ISSN 0976-2256 E-ISSN: 2249-6653 The journal is indexed with ‘Indian Science Abstract’ (ISA) (Published by National Science Library), www.ebscohost.com, www.indianjournals.com JADCH is available (full text) online: Website- www.adc.org.in/html/viewJournal.php This journal is an official publication of Ahmedabad Dental College and Hospital, published bi-annually in the month of March and September. The journal is printed on ACID FREE paper.

Editor - in - Chief Dr. Darshana Shah Co - Editor Dr. Rupal Vaidya DENTISTRY TODAY... Assistant Editor: We are living in an era in which community experience for Dr. Harsh Shah students is becoming a more essential component to the mission of dental education. Dental Public Health aims to improve the oral health of the population through preventive and curative services. The Editorial Board: introduction of mobile clinics into dentistry dates back to 1924. They have Dr. Mihir Shah been successfully used to provide dental treatment to schools, disabled patients, rural communities, industries and armed forces of various Dr. Vijay Bhaskar countries. Outreach programs using Mobile Dental Vans (MDV) are desirable model of clinical practice in a non-conventional setting, and help Dr. Monali Chalishazar the student to disassociate the image that best dentistry can only be Dr. A. R. Chaudhary practiced in conventional clinical settings. Confrontation with limited resources and economic barriers to Dr. Neha Vyas dental care for patients requiring more extensive procedures also serve as an additional learning experience in community-based programs. Unlike Dr. Sonali Mahadevia stationary dental clinics, mobile clinics provide greater physical access to dental care for medically underserved populations in poor urban and Dr. Shraddha Chokshi remote rural communities. The MDVs are regularly used for providing dental health care to the poor, needy and rural population through dental Dr. Bhavin Dudhia camps. Dental camps as practiced in Indian institutions are usually a day Dr. Mahadev Desai long visit to rural or remote places or school setting for the provision of services like preventive care, curative care, screening for diseases and Dr. Darshit Dalal health education. In India, for over ten years, the department of Public Health Dentistry in postgraduate institutions of India are regularly conducting MDV programs, but the conduct of these programs are not yet evaluated.

A Contents EDITORIAL

FROM THE EDITOR'S DESK ...... 1 DARSHANA SHAH

REVIEW ARTICLES

1) FORENSIC ODONTOLOGY – A COMPREHENSIVE REVIEW ...... 2 BHAVIN B. DUDHIA*, PURV S. PATEL**, YESHA V. JANI***, ROSELINE A. PATEL****

2) PERI IMPLANT BONE LOSS AROUND SINGLE AND MULTILE PROSTHESIS-A SYSTEMATIC REVIEW...... 10 CHIRAG CHAUHAN* DARSHANA SHAH**, PARAS DOSHI***, HARSHIT PATEL****, ISHAN PATEL*****, MIT PATEL******

3) SMOKING, WEIGHT LOSS AND DIABETES: THE MYTH AND MYSTERY...... 16 CHITRANG P SHAH*, DARSHAN PRAJAPATI.**, HARSH G SHAH***, VASUDHA SODANI****

ORIGINAL ARTICLES

4) BE SMART EAT SMART!...... 20 ANUPRIYA MALONIA*, MAITRY MEHTA**, VIJAY BHASKAR***, KRUNAL CHOKSHI****, VASUDHA SODANI*****

5) INSTANT DENTIN HYPERSENSITIVITY RELIEF WITH A SINGLE TOPICAL APPLICATION OF AN IN-OFFICE 8% ARGININE CONTAINING DESENSITIZING PASTE ...... 24 ARCHITA KIKANI*, HIRAL PARIKH**, SUNITA DHAKA***, ANKINA JOSHI****, HARSH SHAH*****, MIHIR SHAH******

6) EVALUATION OF EFFECTIVENES OF PAIN OUT DENTAL GEL AS A TEMPORARY ANALGESIC IN PROVIDING ...... EXPRESS INSTANTANEOUS RELIEF OF ODONTOGENIC CAUSES OF TOTH ACHE ...... 29 AISHWARYA KRISHNAN*, ARCHITA KIKANI**, SAPNA . T***, MIHIR SHAH****, HARSH SHAH*****, VASUDHA SODANI******

7) CULTURAL COMPETENCY AMONGST DENTAL PRACTITIONERS IN MUMBAI – A KAP STUDY...... 34 SUYOG CHANDRASHEKHAR SAVANT*, SAHANA HEGDE**, RAVI V. SHIRAHATTI***, DEEPTI AGARWAL****

CASE REPORT

8) RADICULAR CYST: A REPORT OF TWO CASES...... 41 YESHA JANI*, ABHISHEK BAROT**, TWINKAL PATEL***, MANISHA LALWANI****

9) AMELOGENESIS IMPERFECTA IN SIBLINGS – A REPORT OF TWO CASES...... 45 ROSELINE PATEL*, RUTU JANI**, PRUTHA NEMADE***, ABHINANDAN GOKHROO****

10) LOWER LIP SUCKING HABIT TREATED WITH A LIP BUMPER APPLIANCE ...... 50 HIRAL VAYEDA*, VIJAY BHASKAR**, BHUMI SARVAIYA ***, RAJAL PATHAK****, TITHI ACHARYA*****

11) MANAGEMENT OF HIGHLY PLACED PERMANENT MAXILLARY CANINES USING CANTILEVER SPRINGS ...... 53 ANUSHREE GURU*, HITEN PANDAV**, AATMAN JOSHIPURA ***, ARTH PATEL****

12) REHABILITATION OF OCULAR DEFECT USING CUSTOM MADE OCULAR PROSTHESIS- A CASE REPORT ...... 56 DARSHANA SHAH*, CHIRAG CHAUHAN**, FORAM SUTARIA ***, JENISH SOLANKI****

Subscription: Rate per issue: ` 400/-, for one year: ` 750/-, for three years: ` 2,000/- Contact: Ahmedabad Dental College & Hospital Vivekanand Society, Bhadaj-Ranchhod Pura Road, Santej, Post: Rancharda, Ta: Kalol, Dist: Gandhinagar, Gujarat, India. B ____From Editor’s desk

Community Dental Services

Dear friends,

As India being predominantly a rural country, over 70% of the population stays in rural areas where dental facilities are available in rare cases. To give the best possible dental treatment to people staying in such areas can only be possible via community dental services. Community or public health dentistry usually aims to prevent and control the dental diseases in addition to promote the dental health through organized efforts.

The purpose of the entire oral health care system of community dental service is to influence the population's way of life so that oral health is promoted or maintained and oral diseases are prevented. The best way is by organizing the dental camps at community level. They are helpful to in providing the oral health care to poor, needy and rural population. The community dental service forms a 'safety net' treatment service for those who are unable or unwilling to access care within the general dental services.

The dental public health field has been expanding day by day in scope and complexity with more emphasis being placed on the total dental care delivery system. To improve the present scenario, institutions of India have to take a lead, make and implement strategies to reach successfully to population and provide oral health.

Dr. Darshana Shah Editor JADCH Editorial Office: Prof. & Head Dept. of Prosthodontics Ahmedabad Dental College & Hospital, Dist.: Gandhinagar, Gujarat. Email: [email protected]

The Journal of Ahmedabad Dental College and Hospital; 7 (1), March 2016 - August 2016 1 FORENSIC ODONTOLOGY Review Article – A COMPREHENSIVE REVIEW

Bhavin B. Dudhia*, Purv S. Patel**, Yesha V. Jani***, Roseline A. Patel**** ABSTRACT Forensic odontology or forensic dentistry is the branch connecting dentistry with law. With an increasing number of criminal cases in the Indian subcontinent being solved with the aid of forensic odontology by the very few certified forensic dentists available, the demand of professionals in this field has risen. Also, there is a need for educating the dentist professionals as well as the dental academicians regarding their roles and duties towards the forensic aspects of dentistry. This comprehensive review is an attempt to invoke interest of the readers as well as to educate them regarding the field of forensic odontology. KEYWORDS: Forensic odontology, Forensic dentistry, Age estimation, Bite marks Received: 20-01-2016; Review Completed: 16-04-2016; Accepted: 31-05-2016 INTRODUCTION: identification.1, 5, 7, 8 After the end of World War II, Forensic (from the Latin word forum) means 'court rumours were rampant that Adolf Hitler had of law'. Odontology refers to study of teeth.1 escaped with his wife, Eva Braun. Finally, pieces of Federation Dentaire Internationale (FDI) thus Hitler's jaw were found that showed remnants of a defines Forensic Odontology as 'that branch of bridge, as well as unusual forms of reconstruction, dentistry which, in the interest of justice, deals with and evidence of periodontal disease. Hitler's the proper handling and examination of dental identity was confirmed when the dental work matched the records kept by Hitler's dentist, Hogo evidence and with the proper evaluation and 9 presentation of dental findings' (by Keiser- Blaschke. Neilson). 1-5 According to the American Society of Forensic Odontology, forensic odontology is the application of dental science to the law. 2, 6 HISTORY OF FORENSIC ODONTOLOGY Forensic odontology has been with us since the beginning when, according to the Old Testament, Adam was convinced by Eve to put a 'bite mark' in apple. 2,7 The great Indian age Vatsayana depicted, in detail the human bite marks and its classification of skin pertaining to love making for the first time in Indian literature.1 In 1776, the first dental identification was done by dentist patriot Paul Revere, who identified his friend and patient Dr. I M P O R T A N C E O F F O R E N S I C Joseph Warren. Warren was killed in the battle of ODONTOLOGY Bunker Hill and interred in an unmarked grave. The Natural teeth are the most durable organs in the exhumed body was identified by a prosthesis 5 recognized by Revere.1 However, forensic body. The diversity of dental characteristics is odontology, as science, did not appear before 1897 wide, making each dentition unique. The dental when Dr. Oscar Amoedo (considered as Father of enamel is the hardest tissue in the body, and would thus withstand peri and post mortem damages, and Forensic Odontology) [Figure 1] wrote his doctoral 5, 8, 10 thesis entitled “L'Art Dentaire en Medecine Legale” so would dental materials adjoined to teeth. describing the utility of dentistry in forensic Being diverse and resistant to environmental medicine with particular emphasis on challenges, teeth are considered excellent post mortem material for identification with enough

* Professor & Head, **Senior Lecturer, *** Senior Lecturer, **** Senior Lecturer DEPARTMENT OF ORAL MEDICINE & RADIOLOGY DEPARTMENT, AHMEDABAD DENTAL COLLEGE & HOSPITAL.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Purv Patel, TEL: +91 9427219470

2 Bhavin B. Dudhia et. al. : Forensic Odontology – A Comprehensive Review concordant points to make a meaningful the dental findings and taking photographs and comparison. 5, 8 radiographs. An antemortem dental record will ROLES OF FORENSIC ODONTOLOGIST/ contain written notes, charts, diagrams, dental and FORENSIC DENTIST medical histories, radiographs, clinical photographs, study models, results of specific tests, The major fields of activity of forensic odontology prescriptions, and referral letters and other can be divided in to civil, criminal and research information. (Avon). 1, 11 The civil sector includes malpractice and other aspects of fraud and neglect in which compensation is sought. Identification of dead and living persons also comes under this category. Criminal sector includes identification which is done by teeth and from bite marks that may be present on the victim, assailant or on some inanimate objects like food items. Research field encompasses academic courses for undergraduate and postgraduate training, teaching forensic odontology to police and new research work. 1 However, so many evidences are available with the aid of forensic odontology like: 1. Identification of tooth as well as person 2. Dental age determination 3. Identification in mass disaster 4. Dental radiographic comparison between antemortem and postmortem data 5. Bite mark evaluation and evaluation 6. Trauma and abuse cases 7. Dental malpractice and negligence 8. Reconstruction of face 9. Anthropological study and research 12 HUMAN IDENTIFICATION (Comparative Identification) [Figure 2] Their accuracy and availability have a This branch has been utilized for many years for the huge impact on the speed and efficacy of identification of victims and suspects in mass identification. Problems are encountered when the disaster, abuse and organized crimes. Dental dental records are incomplete, irregular, lost or identification has played a very important role in 3 damaged and have poor quality radiographs. Good natural as well as manmade disasters. The common quality dental records are an essential part of patient reasons for identification of found human remains care, a medico-legal requirement, and are necessary are categorized as criminal, marriage, monetary, 13, 14 for dental identification. On completion a burial, social and closure. comparison between the two is carried out, Identification is based on comparison between similarities and discrepancies are noted on the known characteristics of a missing individual comparison and a result is established. The (termed ante-mortem data) with recovered American Board of Forensic Odontology characteristics from an unknown body (termed recommends that these be limited to the following post-mortem data). A forensic dentist records the four conclusions: postmortem records completely by charting down l Positive identification: The antemortem and

