apex is 0.2 or invaginate at the proper horizontal level, Keene HJ in 1966 gave the taurodont greater; and if the distance from the resulting in a tooth with short roots, index in order to classify the degree of highest point at the apical end of the elongated body, an enlarged pulp, and taurodontism as ratio of height of pulp chamber to the cementoenamel 22 normal dentin . Interference in the chamber to the length of the longest root. junction (CEJ) is greater than 2.5 mm. epitheliomesenchymatose induction has height of pulp chamber also been proposed as a possible Taurodont Index = Degree of taurodontism was determined 23 length of the longest root aetiology . to be: hypotaurodontism if TI is 20-30%, Previously, taurodontism was related to mesotaurodontism if TI is 30-40% and various syndromes such as Down's and hyper taurodontism if TI equals 40- 24 Klinefelter's . So suggested that According to this index, value of 75%12 . taurodontism may be genetically 0 - 24% is cynodont, This index has overcome many transmitted25, 26 . Varrela J and Alvesalo 25- 49.9% is hypotaurodont, disadvantages of previous methods, L27 supported the concept that the 50- 74.9% is mesotaurodont however in few cases this formula fails, prevalence of taurodontism increases as and 75- 100% is hypertaurodont. as in teeth that subjectively appeared to the number of X chromosomes increases be taurodonts but did not meet the above The major drawback of this index is that it 3 3 and also indicate that expression of the criteria due to strange pulp makes use of landmarks in biological trait and the number of X chromosomes configuration. structure which are liable to change with may be positively correlated. They have In addition to all these methods, time due to formation of reparative 36 further suggested that the X chromosome Tulensalo T. et al. examined a simple dentin. gene(s) influencing development of method of assessing taurodontism using Another method was discussed by enamel may also be involved in the 10 orthopantomograms (OPG) by Blumberg et al. in 1971. Though his development of taurodontism. measuring the distance between the landmarks were relatively stable, but the Except genetic transmission, other baseline (connecting the mesial and distal formula was quite cumbersome for external factors can also damage points of the CEJ) and the highest point of regular clinical use. developing dental structures in children 34 the floor of the pulp chamber. They and adolescents as infection So, Feichtinger C & Rossiwall B. concluded that this technique is reliable (osteomyelitis)2 8 , disrupted further on the basis of the work of earlier in epidemiologic investigations for developmental homeostasis29 , high-dose authors, gave an easier method and stated assessing taurodontism in a developing chemotherapy30 , and a history of bone that if the distance from the furcation of dentition. marrow transplantation31 . the roots to the cementoenamel junction But now a days, taurodontism especially was greater than the occlusal cervical Clinical and radiographic features distance, taurodontism is present. hypotaurodontism is considered as an 12 A taurodontic tooth has certain anatomic anatomic variance that could occur in a Further, Shifman A and Chanannel I in normal population12 . Distance From The Lowest Point At The Occlusal Classification End Of The Pulp Chamber To The Highest Point At The Apical End Of The Chamber The common problem that arises in Taurodontism index = X 100 taurodontism is that there are differences Distance From The Lowest Point At The Occlusal of opinion regarding how much End Of The Pulp Chamber To The Apex displacement and how much morphologic change constitutes

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 116 characteristics. First, the cervical pulp testing contribute little information Technology, San Diego, CA, USA)43 . constriction is less marked than the about the effect of a large pulp chamber About the surgical part, extraction of a normal tooth form. Further, the tooth on tooth sensitivity43 . taurodont tooth is usually complicated must have an apically displaced furcation There are different views regarding because of a dilated apical third24 . In and short roots. However, clinically the access cavity design and preparation: contrast, it has also been hypothesized taurodont appears as a normal tooth Shifman A & Buchner A14 argued that that because of its large body, little because body and roots of a taurodont lie access to the root canal orifices can easily surface area of a taurodont tooth is below the alveolar margin. obtained as the floor of the pulp chamber embedded in the alveolus. This feature Radiographically, involved teeth are cannot affected by the formation of would make extraction less dif?cult44 . frequently found to be rectangular in reactionary dentine as in normal teeth. In For the prosthetic treatment of a overall shape rather than tapering toward contrast, Durr et al.44 suggested that taurodont tooth, it has been the roots. The pulp chamber is extremely morphology could hamper the location of recommended that post-placement be large with a much greater apico-occlusal the orifices, thus creating difficulty in avoided for tooth reconstruction43 . height than normal. In addition, the pulp instrumentation and filling. It also shows Further as less surface area of the tooth is lacks the usual constriction at the cervical wide variation in the size and shape of the embedded in the alveolus, a taurodont region of the teeth and the roots are pulp chamber, varying degrees of tooth may not have as much stability as a exceedingly short. The bifurcation or obliteration and canal configuration, cynodont when used as an abutment for trifurcation may be only a few millimeter apically positioned canal orifices, and the either prosthetic or orthodontic above the apices of the roots. potential for additional root canal purposes44 . systems. From a periodontal standpoint, taurodont Diagnosis A complicated root canal treatment has teeth may, in specific cases, offer The above described external features been reported for a mandibular taurodont favorable prognosis. Where periodontal have been primarily used for the tooth with five canals, only three of pocketing or gingival recession occurs, diagnosis of taurodontism. However, it which could be instrumented to the the chances of furcation involvement are should be noted that gross external apex45 . Therefore, careful exploration of considerably less than those in normal characteristics are not sufficient to the grooves between all orifices is teeth because taurodont teeth have to 15 generate diagnosis . Further, clinical recommended to reveal additional demonstrate significant periodontal crowns of these teeth have near to normal orifices and canals. Further use of destruction before furcation involvement characteristics; therefore, taurodontism magnification43 is helpful in easy location occurs2, 14 . may be diagnosed only radiologically of the canal orifices. either from IOPA or OPG. Because the pulp of a taurodont is usually Conclusion voluminous, in order to ensure complete It can be seen that taurodontism has Syndromes removal of the necrotic pulp, 2.5% received insufficient attention from Taurodontism appears mostly as an sodium hypochlorite has been suggested clinicians. Special attention is required to isolated anomaly; but it has also been initially as an irrigant to digest pulp indentify the anomaly. In performing root associated with several syndromes like tissue4 6 . Moreover, as adequate canal treatment on these teeth, one should Down syndrome, Klinefelter's syndrome, instrumentation of the irregular root appreciate the complexity of the root trichodento-osseous syndrome, and 47 canal system. Careful exploration of the 37-42 canal system cannot be anticipated , others . Many of these disorders have suggested that additional efforts should grooves between all orifices, particularly oral manifestations, which can be be made by irrigating the canals with with magnification; ultrasonic irrigation; detected on dental radiographs as 2.5% sodium hypochlorite in order to and a modified filling technique are alterations in the morphology or dissolve as much necrotic material as recommended. Care should also be chemical composition of the teeth.. So, possible. Application of final ultrasonic exercised during extractions and post dentist being familiar with taurodontism irrigation may ensure that no pulp tissue endodontic rehabilitation. Finally may disclose systemic problems that 46 although taurodontism is a dental rarity, 6 remains . would otherwise remain undetected . Finally, it should be noted that in cases of this unusual radicular form should be Several patients with taurodontism hypertaurodont (where the pulp chamber considered during planning the associated with some other recognizable nearly reaches the apex and then breaks treatment. dental anomaly are seen. In these cases, up into two or four channels) vital there is no reason to suspect that pulpotomy instead of routine pulpectomy References taurodontism and the other anomaly were may be considered as the treatment of 1. Slowey RR. Root canal anatomy: linked. choice2, 14 . road map to successful endodontics. Because of the complexity of the root Dent Clin North Am 1979; 23: 555- Clinical significance canal anatomy and the proximity of the 73. The presentation of taurodont forms buccal orifices, complete filling of the 2. Neville BW, Damm DD, Allen CM, complicates nonsurgical, endodontic root canal system in taurodontism is Bouquot JE. Oral & Maxillofacial procedures because of the impact of the challenging. A modified filling technique Pathology, 5th edn. Philadelphia: morphology on location of orifices and W.B. Saunders. 2002 4 3 has been proposed, which consists of instrumentation and obturation . combined lateral compaction in the 3. Gorjanovic Kramberger K. Über Although there is a characteristic apical region with vertical compaction of prismatische molarwurzein rezenter radiographic picture, the pretreatment the elongated pulp chamber, using the und diluvialer menschen. films provide little information about the system B device (EIE / Analytic Anatomischer Anzeiger 1908; 32: root canal system23 . Finally, the results of 401-13.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 117 4. Barker BCW. Taurodontism: the 21. L a a t i k a i n e n T, R a n t a R . 34. Shaw J C M. Taurodont teeth in South incidence and possible significance Taurodontism in twins with cleft lip African Races. J Anat 1928; 62: 476- of the trait. Aust Dent J 1976; 21: and / or palate. European J Oral Sci 99. 272-6. 1996; 104: 82-6. 35.Feichtinger C, Rossiwall B. 5. Keith A. Problems relating to the 22. Hamner J E, Witkop CJ, Metro PS. Taurodontism in human sex teeth of the earlier forms of Taurodontism. Report of a case. Oral chromosome aneuploidy. Arch Oral prehistoric man. J Royal Soc Med Surg Oral Med Oral Pathol 1964; 18: Biol 1977; 22:327-329. 1913; 6: 103-24. 409-18. 36. Tulensalo T, Ranta R, Kataja M. 6. Witkop CJ. Clinical aspects of dental 23.Llamas R, Jimenez-Planas A. Reliability inestimatIng anomalies Int Dent J 1976; 26: 378- Taurodontism in premolars. Oral taurodontism of permanent molars 90. Surg Oral Med Oral Pathol 1993; 75: from orthopantomograms. Comm 7. Mjör IA. The structure of taurodont 501-5. Dent Oral Epidemiol 1989; 17: 258- teeth. J Dent Child 1972; 39: 459-63. 24. Yeh SC, Hsu TY. Endodontic 62. 8. Sciulli P W. A descriptive and treatment in taurodontism with 37. Chichon JC, Pack RS. Taurodontism: comparative study of the deciduous Klinefelter's syndrome: a case report. review of literature and report of case. dentition of prehistoric Ohio Valley Oral Surg Oral Med Oral Pathol Oral J Am Dent Assoc 1985; 111: 453-5. Amerindians. Am J Phy Anthropol Radiol Endod 1999; 88: 612-5. 38. Jaspers MT, Witkop CJ Jr. 1977; 47: 71-80. 25. Goldstein E, Gottlieb MA. Taurodontism, an isolated trait 9. Pindborg JJ. Pathology of the dental Taurodontism: familial tendencies associated with syndromes and X- hard tissues. Munksgaard, demonstrated in eleven of fourteen chromosomal aneuploidy. Am J Hum Copenhagen 1970, p.44. case reports. Oral Surg Oral Med Oral Genet 1980; 32; 396-413. 10. Blumberg JE, Hylander WL., Goepp Pathol 1973; 36: 131-44. 39. Alfred MJ, Crawford PJ. Variable RA. Taurodontism, a biometric study. 26. Witkop CJ. Manifestation of genetic expression in amelogenesis Am J Phy Anthropol 1971; 34: 243- disease in the human pulp. Oral Surg imperfecta with taurodontism. J Oral 256. Oral Med Oral Pathol 1971; 32: 278- Pathol 1988; 17:327-33. 11. Keene HJ. A morphological and 316. 40. Ogden GR. Taurodontism in biometric study of taurodontism in a 27. Varrela J, Alvesalo L. Taurodontism dermatologic disease. Int J Dermatol contemporary population. Am J Phys in females with extra X 1988; 27: 360-4. Anthropol. 1966; 25: 208-209. chromosomes. J Craniofac Genet 41. Bell J, Civil CR, Townsend GC, 12. Shifman A, Chanannel I. Prevalence Dev Biol 1989; 9: 129-33. Brown RH. The prevalence of of taurodontism found in 28. Reichart P, Quast U. Mandibular taurodontism in Down's syndrome. J radiographic dental examination of infection as a possible aetiological Ment Defic Res 1989; 33: 467-76. 1200 young adult Israeli patients. factor in taurodontism. J Dent 1975; 42. Lichtenstein JR, Warson R, Com Dent Oral Epidemiol 1978; 6: 3: 198-202. Jorgenson R, Dorst JP, Mc Kusick 200-3. 29. Witkop CJ Jr, Keenan KM, Cervenka VA. The trichodento-osseous (TDO) 13. Sert S, Bayrili G. Taurodontism in six J, Jaspers MT. Taurodontism: syndrome. Am J Hum Genet 1972; molars: a case report. J Endod 2004; ananomaly of teeth re?ecting 24: 569-82. 30: 601-2. disruptive developmental 43. Tsesis I, Shifman A, Kaufman AY. 14. S h i f m a n A , B u c h n e r A . homeostasis. Am J Med Genetics Taurodontism: an endodontic Taurodontism: Report of sixteen 1988; 4: 85-97. challenge. Report of a case. J Endod cases in Israel. Oral Surg Oral Med 30. Greenberg MS, Glick M Burket's 2003; 29: 353-5. Oral Pathol 1976; 41: 400-405. Oral Medicine- Diagnosis and 44. Durr DP, Campos CA, Ayers CS 15. Mena CA Taurodontism. Oral Surg Treatment, 10 th edn. Hamilton, ON, Clinical signi?cance of taurodontism. Oral Med Oral Pathol 1971; 32: 812- Canada: BC Decker 2003 J Am Dent Assoc 1980; 100: 378-81. 23. 31. Vaughan M D, Rowland CC, Tong X 45. Hayashi Y. Endodontic treatment in 16. Osborn JW. Dental Anatomy and Dental abnormalities in children taurodontism. J Endod 1994; 20: 357- Embryology. Oxford: Blackwell preparing for pediatric bone marrow 8. scienti?c publications. 1981. transplantation. Bone Marrow 46. Prakash R, Vishnu C, Suma B, 17. MacDonald-Jankowski DS, Li TT. Transplant 2005; 36: 863-6. Velmurugan N, Kandaswamy D Taurodontism in a young adult 32. Madeira MC, Leite HF, Niccoli Filho (2005) Endodontic management of Chinese population. Dent MaxilloFac WD, Simoes S. Prevalence of taurodontic teeth. Indian J Dent Res Radiol 1993; 22: 140-4. taurodontism in premolars. Oral 2005; 16: 177-81. 18. Goaz PW, White SC. Oral Radiology Surg, Oral Med Oral Pathol 1986; 61: 47. Widerman FH, Serene TP (1971) (Principles and Interpretation), 3rd 158-62. Endodontic therapy involving a edn. Louis, USA: Mosby. 1994 33. Ruprecht A, Batniji S, el-Neweihi E. taurodontic tooth. Oral Surg, Oral 19. Rao A, Arathi R Taurodontism of The incidence of taurodontism in Med and Oral Path 1971; 32: 618-20. deciduous and permanent molars: dental patients. Oral Surg, Oral Med report of two cases. J Ind Soc Pedo Oral Pathol 1987; 63: 743-7. Prev Dent 2006; 24: 42-4. 20. White SC, Pharoah MJ. Oral Radiology. Principles and Source of Support : Nill, Conflict of Interest : None declared Interpretation, 5th edn. St.Louis, USA: Mosby 2004.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 118 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Platelet Concentrates – Part I 1 Vishal Sood 2 Sujata Surendra Masamatti 3 Manish Khatri 4 Ashish Kumar Abstract 5 Vikas Jindal Platelet concentrates have wide clinical application in the medical and dental fields. The aim of 1,3 reconstructive surgeries is to jump-start the healing process to maximize predictability as well as Professor 4 Reader the volume of regenerated bone. Several techniques for platelet concentrates have been Department of Periodontics, developed; each method leads to a different product with different biology and potential uses. This Institute of Dental Studies & Technologies, review presents the classification of the different platelet concentrates which can be differentiated Kadrabad, Modinagar, Uttar Pradesh, India into four categories, depending on their leucocyte and fibrin content: pure platelet-rich plasma (P- 2 Senior Lecturer PRP); leucocyte- and platelet-rich plasma (L-PRP); pure platetet- rich fibrin (P-PRF); and Department of Periodontics, leucocyte and platelet-rich fibrin (L-PRF), such as Choukroun's PRF. I.T.S. - Centre for Dental Studies & Research Murad Nagar, Ghaziabad, Uttar Pradesh, India 5 Director Key Words platelet, fibrin, centrifuge,defect Department of Periodontology Himachal Dental College Sundernagar, District Mandi ,HP