3 Bhavin B. Dudhia et. al. : Forensic Odontology – A Comprehensive Review postmortem data match in sufficient detail, with no and form. A forensic dentist can determine race unexplainable discrepancies, to establish that they within the three major groups: Caucasoid, are from the same individual. Mongoloid and Negroid based on the skull l Possible identification: the antemortem and appearance. Additional characteristics, such as postmortem data have consistent features but, cusps of Carabelli, shovel shaped incisors and because of the quality of either the postmortem multi-cusped premolars, can also assist in remains or the antemortem evidence, it is not determination of ancestry. possible to establish identity positively. Sex l Insufficient evidence: The available Sex determination is usually based on cranial information is insufficient to form the basis for a appearance, as no sex differences are apparent in the conclusion. morphology of teeth. l Exclusion: the antemortem and postmortem data are clearly inconsistent. 3 There are a certain limitations to various methods employed in forensic odontology. In our country, antemortem records are scant and if available are either incomplete or improper. 15 The production, retention and release of clear and accurate patient records are hence an essential part of a dentist's professional responsibility. 16, 17 There can be changes after obtaining antemortem records which can mislead the investigators. Inherent poor image quality is one of the most anticipated drawbacks. There are difficulties in matching the viewing angles, exposure and similar magnification in postmortem radiographs to those taken antemortem. Photographs also have considerable [Figure 3] Discriminant function analysis, a inherent limitations and stringent requirements are statistical method used for determination of sex needed for accurate reproduction. The basic based on tooth measurements showed a success rate difficulty arises when three dimensional objects are of 92.5%. Minute quantities of DNA even from very replicated as two dimensional photographs, which old tooth specimens are helpful in determining the can create distortion and colour change. sex. Ameloblasts of the enamel secrete amelogenin Photographs are sometimes associated with (AMEL gene) which is present in the X and Y parallax errors. Photographs without a scale or any chromosomes of humans, females have two circular reference devices may be inherently 15 identical AMEL genes (XX) and males have two inaccurate. non-identical AMEL genes (XY). Discrimination of DENTAL PROFILING (Reconstructive male and female is based on the length of the base Identification) pairs of the gene which is 106 and 112 for X and Y 3 In cases where ante-mortem dental records are not gene respectively. available, forensic odontology can still contribute Age to establishing the identity by creating a profile of The age estimation should be as accurate as possible how the deceased person was during life. This since it narrows down the search within the missing includes any unusual oral habits, type of diet, socio- persons files and enables a more efficient and time economic status, but most importantly the age of the saving approach. person at the time of death. 8 The age estimation in children and adolescents can Race be done by Atlas approach where the Dentists with the help of a forensic anthropologist morphologically distinct stages of mineralization can determine the sex and ancestry from skull shape that all teeth share are observed. The Tables of

4 Bhavin B. Dudhia et. al. : Forensic Odontology – A Comprehensive Review

Schour & Massler have become a classic example observed on periapical radiographs from six types of an atlas approach. of teeth: maxillary central and lateral incisor and second biscuspid and mandibular lateral incisor, canine and bicuspid. The age estimation is based on gender and the calculation of several length and width ratios in order to compensate for magnification and angulation of the original tooth image on the radiograph. 18 DNA Teeth present as an excellent source as DNA material and its sources are pulp, dentine, cementum and periodontal ligament fibers. DNA from teeth and bone are preserved for many years even after putrefaction of remains. The other sources include saliva and mucosal swabs. Saliva may also be isolated from various sources in the crime scene, for example, postage stamps and [Figure 4] The neonatal line formation and envelopes, glasses, cigarettes, straws, food and incremental lines of Retzius are other methods. chewing gum, toothbrushes and dental floss, and Moorrees et al divided dental maturation of the dental impressions. Use of DNA for human identification is proved to be very effective and has permanent dentition into 14 different stages ranging 3 from “initial cusp formation” up to “apical closure been documented. The human identification complete” and designed different tables for males methodology relies upon three important steps: and females. 18 Among many proposed methods, the DNA isolation or extraction, amplification of specific DNA regions using PCR techniques and Demirjian method (1973) of age assessment has 20, 21 been widely accepted. The classification of stages molecular profiles analysis. The amplified DNA proposed by Demirjian appears to be best suited for is then compared with antemortem samples such as stored blood, hairbrush, clothing, cervical smear, forensic purpose, since stages are defined by 3 changes in form and development of teeth and these biopsy specimens. stages are independent of possibly complicated IDENTIFICATION IN MASS DISASTERS 19 length measurements. Transport accidents form the majority of cases in The age estimation in adults are the morphological which dental identifications are needed, and radiological techniques such as Gustafson, particularly aircraft accidents in which both fire and Bang and Ramm, Solheim, Kvaal and Solheim & trauma are often severe. Fires in and collapse of Kvaal methods. 19 Amongst the morphological heavily occupied buildings are another source of methods, an early age estimation technique was multiple problems of identification. Generally, the published by Gustafson. It is based on the team includes a coordinator or head of the team, a measurement of regressive changes in teeth such as pathologist and various specialists with experience the amount of occlusal attrition, the amount of related to the particular type of disaster, in addition coronal secondary dentine formation, the loss of to the forensic odontologist. In a situation involving periodontal attachment, the apposition of fire or severe trauma, physical features are often cementum at the root apex, the amount of apical destroyed. Because teeth are heavily calcified, they resorption and the transparency of the root. For each can resist fire as well as a great majority of traumas. of these parameters, Gustafson assigned different Dental examination is significantly confounded scores on a scale from 0 to 3 and by adding these, an when heat and flames have fragmented tooth overall score was obtained which was linearly enamel, and soot and smoke have been deposited on related to an estimated age. Amongst the the teeth. Generally, teeth and restorations are radiological techniques, Kvaal et al developed a resistant to heat, unless they are exposed directly to method from measurements of the size of the pulp flame. Preservation is possible in most cases. 22

5 Bhavin B. Dudhia et. al. : Forensic Odontology – A Comprehensive Review

BITE MARK ANALYSIS Criminal cases in which a suspect or a victim has left his or her teeth marks on another person or on an inanimate object such as a candy bar, an apple, cheese or even a beer can seem to occur more frequently. Although in a crime involving shooting it may be possible to determine that a bullet was fired by a particular weapon, it may be more difficult to relate the weapon to the assailant. When the teeth are used as weapons, they are not so easily disposed, and they can be related to the person inflicting the wound. Bite marks occur under various circumstances, usually associated with murder or rape with sexual motives. Bite marks may be identified on both the living and the dead and in the latter case may be ante mortem or post-mortem injuries. 23 BITES IN HUMAN TISSUE The scientific examination of bite-mark evidence is interesting and tough. 23 Bitemarks will typically present as a semi-circular injury which comprises siloxane impression made immediately after two separate arcs with either a central area absent of 24, 25 swabbing the bite mark for secretions containing injury or with a diffuse bruise present. Human DNA. This impression will help provide a three- bitemarks are most often found on breast and legs in 26 dimensional model of the bite mark. Written females and on arms and shoulders in males. The observations and photographs should be repeated force required to penetrate the skin is considerable, daily for at least 3 days to document the evolution of and bites showing laceration of the tissue are 23 the bite. Because each person has a characteristic necessarily aggressive in nature. Bite marks may bite pattern, a forensic odontologist may be able to have a central area of ecchymoses (contusions) match dental models (casts) of a suspected abuser's caused by 2 possible phenomena: (1) positive teeth with impressions or photographs of the bite. pressure from the closing of the teeth with DNA is present in epithelial cells from the mouth disruption of small vessels or (2) negative pressure and may be deposited in bites. Even if saliva and caused by suction and tongue thrusting. An cells have dried, they should be collected by using intercanine distance (i.e. the linear distance the double-swab technique. First, a sterile cotton between the central point of the cuspid tips) swab moistened with distilled water is used to wipe measuring more than 3.0 cm is suspicious for an the area in question, dried, and placed in a specimen adult human bite. The pattern, size, contour, and tube. A second sterile, dry cotton swab cleans the color of the bite mark should be evaluated by a same area and then is dried and placed in a specimen forensic odontologist. The photograph should be 27 tube. The ABFO provide a range of conclusions to taken such that the angle of the camera lens is describe whether or not an injury is a bite mark. directly over the bite and perpendicular to the plane These are: of the bite to avoid distortion. A special photographic scale was developed by the American l Exclusion – The injury is not a bitemark Board of Forensic Odontology (ABFO) for this l Possible bitemark – An injury showing a purpose as well as for documenting other patterned pattern that may or may not be caused by teeth, injuries and can be obtained from the vendor could be caused by other factors but biting cannot be (ABFO No. 2 reference scale). [Figure 5] In ruled out addition to photographic evidence, every bite mark l Probable bitemark – The pattern strongly that shows indentations should have a polyvinyl suggests or supports origin from teeth but could

6 Bhavin B. Dudhia et. al. : Forensic Odontology – A Comprehensive Review conceivably be caused by something else LITIGATION TO DENTAL MALPRACTICE l Definite bitemark – There is no reasonable AND NEGLIGENCE doubt that teeth created the pattern. 24 Negligence, in general, is the breach of duty caused Bites in Other Materials by omission to do something which a reasonable person would do, or doing something which a Criminals may, from time to time, leave their dental prudent and a reasonable person would not do. signature in bitten apples, chocolate, cheese, or Malpractice on the other hand is the failure to other foods left at the scene of a crime. There are exercise knowledge, skill and care with resultant cases in which assailants have bound victims with injury to the patient. 28 Because neither the judge nor adhesive tape and torn off section of the tape with the jury may fully understand the complexities in their teeth, leaving identifiable bite marks on the matters before the bar, the law allows for the use of tape. The same principles of analysis apply as in the the expert witnesses. Unlike other (fact) witnesses, case of tissue bites, but bites in artificial substances an expert witness is allowed to testify or present his of foods can often yield more information because or her opinion. That opinion is based upon the of the lack of distortion of the material and its ability expert's training, education and experience. An to make a good impression of the biting edges of the 23 expert may conduct tests or other activities that teeth. assist him or her in reaching that opinion. However, CHILD ABUSE AND NEGLECT the expert's testimony and opinion must be 9 Craniofacial, head, face, and neck injuries occur in grounded in accepted theory and practice. more than half of the cases of child abuse. Oral CHEILOSCOPY injuries may be inflicted with instruments such as Lip prints are normal lines and fissures in the form eating utensils or a bottle during forced feedings; of wrinkles and grooves present in the zone of hands; fingers; or scalding liquids or caustic transition of human lip, between the inner labial substances. The abuse may result in contusions, mucosa and outer skin, examination of which is burns, or lacerations of the tongue, lips, buccal known as cheiloscopy. Lip prints are unique for mucosa, palate (soft and hard), gingiva alveolar individuals like the finger prints. Lip print recording mucosa, or frenum; fractured, displaced, or avulsed is helpful in forensic investigation that deals with teeth; or facial bone and jaw fractures. identification of humans, based on lip traces. A lip Unintentional or accidental injuries to the mouth are print may be revealed as a surface with visible common and must be distinguished from abuse by elements of lines representing the furrows. This judging whether the history, including the timing characteristic pattern helps to identify the and mechanism of injury, is consistent with the individuals since it is unique for individuals. 5 characteristics of the injury and the child's developmental capabilities. Multiple injuries, Lip prints have to be obtained within 24 hours of injuries in different stages of healing, or a time of death to prevent erroneous data that would discrepant history should arouse a suspicion of result from post mortem alterations of lip. Lip print abuse. Consultation with or referral to a pattern depends on whether mouth is opened or knowledgeable dentist may be helpful. 27 closed. In closed mouth position, lip exhibits well defined grooves, where as in open position the DENTAL NEGLECT grooves are relatively ill defined and difficult to Dental neglect is the “willful failure of parent or interpret. guardian to seek and follow through with treatment Suzuki and Tsuchihashi (1970) have proposed a necessary to ensure a level of oral health essential classification of lip prints also known as for adequate function and freedom from pain and Tsuchihashis classification, [Figure 6] these are infection.” Dental caries, periodontal diseases, and most widely used classification in literature. They other oral conditions, if left untreated, can lead to classified the natural lip marks/fissures in four types pain, infection, and loss of function. These as: undesirable outcomes can adversely affect learning, communication, nutrition, and other activities necessary for normal growth and development. 27