Address For Correspondence: Introduction a different product with different biology Dr. Vishal Sood, The greatest challenge in clinical and potential uses.For all practical Professor, Department of Periodontics, research is development of bioactive reasons these concentrates can be Institute of Dental Studies & Technologies, surgical additives, which help to regulate classified into four categories.6 Kadrabad, Modinagar, Uttar Pradesh, India. inflammation and increase the speed of Ph: +91 98730 82928 1 healing process. Platelets isolated from P-PRP - Pure Platelet Rich Plasma E-mail: [email protected] the peripheral blood are an autologous L-PRP - Leucocyte and Platelet Rich Submission : 27th August 2011 source of growth factors i.e. growth Plasma Accepted : 14th April 2012 factors stored in the alpha granules of P-PRF - Pure Platelet Rich Fibrin platelets include platelet derived growth L-PRF - Leucocyte and Platelet Rich factor, insulin like growth factor, Fibrin Quick Response Code vascular endothelial growth factor and To understand the concept a set of three transforming growth factor beta2 which parameters must be defined which are as are able to stimulate cell proliferation, follows: matrix remodeling and angiogenesis. A) Preparation kits and centrifuge used: A1) Size of the centrifuge These growth factors are released by A2) Duration of the procedure activation of the platelets by substances A3) Cost of the device and kits or stimuli such as thrombin, calcium A4) Theergonomy of the kit and the pharmacological relevance of the chloride, collagen or adenosine 5c - complexity of the procedure. product and lead to indications for diphosphate.3 Platelet concentrates were potential application. originally used in transfusion medicine Size of the centrifuge could be B1)Final volume of the concentrate for the treatment and prevention of heavy(cumbersome) or light (compact). (depends on the initial blood harvest). hemorrhage due to severe thrombopenia, A compact centrifuge would be a B2)Efficiency in collecting the platelets. which is often caused by medullar preferable choice for clinical B3)Efficiency in collecting leucocytes. aplasia,acute leukemia or significant applications in dentistry. Duration of the B4)Preservation of these contents during blood loss during surgeries which are procedure couldbequick (<20 min.), long the process. long lasting.4 The use of platelet (20 - 60 min.), very long (>1 hr.).Cost of concentrates to improve healing and to the device and repeated cost of reagents C) Relates to fibrin network that supports replace fibrin glues, as first described by and kits are also an important parameter. the platelet and leucocyte concentrate Whitman et al5 has been explored Automated systems were developed for during its application considerably during the last decade. the sole reason of ergonomics. C1)Density depends on the fibrinogen Parameters (A) define the practical during preparation.7 Classification of platelet concentrates characteristics of each technique. C2)Fibrin Polymerization type Several techniques for platelet concentrates have been devised, however B) Contents of the concentrates:These Most protocols lead to low density fibrin confusion exists as each method leads to parameters define the basic gel which can be utilized for surgical

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 119 application but lack a true fibrin support 2) VIVOSTAT PRF CENTRIFUGE Although it is an inexpensive method matrix. On the contrary, a (VIVOLUTION, Denmark): This is but lacks the ergonomy and highdensityfibrin network means that, a advanced cell separator and was reproducibility. not only the platelet concentrates act as a designed to produce the vivostat 2) NAHITA's PRP: is similar to biomaterial but also the matrix itself has fibrin sealent. It produces a leucocyte Anituas method.17 healing effects.8 poor platelet concentrate for surgical LEUCOCYTE- AND PLATELET use with the help of a specific RICH PLASMA (L-PRP) Fibrinogen is activated by thrombin, preparation kit. The drawbacks which initiates polymerization into include only a few publications Manual Protocol fibrin. Two distinct biochemical studies,cumbersome and very CURASAN METHOD (Germany): 10 architectures of fibrin fibrillae can be expensive procedure and damage to Most commonly used method. The blood observed:9 the platelets occur during the sample is drawn into a citrated tube. The process.11 sample tube is then spun in a standard A) Condensed Tetramolecular or centrifuge for 10 minutes at 2400 rpm to bilateral junctions Manual Protocol produce PPP. The PPP and buffy coat is B) Connected Trimolecular or 1) ANITUA's PRGF (Plasma rich in taken up into a syringe with a long equilateral junctions growth factors): In 1999,Anitua first cannula and an additional air-intake described plasma rich in growth cannula. A second centrifugation(15 From a clinical perspective the bilateral factors12 or Preparation rich in growth minutes at 3600 rpm) is performed to junctions result due to high thrombin factors.13 Subsequently it was concentrate the platelets. The second concentrations, which leads to a dense commercialized by BTI (Bio supernatant is also taken up by along network of monofibers similar to a fibrin technology institute,Victoria Spain). cannula and an air-intake cannula. For glue. This type is least favorable to The protocol includes the collection each 8 mL of blood, the volume of cytokine enmeshment and cellular of venous blood that is centrifuged in supernatant is about 0.6-0.7 mL; this is migration. On the other hand a slow several small test tubes for 8 minutes the PRP, to be used for then surgical physiological fibrin polymerization at 460g. After the centrifugation cycle procedure. Just before the time of the results in higher percentage of equilateral typically three layers are seen in the application,the PRP is combined with an junctions, leading to a flexible network test tube. The top most part in the test equal volume of a sterile saline solution capable of cytokine entrapmentand tube contains Plasma poor in growth containing 10% calcium chloride (a cellular migration.9 factors (PPGF) which is discarded citrate inhibitor that allows the plasma to with help of pipetting, at this point coagulate) and 100 U/mL of sterile Based on the above mention care should be taken to avoid bovine thrombin (an activator that allows classification each category of turbulence, remaining plasma i.e. polymerization of the fibrin into an concentrates will be discussed in relation (PRGF) is collected with a insoluble gel, which causes the platelets to the protocol used. pipette,using 'eyeballing' as to degranulate and release theindicated measuring tool. (The act of mediators and cytokines); the result LEUCOCYTE POOR or PURE eyeballing is to measure or weigh should be asticky gel that will be PLATELET - RICH PLASMA (P-PRP) something without any tools). 10% relatively easy to apply to the Pure platelet concentrates for topical use calcium chloride solution is added to surgicaldefects. The PPP can be stored were first developed as an application for induce fibrin polymerization. An for use as a protective barrier over the the classical transfusion platelet units and unstable PRGF gel is obtaining after wound.18,19,20 were first reported for maxillofacial 15 mins, which has to be used surgery.3 The P-PRP can be obtained by immediately. Recent publications have indicated that automated or manual methods. Some inconsistencies in the PRGF PRP prepared from 8 to 10 mL of whole protocol exist e.g In the original blood is sufficient for periodontal Automated Protocol: description of the protocolmost of the regenerative therapies.21 However, in oral 1) PLASMAPHERESIS: The first plasma (after discarding a small and maxillofacial reconstruction, 8 to method of producing the platelet fraction as described above) was 500 mL of whole blood should be drawn, concentrates for topical use was collected, including the 'buffy coat' so as to obtain the greater amounts of PRP known as plasmapheresis, which was layer that contains most of the needed for larger surgical defects.3,22 a cell separator resulting in platelets and leucocytes but in later differential ultracentrifugation applications of this method14,15 the FRIADENT SCHUTZE (Austria) : 23 (3000g). Different blood authors claim that the buffy coat layer Uses similar protocol as described above. components,such as platelets, was not collected. The objective of leucocytes and RBC's were first this approach was to avoid the REGEN (Switzerland) : Regen method separated from platelet poor plasma collection of leucocytes, but it seems uses a separator gel within the which was then re-infused in the to be technically imprecise and in centrifugation tubes with the aim of patient.10 Despite the sophisticated danger of yielding irreproducible improving the collection of platelets and equipment used, the final PRP always results. Moreover, it also leads toa leucocytes. contained residual RBC's and low platelet collection. Efficiency leucocyte and it was a cumbersome because platelets and leucocytes are PLATELTEX (Slovakia): The Plateltex process which required the help of found together in the intermediate protocol uses specific gelifying agents, haemotologist. layer after lowspin centrifugation.16 such as calcium gluconate and

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 120 lyophilized purified batroxobin, which is an enzyme that cleaves fibrinopeptide. This brings about fibrin polymerization without bovine thrombin and resultant gelling in about 10 minutes.24

The drawbacks of these techniques are that these protocols require substantial manual procedures, meaning that the preparation process is time consuming, and only lead to small volumes of L-PRP. Apart from the above-mentioned drawbacks adapted kits can be quite expensive if used frequently and the final product exhibits a low-density fibrin matrix, which is strong enough for application as fibrin glue but quickly dissolves. The reproducibility of the end product is questionable that is in case the buffy coat layer is not completely Figure 1.Classical manual platelet-rich plasma (PRP) protocol using a two-step centrifugation procedure .Three layers collected,the platelet collection are obtainedafter first centrifuge cycle: red blood cells (RBCs), 'buffy coat' (BC) layer and platelet-poor plasma (PPP). efficiency decreases and a PPRP can sometimes be obtained instead of LPRP. (Figure 1) risk of disease transmission. SmartPReP quickly, similar to fibrin glue. Their use system produces PRP gel as well as fibrin in daily practice remains uncommon and Automated Protocol glue. Furthermore, this system has larger itis no longer available. PCCS(Platelet Concentrate Collection blood containers for centrifugation that System): was developed by 3I enables the operator to obtain 90 to 180 LEUCOCYTE-POOR OR PURE mL of whole blood, leading to PLATELET-RICH FIBRIN (P-PRF) Citrated whole blood is transferred into sufficientamount of PRP for Fibrinet PRFM kit is the only system the first compartment and centrifuged for maxillofacial or plastic and under this category a short period to obtain the three layers reconstructive surgical procedures. The system comprises of two tubes, one RBC, buffy coat, PPP.Then, by opening for blood collection and another of a tubule and using air pressure, MAGELLAN APS SYSTEM forPRFM clotting, together with a thesuperficial layers (i.e. PPP and buffy The Magellan APS (Autologous Platelet transfer device. A small amount of blood coat) are transferred to the second Separator) is anadvance cell separator (9 mL) is drawn into a collectiontube, chamber and centrifuged again but for a with optical reader. This device is which contains tri-sodium citrate as an longer period. At the final step using the compact and designed for small blood anticoagulantand a proprietary separator same air pressure system,most of the PPP samples of up to 50 mL. Platelet gel, which is then centrifuged for layer is transferred back into the first collection efficiency is high, but cell sixminutes at high speed. compartment and thus discarded. Finally preservation is not known.The company product is leucocyte rich and has similar claims that the leucocyte content is also Typically three layers in the order of characteristics to the manual Curasan 28 RBCs,buffy coat and PPP are obtained. PRP describedin the beginning. high. Buffy coat and PPP areeasily transferred