7 Bhavin B. Dudhia et. al. : Forensic Odontology – A Comprehensive Review

l Type V – Other patterns 29 One common problem that is encountered during the cheiloscopic studies is that of smudging or spoiling of lip prints leading to unidentifiable marks When the lines are not clear (only the shape of lines is printed), individual identification of human being based on this trace is extremely difficult, unless the trace contains more individual characteristics like scars, clefts etc, and often identification ends with group identification. 5 A lip print at the scene of a crime can be a basis for conclusions as to the character of the event, the number of the people involved, sexes, cosmetics used, habits, occupational traits, and the pathological changes of lips themselves. 29 PALATOSCOPY & RUGOSCOPY The study of palate in general is called as Palatoscopy and the study of the patterns of the grooves and ridges (rugae) of the palate to identify individual patterns is called as Rugoscopy. Palatal rugae comprise about three to seven ridges radiating out tangentially from the incisive papilla. The most prevalent palatal rugae shape is sinuous followed by curve, line, point and polymorphic varieties. The palatal rugae that are larger were the sinuous. [Figure 7] The pattern of these rugae is considered unique to an individual and can be used as reliable method in postmortem cases.5 In addition, rugae patterns may be specific to ethnic groups facilitating population differences. 3 0 The shortcomings in applying rugoscopy as a definitive tool in forensic odontology are many. Postmortem identification is not possible without the l antemortem records. To give rugoscopy such Type I – Vertical importance, previous recording, scanning and l Type I' – Partial length across the lip grooves of preservation through dental casts and computer Type I records are essential. Palatal rugae are often l Type II – Branched grooves destroyed in fire accident cases and in those cases of decomposition and thus rugoscopy does not have l Type III – Intersecting grooves 5 application after this stipulated period. l Type IV – Reticular grooves

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5. Jahagirdar P, Anand M, Vidhil S. Role of 18. Guy W. A review of the most commonly used forensic odontologists in post mortem person dental age estimation techniques. J Forensic identification. Dent Res J 2012; 9(5): 522 – 30. Odonto Stomat 2001; 19(1): 9 – 17. 6. Dorota M, Agnieszka P, Marzena L, Anna K. 19. Purv P, Anjani C, Bhavin D, Parul B, Naresh S, Current status of forensic odontology education Yesha V. Accuracy of two dental and one – The underestimation of needs. Dent Med skeletal age estimation methods in 6 – 16 year Probl 2013; 50(2): 217 – 22. old Gujarati children. J Forensic Dent Sci 2015; 7(1): 18 – 27. 7. Karanprakash S, Chitra A, Ramanpreet B, Anil A, Harshvardhan C, Ankur T. Teeth and their 20. Rohit M, Deepankar M, Srivastava P, Akansha secrets – Forensic dentistry. J Forensic Res M. Application of genetics and molecular 2012; 3(1): 141 – 3. biology in forensic odontology. J Indian Acad Forensic Med 2012; 34(1): 55 – 7. 8. Suhail A. Forensic odontology. Smile Dent J 2009; 4(1): 22 – 4. 21. Ricardo S, Arsenio S, Rogerio O, Fernando O, Silvia C. Use of DNA technology in forensic 9. David S, Paul S. Forensic dentistry, 2nd dentistry. J Appl Oral Sci 2007; 15(3): 156 – 61. Edition; Florida, 2010. 22. Avon S. Forensic odontology: The roles and 10. Shubhangi B, Rohit M, Alka D, Samatha T, responsibilities of the dentist. J Can Dent Assoc Ashish B, Akshay D. Effect of various 2004; 70(7): 453 – 8. temperatures on restored and unrestored teeth: Forensic study. J Forensic Dent Sci 2014; 6(1): 23. Sunit J. Role of dentist in forensic 62 – 6. investigations. J Forensic Res 2012; 3(5): 148 – 53. 11. Thorakkal S. Forensic odontology. J Phy Surg 2012; 22(4): 240 – 5. 24. Pretty I. Forensic dentistry: Bitemarks and bite injuries. Dent Update 2008; 35: 48 – 61. 12. Shyamal B, Surajit B. Forensic odontology: The new aspects of forensic science and 25. Darnell K. Forensic dentistry and microbial important role of dentistry. Sci & Cult 2010; analysis of bite marks. Asian Pac J 2011; 6 – 15. 76(3-4): 135 – 7. 26. Sweet D, Pretty I. A look at forensic dentistry – 13. Pretty I, Sweet D. A look at forensic dentistry – Part 2: Teeth as weapons of violence – Part 1: The role of teeth in the determination of Identification of bitemark perpetrators. Brit human identity. Brit Dent J 2001; 190(7): 359 – Dent J 2001; 190(8): 415 – 8. 66. 27. Nancy K. Oral and dental aspects of child abuse 14. Roma G, Rishabh G, Rashi J. Role of and neglect. Pediatrics 2005; 116(6): 1565 – 8. prosthodontics in forensic odontology. Int J 28. Ashith A, Savitha J, Suresh V. Professional Clin Dent Sci 2011; 2(4): 85 – 9. negligence in dental practice: Potential for civil 15. Kavitha B, Einstein A, Sivapathasundharam B, and criminal liability in India. J Forensic Dent Saraswathi T. Limitations in forensic Sci 2009; 1(1): 2 – 7. odontology. J Forensic Dent Sci 2009; 1(1): 8 – 29. Vamsi R. Lip prints: An overview in forensic 10. dentistry. J Adv Dent Res 2011; 2(1): 17 – 20. 16. Charangowda B. Dental records: An overview. 30. Rachna R, Ajay R. Palatal rugae: An effective J Forensic Dent Sci 2010; 2(1): 5 – 10. marker in population differentiation. J Forensic 17. Arishka D. What's the deal with dental records Dent Sci 2014; 6(1): 46 – 50. for practicing dentists? Importance in general and forensic dentistry. J Forensic Dent Sci 2014; 6(1): 9 – 15.

9 PERI IMPLANT BONE LOSS AROUND SINGLE Review Article AND MULTILE PROSTHESIS-A SYSTEMATIC REVIEW

Chirag Chauhan*, Darshana Shah**, Paras Doshi***, Harshit Patel****, Ishan Patel*****, Mit Patel****** ABSTRACT Purpose: The objective of this systematic review was to assess and compare the marginal bone loss around implants supporting single fixed prostheses and multiple-unit screw-retained prostheses. Materials and Methods: The literature was searched electronically to identify studies in which the marginal peri-implant bone loss around single-implant prostheses and multiple-implant prostheses was evaluated radiographically. The random-effects method was used to obtain estimates of marginal peri-implant bone loss (means and 95% confidence intervals [CIs].Results: Of the 188 studies identified by a preliminary search, 28 fulfilled the inclusion criteria; 12 were related to single-implant prostheses and 16 to multiple-implant screw retained fixed prostheses. The mean marginal peri-implant bone loss was 1.08 mm (95% CI, 0.253 to 0.283 mm) for multiple-implant retained prostheses and 0.88 mm (95% CI, 0.519 to 0.593 mm) for single-implant prostheses. Conclusion: The mean marginal bone loss is less in single implant supported prosthesis (0.88 mm) compare to multiple implant supported prosthesis (1.08 mm). KEYWORDS: multiple implant–supported prosthesis, peri-implant bone loss, single implant–supported prosthesis, systematic review Received: 20-01-2016; Review Completed: 18-4-2016; Accepted: 27-05-2016 INTRODUCTION: itself, if the misfit is too extreme.13,14 One way to avoid such failures during dental prosthesis Peri-implant marginal bone loss is influenced by 15 many factors, including surgical technique1, fabrication is to achieve passive fit. An absolute 2 3 passive fit seems to be difficult to achieve through implant positioning , tissue thickness , the presence 16 of a microgap4 at the implant-abutment interface5, conventional casting procedures , as the fit is 6 affected by each step of the prosthesis and implant design , all of which can also influence 17 the marginal bone loss. One of the possible theories manufacturing process. In fact, computer-aided of the pathogenesis of marginal peri-implant bone procedures are able to produce frameworks with greater precision compared with traditional casting loss, a common phenomenon ranging from minor 18,19 marginal bone loss to implant failure, is that the methods. stresses in the prosthesis / implant / bone system Absolute passive fit between implants and contribute to the process.7 Any stress generated by prostheses has been widely discussed as a way of the transmission of forces to the bone can cause reducing biomechanical complications in the problems in the prosthesis (screw loosening or treatment of total or partial edentulism.20,21 When the fracture), the implant (implant fracture),8,9 or the adaptation between the implants and the prosthesis bone (marginal peri-implant bone loss or is inaccurate, some units support the major part of osseointegration failure). the load, whereas others bear virtually no load.22 Adequate clinical adaptation of the prosthesis Therefore, single fixed prostheses tend to show with passivity is important in maintaining better passive fit than multiple screw-retained osseointegration, although a specific level of such prostheses and thus induce little or none of the passivity has not yet been established.10 The absence tension caused by a lack of passivity, leading to the hypothesis that a single fixed prosthesis will show of the periodontal ligament may prevent the implant 23-26 from proper seating in a nonpassively fitting less bone loss. situation, which occurs independent of the moment The vast number of available publications has of loads applied to the implants.11 In fact, a certain created a need for syntheses to facilitate access to biologic bone tolerance for stress caused by the the full data set and allow conclusions to be drawn misfit may be present.12 Inaccurate adaptation of the from the comparison or combination of results from prosthesis to the implants causes stress that can lead multiple sources. One way to accomplish this is to biologic or mechanical failure of the implant through systematic reviews with or without meta-

*Professor, **Professor & Head, *** Professor, **** Post Graduate Student, *****Post Graduate Student, ******Post Graduate Student DEPARTMENT OF PROSTHODONTICS, CROWN AND BRIDGE AND ORAL IMPLANTOLOGY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL, GANDHINAGAR, GUJARAT- 382115, INDIA

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Chirag Chauhan, TEL: +91 9824165096

10 Chirag Chauhan et. al. : Peri Implant Bone Loss Around Single And Multile Prosthesis-a Systematic Review analysis.27 Recently, systematic reviews in the field 5) Platform switched implants/External hex of implant dentistry have been performed with the implants. objective of establishing evidence-based 28-31 6) Screw and cement retained implants practices. prosthesis. Material and Methods 7) Studies with minimum 1 year of follow up. Sources used: Exclusion criteria: An electronic search was conducted for articles in 1) Case reports. English, translated into English listed with Science Direct till January 2015. 2) Studies in animals. The search methodology applied was a combination 3) Studies in cadavers. of keywords: marginal bone loss, dental implants, 4) In vitro studies. single implant supported prosthesis, multiple 5) Immediate implants. implant supported prosthesis. 6) Immediate loading. Review articles as well as references from different 7) Bone Grafts. studies were also used to identify the relevant articles. Further the manual search was conducted 8) Systemic diseases. and additional articles could not be identified. 9) Removable prosthesis. Selection of studies: 10) With cantilevers. The review process consist of two phases. In first 11) Incomplete data. phase titles and abstract of the search were initially Results of the search: screened for relevance and the full text of relevant abstract were obtained and accessed. The hand The database search yielded 188 titles, Out of search of selected journals as well as search of which 64 titles were discarded after reading the reference of the selected studies were also done. abstracts, full text was obtained for the remaining The articles were obtained after first step of the 124 articles. 30 articles were selected based on review process using the following inclusion and inclusion and exclusion criteria, out of the 30 exclusion criteria were screened in second phase articles, 2 did not provide clear information and relevant and suitable articles were isolated for regarding the variables of interest and thus were further processing and data extraction. excluded and finally 28 titles were selected for data extraction. Inclusion criteria: Data extraction: 1) Prospective study. Data of the finally included studies were tabulated 2) Retrospective study. and the following information were extracted. 3) Studies mentioned mean marginal bone loss Study, no. of patients, no. of implants, implant with standard deviation in milimeter. system, type of retention, follow up, jaw and region, 4) Articles published in English up to and implant design, prosthetic connection, including January 2015. success/survival rate, marginal bone loss. The specified values were tabulated and subjected to statistical analysis. Table 1 : Data collected for single implant supported prosthesis 1 Study (YEAR) No.of patients No.of implants System/mfr Retention Follow up Jaw and region Implant Design Prosthetic connectionSurvival/success rate Marginal bone loss SD(mm) 2 Henrikson and jemt (2003) 11 11 MK III, Nobel Biocare Screwed 1 yr Ant max cylindric external 100%/- 0.4±0.3 3 Drago(2003) 69 104 Osseotite, Biomet 3i cemented 1 yr cost max, post manc cylindric external 100%/- 0.45±0.16 4 Henrikson and jemt(2003) 9 13 MK III cemented 1 yr Ant Max cylindric external 100%/- 0.3±0.6 5 Glauser et al (2004) 19 36 MK II cemented 4 yr d,incisors, canines,p cylindric external – 1.2±0.5 6 Vigolo et al(2006) 20 40 osseotit cemented 4 yr post max, post mand cylindric external -/100% 0.4±0.3 7 Hall et al(2007) 14 14 Southern implants screwed 1 yr Ant max cylindric external – 0.78±1.01 8 Jemt(1996) 27 32 Branmark, Nobel Biocare cemented 15 yr Ant max cylindric external 100%/- 0.66±0.78 9 vigolo and Zaccaria(2010) 44 60 Osseotite, Biomet 3i cemented 5 yr post max cylindric external 100%/- 0.8±0.2 10 Michael(2006) 54 173 Astra Tech cemented 1 yr max post, mand post cylindric Internal 99.4%/- 0.65±0.52 11 David L. Cochrane(2009) 53 139 Straumann cemented 5 yr max/mand cylindric Internal – 2.90±1.56 12 13 14 Ant=anterior: Post=posterior: max=Maxilla: mand=mandible: mfr=manufacture

11 Chirag Chauhan et. al. : Peri Implant Bone Loss Around Single And Multile Prosthesis-a Systematic Review

Table 2 : Data collected for Multiple implant supported prosthesis Prosthetic Survival/ Marginal bone 1 Study No.of patients No.of implants System/mfr Total/Partical Relention Follow up Jaw and region Implant Design connection success rate loss SD(mm) 2 Steenberghe et al (1990) 147 427 Branemark Partial screwed 5 yr Ant/post max/manc cylindric external – 0.4±0.65 3 Jemt and Book(1996) 7 44 Branemark Total screwed 1 yr Ant max cylindric external – 0.5±0.56 4 Lindquist et al(1996) 45 270 Branemark Total screwed 15 yr Ant mand cylindric external -/98.9% 1.2±0.74 5 Arvindson et al(1998) 91 517 Astra Tech Total screwed 5 yr Ant mand cylindric external 98.7%/- 0.26±0.53 6 Carlsoon et al(2000) 44 237 Branemark Total screwed 15 yr ncisors, canines, per cylindric external 98.9%/- 1.4±0.40 7 Brayat and Zarb(2003) 66 306 Branemark Partial screwed 11 yr Ant/post max/mand cylindric external 89.1%/- 1.62±0.84 8 Ekelund et al(2003) 30 179 Branemark Total screwed 20 yr ant mand cylindric external 98.9%/- 1.6±0.9 9 Fischer et al(2008) 7 39 SLA, Straumann Total screwed 5 yr Ant max cylindric external 95.7%/- 0.3±1.0 10 Change and Wennstrom(201 16 43 Osseotite, Biomet 3 Partial screwed 3 yr post max, post manc cylindric external – 0.6±1.4 11 Mertens et al(2012) 15 94 Tioblast, Astra Tech Total screwed 11 yr Ant/post max cylindric Internal 96.8%/92.6% 0.88±0.99 12 David L Cochrane(2009) 43 117 Nobel Direct Partial cemented 1 yr max/manx cylindric Internal -/94.0% 2.4±1.5 13 N.Fernandez(2012) 51 114 Straumann Partial cemented 1 yr max post/mand post cylindric Internal – 0.68±0.88 14 David L. Cochrane(2009) 139 457 Straumann Partial cemented 5 yr max/mand cylindric Internal – 2.90±1.56 15 MM Goswami (2009) 20 40 io-oss, Nobel replas Partial cemented 1 yr mand post cylindric Internal – 1.4±0.31 16 R J Ebbetson (2007) 14 14 Southern implants Partial screwed 1 yr Ant max conical Internal – 0.78±1.01 17 John P Gage(2006) 54 173 Astra Tech Total cemented 1 yr max post, mand post cylindric Internal 99.4%/- 0.65±0.52 18 Peeter F(2003) 9 13 MK III Partial cemented 1 yr Ant max cylindric Internal 100%/- 0.3±0.6 19 20 21 Ant=anterior: Post=posterior: max=Maxilla: mand=mandible: mfr=manufacture Table 3 : Marginal bone loss in two groups Std. 95% 95% Mean Std. Error Mean Std. Error Lower Upper P GROUP N (mm) Deviation Mean Difference Difference Diffrence Difference Value Marginal single bone implant 12 0.88 0.72 0.207 loss prosthesis -0.21 0.30 -0.82 0.41 0.494 multiple implant 16 1.08 0.82 0.211 prosthesis

Figure 1 : Graph depicting the linear marginal bone single implant prosthesis multiple implant prosthesis loss in single and multiple implant supported prosthesis Table 4 : Survival rate of two groups (single implant prosthesis and multiple implant prosthesis) Std. Error Std. 95% 95% Mean Std. Mean Error Lower Upper P GROUP Deviation Mean Difference Difference Difference Difference Value (%) (in mm) N Survival single rate implant 99.90 0.100 prosthesis 6 0.24

3.55 1.55 0.10 7.00 0.045 multiple implant 96.35 1.546 6 3.79 prosthesis

12 Chirag Chauhan et. al. : Peri Implant Bone Loss Around Single And Multile Prosthesis-a Systematic Review

16 studies. Therefore, two separate meta-analyses were conducted to evaluate marginal peri-implant bone loss around single and multiple-unit prostheses, which allowed indirect comparison of marginal peri-implant bone loss. Well-elaborated inclusion and exclusion criteria must be established to minimize the risk of introducing bias during the selection of studies and, consequently, into the results of a review.53 In the present study, the inclusion and exclusion criteria single implant prosthesis multiple implant prosthesis were rigorously elaborated, which was confirmed by the homogeneity observed among the studies. Figure 2 :Graph depicting Survival rate of two The use of the periapical radiographic technique for groups (single implant prosthesis and multiple evaluating bone loss was used as an inclusion implant prosthesis) criterion in this study. Several studies have DISCUSSION demonstrated the accuracy of this technique for evaluating changes in the bone crest as well as its This result showed a mean marginal peri implant superiority to panoramic radiographs for this bone loss of 0.88 mm for single unit screw retained purpose.29,54,55 This led the authors to consider the prostheses and 1.08 mm for multiple fixed panoramic technique less than ideal for the present prostheses. study, as its use could introduce bias. Another Unlike conventional prostheses, under which important aspect in the choice of inclusion / an abutment tooth can move up to 100 µm inside its exclusion criteria is the fact that only studies with a periodontal ligament and thus compensate for a follow-up period of at least 1 year were selected. certain degree of imprecision in a fixed prosthesis, The classic study of Adell et al36 showed that implants can move only within a 10-µm range. 32,33 marginal peri-implant bone loss occurs during the An in vitro study showed that the implant- first year and then tends to stabilize for the majority prosthesis interface had a mean misfit value of of implants.36 31.63 µm, which is greater than the bone CONCLUSION compensation limit of 10 µm. This lack of flexibility at the bone-implant interface means that From the systamatic review of available any traction, compression, or flexion forces literature following conclusion can be drawn: imposed by superstructure misfit can lead to lack of 1. The mean marginal bone loss is less in single passive fit, which can result in problems such as implant supported prosthesis (0.88 mm) compare marginal periimplant bone loss. 34–37 Another factor to multiple implant supported prosthesis (1.08 mm). that can compensate for the limited flexibility in the 2. The survival rate of single implant supported bone-implant interface of multiple-unit prostheses 38 prosthesis is greater than multiple implant is the cementation line. Bottino et al showed that supported prosthesis. the smallest values of maladaptation for cemented prostheses were greater than 36.6 µm, regardless of the type of cement used. Because these values were greater than the mean misfit in the implant- prosthesis interface, it was assumed that cement- retained multiple prostheses would easily achieve passive fit without causing tension at the bone- implant interface. The marginal peri-implant bone loss was evaluated for single prostheses in twelve studies and for multiple-unit screw-retained prostheses in

13 Chirag Chauhan et. al. : Peri Implant Bone Loss Around Single And Multile Prosthesis-a Systematic Review

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15 SMOKING, WEIGHT LOSS AND DIABETES: Review Article THE MYTH AND MYSTERY

Chitrang P Shah*, Darshan Prajapati.**, Harsh G Shah***, Vasudha Sodani**** ABSTRACT Apart from its Dopamine releasing action which produces the “Pleasure effect”, Nicotine (Tobacco) has also been associated with weight loss. The association between Smoking and weight loss or say the correlation between the high levels of nicotine in the blood and the increased blood glucose levels has been intriguing. Also, Nicotine induced Insulin Sensitivity has also been observed among the smokers which in turn predisposes the addicted to Type 2 Diabetes. On the other hand, cigarette smoking; for its predicated weight loss effect, has been practiced by a lot of people since decades. The actual mechanism by which it causes the weight loss revolves around how nicotine raises the blood glucose levels by its catecholamine releasing action and the increased satiety which follows it. Also, the lipolysis induced by the nicotine has also been considered one of the factors aiding the presumed weight loss. KEYWORDS: Smoking, Tobacco, Cessation. Received: 08-02-2016; Review Completed: 01-06-2016; Accepted: 28-06-2016 INTRODUCTION: constitute potentially important loci for nicotine- [3] Cigarette smoking for weight loss is a practice mediated changes in feeding behavior.” Thus the dating to early knowledge of nicotine as an appetite cultural associations between smoking and weight suppressant. Tobacco use was associated with control in part reflect the body’s physiological appetite suppression among pre-Columbian reactions to nicotine. indigenous Americans and old world Europeans.[1] Nicotine gum has similar effects to cigarettes in For decades, tobacco companies have employed terms of appetite suppression, and there are some these connections between slimness and smoking in people who do not smoke, but use nicotine gum or their advertisements, mainly in brands and any other Nicotine replacement product for the advertisements targeting women. Culturally, the purpose of weight control or weight loss. links between smoking cigarettes and controlling Nicotine can also lower insulin levels in a person’s weight run deep. While it is unclear how many bloodstream, which can reduce cravings for sugary people begin or continue smoking because of foods.[4] Furthermore, “nicotine-triggered effects of weight concerns, research reveals that white female adrenaline on the stomach’s musculature” lead to adolescents with established weight-related temporary feelings of subsided hunger.[5] Other anxieties are particularly prone to initiate smoking. studies have shown that smokers expend more Although knowledge of nicotine’s effects upon the calories while engaged in activity, which echo appetite can contribute to people smoking for conclusions that smokers experience heightened weight control purposes, studies have not shown metabolic rates.[6] Also worth noting are the diuretic that people smoke exclusively to maintain or lose properties of nicotine, which causes lower calcium weight. levels in the blood. Though smoking is widely discouraged by public There is much controversy concerning whether health professionals for its countless negative smokers are actually thinner than nonsmokers.[2] health consequences, nicotine may be an appetite Some studies have shown that smokers—including suppressant.[2] Nicotine could reduce appetite and long term and current smokers—weigh less than influence an individual’s eating habits. A study on nonsmokers, and gain less weight over time.[7] nicotine’s effects on appetite demonstrated that “net Conversely, certain longitudinal studies have not effects of nicotine include elevated blood pressure, shown correlation between weight loss and heart rate, and gastric motility while eliciting a smoking at least among young persons.[8] sustained decrease in food intake or appetite. Accordingly, while the connection between Autonomic, sensory, and enteric neurons each nicotine and appetite suppression, as well as other

* Junior Lecturer, **Junior Lecturer, ***Reader, **** Reader DEPARTMENT OF PUBLIC HEALTH DENTISTRY, AHMEDABAD DENTAL COLLEGE & HOSPITAL

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Chitrang Shah, TEL: +91 9898459197

16 Chitrang P Shah Et. Al. : Smoking, Weight Loss And Diabetes: The Myth And Mystery physiological responses to nicotine consumption, control techniques, are at a higher risk of has been established, whether these chemical and smoking.[17] biological reactions translate to smokers being Mechansim20,21,22,23 thinner than nonsmokers (at least concerning certain age groups), is still debated. Age may act as a Nicotine induced secretion of Catecholamines, as compounding factor in some of these studies. well as other hormones, such as glucagon and Essentially, a causal relationship has not been human growth hormone (HGH), impair the action explicitly established between physiological effects of insulin and can induce insulin insensitivity. In of nicotine and epidemiological findings about fact, it has been reported that, at the cellular level, weight among smokers and nonsmokers. catecholamines impair the pathways that are related to the production of insulin, and the activity and Perceptions of weight control among adolescent synthesis of the proteins that transport glucose to users: cells. It is possible then that nicotine – via these and While most adults do not smoke for weight probably other as yet poorly understood brain and control,[9] studies have shown that associations tissue-receptor mechanisms – impairs both insulin between tobacco use, being thin and desire for sensitivity and insulin secretion. It is possible that weight control do influence adolescents in terms of nicotine impairs both insulin sensitivity and insulin smoking behavior. Research demonstrates that secretion adolescent girls that strongly value being thin are [10] Studies have shown that smokers tend to become more likely to initiate smoking. Additionally, insulin resistant, and to compensate, their blood girls already engaged in risky behavior for weight sugar levels rise to levels higher than normal, but control are at increased odds to begin smoking as [11] not to full-blown diabetic levels. Some studies well. demonstrate that nicotine and cigarette smoking Further research needs to examine trends in induce high levels of the stress hormone cortisol. As ethnicity concerning women and smoking for cortisol excess is known to induce insulin weight control. So far, studies have shown that resistance, it has been suggested that young white women may be more prone to use glucocorticoids, such as cortisol, are the missing cigarettes to manage their weight. Advertisements [causative] link between cigarette smoking and for particular brands and types of cigarettes seem to insulin resistance. target this demographic accordingly. Fats: Several studies have been conducted over the past [12][13][14][15] Additionally, the intake of nicotine provokes an decade examining this issue in depth. increase in the breakdown of fats (lipolysis) and a While it has generally been found that white rise in levels of free fatty acids in a person’s blood. females are more apt to smoke to lose weight, one Nicotine does this in part by activating the study found that smoking to lose or control weight is adrenaline-related mechanisms in the brain and by not limited to white females, but is prevalent across [16] directly activating a lipolytic cell surface receptor, racial and gender boundaries. Within all racial located in fatty tissue. In turn, this chronic increase groups, it was found that weight concerns and in levels of fatty acids adversely affects insulin negative body perceptions were a significant factor sensitivity and insulin secretion through direct in an adolescent's decision to smoke. However, it effects on the liver, pancreas and muscle. should be noted that the relationship between weight and smoking amongst young men was only Oxidative stress: statistically significant in white or mixed race Finally, we know that smoking increases oxidative groups. stress, causes inflammation, and reduces the flow of In the past, studies have shown that adolescent girls blood to muscle, further contributing to the do consider weight loss or weight control to be one development and progression of insulin of the positive values of smoking. Overall, young insensitivity and type 2 diabetes. However, women and girls concerned about weight control, although these factors have been found to be closely particularly those already using unhealthy weight related to insulin insensitivity and impaired glucose