25-27 GPS (Gravitational Platelet to a second tube containing CaCl with Published reports point out to the fact 2 Separation System) that these systems (Curasan and PCCS) the help of a specifically designed tube This system uses a two-chamber have greater ease of handling and shorter connection system.The clotting process centrifugation device with two-step is triggered by the presence of CaCl2 and preparation times than the SmartPReP 29 and Tisseel systems. centrifugation protocol. The main the tube is immediately centrifuged for difference is that the PPP is discarded 15 min, after which a stable PRFM clot SMARTPReP SYSTEM after the first centrifugation using a can be collected. It is claimed by the The two-chamber device automatically syringe and tubules, and the second company that the system produces a transfers the top layers(PPP and buffy centrifugation step is performed with the 'natural' platelet concentrate owing to the coat) into the second chamber based on RBC layer. The final PRP concentrate is absence of bovine thrombin. However, variations in weight and centrifugation collected by aspiration of the buffy coat this claim is doubtful because the blood is speed. SmartPReP is a multifunction layer on the surface of the RBC base. The mixed with anticoagulant and separation 21 procedure is thus inversed, but the final system, using a specific collection and gel, leading to what could be considered result seems to be similar. The main separation kit. The centrifuge usedin this unnatural conditions. drawbacks of all these techniques are that system can also be used to concentrate they require expensive and cumbersome stem cells from bone marrow aspirates. This protocol is similar to L-PRP centrifuges and collection/preparation It has the advantage of being an protocols, such as the Curasan method. kits, the final concentrates dissolve autologous system and hence there is no The main difference is that only very low

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 121 amounts of leucocytes are collected PRF).Trends Biotechnical 2009; owing to the specific separator gel used in Conclusion 27:158- 167. the method. The advent of second generation platelet 7. Mosesson MW, Siebenlist KR, Meh concentrates i.e. Choukroun's PRF has DA. The structure and biological LEUCOCYTE - AND PLATELET- overcome the drawbacks encountered in features offibrinogen and fibrin.Ann RICH FIBRIN (L-PRF) OR the PRP protocol. The Choukroun's N Y Acad Sci. 2001; 936:11-30. CHOUKROUN'S PRF protocol allows the production of a high 8. Clark, R.A. Fibrin and wound Was developed in France by Choukroun quantity of L-PRF clots using either a healing. Ann N Y Acad. et al.30 It can be considered as a second- specific centrifuge that takes eight tubes Sci.2001;936: 355-367. generation platelet concentratebecauseit or any modified laboratory centrifuge, 9. Van Hinsbergh VW, Collen A, is produced without any anticoagulants making it possible to produce even more Koolwijk P. Role of fibrin matrix in or gelifying agents.1 Venous blood clots for larger surgeries. Additional angiogenesis.Ann N Y Acad Sci. iscollected in dry glass tubes(without advantage of this method is its low cost 2001; 936: 426-37. anticoagulants) and centrifuged at low and the simplicity of the procedure, 10. Weibrich G, Kleis WK, Hafner G, speed 3000rpm at about 400g for which allowsnatural means, that is, Hitzler WE, Wagner W. Comparison 12min(Process protocol, Nice, France).31 without the use of chemicals or unnatural of platelet, leukocyte, and growth PRF can be considered as an autologous conditions. Therefore, this method seems factor levels in point-of-care platelet- healing biomaterial, incorporating in a to be most suitable for widespread use in enriched plasma, prepared using a matrix of autologous fibrin most daily practice and is actually the main modified Curasan kit, with leukocytes, platelets and growth factors technique in some countries, including preparations received from a local harvested from a simple blood France, Italy and Israel. An accurate blood bank.Clin Oral Implants Res. sample.32,33(Fig 2) working knowledge of the biomaterial, 2003;14:357-62. its biology, efficiency and limits are 11. Leitner GC, Gruber R, Neumüller J, necessary to optimize its use in daily Wagner A, Kloimstein P, Höcker P, practice for a widespread use. Körmöczi GF, BuchtaC.Platelet content and growth factor release in References platelet-rich plasma: a comparison of 1. Dohan DM, Choukroun J, four different systems.Vox Sang. DissA,Dohan SL, DohanAJ, Mouhyi 2006; 91:135-9. J, Gogly B. Platelet-rich fibrin 12. Anitua, E. Plasma rich in growth (PRF): a second generation platelet factors: preliminary results of use in concentrate. Part I: Technological the preparation of future sites for concepts and evolution. Oral Surg implants.Int J Oral Maxillofac Oral Med Oral Pathol Oral Implants. 1999;14:529-35. RadiolEndod 2006;101: e37-e44. 13. Anitua E, Sánchez M, Orive G, Andía 2. Toffler M, Toscano N, Holtzclaw D, I. The potential impact of the Del Corso M, EhrenfestDohan D. preparation rich in growth factors Introducing Choukroun's Platelet (PRGF) in different medical fields.

Figure 2.Choukroun'sPRF : PPP at the top layer, PRF clot Rich Fibrin (PRF) to the Biomaterials2007;28: 4551-4560. in the middle and RBC's in the bottom layer reconstructive surgery Milieu. The 14. Anitua E, Aguirre JJ, Algorta J, Journal of Implant and Advanced Ayerdi E, Cabezas AI, Orive G, Andia Clinical Dentistry 2009; 1: 21-32. I.Effectivenessof autologous 3. Marx RE, Carlson ER, Eichstaedt preparation rich in growth factors for In the absence ofanticoagulants, platelet RM, Schimmele SR, Strauss JE, the treatment of chronic cutaneous activation and fibrin polymerization are GeorgeffKR.Platelet-rich plasma: ulcers.J Biomed Mater Res B triggeredin a natural manner growth factor enhancement for bone ApplBiomater. 2008;84:415-21. immediately. After centrifugation,three grafts. Oral Surg Oral MedOralPathol 15. Sánchez M, Anitua E, Azofra J, Andía layers are formed: the RBC layer at the Oral RadiolEndod. 1998; 85: 638- I, Padilla S, Mujika I.Comparison of base, acellular plasmalayerat the top and 646. surgically repaired Achilles tendon a PRF clot in the middle. 4. Sunitha R, Munirathnam N. Platelet tears using platelet-rich fibrin rich fibrin: Evolution of a second matrices. Am J Sports Med. The PRF clot forms leads to formation of generation platelet concentrate. 2007;35:245-51. a strong fibrin matrix with a complex Indian J Dent Res 2008;19:42-46. 16. Weibrich G, Kleis WK, Hitzler WE, three-dimensional architecture, in which 5. Whitman DH, Berry RL, Green DM. Hafner G.Comparison of the platelet most ofthe platelets and leucocytes from Platelet gel: an autologous alternative concentrate collection system with the harvested blood are concentrated.The to fibrin glue with applications in oral the plasma-rich-in-growth-factors kit PRF clot becomes a strong membrane, and maxillofacial surgery.J Oral to produce platelet-rich plasma: a when pressed between to sterile gauze Maxillofac Surg. 1997;55:1294-9. technical report. Int J Oral Maxillofac pieces. Applications of this autologous 6. DohanEhrenfest DM, Rasmusson L, Implants. 2005;20:118-23. biomaterial have been describedin oral,34 Albrektsson T. Classification of 17. Ta m i m i F M , M o n t a l v o S , maxillofacial,35 ENT (ear, nose, throat) 36 platelet concentrates: from pure Tresguerres I, Blanco Jerez L. A and plastic surgery.37 platelet rich plasma (P-PRP) to comparative study of two methods for leucocyte and platelet - rich fibrin (L- obtaining platelet-rich plasma.J Oral

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 122 Maxillofac Surg. 2007;65:1084-93. methods: curasan-type PRP kit versus generation platelet concentrate. Part 18. Camargo PM, Lekovic V, PCCS PRP system. Int J Oral IV: clinical effects on tissue healing. Weinlaender M, Vasilic N, Maxillofac Implants 2002;17:184- Oral Surg Oral Med Oral Pathol Oral Madzarevic M, Kenney EB. Platelet- 90. RadiolEndod. 2006;101:e56-60. rich plasma and bovine porous bone 28. Christensen K, Vang S, Brady C, Isler 35. Choukroun J, Diss A, Simonpieri A, mineral combined with guided tissue J, Allen K, Anderson J, Holt Girard MO, Schoeffler C, Dohan SL, regeneration in the treatment of D.Autologous platelet gel: an invitro Dohan AJ, Mouhyi J, Dohan DM. intrabony defects in humans. J analysis of platelet-rich plasma using Platelet-rich fibrin (PRF): a Periodontal Res2002; 37:300-6. multiple cycles. J Extra Corpor secondgeneration platelet 19. L e k o v i c V, C a m a r g o P M , Technol. 2006; 38:249-53. concentrate. Part V: histologic Weinlaender M, Vasilic N, Kenney 29. Marlovits S, Mousavi M, Gäbler C, evaluations of PRF effects on bone EB. Comparison of platelet-rich Erdös J, Vécsei V.A new simplified allograft maturation in sinus plasma, bovine porous bone mineral, technique for producing platelet-rich lift.OralSurg Oral Med Oral Pathol and guided tissue regeneration versus plasma: a short technical note. Eur Oral RadiolEndod. 2006;101:299- platelet-rich plasma and bovine Spine J. 2004; 13:S102-6. 303. porous bone mineral in the treatment 30. Choukroun J, Adda F, Schoeffler C, 36. Diss A, Dohan DM, Mouhyi J, of intrabonydefects: a reentry study. J Vervelle A. Uneopportunité en paro- Mahler P.Osteotome sinus floor Periodontol2002; 73:198-205. implantologie: le elevation using Choukroun'splatelet- 20. Man D, Plosker H, Winland-Brown PRF.Implantodontie 2001; 42:55-62. rich fibrin as grafting material: a one- JE. The use of autologous platelet- (French). year prospective pilotstudy with rich plasma (platelet gel) and 31. Dohan DM, Del Corso M, Charrier microthreaded implants. Oral Surg autologous platelet-poor plasma JB. Cytotoxicityanalyses of Oral Med Oral Pathol Oral (fibrin glue) in cosmetic surgery. Choukroun's platelet-rich fibrin RadiolEndod. 2008; 105:572-9. PlastReconstrSurg2001; 107:229 - (PRF)on a wide range of human cells: 37. Choukroun JI, Braccini F, Diss A, 37. The answer toa commercial Giordano G, Doglioli P, Dohan DM 21. Weibrich G, Kleis WK, Kunz- controversy. Oral Surg Oral MedOral Influence of platelet rich fibrin (PRF) Kostomanolakis M, Loos AH, Pathol Oral RadiolEndod 2007; onproliferation of human Wagner W. Correlation of platelet 103:587-593. preadipocytes and tympanic concentration in platelet-rich plasma 32. Dohan DM, Choukroun J, Diss A, keratinocytes: anew opportunity in to the extraction method, age, sex, Dohan SL, Dohan AJ, Mouhyi J, facial lipostructure (Coleman's and platelet count of the donor. Int J Gogly B. Platelet-rich fibrin(PRF): a technique) andtympanoplasty? Rev Oral Maxillofac second-generation platelet LaryngolOtolRhinol (Bord). Implants2001;16:693-9. concentrate. Part II: platelet-related 2007;128:27-32. 22. Gonshor A. Technique for producing biologic features. OralSurg Oral Med platelet-rich plasma and Oral Pathol Oral RadiolEndod. 2006; plateletconcentrate: background and 101: e45-50. process. Int J Periodontics 33. Dohan DM, Choukroun J, Diss A, Restorative Dent 2002; 22:547-57. Dohan SL, Dohan AJ, Mouhyi J, 23. Weibrich G, Kleis WK, Buch R, Gogly B. Platelet-rich fibrin (PRF):a Hitzler WE, HafnerG.The Harvest second-generation platelet Smart PRePTM system versus the concentrate. Part III: leucocyte Friadent-Schütze platelet-rich activation: a new feature for plasma kit.Clin Oral Implants Res. plateletconcentrates? Oral Surg Oral 2003;14:233-9. Med Oral Pathol Oral RadiolEndod 24. Mazzucco L, Balbo V, Cattana E, 2006; 101: e51-55. BorziniP.Platelet-rich plasma and 34. Choukroun J, Diss A, Simonpieri A, platelet gel preparation using Girard MO, Schoeffler C, Dohan SL, Plateltex. Vox Sang. 2008;94:202-8. Dohan AJ, Mouhyi J, Dohan DM. 25. Weibrich G, Kleis WK. Curasan PRP Platelet-rich fibrin (PRF): a second kit vs. PCCS PRP system. Collection efficiency and platelet counts of 2 different methods for the preparation of platelet-rich plasma. Clin Oral Implants Res 2002;13:437-43. 26. Appel TR, Pötzsch B, Müller J, von Source of Support : Nill, Conflict of Interest : None declared Lindern JJ, Berge SJ, Reich RH. Comparison of three different preparations of platelet concentrates for growth factor enrichment. Clin Oral Implants Res2002; 13:522-8. 27. Weibrich G, Kleis WK, Hafner G. Growth factor levels in the platelet- rich plasma produced by 2 different

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 123 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Periodontal Diseases & Coenzyme Q10 : A 1 H.L. Gupta 2 Shweta Soni Review 3 Vivek Chaturvedi 4 Vikas Dev Abstract 1 Reader, Department of Periodontics Reactive oxygen species (ROS) not only play an important role in cell signaling and metabolic Rajasthan Dental College, Ajmer Road, Jaipur processes but are also thought to be implicated in the pathogenesis of a variety of inflammatory 2 Sr. Lecturer, Department of Periodontics disorders. Indeed, novel therapies are being developed, specifically aimed at reducing oxidative Vyas Dental College, Jodhpur, Rajasthan stress at the tissue and cellular level . Oxidative stress arises within tissues when the normal 3 Prof. & Head, Department of Periodontics balance between ROS generation and antioxidant defence shifts in favour of the former, a situation Rajasthan Dental College, Ajmer Road, Jaipur 4 Sr. Lecturer, Department of Peroidontics arising from either an excess of ROS and/or a depletion of antioxidants . Periodontitis is a term used to describe an inflammatory process, initiated by the plaque biofilm, that leads to loss of Rajasthan Dental College, Ajmer Road, Jaipur. periodontal attachment to the root surface and adjacent alveolar bone and which ultimately results Address For Correspondence: in tooth loss. Periodontal pathogens can induce ROS overproduction and thus may cause Dr. H.L. Gupta, Reader, Deptt. of Periodontics collagen and periodontal cell breakdown. When ROS are scavenged by antioxidants, there can be Rajasthan Dental College, Ajmer Road, Jaipur Email :[email protected] a reduction of collagen degradation. Coenzyme Q10 serves as an endogenous antioxidant which th increases the concentration of CoQ10 in the diseased gingiva and effectively suppresses Submission : 07 October 2011 advanced periodontal inflammation. Accepted : 04th May 2012

Key Words Quick Response Code Antioxidant, bioscavenger, coenzyme Q10, periodontal disease

Introduction Antioxidants, such as CoQ10, can Coenzyme Q10 (CoQ10) is a compound neutralize free radicals and may reduce or found naturally in the energy-producing even help prevent some of the damage center of the cell known as the they cause.[3,4] mitochondria. Because of its ubiquitous Although CoQ10 can be synthesized in presence in the nature and its quinone body, situation may arise in which the from the mitochondria of beef heart in structure ( similar to that of vitamin K), body's synthetic capacity is insufficient 1957.[6] In 1961 Peter Mitchel proposed CoQ10 is also known as ubiquinone.[1,2] to meet CoQ10 requirements. the electron transport chain (which The primary biochemical action of Susceptibility to CoQ10 deficiency includes the vital proton-motive role of CoQ10 is a cofactor in the electron- appear to be greatest in cell that are CoQ10). In 1972, Gian Paolo Littarru and transport chain, the series of redox metabolically active (such as heart, Karl Folkers separately demonstrated a reactions that are involve in the immune system, gingiva and gastric deficiency of CoQ10 in human heart biosynthesis adenosine triphosphate ( mucosa), since these cells presumably disease. The antioxidant role of the ATP). ATP serves as the cell's major have the highest requirements for molecule as a free radical scavenger was energy source and drives a number of CoQ10.[3] Tissue deficiencies of CoQ10 widely studied by Lars Ernster.[1] biological processes, including muscle have been occur in the wide range of contraction and the production of protein. medical and dental conditions, including Common Names CoQ10 also works as an antioxidant, so cardiovascular diseases, periodontal Coenzyme Q10 is also known as the CoQ10 is essential for the health of diseases, gastric ulcer, cancer and Coenzyme Q, CoQ, CoQ10, Ubiquinone, virtually all human tissue and organs.[1,2] acquired immunodeficiency syndrome ( Ubiquinone-Q10, Ubidecarenone, and Antioxidants are substances that AIDS). A deficiency may result from: i) Vitamin Q10. scavenge free radicals, damaging impaired synthesis due to nutritional compounds in the body that alter cell deficiencies ii) genetic or acquired defect Biochemistry membranes, tamper with DNA, and even in synthesis or utilization iii) increased Normal blood levels of CoQ10 are 0.7 - 1 cause cell death. Free radicals occur tissue needs resulting from illness iv) mcg/ml4 [7] . CoQ10 is another name for naturally in the body, but environmental CoQ10 levels decline with advancing 2,3-dimethoxy-5-methylbenzoquinone toxins (including ultraviolet light, age.[5] to which a terpenoid side chain radiation, cigarette smoking, and air (consisting of ten monounsaturated pollution) can also increase the number Historical context trans-isoprenoid units) is attached. It is a of these damaging particles. Scientists Coenzyme Q-10 (CoQ-10 or fat soluble quinone, structurally similar believe free radicals contribute to the Ubiquinone) is a naturally occurring to vitamin K2.[8] Quinones with six to 10 aging process, as well as the development quinone that is found in most aerobic side chains (CoQ6 -CoQ10) are found in of a number of health problems, organisms from bacteria to mammals. It mammals. Human cells synthesize including heart disease and cancer. was first identified in 1940 and isolated CoQ10 in an eight-step cascade starting

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 124 from the amino acid, tyrosine. The increased by CoQ10 supplementation colonize the periodontal and associated synthetic chain requires adequate levels with concomitant functional tissues involve the systemic circulation of folic acid, niacin, and vitamins B2, B6, improvement as evidenced by enhanced and ultimately the peripheral systems of and C3. CoQ10 is slowly absorbed after reversal of oxidative DNA damage.[15] the body. This creates a complex bi- oral administration.[9] Antioxidant function of CoQ10: directional series of host- microbial It is taken up by chylomicron, distributed The antioxidant nature of CoQ10 derives interactions involving cellular and to the liver and incorporated into very from its energy carrier function. As an humoral factors and networks of low density lipoproteins.[8] Peak blood energy carrier, the CoQ10 molecule is cytokines, chemokines, and growth levels occur 5 - 10 hours after ingestion; continuously going through an factors. The majority of periodontal the elimination half life is 34 hours, and it oxidation-reduction cycle. As it accepts tissue destruction is caused by an is primarily excreted through the biliary electrons, it becomes reduced. As it gives inappropriate host response to tract. Typical adult daily doses of 100 - up electrons, it becomes oxidized. In its periopathogens and their products[21] . 150 milligrams double normal serum reduced form, the CoQ10 molecule holds Whether acute or chronic, inflammation levels.[8] Absorption of the substance electrons rather loosely, so this CoQ is dependent upon regulated humoral and largely depends on its physiochemical molecule will quite easily give up one or cellular responses, and the molecules characters in the preparation and hence both electrons and, thus, act as an considered to mediate inflammation at coenzyme Q10 in powder, suspension, antioxidant. CoQ10 inhibits lipid one time or another are legion.[22] oil solution, or solubilized form exhibits peroxidation by preventing the However, an event characteristic of different bioavailability. Study has production of lipid peroxyl radicals mammalian inflammation, tissue shown that solubilized coenzyme Q10 is (LOO).[16] In addition, the reduced form infiltration by polymorphonuclear obviously preferred due to its better of CoQ effectively regenerates vitamin E leukocytes and monocytes and absorption, higher plasma concentration, from the a-tocopheroxyl radical and, subsequent phagocytosis features non- and consequently better bioavailability thereby interfering with the propagation mitochondrial O2 consumption, which [10] indicating that plasma concentrations step. Furthermore, during oxidative may be 10 or 20 times that of resting of coenzyme Q10 are 2-2.5 times higher stress, interaction of H2O2 with metal consumption ultimately ends in during long-term oral therapy with ions bound to DNA generates hydroxyl generating free radicals (FRs) and solubilized forms [ 1 1 ] and the radicals and CoQ efficiently prevents the reactive oxygen species (ROS), such as bioavailability is 3-6 times higher in oxidation of bases, in particular, in superoxide anion radicals, hydrogen comparison with powder.[12] mitochondrial DNA.In contrast to other peroxide, hydroxyl radicals, and Functions of CoQ10: antioxidants, this compound inhibits both hypochlorous acid, all capable of Physiologically, CoQ10 plays four major the initiation and the propagation of lipid damaging either cell membranes or [15] [23] roles. It has an essential role in and protein oxidation. associated biomolecules. Because of mitochondrial energy (ATP) production Immune function: their high reactivity, several FRs and through redox activity in the respiratory Cells and tissues that play a role in ROS can rapidly modify either small, chain, transporting electrons between immune function are highly energy- free biomolecules (i.e., vitamins, amino enzymes. Second, it plays a role in extra dependent and therefore require an acids, carbohydrates, and lipids) or mitochondrial redox activity in the cell adequate supply of CoQ10 for optimal macromolecules (i.e., proteins, nucleic membrane and endomembranes. CoQ10 function. Several studies have been acids) or even supramolecular structure also functions as an antioxidant, demonstrated immune-enhancing effects (i.e., cell membranes, circulating inhibiting lipid peroxidation and of CoQ10 or its analogues.[17,18] These lipoproteins). scavenging free radicals. Finally, it plays effect included increase phagocytic Usually, the oxidative damage is an important role in membrane activities of macrophage, increase perfectly controlled by the anti-oxidant stabilization and fluidity.[8,13] proliferation of granulocytes in response defense mechanisms of the surrounding Ubiquinone molecules are classified to infection and treatment of infected tissues but plaque microorganisms based on the length (n) of their isoprenoid animals with CoQ10 increased the promoting periodontitis can unbalance side chain (Ubiquinone -n). For example, survival rate. In a study of eight this equilibrium. A massive neutrophil the main species in humans is chronically ill patients, administration of migration to the gingiva and gingival Ubiquinone -10, in rodents it is 60mg/day of CoQ10 was associated with fluid leads to abnormal spreading of Ubiquinone-9, in Escherichia coli it is significant increase in serum level of FR/ROS produced. Consequently, this Ubiquinone -8 and, in Saccharomyces immunoglobulin G(IgG) in 27 - 98 days led to a search for appropriate cerevisiae, it is Ubiquinone -6 in varying of treatment. These study suggest that "antioxidant therapy" in inflammatory [23] amounts.[14] CoQ9 is the predominant CoQ10 may help prevent or reverse the periodontal disease. form in relatively short-lived species immunosupression that is associated Periodontal disease (gum disease) affects [19] such as rats and mice whereas in humans with aging and chronic diseases. 60% of young adults and 90% of and other long-lived mammals the major CoQ10 and Periodontal diseases: individuals over age 65. Healing and homolog is CoQ10. Among blood cells, Periodontitis is a term used to describe an repair of periodontal tissue requires lymphocytes and platelets contain inflammatory process, initiated by the efficient energy production. A metabolic significant amounts of CoQ10 whereas plaque biofilm, that leads to loss of function dependent on an adequate red blood cells which lack mitochondria periodontal attachment to the root surface supply of CoQ10. CoQ10 deficiency has contain only a tiny amount that is likely to and adjacent alveolar bone and which been reported in gingival tissue of be associated with membranes. ultimately results in tooth loss. The patients with periodontal disease. Lymphocyte CoQ10 content can be inflammatory and immune responses to Gingival biopsies revealed subnormal the bacteria and also viruses[20] that tissue level of CoQ10 in 60% to 96%