17 Chitrang P Shah Et. Al. : Smoking, Weight Loss And Diabetes: The Myth And Mystery tolerance, the potential role of chronic process of quitting smoking are recommended to inflammation and/or increased oxidative stress in follow a healthy diet and to exercise regularly. Most the development of type 2 diabetes has not yet been quitting advice encourages people to not be fully established. Smoking may impact on the discouraged should they experience weight gain distribution of a person’s body fat. It is possible that while quitting smoking, as the health benefits of some of these factors play an important role in quitting almost always exceed the costs of weight mediating some of the negative effects of tobacco gain. Studies have shown that weight gain during smoke on a person’s glucose and fat metabolism. the smoking cessation process can often be lost Tobacco cessation and the associated Weight eventually through diet and exercise. Gain An Urgent need for prevention: Weight gain as a side effect of smoking cessation There is abundant published evidence to support the remains a major aspect of smoking and weight strength and biological plausibility of the control. People can be discouraged by weight gain associations between tobacco smoke, reduced experienced while quitting smoking. Weight gain is insulin sensitivity and the increased risk of a common experience during smoking cessation, developing type 2 Diabetes. Diabetes and tobacco with roughly 75% of smokers gaining weight after use is a harmful combination. It is extremely quitting.[18] As nicotine is an appetite suppressant important for people to stop smoking, or better still, and smokers expend more energy, weight gain due never to start using tobacco. Every effort should be to smoking cessation is generally attributed to made to implement urgent lifestyle changes where increased caloric intake and a slowed metabolic necessary in order both to prevent the development rate. of diabetes and, in people with the condition, to Weight gain can be a deterrent in the smoking reduce the progression of chronic diabetes cessation process, even if many smokers did not complications. smoke for weight control purposes.[19] Those in the

REFERENCES: 6. Kluger, Richard Ashes to Ashes: America’s Hundred-year Cigarette War, the Public Health, 1. Gatley, I. 2003. Tobacco: A Cultural History of and the Unabashed Triumph of Philip Morris, How an Exotic Plant Seduced Civilization. (New York: Alfred A. Knopf Inc., 1996) New York: Grove Press, p.38 7. Albanes, Demetrius, D. Yvonne Jones, Marc 2. Chiolero, A; Faeh, D; Paccaud, F; Cornuz, J Micozzi, and Margaret E. Mattson, (Apr 2008). "Consequences of smoking for “Associations between Smoking and Body body weight, body fat distribution, and insulin Weight in the US Population: Analysis of resistance.". The American Journal of Clinical NHANES II,” American Journal of Public Nutrition87 (4): 801–9 Health 77.4 (1987) 3. Young-Hwan, Jo, David A. Talmage, and Lorna 8. Nichter, Mimi, Mark Nichter, Nancy Vuckovic, W. Role, “Nicotinic Receptor-Mediated Effects laura Tesler, Shelly Adrian, and Cheryl on Appetite and Food Intake,” Journal of Ritenbaugh, “Smoking as a Weight-Control Neurobiology 53.4 (2002), p.622. Strategy among Adolescent Girls and Young 4. Kluger, Richard Ashes to Ashes: America’s Women: A Reconsideration,” Medical Hundred-year Cigarette War, the Public Health, Anthropology Quarterly 18.3 (2004): 307 and the Unabashed Triumph of Philip Morris, 9. Nichter, Mimi, Mark Nichter, Nancy Vuckovic, (New York: Alfred A. Knopf Inc., 1996), p.418. laura Tesler, Shelly Adrian, and Cheryl 5. Kluger, Richard, Ashes to Ashes: America’s Ritenbaugh, “Smoking as a Weight-Control Hundred-year Cigarette War, the Public Health, Strategy among Adolescent Girls and Young and the Unabashed Triumph of Philip Morris, Women: A Reconsideration,” Medical (New York: Alfred A. Knopf Inc., 1996) Anthropology Quarterly 18.3 (2004)

18 Chitrang P Shah Et. Al. : Smoking, Weight Loss And Diabetes: The Myth And Mystery

10. Honjo,K. and M. Siegel, “Perceived Gender and Racial/Ethnic Differences.” Importance of Being Thin and Smoking Journal of Adolescent Health (32.306), p.310 Initiation among Young Girls,” Tobacco 17. Elliot, Rosemary. Women and Smoking Since Control 12.3 (2003), p.293 1890. Routledge: New York, 2008, p.134 11. French, Simone A. and Cheryl L. Perry, 18. Borrelli, B and R Mermelstein. 1998. “The role “Smoking among Adolescent Girls: Prevalence of weight concern and self-efficacy in smoking and Etiology,” Journal of American Medical cessation and weight gain among smokers in a Women’s Association 51.1 & 2, (1996), p.28 clinic-based cessation program.” Addictive 12. Saarni, SE, K Silventoinen, A Rissanen, S Behaviors (23.5), p.609 Sarlio-Lähteenkorva and J Kaprio. 2004. 19. Pirie, PL, CM McBride, W Hellerstedt, R W “Intentional weight loss and smoking in young Jeffrey, D Hatsukami, S Allen and H Lando. adults.” International Journal of Obesity (28) 1992. “Smoking cessation in women concerned 13. Nichter, Mimi, Mark Nichter, Nancy Vuckovic, about weight.” (82.9) American Journal of Laura Tesler, Shelly Adrian and Cheryl Public Health (82.9), p.1238 Rittenbaugh. 2004. “Smoking as a Weight- 20. Eliasson B. Cigarette smoking and diabetes. Control Strategy among Adolescent Girls and Prog Cardiovasc Dis 2003; 45: 405-13 Young Women: A Reconsideration.” Medical Anthropology Quarterly (18.3) 21. Tziomalos K, Charsoulis F. Endocrine effects of tobacco smoking. Clin Endocrinol 2004; 61: 14. Honjo, H. and M Siegel. 2003. “Perceived 664-74. importance of being thin and smoking initiation among young girls.” Tobacco Control (12) 22. Targher G, Alberiche M, Zenere MB, Bonadonna RC, Muggeo M, Bonora E. 15. Fulkerson, Jayne A, Ph.D and Simone A. Cigarette smoking and insulin resistance in French, Ph.D. 2003. “Cigarette Smoking for patients with non-insulin-dependent diabetes Weight Loss or Control Among Adolescents: mellitus. J Clin Endocrinol Metab 1996; 82: Gender and Racial/Ethnic Differences.” 3619-24 Journal of Adolescent Health (32.306) 23. Bjorntorp P, Holm G, Rosmond R. 16. Fulkerson, Jayne A, Ph.D and Simone A. Hypothalamic arousal, insulin resistance and French, Ph.D. 2003. “Cigarette Smoking for type 2 diabetes mellitus. Diabet Med 1999; 16: Weight Loss or Control Among Adolescents: 373-83.

19 BE SMART EAT SMART! Original Article

Anupriya Malonia*, Maitry Mehta**, Vijay Bhaskar***, Krunal Chokshi****, Vasudha Sodani***** ABSTRACT The basis of our dietary choices and our nutritional status is established early in life. The patterns initiated in childhood can affect our health and well being at every stage. Aims & Objectives: The aim of this study was to investigate the dietary patterns and nutritional status of children in Ahmedabad city. Materials and Methods: In structured interviews, 200 mothers were asked to give information about their child's feeding habit during childhood, daytime sugar intake, awareness regarding the nutritional needs at various ages. Result: Most mothers follow the traditional Indian meal pattern whereas 75% of kids snack twice a day. Kids were a part of the family's food selection and purchase process. Most mothers follow a routine fixed diet from Monday to Saturday and on weekends that they tend to modify. Conclusion: It was concluded from the study that nutrient requirements of most children were not met on daily basis. There was irregularity in taking meals and most families did not follow a proper dietary regimen. Also there was lack of reinforcement for healthy snacking pattern. KEYWORDS: childhood, nutritional status, meals. Received: 04-03-2016; Review Completed: 01-06-2016; Accepted: 21-06-2016 INTRODUCTION: stomatognathic apparatus undergo periods of The concept of oral health correlated to quality of intense growth alternated with periods of relative life stems from the definition of health that the quiescence: it is clear that a nutritional imbalance in a very active period of growth will produce greater WHO gave in 1946. Health is understood to be “a 3 state of complete physical, mental, and social well- damage . being and not merely the absence of disease or A shortage of vitamins and minerals in the phase infirmity”. The programs for the prevention of oral before conception influences the development of diseases concern teaching about oral hygiene and the future embryo, influencing dental healthy eating, fluoride prophylaxis, periodic organogenesis, the growth of the maxilla, and check-ups, sessions of professional oral hygiene, skull/facial development1,2. 1 and secondary prevention programs . The term Despite credible scientific advances and the fact “bionutrition” refers to the important interactions that caries is preventable, dental decay in the which exist between diet, use of nutrients, genetics, primary dentition of young children continues to and development. This term emphasizes the role of pose a serious threat to child welfare. In developing nutrients in maintaining health and preventing countries like India, changing lifestyle and dietary pathologies at an organic, cellular, and subcellular 2 patterns are markedly increasing the caries level . incidence7. There exists a unique relationship between diet and Mothers are primary promoters of oral hygiene and oral health: a balanced diet is correlated to a state of they have a major influence on the dietary habits oral health (periodontal tissue, dental elements, and food choices of children. Patterns of behaviour quality, and quantity of saliva). Vice versa, an learnt in early childhood are deeply ingrained and incorrect nutritional intake correlates to a state of 3-6 resistant to change. Mothers have an important role oral disease . in this aspect8. Significantly, more mothers of Diet influences the development of the oral cavity: children with caries, lack knowledge about some of depending on whether there is an early or late the determinants and prevention of caries. It is nutritional imbalance, the consequences are assumed that an increase in the knowledge of certainly different. In fact, an early nutritional mothers will influence their self-care habits and imbalance influences malformations the most. dietary practice and, in turn, improve the dietary and Moreover, the different components of the oral hygiene habits of children to prevent caries9.