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 125 patients with periodontal disease and low period, significant reduction in gingival ringing in the ears[35] level of CoQ10 in leukocytes in 86% of crevicular fluid flow, probing depth and ?Delay the aging process and increase cases.[24,25] These finding indicated that attachment loss were found and longevity[33] periodontal disease is frequently significant improvements in modified associated with CoQ10 deficiency. gingival index, bleeding on probing and Side effects of CoQ10: Patients with periodontal disease have peptidase activity derived from No serious side effects have been low concentrations of CoQ10 in gingival periodontopathic bacteria. reported from the use of CoQ10. Some tissue and blood.[20,21,22] This has led some A study evaluated the periodontium patients using CoQ10 have experienced clinical investigators and dentists to condition after oral applications of mild insomnia, elevated level of recommend CoQ10 supplementation, coenzyme Q10 with vitamin E. The total enzymes, rashes, nausea and upper particularly for diabetic patients and antioxidant status in the mixed saliva by abdominal pain.[36] others at risk for periodontal disease. A the colorimetric method was determined case report of one patient with severe twice. The average value of plaque index Conclusion: periodontal disease who had a dramatic decreased from 1.0 to 0.36, average value The major use for CoQ10 is the improvement with CoQ10 therapy of interdental hygiene index was reduced prevention and treatment of prompted several open label trials.[24] from 39.51-6.97%, gingival index values cardiovascular diseases including In one case series, eight patients with decreased from 0.68 to 0.18, and the chronic heart failure, atherosclerotic and periodontal disease were treated with values of sulcus bleeding index ischemic heart disease, ischemia CoQ10 (50 mg daily); symptoms were decreased from 7.26 to 0.87. Periodontal associated with cardiac surgery, toxin- significantly reduced over 21 days of pockets also shallowed by 30%. The induced cardiomyopathies and treatment[26,27] . In an open label study of laboratory examination result improved hypertension. Other popular uses include ten adult patients with periodontal by 20%. It concluded that coenzyme Q10 adjunctive therapy for periodontal disease, topical therapy with CoQ10 was with vitamin E had a beneficial effect on disease, cancer and diabetes and to [32] associated with significant improvement the periodontal tissue. enhance athletic performance. CoQ10 is in disease[28] . Because it is an antioxidant, coenzyme a natural human ubiquinone, but it can be In an open trial, administration of CoQ10 Q10 has received much research chemically synthesized. It has an produced " extraordinary post surgical attention in the medical literature in the important role in mitochondrial healing ( 2 to 3 time faster than normal) in last several years. Although coenzyme metabolism, and it functions as an 7 patients in advanced periodontal Q10 may have been viewed as an antioxidant. Data from animal studies, disease. The beneficial effect of CoQ10 alternative medication, it is used case series, open-label trials and has also been confirm in dogs, where it routinely, both topically and comparison studies support its use in reduced the severity of experimentally systemically. treating ischemic heart disease, ischemia induced periodontal disease.[29] Preliminary clinical studies also suggest associated with cardiac surgery, chronic The specific activity of succinic that CoQ10 use as a therapeutic agent in: heart failure, hypertension, and dehydrogenase-coenzyme Q10 reductase ?Researchers believe that the ventricular arrhythmias. Additional in gingival tissues from patients with beneficial effect of CoQ10 in the studies are needed to define its precise periodontal disease against normal prevention and treatment of heart role in the treatment of these conditions [33] periodontal tissues has been evaluated disease and to evaluate its use as an adjunctive using biopsies, which showed a ?High blood pressure and high therapy for cancer and periodontal [33] deficiency of CoQ10 in patients with cholesterol disease. periodontal disease. On exogenous ?CoQ10 supplements may improve CoQ10 administration, an increase in the heart health and blood sugar and help Reference specific activity of this mitochondrial manage high cholesterol and high 1. Ernster, L; Dallner, G (1995). enzyme was found in deficient blood pressure in individuals with "Biochemical, physiological and [33] patients.[24,26,29] The periodontal score was diabetes. medical aspects of ubiquinone also decreased concluding that CoQ10 ?Malignancies[33] function". Biochimica Biophysica should be considered as an adjunct for the ?Improve immune function in Acta (1): 195-204. treatment of periodontitis in current individuals with immune deficiencies 2. Al-Hasso. Coenzyme Q10: a review. dental practice.[27] (such as acquired immunodeficiency Hosp Pharm. 2001;36(1):51-66. Many clinical trials with oral syndrome or AIDS) and chronic 3. Raitakari OT, McCredie RJ, Witting administration of CoQ10 to patients with infections (such as yeast, bacteria, P, Griffiths KA, Letter J, Sullivan D, periodontal disease have been conducted. and viral infections)[33] Stocker R, Celermajer DS. The results have shown that oral ?Be used as part of the treatment for Coenzyme Q improves LDL administration of CoQ10 increases the Alzheimer's disease and Parkinson's resistance to ex vivo oxidation but concentration of CoQ10 in the diseased disease[34] does not enhance endothelial gingiva and effectively suppresses ?Reduce damage from stroke[33] function in hypercholesterolemic advanced periodontal inflammation[26,30,31] ?Enhance physical activity in people young adults. Free Radic Biol Med. and periodontal microorganisms. with fatigue syndromes[34] 2000;28(7):1100-1105. Topical application of CoQ10 to the ?Improve exercise tolerance in 4. Aberg, F; Appelkvist, EL; Dallner, G; periodontal pocket was evaluated with individuals with muscular Ernster, L (1992). "Distribution and and without subgingival mechanical dystrophy[34] redox state of ubiquinones in rat and debridement. In the first three-week ?Improve symptoms of tinnitus, or human tissues". Archives of biochemistry and biophysics 295 (2):

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 126 230-4. functions. Biochem Biophys Res Chem Pathol Pharmacol 1975; 5. Shindo, Y; Witt, E; Han, D; Epstein, Commun 2010, 396(1):74-79. 12:111-23. W; Packer, L (1994). "Enzymic and 17. Mayar P, Hamberger H, Drews J , 27. Wilkinson EG, Arnold RM, Folkers non-enzymic antioxidants in Defferential effect of Ubiquinone Q7 K. Bioenergetics in clinical medicine. epidermis and dermis of human skin". and Ubiquinone analogs on VI. Adjunctive treatment of The Journal of investigative macrophage activation and periodontal disease with coenzyme dermatology 102 (1): 122-4. experimental infections in Q10. Res Commun Chem Pathol 6. Crane, F; Hatefi, Y; Lester, R; granulocytopenic mice. Infection Pharmacol 1976; 14:715-9. Widmer, C (1957). "Isolation of a 1980;8: 256-261. 28. Hanioka T, Tanaka M, Ojima M, quinone from beef heart 18. Saiki I, Tokushima Y, Nishimura K, Shizukuishi S, Folkers K. Effect of mitochondria". Biochimica et Azuma I.Mcrophage activation with topical application of coenzyme Q10 Biophysica Acta 25 (1): 220-1. Ubiquinone and their related on adult periodontitis. Mol Aspects 7. Lockwood K, Moesgaard S, Hanioka compounds in mice. Int J Vitam Nutr Med 1994; 15:s241-8. T, Folkers K. Apparent partial Res 1983;53:312-320. 29. Wilkinson EG, Arnold RM, Folkers remission of breast cancer in 'high 19. Folker K,Shizukuishi S, Tekemura K, et al. Bioenergetics in clinical risk' patients supplemented with K, et al. Increase level of IgG in serum medicine. II. Adjuntive treatment nutritional antioxidants, essential of patients treated with coenzymes with CoQ10 in periodontal therapy. fatty acids and coenzyme Q10. Mol Q10. Res Commun Chem Pathol Res Commun Chem Pathol Aspects Med 1994; 15:s231-40. Pharmecol 1982;38:335-338. Pharmacol 1975;12:111-124. 8. Greenberg S, Frishman WH. Co- 20. Slots J. Herpesviruses in periodontal 30. S h i z u k u i s h i S , H a n i o k a T, enzyme Q10: a new drug for diseases. Periodontol 2000 2005: 38: Tsunemitsu A, Fukunaga Y, Kishi T, cardiovascular disease. J Clin 33-62. Sato N. Clinical effect of Coenzyme Pharmacol1990; 30:596-608. 21. Lamster IB, Novak MJ. Host 10 on periodontal disease; evaluation 9. Folkers K. Relevance of the mediators in gingival crevicular of oxygen utilisation in gingiva by biosynthesis of coenzyme Q10 and of fluid: implications for the tissue reflectance spectrophotometry. the four bases of DNA as a rationale pathogenesis of periodontal disease. Amsterdam: Elsevier; 1986: 359-68. for the molecular causes of cancer Crit Rev Oral Biol Med 1992: 3: 31- 31. McRee JT, Hanioka T, Shizukuishi S, and a therapy. Biochem Biophys Res 60. Folkers K. Therapy with Coenzyme Commun 1996; 224:358-61. 22. Bliznakov EG, Chopra RK, Q10 for patients with periodontal 10. Kalenikova EI, Gorodetskaya EA, Bhagavan HN. Coenzyme Q10 and disease. 1. Effect of Coenzyme Q10 Kolokolchikova EG, Shashurin DA, neoplasia: Overview of experimental on subgingival micro-organisms. J Medvedev OS. Chronic and clinical evidence. In: Bagchi D, Dent Health. 1993;43:659-66. administration of coenzyme Q10 Preuss HG, editors. 32. Brzozowska TM, Flisykowska AK, limits postinfarct myocardial Phytopharmaceuticals in Cancer OEwitkowska MW, Stopa J. Healing remodeling in rats. Biochemistry Chemoprevention. Boca Raton: CRC of periodontal tissue assisted by (Mosc) 2007;72:407-15. Press; 2004. pp. 599-622. Coenzyme Q10 with Vitamin E: 11. Chopra RK, Goldman R, Sinatra ST, 23. Battino M, Bullon P, Wilson M, Clinical and laboratory evaluation. Bhagavan HN. Relative Newman H. Newman Oxidative Pharmacol Rep. 2007;59:251-60. bioavailability of coenzyme Q10 injury and Inflammatory periodontal 33. Dhanasekaran M, Ren J. The formulations in human subjects. Int J diseases: The challenge of anti- emerging role of coenzyme Q-10 in Vitam Nutr Res. 1998;68:109-13. oxidants to free radicals and reactive aging, neurodegeneration, 12. Miles M, Horn P, Miles L, Tang P, oxygen species. Crit Rev Oral Biol cardiovascular disease, cancer and Steele P, DeGraw T. Bioequivalence Med. 1999;10:458-76. diabetes mellitus. Curr Neurovasc of coenzyme Q10 from over-the- 24. Nakamura R, Littarru GP, Folkers K, Res. 2005;2(5):447-59. counter supplements. Nutr Res. Wilkinson EG. Study of CoQ10 in 34. Bustos F, Molina JA, Jimenez-Jimenz 2002;22:919-29. gingiva from a patients with FJ, Garcia-Redondo A, Gomez- 13. Rauchova H, Drahota Z, Lenaz G. periodontal disease and evidence for Escalonilla C, Porta-Etessam J, et al. Function of coenzyme Q in the cell: deficiency of Coenzymes Q10.Proc Serum levels of coenzyme Q10 in some biochemical and physiological Natl Acad Sci 1974;71:1456-1460. patients with Alzheimer's disease. J properties. Physiol Res 1995; 44:209- 25.Hansen IL, Iwamoto Y, Kishi Neural Transm. 2000;107(2):233- 16. T,Folker K. Bioenergetic in clinical 239. 14. Cluis CP, Burja AM, Martin VJ. medication.I X. Gingival and 35. Khan M, Gross J, Haupt H, et al., A Current prospects for the production leukocytic deficiencies of coenzymes pilot clinical trial of the effects of of coenzyme Q10 in microbes. Q10 in a patients with periodontal coenzyme Q10 on chronic tinnitus Trends Biotechnol. 2007;25:514-21. disease. Res Commun Chem Pathol aurium. Otolaryngol Head Neck 15. Tomasetti M, Alleva R, Borghi B, Pharmecol 1976;14:729-738. Surg. 2007;136(1):72-7. Collins AR. Collins In vivo 26. Wilkinson EG, Arnold RM, Folkers 36. Ernster, L; Dallner, G. "Biochemical, supplementation with coenzyme Q10 K, Hansen I, Kishi H. Bioenergetics physiological and medical aspects of enhances the recovery of human in clinical medicine II. Adjunctive ubiquinone function". Biochimica et lymphocytes from oxidative DNA treatment with coenzyme Q in Biophysica Acta 1995(1): 195-204. damage. FASEB J. 2001;15:1425-7. periodontal therapy. Res Commun 16. Bentinger M, Tekle M, Dallner G: Coenzyme Q--biosynthesis and Source of Support : Nill, Conflict of Interest : None declared

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 127 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 A Cigarette A Day, Keeps The Doctor In Pay 1 Dipika Garg 2 Sidharth Narula 3 Varun Jindal

Abstract 1 Smoking is one of the most common forms of recreational drug use. Tobacco smoking is today by St. Louis (MO) U.S.A. 2 Professor, far the most popular form of smoking and is practiced by over one billion people in the majority of all Darshan Dental College, Udaipur. human societies. The history of smoking can be dated to as early as 5000 BC, and has been 3 Sr. Lect recorded in many different cultures across the world. Only relatively recently, and primarily in Bhojia Dental College, Baddi industrialized Western countries, has smoking come to be viewed in a decidedly negative light. Address For Correspondence: Today medical studies have proven that smoking tobacco is among the leading causes of many Dr. Dipika Garg MDS, diseases such as lung cancer, heart attacks, COPD, erectile dysfunction and can also lead to birth St. Louis (MO) U.S.A. defects. The inherent health hazards of smoking have caused many countries to institute high Email : [email protected] taxes on tobacco products and anti-smoking campaigns are launched every year in an attempt to th curb tobacco smoking. Smoking cessation, referred to as "quitting", is the action leading towards Submission : 17 December 2011 th abstinence of tobacco smoking. There are a number of methods such as nicotine replacement Accepted : 14 May 2012 therapy, antidepressants, hypnosis, self-help, and support groups. Quick Response Code Key Words Smoking, Drug, Tobacco, Cancers