*PG Student, **PG Student, ***Professor & HOD,****Sr. Lecturer, *****Reader DEPARTMENT OF PEDODONTICS AND PREVENTIVE DENTISTRY DEPARTMENT, AHMEDABAD DENTAL COLLEGE & HOSPITAL.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Anupriya Malonia, TEL: +91 9998968544

20 Anupriya Malonia et. al. : Be Smart Eat Smart!

AIM AND OBJECTIVES Knowledge about Technical Aspects The aim of this study was to investigate the dietary of Meal patterns and nutritional status of children in Ahmedabad city. The objective was to determine 36.7 the knowledge and attitude of mothers regarding nutrition and health. 25.0 MATERIALS AND METHOD 20.0 18.3 In structured interviews, 200 mothers were asked to give information about their child's feeding habits during childhood, daytime sugar intake, awareness regarding the nutritional needs at various ages. 30% carbohydrate 70% protein Patient proforma contained total 24 questions 50% carbohydrate 50% protein regarding the present feeding practices of children as well as regarding maternal attitude and Though most mothers claimed that they provided awareness about the nutrition and oral health. adequate meals a day and did incorporate RESULTS carbohydrate, proteins, fats, they were not aware The result of the questionnaire was as follows: of their appropriate proportions according to their child's age. How many times a day does your child take snacks? Does your child indulge in any of the following activity along 75.0 80.0 with meal? 60.0 70.0 58.3 60.0 40.0 50.0 20.0 15.0 8.3 40.0 31.7 1.7 30.0 0.0 20.0 5.0 2 3 4 6 10.0 1.7 3.3 0.0 Most mothers followed the traditional Indian meal .. pattern whereas 75% of kids snack twice a day. TV

watch feel stressed Do homework No otheractivity Do you consciously attempt to incorporate Any other activity carbohydrate, proteins and fats on routine basis in food? Only 31% of kids did no other activity except 100.0 eating. Most children were not emotionally 78.3 involved in the food they eat. 80.0 60.0 40.0 21.7 20.0 0.0 Yes No

21 Anupriya Malonia et. al. : Be Smart Eat Smart!

In urban areas though mothers made efforts to Do you include your child in food make meal nutritious and appealing, despite it purchasing and preparation? they were not able to make their children consume it entirely. 65.0 Are you satisfied with your child's nutritional intake? 61.7

35.0 38.3

Yes No

The nutritional intake was adequate according to Yes No the mothers, but it was not adequate according to Kids were a part of the family's food selection the scientifically recommended principles. and purchase process Are you aware that syrups and antibiotics Does your family follow a given in the 1st year of life can cause structured diet plan? tooth decay? 70.0 58.3 60.0 41.7 50.0 40.0 30.0 Yes No 20.0 10.0 How many times a day does your 0.0 child take candies / toffees / chocolate? Yes No 45.0 Most mothers followed a routine fixed diet from 35.0 Monday to Saturday. It was only on weekends 15.0 5.0 that they tend to modify. Do you substitute a food item with another with similar nutritional value one twice more not at all than 3 when it is rejected by your child? times 81.7 A significant proportion of mothers were not 18.3 aware that syrups caused tooth decay Also only 35% kids did not take chocolates at all, rest Yes No consumed chocolates at will.

22 Anupriya Malonia et. al. : Be Smart Eat Smart!

l What additional agent do you There is a need to incorporate education to add to your child's milk everyday? mothers l Provide the mothers with structured plan for 51.7 the child at every stage of growth l Assess the nutritional principles of families and suggest them with rectification in case of 23.3 improper diet regimens 13.3 11.7 l There is a need to organize workshops for mothers sugar bournvita none dry fruits l Every child can be made healthy l A simple modification / addition of foods from Most mothers made conscious attempts towards everyday routine is what is required their child's nutritional intake. But most were l random without any guided principle All that the mothers need is guidance l DISCUSSION Just knowing nutritional knowledge is not sufficient l From the time a baby is born till adulthood , it is l the mother who is responsible for the Empowering them with a technical know- how nutritional requirements of the child could change a lot. l The study mainly emphasis that in urban areas CONCLUSIONS the knowledge regarding nutritional needs is From the above study it is concluded that adequate but there still is a lag in nutrient requirements of most children are not met implementation of habits on daily basis. There is irregularity in taking meals l Whereas in rural areas there is still a need to and most families do not follow a proper diet empower mothers regarding the technical regimen. Also there is lack of reinforcement for aspects of food selection healthy snacking pattern.

REFERENCES: Aguilar ED. Overview and quality assurance 1. Belcastro G, Rastelli E, Mariotti V, Consiglio C, for the oral health component of the National Facchini F, Bonfiglioli B. Continuity or Health and Nutrition Examination Survey discontinuity of the life-style in central Italy (NHANES), 2005–08 J Public Health Dent. during the Roman imperial age-early middle 2011 Winter;71(1):54-61. ages transition: diet, health, and behaviour. Am 6. Scardina GA, Messina P. Nutrition and oral J Phys Anthropol. 2007 Mar;132(3):381-94. health, Recenti Progressi in Medicina Recenti 2. Dion N, Cotart JL, Rabilloud M. Correction of Prog Med. 2008 Feb;99(2):106-11. nutrition test errors for more accurate 7. Rao A, Sequeira SP, Peter S., “Prevalence of quantification of the link between dental health dental caries among school children of a n d m a l n u t r i t i o n . N u t r i t i o n . 2 0 0 7 Moodbidri,” J Indian Soc Pedod Prev Dent. Apr;23(4):301-7. 1999 Jun;17(2):45-8. 3. Singh A, Bharathi MP, Sequeira P, Acharya S, 8. Sudha P, Bhasin S, Anegundi RT, “Prevalence Bhat M. Oral health status and practices of 5 of dental caries among 5–13-year-old children and 12 year old indian tribal children. J Clin of Mangalore city,” J Indian Soc Pedod Prev Pediatr Dent. 2011 Spring;35(3):325-30. Dent. 2005 Jun;23(2):74-9. 4. Chicago Dental Society. Good oral health starts 9. Jalili VP, Samraj T, Chitre DA “Dento-facial with exercise, eating right. CDS Rev. 2011 anomalies in India. (Goals and strategies to Mar-Apr;104(2):34. achieve by 2000 AD), J Indian Dent Assoc. 5. Dye BA, Barker LK, Li X, Lewis BG, Beltrán- 1985 Oct;57(10):401-5.

23 INSTANT DENTIN HYPERSENSITIVITY RELIEF WITH A SINGLE Original Article TOPICAL APPLICATION OF AN IN-OFFICE 8% ARGININE CONTAINING DESENSITIZING PASTE Archita Kikani*, Hiral Parikh**, Sunita Dhaka***, Ankina Joshi****, Harsh Shah*****, Mihir Shah****** ABSTRACT Objective: The aim of this survey was to evaluate the clinical efficacy of the desensitizing paste with pro-argin™ formula containing 8% arginine and calcium carbonate on dentinal hypersensitivity relief after a single professional application without further at-home brushing. Materials and methods: This survey was carried out in 288 patients taken from the OPD of department of periodontology in Ahmedabad dental hospital with age of 18 to 70 years in 2 months period of time duration. They were required to possess a minimum of two hypersensitive teeth in two different quadrants which demonstrated cervical erosion/abrasion or gingival recession. Dentinal hypersensitivity evaluation was carried out in one or two severely affected teeth in oral cavity with different etiologic factors like gingival recession, abrasion, attrition, erosion or post scaling in 288 different subjects by single investigator. Dentinal hypersensitivity severity and its relief after application of the desensitizing tooth paste was evaluated by using the visual analog score (VAS) card. Conclusion: The in-office desensitizing paste containing 8% arginine and calcium carbonate provides significant reduction in dentin hypersensitivity instantly after a single professional application of the product and this reduction is maintained for 12 weeks without further application of arginine. KEYWORDS: dentinal hypersensitivity, desensitizing paste, visual analog score Received: 16-03-2016; Review Completed: 25-05-2016; Accepted: 08-06-2016

INTRODUCTION: than is heat.1 Dentin hypersensitivity is characterized by short, T h e h y d r o d y n a m i c t h e o r y o f d e n t i n sharp pain arising from exposed dentin in response hypersensitivity, as this mechanism has become to external stimuli, typically thermal, evaporative, known, requires that dentin tubules are open at the tactile, osmotic or chemical, and which cannot be dentin surface and patent to the pulp.9,10 ascribed to any other form of dental defect or 1,2 Dentin can become exposed through gingival disease. The most frequently experienced pain recession or through enamel loss. Gingival from dentin hypersensitivity is characterized by a recession and exposure of the underlying dentin are rapid onset, sharp burst of pain of short duration caused by overzealous tooth brushing and improper (seconds or minutes) associated with A-beta and A- 1,3,4 tooth brushing technique, or by periodontal disease delta nerve responses to stimuli. As several oral and its surgical and non-surgical treatment.1,11 Based conditions can give rise to dental pain, such as on in vitro and in situ studies, it appears that normal untreated caries, a split tooth or a cracked cusp, the tooth brushing does not cause significant enamel correct attribution of dental pain to dentin loss. However, erosion from acidic foods and hypersensitivity is essential to assess appropriate 5,6 drinks, in combination with tooth brushing, can treatment options. result in significant tooth wear on any aspect of the Typically, dentin hypersensitivity occurs when the tooth surface, especially the cervical area.1,12-14 external stimulus contacts exposed dentin, triggers Experts have concluded that gingival recession, a rapid outflow of dentin fluid, and the resultant rather than cervical enamel loss, is the key pre- pressure change across the dentin activates intra- disposing factor for dentin hypersensitivity.1 1,7,8 dental nerve fibers to cause immediate pain. Exposed dentin tubules are loosely occluded by a Tactile, cold and osmotic stimuli all trigger rapid coating, known as the smear layer, comprised of fluid outflow. Heat, on the other hand, triggers a protein components and calcium phosphate slow retreat of dentin fluid, and the resultant deposits derived from saliva. On the basis of in vitro pressure change activates the nerve fibers in a less studies, it has been suggested that both chemical dramatic fashion, consistent with the observation and physical forces can remove the smear layer to that cold is generally more problematic to sufferers open exposed dentin tubules.1 While there seems

*Professor, **Professor, ***Post Graduate Student, **** Post Graduate Student, *****Reader, ****** Professor and Head of Department. DEPARTMENT OF PERIODONTICS AND ORAL IMPLATOLOGY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA. DEPARTMENT OF PUBLIC HEALTH DENTISTRY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL. ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Archita Kikani, TEL: +91 9825436907

24 Archita Kikani et. al. : Instant Dentin Hypersensitivity Relief With A Single Topical Application of An In-office 8% Arginine Containing Desensitizing Paste little doubt that acidic foods and drinks are able to occlusion. Investigations of the science remove the smear layer and soften dentin rendering underpinning the mechanisms of natural occlusion the surface softened dentin tissue susceptible to have resulted in the development of a new “saliva- physical forces, such as tooth brushing, clinical data based composition” comprising arginine, an amino suggest that physical forces alone are not a key acid which is positively charged at physiological factor in removing the smear layer and opening pH, bicarbonate, which is a pH buffer, and calcium exposed dentin tubules.1 carbonate, which is a source of calcium.15 A recent 14 Dentin hypersensitivity is typically experienced by clinical study sponsored by the Colgate-Palmolive the adult population, age range from 20-49 years, Company has confirmed that this in-office with peak incidence between 30-39 years. The desensitizing paste provides instant buccal cervical regions of the permanent teeth are sensitivity relief, when applied after professional the most commonly affected surfaces, with canine, cleaning procedures, and that the treatment effects pre-molar and incisor teeth being more frequently last for at least 28 days. Colgate has further affected than molars.1,5 Studies of the prevalence of developed this innovative technology by combining dentin hypersensitivity have reported levels in the the key components, arginine and calcium range 4-57% in general dental practice settings, carbonate, with fluoride to provide a significant others have suggested levels of 15-25% are typical. advance in everyday treatment of dentin The reported wide variations have been attributed to hypersensitivity.16 different methods of assessment, self-reported or A new dentifrice containing 8.0% arginine, calcium professional clinical diagnosis, the population base carbonate, and 1450 ppm fluoride, as MFP, has been and setting, and behavioral factors, such as oral clinically proven to provide lasting relief of hygiene habits and intake of acidic foods and 1,5,7,12 sensitivity and superior relief. drinks. Levels of dentin hypersensitivity are 15 higher, ranging from 60-98%, in patients following Kleinberg suggested that the arginine physically periodontal treatment.1,5,1 adsorbs onto the surface of the calcium carbonate in vivo, forming positively charged agglomerate The theory of hydrodynamic transmission proposed 13 which readily binds to the negatively charged dentin by Brännström is generally accepted for pain on the exposed surfaces and within the tubules. In generation: an external stimulus provokes a addition, the pH of the arginine-calcium carbonate movement in the dentin fluid, which in turn triggers agglomerate is sufficiently alkaline to facilitate nerve endings within the pulp. Products for the deposition of calcium and phosphate from saliva management of dentin hypersensitivity typically and/or dentin fluid. The results of the mechanism of aim to control the hydrodynamic mechanisms of 14 action studies are consistent with Kleinberg's pain. Approaches to control the condition fall into hypothesis and support that interaction of arginine two broad categories: agents or products that reduce and calcium carbonate in vivo triggers deposition of fluid flow within the dentin tubules by occluding the phosphate, in addition to arginine, calcium, and tubules themselves, thereby blocking the stimuli, carbonate on the dentin surface and within the and those that interrupt the neural response to 17 14 dentin tubules. Four clinical studies have shown stimuli. that a single in-office application resulted in instant The development of a new technology, ProArgin, relief of Dentinal hypersensitivity and that the relief based upon saliva's role in the natural process of was maintained with subsequent twice-daily at- tubule occlusion for instant and lasting relief of home brushing.18-22 Preferably, a desensitizing in- sensitivity. Saliva plays a role in naturally reducing office product should result in instant relief of DH dentin hypersensitivity by transporting calcium and and the relief should be maintained without further phosphate into dentin tubules to induce tubule interventions. Therefore, this survey was carried plugging and by forming a surface protective layer out to evaluate the clinical efficacy of the of salivary glycoprotein with calcium and desensitizing paste with pro-argin™ formula phosphate. Because alkaline pH favors these containing 8% arginine and calcium carbonate on processes, salivary factors that maintain slightly DH relief after a single professional application alkaline pH in vivo have been suggested to favor without further at-home brushing.

25 Archita Kikani et. al. : Instant Dentin Hypersensitivity Relief With A Single Topical Application of An In-office 8% Arginine Containing Desensitizing Paste Materials and Method: providing relief from tooth pain. This survey was carried out in 288 patients taken l Score: from the OPD of department of periodontology in Ahmedabad dental hospital with age of 18 to 70 VAS score Difference Effectiveness Quotient years in 2 months period of time duration. They 1-2 Low effectiveness were required to possess a minimum of two hypersensitive teeth in two different quadrants 3 Moderate effectiveness which demonstrated cervical erosion/abrasion or 4-5 High effectiveness gingival recession. Any teeth with cracked enamel, caries, mobility greater than one or The subjects scored pain intensity on a visual extensive/defective restorations, teeth used as analogue scale (VAS) (0=no pain and 10=extreme, abutments and teeth with orthodontic appliances unbearable pain). Patients were instructed to point were excluded. Additional exclusion criteria were: to the VAS. (Difference of 3-5 is considered as subjects with gross oral pathology, chronic disease, significant relief from tooth pain) advanced periodontal disease, periodontal or Results: orthodontic treatment (within the last 6 months), Data of this survey showed, among 288 subjects: eating disorders, excessive (Female: 71% and male: 29%) exposure to acids, pregnant or lactating women, current users of anti-convulsants, antihistamines, Effectiveness Number of subjects antidepressants, sedatives, tranquilizers, anti- High 177 inflammatory drugs or daily analgesics, as well as subjects who used a desensitizing dentifrice within Moderate to low 59 the last 3 months or with a history of allergy to oral No effectiveness 52 care/personal care consumer products or their ingredients. Females showed higher prevalence of dentinal Clinical interventions hypersensitivity, 71% compared to males 29% in this survey. Dentinal hypersensitivity evaluation was carried out in one or two severely affected teeth in oral Results of this survey showed greater effectiveness cavity with different etiologic factors like gingival of in office clinical application of 8% arginine recession, abrasion, attrition, erosion or post scaling containing desensitizing paste among the maximum in 288 different subjects by single investigator. no. of the subjects. Dentinal hypersensitivity severity and its relief after Discussion: application of the desensitizing tooth paste was Dentinal hypersensitivity (DH) is a problem that evaluated by using the visual analog score (VAS) plagues many patients. In the majority of cases DH card. Technique of using the paste is described as is chronic and recurring due to a given action, e.g. below: drinking cold beverages, eating hot used for Technique: treatment of DH are diverse, suggesting uncertainty l The patient is requested indicate the severity of among dentists about the best way to treat patients, pain in the VAS card. as well as dissatisfaction with outcomes of available treatments.23 The development of a therapy that can l Desensitizing paste is applied with a finger tip provide both immediate relief following on affected area by the patient. professional application and a lasting desensitizing l After waiting for 5 minutes, patient is effect for a significant time period after use would requested to indicate the level of tooth pain in the be of great assistance to clinicians in dealing with VAS score card. DH.14 l The difference between before and after score In this survey, 288 subjects were advised to use on the VAS card is used by the dentist to determine local application of desensitizing paste and in office the level of effectiveness of desensitizing paste in checkup were done. The data showing the results

26 Archita Kikani et. al. : Instant Dentin Hypersensitivity Relief With A Single Topical Application of An In-office 8% Arginine Containing Desensitizing Paste with higher effectiveness of paste in 177 subjects, effectiveness after single clinical application of this moderate to low in 59 subjects and no change in 52 paste. Further studies are yet to be required to find subjects. This had proven the clinical effectiveness the underline causative factors for no effectiveness of the desensitizing paste in instant relief to treat of paste. dentinal hypersensitivity. The essential components CONCLUSION of the tested in-office desensitizing paste are arginine (an amino acid), bicarbonate (a pH buffer) The in-office desensitizing paste containing 8% and calcium carbonate (a source of calcium).24 The arginine and calcium carbonate provides significant significant reduction in DH after a single topical reduction in dentin hypersensitivity instantly after a application in the present study confirms the results single professional application of the product and of previous clinical 18-22 studies. this reduction is maintained for 12 weeks without further application of arginine. However, 52 subjects showed no change in clinical

REFERENCES: hypersensitivity: A study of the patency of dentinal tubules in sensitive and non-sensitive 1. Addy M. Dentine hypersensitivity: New cervical dentine. J Clin Periodontol 1987; 14: perspectives on an old problem. Int Dent J 280-284. 2002; 52 (Suppl 5) 367-375. 10. Absi EG, Addy M, Adams D. Dentin 2. Canadian Advisory Board on Dentin hypersensitivity: The development and Hypersensitivity. Consensus based evaluation of a replica technique to study recommendations for the diagnosis and sensitive and non-sensitive cervical dentine. J management of dentin hypersensitivity. J Can Clin Periodontol 1989; 16: 190-195. Dent Assoc 2003; 69: 221-226. 11. Drisko CH. Dentine hypersensitivity – Dental 3. Markowitz K, Pashley DH: Discovering new hygiene and periodontal considerations. Int treatments for sensitive teeth: The long path Dent J 2002; 52: 385-393. from biology to therapy. J Oral Rehabil 2007; 35: 300-315. 12. Dababneh RH, Khouri AT, Addy M. Dentine hypersensitivity. An enigma? A review of 4. Narhi M, Jyvasjarvi E, VirtanenA, Huopaniemi terminology, epidemiology, mechanisms, T, Ngassapa D, Hirvonen T: Role of intradental aetiology and management. Br Dent J 1999; A delta and C- type nerve fibres in dental pain mechanisms. Proc Finn Dent Soc1992; 88 187:606-611. (Suppl 1): 507-516. 13. Brannstrom M. Dentin sensitivity and 5. Pashley DH, Tay FR, Haywood VB, Collins aspiration of odontoblasts. J Am Dent Assoc MC, Drisko CL. Dentin hypersensitivity: 1963; 66:366–70. Consensus based recommendations for the 14. Schiff T, Delgado E, Zhang YP, Cummins D, diagnosis and management of dentin DeVizio W, Mateo LR. Clinical evaluation of hypersensitivity. Inside Dentistry 2008; 4: 9 (Sp the efficacy of an in-office desensitizing paste Is): 1-35. containing 8% arginine and calcium carbonate 6. Ide M. The differential diagnosis of sensitive in providing instant and lasting relief of dentin teeth. Dental Update 1998; 25: 462-466. hypersensitivity. Am J Dent 2009; 22: 8A–15A 7. West NX. Dentine hypersensitivity. In: Lussi A. 15. Kleinberg I. Sensistat. A new saliva-based Dental erosion. Monogr Oral Sci 2006; 20: 173- composition for simple and effective treatment 189. of dentinal sensitivity pain. Dent Today 2002; 21: 42-47. 8. Brännström M. Etiology of dentin hypersensitivity. Proc Finn Dent Soc 1992; 88 16. Cummins D. The efficacy of a new dentifrice (Suppl 1): 7-13. containing 8.0% arginine, calcium carbonate, and 1450 ppm fluoride in delivering instant and 9. Absi EG, Addy M, Adams D. Dentin

27 Archita Kikani et. al. : Instant Dentin Hypersensitivity Relief With A Single Topical Application of An In-office 8% Arginine Containing Desensitizing Paste lasting relief of dentin hypersensitivity. J Clin Cummins D, Mateo LR. The clinical effect of a Dent 2009; 20 (Sp Is):109-114. single direct topical application of a dentifrice containing 8.0% arginine, calcium carbonate, 17. Petrou I, Heu R, Stranick M, Lavender S, Zaidel and 1450 ppm fluoride on dentin L, Cummins D, Sullivan RJ, Hsueh C, hypersensitivity: the use of a cotton swab Gimzewski JK. A breakthrough therapy for applicator versus the use of a fingertip. J Clin dentin hypersensitivity: How dental products Dent 2009; 20: 131–6. containing 8% arginine and calcium carbonate work to deliver effective relief of sensitive 21. Fu Y, Li X, Que K, Wang M, Hu D, Mateo LR, et teeth. J Clin Dent 2009; 20 (Sp Is):23-31. al. Instant dentin hypersensitivity relief of a new desensitizing dentifrice containing 8.0% 18. Ayad F, Ayad N, Delgado E, Zhang YP, DeVizio arginine, a high cleaning calcium carbonate W, Cummins D, et al. Comparing the efficacy in system and 1450 ppm fluoride: a 3-day clinical providing instant relief of dentin study in Chengdu. China. Am J Dent 2010; 23: hypersensitivity of a new toothpaste containing 8. 8.0% arginine, calcium carbonate, and 1450 ppm fluoride to a benchmark desensitizing 22. Hamlin D, Williams KP, Delgado E, Zhang YP, toothpaste containing 2% potassium ion and De Vizio W, Mateo LR. Clinical evaluation of 1450 ppm fluoride, and to a control toothpaste the efficacy of a desensitizing paste containing with 1450 ppm fluoride: a three-day clinical 8% arginine and calcium carbonate for the in- study in Mississauga, Canada. J Clin Dent office relief of dentin hypersensitivity 2009; 20: 115–22. associated with dental prophylaxis. Am J Dent 2009; 22: 16–20A 19. Nathoo S, Delgado E, Zhang YP, DeVizio W, Cummins D, Mateo LR. Comparing the 23. Cunha-Cruz J, Wataha JC, Zhou L, Manning W, efficacy in providing instant relief of dentin Trantow M, Bettendorf MM, et al. Treating hypersensitivity of a new toothpaste containing dentin hypersensitivity: therapeutic choices 8.0% arginine, calcium carbonate, and 1450 made by dentists of the northwest ppm fluoride relative to a benchmark PRECEDENT network. J Am Dent Assoc desensitizing toothpaste containing 2% 2010; 141: 1097–105. potassium ion and 1450 ppm fluoride, and to a 24. Panagakos F, Schiff T, Guignon A. Dentin control toothpaste with 1450 ppm fluoride: a hypersensitivity: effective treatment with an in- three-day clinical study in New Jersey, USA. J office desensitizing paste containing 8% Clin Dent 2009; 20: 123–30. arginine and calcium carbonate. Am J Dent 20. Schiff T, Delgado E, Zhang YP, De Vizio W, 2009; 22: 3A–7A

28 EVALUATION OF EFFECTIVENESS OF PAIN OUT DENTAL Original Article GEL AS A TEMPORARY ANALGESIC IN PROVIDING EXPRESS INSTANTANEOUS RELIEF OF ODONTOGENIC CAUSES OF TOTH ACHE Aishwarya Krishnan*, Archita Kikani**, Sapna T***, Mihir Shah****, Harsh Shah*****, Vasudha Sodani****** ABSTRACT Pain has the function of a warning to tissue damage and activation of defensive mechanisms, with the aim of prevention of further damage. The stimulus which damages or threatens to damage a tissue activates the nociceptors which in turn carry the information by a system of neurons to cortex, where it is processed and recognized as pain. Most somatosensory information from the area of orofacial system is transported via n. trigeminus. In order to remove pain, it is necessary to recognize and properly diagnose the cause of pain. This is not always easy, due to numerous variations within the clinical findings, and the latent possibility that pain has referred from odontogenis structure onto the nonodontogenis ones, and vice versa. Knowing the pathways and mechanisms of pain, possible causes and different characters of orofacial pain, as well as a thorough anamnesis, clinical examination and testing will eventually lead to a proper diagnosis. Received: 15-03-2016; Review Completed: 26-05-2016; Accepted: 07-06-2016

OBJECTIVE: potential tissue damage, or described in terms of To evaluate the effectiveness of PAIN OUT such damage. It belongs to the sensations that brings information about the state of the organisms and its DENTAL GEL as a temporary analgesic in 1 relieving odontogenic causes of tooth ache and relation with the environment directly to the brain. providing express pain relief after a single It is exactly pain which is the most common reason professional application. Materials and methods: for patients to come to the dental clinic, this pain This survey was carried out in 126 patients taken usually originates in the tooth itself or its supporting from the OPD of department of periodontology in structures. In order to establish a proper diagnosis, it Ahmedabad dental hospital with age of 12 to 70 is absolutely important to take anamnesis, i.e. a years in 2 months period of time duration. They detailed subjective description of the painful were required to possess a minimum of one tooth condition of the patient including the quality, which was painful which could be due to caries, duration, volume, frequency and periodicity of dentinal hypersensitivity, faulty restoration, post pain. surgical pain, food impaction, pain due to Pain is not a disease and is always subjective, it is periodontitis, tooth fracture. Odontogenic pain manifested, in addition to pain, as the activity of severity and its relief after application of the pain sympathicus, producing fear, anxiety, pupillary out gel was evaluated by using the Visual Analog dilation, tears, tachycardia, hypertension, nausea, Score (VAS) card in 126 different subjects by a vomiting, sound effects and facial expressions. The single investigator. Conclusion: The in-office level of perception of pain is not constant. The dental gel containing clove oil, camphor and extract threshold of pain and responses to pain vary under of mentha arvensis provides significant reduction in different conditions. Awareness of pain occurs at the acute odontogenic pain instantly after a single thalamocortical level where many complex professional application of the product interactions shape the overall experience and “For there was never yet a philosopher who could response2. Postcentral girus determines awareness endure the toothache patiently.” of the stimuli, temporal lobus, with the help of –William Shakespeare. memory, identifies the nature of the stimuli, frontal lobus and limbic system provide emotional The International Association for the study of pain reactions and the hypothalamus and pituitary gland defines pain as “an unpleasant sensory and control the autonomic and endocrine response. emotional experience associated with actual or