Introduction knowledge that cigarette smoking is the The main tobacco killers in both sexes are single major cause of cancer and cancers, especially lung cancer, heart cardiovascular disease in the United disease and chronic bronchitis. However, States, contributing to hundreds of social pressures and psychological needs in developing countries with higher level thousands of premature deaths each year, including environmental influence of traditional tobacco use, such as yet one-fourth to one-third of American ,school and peer influence, personal chewing or smoking with the lit end of the adults continue to smoke. factors and knowledge, attitude and chutta inside the mouth, tobacco use is Before examining the negative health beliefs about smoking. associated with high level of oral cancer. effects of tobacco use, we would remind The tobacco market is dependent on a For example, the highest reported rate of the reader that a popular emphasis on mass market. As smokers die or quit, they mouth cancer in the world is among negative aspects is a rather new are keen to recruit new young smokers to women in Bangalore. In India indeed it is phenomenon. Since the Middle Ages maintain their profits, particularly in estimated that tobacco use causes around tobacco leaves have been used as new markets such as developing one in five of all cancers in women. (1) medicinal herbs in ointments, poultices, countries. They tailor a product to appeal This article aims to explore the reasons mouth rinses and smoke. Oral ulcers, to specific target groups by altering its and consider why more attention needs to caries and "toothache" were all treated price, availability and image through be paid to issues around smoking both in with this wonder drug. A product is still packaging, advertisement and promotion terms of research and action. It will not readily available today, called "Dental using images and messages being revisit the pathology associated with Snuff" which was advertised more than a glamorous, sophisticated, romantic, smoking. century ago as a cure for toothache, healthy, sporty, fun, relaxing, liberated, gingivitis, facial neuralgia, caries, and rebellious and, last but not least, History scurvy. Given this positive image slimming. Young teenagers who smoke Tobacco has been variously hailed as a throughout most of its history it's are more appreciative of cigarette gift from the gods, a miraculous cure-all universal popularity is not surprising. It is advertisements than non smokers and the for life's physical ills, a solace to the surprising, rather, that some persons have most heavily advertised brands are more lonely soldier or sailor, a filthy habit, a always been moved to speak out against often bought by teenagers than adult corrupting addiction, and the greatest it, even to the extent of proclaiming its smokers. How smoking is portrayed in disease-producing product known to use a capital offense in some European the media more generally also affects the man. This diversity of opinion has and Asian countries as early as the way in which young people view the continued unchanged for centuries and sixteenth century. habit. Glamorous models, female has appeared until very recently to be personalities, teenage pop idols and film little affected by research results from How smoking spreads stars featuring in magazines, TV soaps, more than 900,000 papers thus far The initiation of smoking among plays and films depict smoking as being published on the topic. It is common adolescence is heavily influenced by part and parcel of their success. However,

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 128 adolescent smokers are more likely to be Smoking is directly responsible for 80 in reducing nicotine reinforcement in under achievers in schools with low percent of lung cancer deaths in women clinically used doses. The NRTs are academic goals. Using smoking to in the U.S. each year.(4) Smoking is effective in relieving tobacco withdrawal bolster self confidence stems from the directly responsible for more than 90 and making abstinence easier in smokers wide spread belief that smoking can help percent of chronic obstructive pulmonary trying to quit. NRTs approximately calm nerves, control moods and alleviate disease (COPD), or emphysema and double the success rate of quitting stress- all important concerns during chronic bronchitis deaths each year.(4) smoking relative to placebo. NRTs can be adolescence. Postmenopausal women who smoke classified as short-acting (gum, lozenge, have lower bone density than women inhaler, and spray) and longer-acting Particularly about women who never smoked. Women who smoke (patch) products. Short-acting NRT Smoking kills over half a million women have an increased risk for hip fracture products are especially effective in acute each year and is the most important compared to never smokers. Cigarette management of tobacco withdrawal and preventable cause of female premature smoking also causes skin wrinkling that craving. An important consideration for death in several advanced countries. could make smokers appear less NRT treatment is titration of the dose Women take up cigarette smoking as a attractive and prematurely old.(5) based on the smoker's nicotine intake, widespread habit later than men, mainly determined roughly by the number of due to socio- cultural factors, such as it Smokeless Tobacco cigarettes smoked per day (CPD). (7,8) not being socially acceptable for women Like cigarettes, smokeless tobacco to be seen smoking in public, religious products contain a variety of toxins Sustained-Release Bupropion attitudes and women being generally less associated with cancer. At least 28 Bupropion, an atypical antidepressant, is affluent than men. Smoking affects cancer-causing chemicals have been approved for treatment of smoking women's health in ways which specific to identified in smokeless tobacco products. cessation. In preclinical studies, them. Research has shown women who Smokeless tobacco is known to cause bupropion reduced nicotine's rewarding smoke (i) have a 10 times higher risks of cancers of the mouth, lip, tongue, and effects and attenuated nicotine heart disease and an increased risks of pancreas. Users also may be at risk for withdrawal symptoms. Its mechanism of stoke if they also use oral contraceptives cancer of the voice box, esophagus, colon action is thought to be mediated by its (ii) have a two fold associated higher and bladder, because they swallow some ability to block the reuptake of risks of cervical cancer and (iii) of the toxins in the juice created by using norepinephrine and DA in the experience detrimental affects on their smokeless tobacco.Smokeless tobacco mesolimbic system and nucleus reproductive health, including can irritate your gum tissue, causing accumbens, a key area for nicotine dysmenorrhoea, reducing fertility and an periodontal (gum) disease. Sugar is often reinforcement. Additionally, bupropion early menopause. Women who smoke added to enhance the flavor of smokeless antagonizes brain nicotinic receptors and during pregnancy also increase by a tobacco, increasing the risk for tooth blocks the reinforcing effects of nicotine. quarter their risks of mis-carriage and by decay. Smokeless tobacco also typically (9) a third the risks of the infants prenatal contains sand and grit, which can wear death, they are twice as likely to have down your teeth. (6) Varenicline (CHANTIX) premature labour and 3 times more likely Varenicline is a partial agonist for the to have a low birth weight baby. In Treating The Addiction á4â2 subtype of nAChRs, which are developing countries where the health of Nicotine, the main addictive chemical in associated with the addictive effects of mother and baby is already jeopardized tobacco smoke, is essential in continued nicotine. Varenicline is also a full agonist through poverty and malnutrition, the and compulsive tobacco use. Seven at the á7 nAChR. In smokers, varenicline effects of smoking are likely to have even medications are currently US Food and attenuates the subjective rewarding greater impact on birth weight and Drug Administration (FDA) approved responses and heart rate increases prenatal mortality. Smoking is more for smoking cessation: five nicotine induced by intravenous nicotine. common among these in low income, replacement therapies (NRTs), Varenicline also improves tobacco who have low status jobs or are bupropion, and varenicline. In addition, withdrawal symptoms, mood, and unemployed, are single parents or clonidine and nortriptyline are effective cognitive performance in abstinent divorced, have low level of academic for smoking cessation but are not FDA smokers. All these effects may contribute achievement and are from under approved for this indication. to varenicline's efficacy for smoking privileged ethnic groups.(2) As one starts cessation. (9) to smoke regularly, his/ her body gets Nicotine Replacement Therapy used to regular nicotine doses and In the US market, five NRT products are Nortriptyline becomes physiologically dependant. currently available: nicotine patch, Nortriptyline, a tricyclic antidepressant, There are no consistent patterns or trends nicotine chewing gum, nicotine lozenge, has been found to be effective for among women. Prevalence rates vary nicotine nasal spray, and nicotine vapor smoking cessation. The underlying from as much as 58% in Nepal and over a inhaler. Nicotine gum, patch, and lozenge mechanism of nortriptyline's efficacy for third in European countries, such as are available as over-the-counter (OTC) smoking cessation might be through Denmark and Poland, to barely products, whereas nasal spray and vapor norepinephrine reuptake inhibition in detectable levels in many African inhaler are available by prescription only. central synapses or through nAChR countries, such as the Ivory Coast and Although initially thought to be a antagonism. In clinical trials for smoking Guinea. (3) "substitution" treatment, similar to cessation, the dose of nortriptyline was methadone treatment for opioid 75 to 100 mg/d, and the length of In the U.S.A. addiction, the NRTs have limited efficacy treatment was 8 to 12 weeks. Compared

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 129 with placebo, nortriptyline Conclusion 4. Centers for Disease Control and approximately doubles the rates of Mark Twain once said "Quitting smoking Prevention. National Center for smoking abstinence. (9) is easy. I have done it a thousand times". Health Statistics. National Vital Smoking cessation programs are useful Statistics Reports. Births: Final Data Clonidine in helping smokers to quit, but smoking is for 2005. December 5, 2007; 56(10). Clonidine, an antihypertensive agent, a very difficult addiction to break and the 5. Smokeless tobacco as a nicotine reduces central sympathetic activity by need for novel and effective approaches delivery device: harm or harm stimulating the á2-adrenergic receptors. to smoking cessation interventions is reduction?Benowitz NL. Clin Clonidine is not FDA approved for unquestionable. Cigarette smoke harms Pharmacol Ther. 2011 Oct;90(4):491- smoking cessation and is a second-line nearly every system of the human body, 3. doi: 10.1038/clpt.2011.191. Epub option. It effectively suppresses the acute thus causing a broad range of diseases, 2011 Aug 10. Review. symptoms of nicotine withdrawal, such many of which are fatal.The risk of 6. The assessment of tobacco as tension, irritability, anxiety, cravings, serious disease diminishes rapidly after dependence in young users of and restlessness. (9) quitting and life-long abstinence. Firm smokeless tobacco. Difranza JR, action needs to be taken now to halt and Sweet M, Savageau JA, Ursprung Electronic Cigarette ultimately reverse this epidemic. WW. Tob Control. 2011 Jun 28. The E-cigarette is a battery-powered 7. The clinical practice guidelines are electronic nicotine delivery device References the main resource for treating (ENDD), often resembling a cigarette. It 1. Oral premalignant lesions: from a individuals with tobacco use and is designed to deliver nicotine to the clinical perspective. Amagasa T, dependence. The guidelines are based respiratory system, where neither Yamashiro M, Uzawa N. Int J Clin on the review of literature for most tobacco nor combustion are necessary for Oncol. 2011 Feb;16(1):5-14. Epub evidence-based treatments. Fiore its operation. Consequently, it is likely 2011 Jan 12. Review. MC, Jaén CR, Baker TB, et al. that this product may be considered as a 2. An overview of principles of Clinical Practice Guideline. lower risk substitute for factory-made effective treatment of substance use Rockville, MD: US Department of cigarettes. disorders and their potential Health and Human Services, Public application to pregnant cigarette Health Service; 2008. Treating An important aspect that needs to be smokers. Heil SH, Linares Scott T, Tobacco Use and Dependence: 2008 highlighted in relation to the findings of Higgins ST. Drug Alcohol Depend. Update. the present case series is the putative risk 2009 Oct 1;104 Suppl 1:S106-14. 8. Comparison of Available Treatments of E-cigarettes. In June 2009, the US 3. Lung cancer in never smokers. Torok for Tobacco Addiction Aryeh I. Food and Drug Administration (FDA) S, Hegedus B, Laszlo V, Hoda MA, Herman and Mehmet Sofuoglu. Curr announced in a press conference that 'a Ghanim B, Berger W, Klepetko W, Psychiatry Rep. 2010 October ; laboratory analysis of electronic cigarette Dome B, Ostoros G. Future Oncol. 12(5): 433-440 samples has found that they contain 2011 Oct;7(10):1195-211. Review. 9. Mooney ME, Sofuoglu M. carcinogens and toxic chemicals such as U.S Department of Health and Bupropion for the treatment of diethylene glycol (DEG), an ingredient Human Services. Health nicotine withdrawal and craving. used in antifreeze'. Consequences of Smoking: A Report Expert Rev Neurother. 2006;6:965- of the Surgeon General. 2004. 981.

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

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 130 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Role Of Occlusion In Dentistry: A Review 1 K.L. Gupta 1 Reader Department of Prosthodontics Abstract Institute of Dental Sciences Occlusion is the integrated relationship of the teeth, periodontium, neuromusculature, and not just Bareilly (U. P.) interdigitation. This relationship is a dynamic entity and can be extremely complex and varied. Address For Correspondence: Even though, studied exclusively, some aspects of "Occlusion" still eludes us, or rather it can be Dr. K.L Gupta Said, that the implications of occlusion on multiple number of situations are still not completely Room No 12, Faculty Residence, understood.The literature throws up some basic recommendations based on these conclusions as Institute of Dental Sciences, regards carrying out advanced and extensive aesthetic work in the dentition. Pillibhit Bypass Road, Studying Occlusion becomes simpler under the following three situations. Opposite Suresh Sharma Nagar ? Occlusion in a state of health Bareilly-243006 U. P., INDIA ? Occlusion in a state of ill health Email: [email protected] ?Occlusion as a consideration in aesthetic dentistry Mobile No : 0-9415078882, 9027094753 Submission : 17th November 2011 Key Words Accepted : 18th February 2012 Aesthetics, Occlusion, Allignment

Quick Response Code Introduction conclusions as regards carrying out “Occlusion” in very simple terms can be advanced and extensive aesthetic work defined as an intercuspal relationship in the dentition. between the set of maxillary and Studying Occlusion becomes simpler mandibular teeth. But encompassing a under the following three situations. broader spectrum, Occlusion is the ?Occlusion in a state of health integrated relationship of the teeth, ?Occlusion in a state of ill health ? periodontium, neuromusculature, and Occlusion as a consideration in I,class II and class III. The key for the not just interdigitation. This relationship aesthetic dentistry Angle classification, which was created is a dynamic entity and can be extremely one century ago (1907) by Edward complex and varied. A. Occlusion in a state of health: Angle, is the relationship between the A singular concept of occlusion cannot be A state of health is considered to be true, upper and lower first molars. It is to be applied to all patients. This relationship as far as the dentition is concerned, when noted at this point, that the relative can exist in a variety of forms, and in a the subject has no complaints and a dental position of the mandible to the maxilla state of normalcy and balance, remains in examination does not reveal any was recorded during the static condition harmony with the other structures , which underlying pathology that is either of "Centric Occlusion". make up the dento-alveolar apparatus. infective or degenerative in nature in A healthy, natural Angle Class I occlusion Even though, studied exclusively, some relation with the entire dental apparatus. is characterized by simultaneous, aspects of "Occlusion" still eludes us, or Once determined, that the oral cavity is in equalized contact of all teeth (anterior rather it can be Said, that the implications a "state of health" the occlusion can be and posterior) in maximum of occlusion on multiple number of examined. A look at literature as well as intercuspation (centric occlusion) (Fig situations are still not completely evidence stemming from experience in 1 and 2) understood. Over the years, a number of dental procedures of a number of attempts have been made to put all the clinicians, it seems to indicate that the parameters of this "intercuspal interface between the maxillary and relationship" into perspective and even mandibular teeth is very adaptive and though some of these guidelines are very can establish itself in a variety of different appropriate, there are a number of relationships. misinterpreted facts on Occlusion which Dental undergraduate students are abound in the literature. usually given to understand occlusal It will be attempted in this article to arrive relationships in terms of relative at some conclusive endpoints, based on a positions. One of the most popular forms lot of current data which is now available of classifications of occlusal relations is Fig 1: A typical angles Cl I occlusion on the subject of "Occlusion". The the "Angles" classification of occlusion. This point shall be elaborated later in this literature throws up some basic In this classification, three primary article. The Class II group has been recommendations based on these divisions have been created, namely class further subdivided into Div I and Div II.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 131 as well as dental relation with a very scientific method. As late as in 2005, a modification of Angles classification was suggested by A. Pitts in the Journal of Orofacial Orthopaedics1 in which he felt that it was not clinically practical to use the large number of measurements Fig 2: The cusp to fossa relationship upper/lower required to classify “occlusal premolars and molar relationships”. He built upon the classical It has been observed that the greater Fig 4 : A classical Angles Cl III Occlusion Angles classification refined with almost majority of the population fall in the a 100 years of additional data, to come up classical "Class I" group. In this relation, These have been the use of the Lateral with a more practically applicable the maxillary teeth encompass the Cephalogram Radiographic picture method of classifying occlusion. mandibular teeth circumferentially and which gives extensive skeletal the cuspal relationship of the first relationship of the maxilla and Class I - He has proposed all maxillary molars is in alignment with the mandible.(Fig 4) malocclusions in the antero-posterior mandibular first molar in such a way that It must be stressed that most of the plane primarily affecting the maxilla to the mesio-buccal cusp of the upper first radiographic analytic methods have been be grouped as Class I with three molar rests in the mesio-buccal groove of primarily aimed towards determining subdivisions. the lower first molar. and predicting growth patterns and if ?Division 1- Maxillary protrusion The Class II group has the mesiobuccal possible interventional methods to guide ?Division 2 - Maxillary retrusion with cusp of the upper first molar resting the growth in a more desirable and normal molar occlusion anterior to the Class I position and may lie favorable pattern. Even though the ?Division 3 - Maxillary retrusion with between the lower first molar and the Tweed and Bolton analysis (to name a secondary mandibular retrusion ( lower second premolar. This has been few) of Angles classification are an corresponding to Angles Class II, Div further sub-divided into two groups. accepted refinement of the study of 2 ) i. Class II Div I in which the maxillary occlusal relationships, they have not anterior teeth are protruded. widened the scope of the occlusion ?Class II - This group is characterized ii. Class II Div II in which the maxillary relationship to bring in the elusive factor by a post- normal relationship of the incisors are retroclined and the lateral of "Function". lower arch to the Upper arch incisors overlap the central incisors As dental students, as academic teachers (corresponding to Angles Class II Div 1) on the mesial side . (Fig 3) as well as clinicians, we tend to regard "Malocclusion" as a pathological Class III - This group has the lower arch condition. Is this true? Should in a mesial relation to the upper arch ( Malocclusion be considered to be a corresponding to Angles Class III) pathologic entity or should it be considered to be just " Relative In fact, the editorial in the Journal of positioning of teeth with an aberration Orthodontics 2 in 2003 very from the majority"? unequivocally states that the This could be considered to be reliance of the Angles classification on "Unaesthetic" with the realization that the molar relationship is quite incomplete "aesthetics" is a very relative and and stresses greater importance on the Fig 3: A classical angles Cl II occlusion subjective consideration. We do have canine relationship. Even from a pure A Class III occlusion is one in which a classical examples of certain media stars orthodontic standpoint , basing a case as reversal takes place and the maxillary who look so cute and attractive with unaesthetic on the classical Angles teeth are contained In the mandibular absolutely out of position, buccally system may not be appropriate in the teeth and the lower anterior teeth are placed canines. On the other hand we also current context. placed labial to the upper anterior teeth. have the handsome and extremely A step further to be built up on this is the According to Angle , whenever teeth do attractive, beautiful faces, which get fundamental question if a "malocclusion" not follow the above exemplary marred by the minutest of discrepancies is a pathological condition which is relationship , they are said to be in a state of position in the anterior segment. deleterious to health and function. of "Malocclusion". In fact even a perfect A look into the literature generates some Class I molar relation, if the rest of the very interesting findings. Most of the B. Occlusion in a State of Ill Health: teeth do not remain in perfect alignment , criticism attributed to Angles it would be considered to be a classification has been that it is very Occlusal relationships can take a malocclusion . Over the years, there have limited in scope and the key factors taken dramatic turnaround when the oral cavity been numerous attempts to refine the into consideration for classifying is in a state of ill health. Ill health signifies traditional "Angles" classification and "Malocclusion" are not complete. In fact, some kind of damage to existing and / or make the groupings more specific and a few elaborate suggestions involve loss of the teeth concomitant with detailed. Additional inputs, other than the extensive and detailed skeletal progressive disease in the existing teeth. basic clinical examination to determine measurements in multiple dimensions. There are two issues which have to be the occlusal position have been included The Witts modification is one such addressed. The first issue arises out of to elaborate the occlusal relationships. excellent attempt to analyze the skeletal loss of key teeth in the dentition. If certain

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 132 key teeth are lost, the transmission of since the pathway of progression of the masticatory loads as well as forces habit is not clearly understood) and generated by any parafunctional habits secondly to counter the ill effects of the become very high. This kind of situation parafunctional habits5 . is also referred to as secondary trauma This can be achieved by the use of from occlusion. The second issue is that occlusal splints which may have to be of damage to existing teeth. The dentition modified over time. The Lucia jig is a usually gets mutilated either due to modification of the occlusal splint. A carious destruction or periodontal newer method which has gained disease. Either of the two is damaging Fig 5: A successful smile design outcome is dependent on considerable grounds over the past few and leads to a complete change of the occlusal correction years has been the NTI device which not orientation of transmission of occlusal only helps in these conditions but also is forces. inability to withstand the high loads. A very effective in countering the more Such kind of situations lead to potential common fallacy is to attribute the severe deleterious effects of the realignment of the existing teeth which damage caused by occlusal disease as a parafunctional habits. can lead to further complexities. natural process of wear and tear of the dentition (Fig 5) . Summary & Conclusion: C. Occlusion as a consideration in A very excellent system of recording and In the last, it can be said, occlusion can aesthetic dentistry: diagnosing the etiology of unaesthetic well be the most critical factor in conditions has been developed by Dr. achieving and establishing aesthetic The role that occlusion plays in any kind Luiz and has been termed as the Dento smiles. Any anterior or for that matter of complex and extensive aesthetic Facial Esthetic Diagnostic System even a posterior restoration or treatment plan is of very high importance (DFED). This system requires a detailed replacement placed as part of the and can be one of the sole reasons for a record of the entire dentition measuring a personality change of an individual, has long and successful outcome of the entire number of parameters. It requires a full to amalgamate the functional aspect of therapy. There have been many an set of IOPA radiographs, an OPG, equilibrated occlusion in centric and instance of a veneers popping off, crowns detailed periodontal charting, models during lateral and protrusive movements chipping, incisal edges breaking down as mounted on a semi adjustable articulator along with the aesthetics. The adage of well as complete breakdown of direct with the transfer done using a Kois face the current era could well be " Aesthetics bonding restorations. bow and a set of 11 clinical photographs4 . is the form that follows the function of At times it is baffling as to why certain Once the entire occlusal pattern has been occlusion". aesthetic restorative procedures work so recorded, it will be possible to attribute excellently and the same amount of specific unaesthetic symptoms of References: diligence and effort does not pay cervical abfractions, tooth chipping and 1. A.T.Pitts, Journal of Orofacial dividends in other cases. The key recession to occlusal disease. The Orthopaedics, April 1931, Volume1, difference generally is the occlusal imperative issue is that the esthetic Number:2. relationship of the teeth. The term which treatment plan has to identify any such 2. Editorial, Journal of is being more and more used now to etiology of "occlusal disease" and once Orthodontics(British Orthodontics address this problem is “Occlusal identified, measures have to be taken for Society ), December 2003,Vol.30, Disease” rectification. No:4, 279. “Occlusal Disease” encompasses under Occlusal disease can be corrected by 3. M.Hisano, K.Soma, Journal of Oral its umbrella a variety of different clinical means of very specific and precise Rehabilitation, October 1999 Volume situations which have not always be equilibration of the occlusion in centric 26, Issue 10, Page 830-835. traditionally attributed to aberrant occlusion to create completely balanced 4. Gordon Christensen, Now it's the occlusal forces. It covers the conditions and equidistributed occlusal loads. It has time to observe and treat dental of bruxism, clenching, primary and to be borne in mind that the equilibration occlusion, J Am Dent Assoc, Vol 132, secondary occlusal trauma afflicting the cannot be done completely in one sitting. No 1, 100-102. periodontium, TMD, abfractions and It will require slow and systematic 5. Jose-Luis Ruiz, Achieving Longevity 3 cervical hypersensitivity . correction over a number of sittings in Esthetic Dentistry by the Proper spread over a few weeks. If the occlusal Diagnosis and Management of Discussion: disease also presents signs of Occlusal Disease, Contemporary The clinician will encounter occlusal parafunctional habits of bruxing and Esthetics & Restorative Practice, disease almost on a daily basis, but specifically “clenching”, it is very June 2007 attempts are usually made to treat the important to try first of all break the problems symptomatically. There is an habits ( which is easier said than done - immediate transient resolution, but no long term benefit in a large number of cases wherein the root cause is occlusal disease. The essence of occlusal disease is the creation of high stress in localized, Source of Support : Nill, Conflict of Interest : None declared isolated parts of the dentition and the consequential breakdown of these areas due to the

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 133 Indian Journal of Dental Sciences. www.ijds.in June 2012 Issue:2, Vol.:4 Review Article All rights are reserved Indian Journal of Dental Sciences E ISSN NO. 2231-2293 P ISSN NO. 0976-4003 Prevention Of Transmission Of Hepatitis C In 1 Namita Dang 2 Rita Rai Health Care Setting 3 Vibha Babbar 1 Prof. & Head 2 Associate Professor Abstract 3 Demonstrator Dept. Of Dentistry, Hepatitis means inflammation of the liver. There are many causes for this inflammation including viruses, alcohol and other drugs. The virus can cause long term liver problems including cirrhosis Dayanand Medical College And Hospital, Ludhiana and hepatocellular carcinoma. In developing countries like India, the nosocomial transmission of new hepatitis C virus infections is a major problem because of the reuse of contaminated or Address For Correspondence: Dr. Namita Dang inadequately sterilized syringes and needles used in medical, paramedical and dental M.D.S Conservative Dentistry and Endodontics procedures. There being no vaccine and the current treatments have limited success, hepatitis C Prof. & Head Department of Dentistry is rarely diagnosed until its chronic stages, when it can cause severe liver damage. To avoid Dayanand Medical College And Hospital transmission of hepatitis C infection, it is essential to have understanding of virus and the potential Ludhiana - 141001, Punjab health and dental health problems associated with it. Standard infection control protocols are Ph: 9855101291, 9814068049 required during dental treatment to prevent virus transmission between patients. Fax - 0161-2302620 Total of 30 Hepatitis C patients who reported for dental treatment were studied. All patients were Email - [email protected] asked about the suspecting root of infection. Their knowledge about the disease, its spread, Submission : 17th November 2011 medical and dental complaints was noted. Dental treatment was provided taking Universal th Precaution System. Accepted : 18 February 2012

Key Words Dental Biofilm, Plaque, Gingivitis Quick Response Code

Key Messages Both these factors are potential source for Special attention should focus on the the spread of Hepatitis C in India. facts that injections, solutions and equipments are frequently purchased Prevalence outside the healthcare system and The World Health Organization estimates injections are dispensed by unqualified that 170 million are infected with personnel in pharmacies or marketplaces. Hepatitis C world wide and 3-4 million sero surveys of voluntary blood donors, It is worth reiterating that the majority persons newly infected each year. In Pakistan the most reported range is people infected with hepatitis C are Although HCV is endemic worldwide, between 2.4% and 6.5%. Egypt, with an unaware of their infection, so there is a large degree of geographical estimated population of 73 million has sterilization, disinfection and general variability in its distribution. Countries the highest reported seroprevalence rate hygiene is important. with the highest reported prevalence rates of 22 %.1 are located in Africa and Asia; areas with Introduction: lower prevalence include the Aim Before testing for the hepatitis C virus industrialized nations in North America, The purpose of this paper is to raise was developed in 1989, it became Northern and Western Europe and awareness regarding the burden of the apparent that some people receiving Australia. disease related to viral hepatitis and the blood transfusions and blood products need for urgent action to prevent hepatitis were contracting hepatitis, despite the There is wide range of prevalence C virus. The cost to treat patients with fact that blood and blood products were estimates among developing countries HCV infection far outweighs the cost of screened for hepatitis B (HBV) and and generally less data available to implementing prevention programs. Hepatitis A (HAV). The majority of these validate assumptions about the burden of cases, known as non A- non B - Hepatitis the disease than in the developed world. A comprehensive strategy is urgently or post transfusion hepatitis have since China, whose citizens' account for 1/5th needed to prevent transmission of these been identified as Hepatitis C (HCV). of the world's population has a reported blood borne pathogens. We should The impact of this infection is just seroprevalence of 3.2%. In India which educate everybody about the risk of emerging in India. India's blood banking holds an additional 1/5th of the world's blood borne pathogen transmission in the system has serious shortcoming. Another population, one community based survey health care setting. Urgent efforts are serious malaise in our health system is the reported an overall rate of 0.97%, needed to ensure patient safety, infection sense of improperly sterilized needles. Indonesia rate is 2.1% but is based on safety, safe dental care and quality assurance in health care.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 134 In providing effective dental care to mode of transmission of hepatitis C Hepatitis B and Hepatitis C have been people infected with the hepatitis C virus, infection as it allows a large quantum seen in the Baghapurana and Nihalsingh the first step is an understanding of the of infective virions into susceptible wala subdivisions of Moga sub district. virus and the potential health and dental patient. In developed countries This outbreak is due to use of health problems associated with hepatitis numerous corrective measures have inadequately sterilized needles and C infection and issues of infection control reduced the spread of infection syringes by unqualified medical and prevention of disease transmission. through this route. In India, practioners. Patients are given injections mandatory screening for HCV was instead of medicines so as to give fast The Virus introduced as late as 2002. relief is the reason for HCV to become Hepatitis C is a RNA virus belonging to 2. IV drug abuse: - Transmission of active in this area. Despite having the flavivirus family and genus hepatitis C occurs with IV and knowledge about parenteral route of hepacivirus. Genetically distinct viral percutaneous drug abuse. This is a transmission of HCV infection, a sizeable groups have evolved with nine different significant problem in northeast India proportion of family physicians in the genotypes of hepatitis C identified and and Definitely in the rest of country as Punjab state continue to reuse needles approximately 40 different genotypes. 2 well. In the study the prevalence of and syringes.7 Prevalence of active HCV was alarming 92% among 77 IV hepatitis C virus infection in apparently Clinical outcomes in HCV infection: - drug users from Manipur. 4 healthy inhabitants of district Faridkot, Initial clinical signs of infection with 3. Dialysis and renal transplant: - was surveyed during Dec 2009 to Dec HCV are often mild. Acute infection is patients on haemodialysis are at 2010. The results showed that 15% of the often subclinical and because of this increased risk for hepatitis C as a people of districts Faridkot are actively many cases go unrecognized. When result of cross contamination from infected with HCV. It was also concluded symptoms do occur they include malaise, dialysis circuits.5 that the prevalence of active HCV nausea, upper right abdominal pain and 4. Health care workers are at a higher infection was high (73%) in males as jaundice. risk as they come in contact with compared to the females (26%). 8 potentially infected patients. Dentists Following primary infection, 15-20% of were found to have significantly high In our Dental Department we have patients clear the virus within 2-6 prevalence of HCV with an estimate received 30 cases of Hepatitis C in 3 months. The remainder 80- 85% of cases of 5.4% in a study reported from month duration. Out of these 30 cases 13 will develop chronic HCV infection; of Rajasthan.5 Transmission by saliva are from villages of Moga district, one these 20% of patients with chronic HCV alone is remote possibility unless the from Mandi Gobindgarh, one from will not develop any significant liver saliva is contaminated with blood. Muktsar, two from Raikot, one from damage. The remaining chronic infected However one study supports the Malerkotla, two from Faridkot, one from patients can have a variety of problems concept that gingival crevicular fluid village of Fatehgarh sahib,four from relating to long term infection with HCV. may be a significant source of HCV in Ludhiana district, one from Barnala, two For example 20-25% of patients will saliva. 6 from Kangra(H.P.), one from Fatehabad develop cirrhosis.3 It is thought that the (Harayana), one from Mansa . Out of development of cirrhosis is compounded Other less common routes of infection these 21 are adult male patients and nine by other factors such as age of the patient are are females. One patient from village (>50years), gender (M>F) and high 1. Mother to baby contact before or charanwal of Barnala district and one alcohol consumption. Long term during birth. HCV mother to child from village Walipur of Ludhiana district consequences of cirrhosis are liver failure transmission in HIV infected women told that their whole family members and or liver cancer. is high. many others families of the same village 2. Sharing razors or toothbrushes which were going to a particular physician and In addition to the specific liver pathology, have been contaminated with blood. all of them are found to be HCV positive. extra hepatic manifestations of HCV 3. The risk of transmitting hepatitis C This is really an alarming situation. infections include glomerulonephritis, via sexual contact is considered cryoglogulinaemia, polyarteritis nodosa, extremely low. It may occur if there is Probable root cause of infection in 17 out vasculitis, peripheral neuropathy, thyroid blood to blood contact during sex. of 30 patients were getting injections for dysfunction, non- Hodgkin's lymphoma, various ailments from quacks. Two thrombocyopenia, lichen planus and Punjab leads in Hepatitis C Cases: patients were chronic alcoholic and drug sjogren's syndrome. The three latter According to a report the state has addicts, rest of the patients were unaware conditions are of particular significance maximum number of hepatitis C cases. of the cause of infection. Most patients in a dental setting and the patients with Out of 200 million suffering from were having non-specific symptoms such HCV infection require a thorough hepatitis C, 25 million are Indians and the as body aches, improper digestion, loss of investigation (including complete blood state shares a percentage of almost 5-7% appetite, weakness and were diagnosed examination and liver function tests) if of the sick. What is more striking is that during routine examination or during invasive procedures are planned. 3 whereas one out of every 12 persons is admission in hospital for any type of suffering from hepatitis virus in world, surgery. Transmission the ratio is one out of every 16 people in Hepatitis C is mainly transmitted via Punjab. Chief Dental Complaints blood to blood contact. The most 1. Xerostomia - complaints of dry important routes of transmission are:- According to report in Times of India, 30 mouth was found in 13 out of 30 1. Blood transfusion is an effective September, 2009 at least 142 cases of patients. Xerostomia can be

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 135 attributed to variety of causes including medications such as antidepressants and methadone, Sjogren's syndrome associated with HCV can also cause dry mouth. 2. Decayed teeth - Multiple decayed teeth were found in 18 out of 30 patients. The main cause of tooth decay is xerostomia and poor dental health. In two patients, large periapical abscess were found in relation to decayed teeth (Fig 1, Fig 2). This can be due to decreased immunity of these patients. Antiviral drugs such as interferon, ribavirin and corticosteroids may lower resistance

to infection. Coates E.A et al also Fig 1- Periapical radiolucency in relation to 45.46 and multiple decayed and missing teeth. found increased incidence of tooth decay in Hepatitis C patients.9 3. Bleeding gums - Bleeding gums were found in 5 out of 30 patients. This can be due to poor oral hygiene and thrombocytopenia. In patients with cirrhosis, there is likelihood of prolonged bleeding following dental procedures caused by a lack of coagulation factors and thrombocytopenia. Consequently, any invasive dental treatment (extractions, surgery and extensive periodontal treatment) should be undertaken after consultation with appropriate medical specialist. In one patient periodontal abscess was found in both upper lateral incisors were seen which did not respond to drugs and periodontal therapy. (Fig 3) 4. Lichen Planus - The association of LP with hepatitis C (HCV) has been widely reported in the literature. Fig 2- periapical radiolucency in relation to 16 However, there are wide geographical variations in the reported prevalence of HCV infection in the patients with Lichen Planus. 10 In our study of 30 patients we found only one case of lichen planus with HCV.

Prevention and Infection Control Hepatitis C is a notifiable disease. The risk of sexual transmission is extremely low. People with Hepatitis C should be advised not to share household items which may carry traces of blood such as toothbrushes, razors, shavers, dental floss or barber's hair cutting equipment, and not to reuse injecting needles. The virus is not transmitted via hugging, kissing or touching.

Standard Precautions Standard Precautions are recommended Fig 3- periodontal abscess in relation to 12. 22.

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 136 for the care and treatment of all patients they have the virus. Unlike HBV, where Pharm Sci. 2011, 3 suppl 4: 57-59. and in handling of- an effective vaccine exists, no such 9. Coates E.A., Brennan D, Logan R.M, 1. Blood vaccine is available to protect against Goss A.N, Scopacasa B, Spencer A.J, 2. All other body fluids, secretions and HCV infection. Patients are not obliged etal. Hepatitis C infection and extractions (excluding sweat), to inform dentists that they have associated Oral Health problems. Aus regardless of whether they contain contracted the virus because adherence to Dental J 2000;45 (2);108-114. visible blood the Universal Precaution System, where 10. de Mattos Camargo Grossman S, de 3. Non intact skin every dentist patient encounter is Aguiar M.C, Teixeira R, do Carmo 4. Mucous membrane considered to have the potential for cross MA. Oral Lichen Planus and chronic infection, should minimize the risk of hepatitis C; a controversial Standard Precautions include new cases of hepatitis C occurring. association. Am J Clin Pathol 2007; 1. Aseptic technique 127(5): 800-4. 2. Hand washing References: 3. Use of appropriate protective 1. Shepard CW, Finelli L and Alter MJ. equipment gloves, gowns, plastic Global epidemiology of Hepatitis C aprons, masks/ face shields and eye Virus infection; Lancet Infect. Dis. protection 2005; 5:558-567. 4. Appropriate reprocessing of 2. Dental Health and Hepatitis C. instruments and equipment www.ashm.org.an/publication 5. Implementing environmental 3. Dr.S R Prabhu,Dr.Bhasker Rao, Dr. controls Anil Kohli; HIV and AIDS in dental practice 2007. Needle stick injury and blood spills 4. Saha M.K, Chakrabarti S, Panda, S, At the time of needle stick injury or other Naik TN, Manna B, Chatterjee A, exposure Detels R and Bhattacharya S.K. Skin - wash with soap and water Prevelance of HCV and HBV Mouth, nose, eyes - rinse well with water infection amongst HIV seropositive or saline. Report the incident and follow I.V drug Usersand their non infecting your local workplace Occupational wives in Manipur. Indian J. Med. Res. Exposure Protocol 2000; 111, 37-39. 5. Mukhopadhya A. Hepatitis C in Conclusion India. J biosci. 2008; 33:465-473. Hepatitis C is an emerging infection in 6. Maticic M, Paljak M, Kramar B, etal. India whose long term implications will Detection of hepatitis C virus RNA be felt in the decades to come. It is a from gingival crevicular fluid and its pathogen that is already responsible for relation to virus presence in saliva. significant proportion of liver disease in Journal of Periodontology, 2001; various regions of India. Stringent blood 72(1); 11-16. banking laws needs to be introduced and 7. Sood A,Midha V, Avasthi G. Hepatitis sterilization and reuse of needles C - Knowledge and practices among discouraged. All this is not possible the family physicians. Trop without increased public awareness of Gastroenterol 2002: 23 (4); 198-201. the magnitude and implications of this 8. Deepak Arora, Neerja Jindal, Raman chronic infection and its mode of spread. Dang, Rajiv Kumar. Rising seroprevelance of HCV a silent killer Not all people with hepatitis C know that - Emerging problem.Int J of Pharm

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

©Indian Journal of Dental Sciences. (June 2012 Issue:2, Vol.:4) All rights are reserved. 137