*Post graduate student, **Professor, ***Senior Lecturer, **** Professor and Head of Department, *****Reader, ****** Reader DEPARTMENT OF PERIODONTICS AND ORAL IMPLATOLOGY, DEPARTMENT OF PUBLIC HEALTH DENTISTRY. DEPARTMENT OF PEDODONTICS. AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Aishwarya Krishnan, TEL: +91 9998035395

29 Aishwarya Krishnan et. al. : Evaluation Of Effectiveness Of Pain Out Dental Gel As A Temporary Analgesic In Providing Express Instantaneous Relief Of Odontogenic Causes Of Toth Ache Odontogenic pain has its source in the connect teeth with the central nervous system pulpodentinal complex and / or periapical tissue. belong to the fifth brain nerve (N. Trigeminus) and These two structures are functionally and autonomic nervous system (sympathetic nervous embryonically different, and consequently the pain system).Sensory nerve fibers in the pulp consist of originating in these areas is perceived differently3. myelinized A-fibers, which prevail, and non- Pulp pain, or pulpalgia, is by far the most commonly myelinized C-fibers. Of the former, these are experienced pain in and near the oral cavity and mainly A-delta fibers, which conduct the impulses maybe classified according to the degree of severity faster, while, speaking of the latter, C-fibers, which and the pathologic process present:7 are thinner and slower conducting. A-delta fibers 1. Hyperreactive pulpalgia are responsible for strong immediate, sharp, well localized pain and C-fibers for dull, continuous, and a. Dentinal hypersensitivity irradiating pain.4 b. Hyperemia The effect of a short heat or cold stimulus is 2. Acute pulpalgia explained by the hydrodynamic theory in the a. Incipient following way: the application of hot stimuli on the exposed dentin leads to the expansion of dentinal b. Moderate fluid, whereas the application of cold stimulicauses c. Advanced its contraction. Both types of stimuli cause fluid 3. Chronic pulpalgia flow, thus the activation of mechanoreceptors of the a. Barodontalgia sensory nerves. 4. Hyperplastic pulpitis CAUSES OF TOOTH ACHE: 5. Necrotic pulp a) Dental caries 6. Internal resorption b) Dental trauma (tooth fracture and /or cracked tooth) 7. Traumatic occlusion c) Damaged filling 8. Incomplete fracture d) Post surgical / post extraction Inflammation of dental pulp is similar to that in other connective tissues. The inflammatory e) Dentinal hypersensitivity response of dental pulp involves vascular reaction, f) Food impaction neuronal activity and infiltration of immune cells at g) PDL pain the site of inflammation. h) Non-odontogenic causes (referred muscle The pulp is supplied by a rich neurovascular pain, trigeminial neuralgia, referred head pain, network that regulates various inflammatory neuropathic pain, shingles, cardiac toothache, mediators; however the dental pulp is enclosed in a psychological disturbances. non-compliant environment by mineralized dentin Characteristics of pain: and has reduced collateral circulation. 1. Quality These anatomic restrictions tend to intensify the injury that results from external irritation and the 2. Intensity harmful side effects of host inflammatory 3. Episodic or continuous mediators. 4. Spontaneous or provoked The pain-process involves a number of chemical 5. Aggravating and alleviating factors pain mediators. Thus, it is known that the teeth are innerved by sympathetic nerve fibers, which release Some patients have a low grade, bothersome ache and others experience excruciating pain, described norepinephrine as a mediator, and the sensory 7 fibers, which release acetylcholine and substance P. as throbbing, sharp or shooting . The pain can be Of other mediators, there are also vasoactive present all the time or come and go. Unexpectedly, peptides and calcitonin, which participate in the the pain can migrate from one tooth to another and increase of the dentine sensitivity. Nerve fibers that even change sides of the mouth. The pain may be

30 Aishwarya Krishnan et. al. : Evaluation Of Effectiveness Of Pain Out Dental Gel As A Temporary Analgesic In Providing Express Instantaneous Relief Of Odontogenic Causes Of Toth Ache present from weeks to several years. kidney functions. A VISUAL ANALOGUE SCALE (VAS) is a • Paracetamol at higher doses and with alcohol measurement instrument that tries to measure a can cause liver toxicity. characteristic or attitude that is believed to range • Opioid pain killers are controlled substances across a continuum of values and cannot easily be and have greater abuse potential. directly measured. The amount of pain that a patient feels ranges across a continuum from none to a • Steroids are immune-suppressants, and hence extreme amount of pain.5 From the patient's not suitable for pain management due to dental perspective, this spectrum appears continuous; their infections. pain does not take discrete jumps, as a It is here that a novel product, Pain Out dental gel, categorization of none, mild, moderate and severe comes into the picture as an effective substitute for would suggest. temporary relief of pain. Operationally, VAS is usually a horizontal line 100 In a study by Oklješa et al. conducted within the mm in length, anchored by word descriptors at each framework of the scientific research by Faculty of end. The patient marks on the line the point that they Dental Medicine in Zagreb, it had been investigated feel represents their perceptions of their current how often patients come to the dental clinic because state. The VAS score is determined by measuring in of toothache or generally any pain in the mouth, and mms from the left hand of the line to the point that what the respective percentages of acute or chronic the patient marks8. pain were. The research was conducted on the These scales are of most value when looking at sample of 2735 respondents over a period of 1 year. change within individuals and are of less value for Pain was present in the 16.49 % of patients, and the comparing across a group of individuals at one point remaining 83.51 % of the patients were without of time. The VAS is generally regarded as a valid pain. With regard to the duration of pain, acute pain and reliable tool for chronic pain measurement. has been significantly higher (about 84 %) than chronic pain (about 16 %). The representation of Due to a number of factors, patients find it difficult acute odontalgia with respect to the total number of to visit the dentist immediately in case of a painful patients was 12.36 % of patients, chronic odontalgia episode and opt for medications to get temporary was represented in 2.38 % of patients.6 symptomatic relief. These medications can be divided into OBJECTIVES: A: Traditional home remedies: 1) To evaluate difference in measurements of VAS scores before and after application of PAIN OUT a. Clove oil DENTAL GEL. b. Neem leaves 2) To evaluate perception of patient's level of c. Salt gargles satisfaction in attaining relief of pain after dental gel B: Pharmacologic drugs: application. a. Pain killers MATERIALS AND METHOD: 1) mild to moderate-Ibuprofen, Diclofenac 126 patients were selected from the outpatient department of Periodontology and Oral 2) Strong opioids Implantology for the study. The procedure was b. Steroids explained and a written consent obtained. Most of these medications are used without proper INCLUSION CRITERIA: medical consultation and their “abuse” can lead to (i) Systemically healthy patients who have unwarranted results and serious side effects. Few of not undergone any surgery in the recent their limitations are as follows: past. • Delayed onset of action (ii) Odontogenic pain caused due to a variety • Contraindicated in certain group of patients of factors like caries, dental trauma, a like those suffering with allergies or with reduced d a m a g e d f i l l i n g , d e n t i n a l

31 Aishwarya Krishnan et. al. : Evaluation Of Effectiveness Of Pain Out Dental Gel As A Temporary Analgesic In Providing Express Instantaneous Relief Of Odontogenic Causes Of Toth Ache hypersensitivity, food impaction, PDL stay for 10 minutes during which period, the patient pain. was not allowed to rinse, gargle or perform any (iii) Patients willing to participate in the study movements that might affect the retention of the gel. A repeat scoring on the VAS score was made by the EXCLUSION CRITERIA: patient 10 minutes after gel application. The mean (i) Patients with inability to make an accurate difference in VAS score values was recorded. (for mark on the VAS scale due to motor, one tooth or two teeth as the case demanded). cognitive or visual impairment Patients were asked to interpret their perception of (ii) Patients who lack sufficient effort to the level of improvement they observed after usage appropriately complete the task due to of the gel. pain or cultured and other behavioural VAS score difference Effectiveness Quotient characteristics 1-2 Low effectiveness (iii) Patients with episodic nature of pain 3 Moderate effectiveness (iv) Patients with chronic disease 4-5 High effectiveness (v) Gross oral pathology The subjects scored pain intensity on a visual (vi) Non-odontogenic causes of tooth pain analogue scale (VAS) (0=no pain and 10=extreme, which include Trigeminal Neuralgia, unbearable pain). Patients were instructed to point Cluster headache, Acute Otitis media, to the VAS. (Difference of 3-5 is considered as Acute maxillary sinusitis, Cardiogenic significant relief from tooth pain) jaw pain, TMJ disorders, Sialolithiasis, Results: Atypical facial pain, Allergic sinusitis, Post herpetic neuralgia, Facial pain as a Distribution of study subjects based on etiology: result of malignant neoplasms (vii) Patients with known allergy to Etiology Frequency components of dental gel Caries 73 (viii) Pregnant patients (ix) Patients on anti-histamines, sedatives, Hypersensitivity 15 anti-depressants, tranquilizers 126 patients were selected from the outpatient Trauma to tooth 08 department of PERIODONTICS AND ORAL Food impaction 19 IMPLANTOLOGY having odontogenic causes of tooth ache. The procedure was explained to them PDL pain 11 and a written consent form obtained. The cause of tooth ache was ascertained using Mean changes in VAS score before and after history, clinical examination (visual inspection, application of dental gel in tooth-1 palpation, percussion and other tests) and VAS score at baseline 7 4 radiographic aids when required. An assessment Tooth 1 was made about the type, quality, intensity, VAS score 10 min after gel 3 frequency, duration and periodicity of pain. One application tooth or 2 teeth (as the case demanded) was taken VAS score at baseline 7 3 for consideration. Patients were asked to rate the VAS score 10 days after gel 4 intensity of the pain that they were experiencing by application pointing to a line in the continuum of values on the VAS score card, a point which represents the analogous score of the level of pain. PAIN OUT DENTAL GEL was applied on the required area of interest using an applicator tip. It was allowed to

32 Aishwarya Krishnan et. al. : Evaluation Of Effectiveness Of Pain Out Dental Gel As A Temporary Analgesic In Providing Express Instantaneous Relief Of Odontogenic Causes Of Toth Ache EFFECTIVENESS No. OF SUBJECTS leaf or stem of the clove plant, syzygium HIGH (4-5) 67 aromaticum. Camphor may be extracted from plants, eg. fromlaurel or rosemary, or synthetically MODERATE TO LOW (3) 37 produced, eg; from oil of turpentine.9 NO EFFECTIVENESS (1-2) 22 In this study, pain out dental gel was applied to Results of this survey showed high level of painful tooth/teeth in 126 subjects. 67 of the 126 effectiveness of PAIN OUT DENTAL GEL in subjects demonstrated high effectiveness of dental providing express pain relief in maximum number gel, 37 subjects showed moderate to low of subjects. Results also showed that dental caries effectiveness while 22 subjects did not demonstrate was the primary etiologic factor responsible for any change. This proves the clinical effectiveness of pain in maximum number of subjects. the dental gel in providing temporary express relief of tooth pain. DISCUSSION: Tooth pain is one of the most common dental problems and a recent study However, 22 patients did not demonstrate any conducted to assess attitudes towards dental care change in the VAS score before and after showed that 37% of people have suffered from tooth application of the gel. Further studies need to be ache in the past 6 to 12 months. Pain out dental gel is carried out to find the causative factors behind the one of a kind first aid solution which provides non-effectiveness of the product and also to temporary relief so that patients can continue with determine if its effectiveness stays for a longer their routine before going to a dentist for permanent duration. cure. Thus it proves to be effective in buying some CONCLUSION : 10 time before a permanent solution can be achieved . The in-office PAIN OUT dental gel containing PAIN OUT DENTAL GEL consists of clove oil, clove oil, camphor and extract of mentha arvensis camphor, extract of mentha arvensis. These provides significant reduction in odontogenic tooth analgesic oils may be from natural sources or may pain instantly after a single professional application be synthetic. Clove oil is extracted from the buds, of the product and this reduction is maintained for 10 days without its further application.

REFERENCES: 63 No.511, Nov.2011, pp 5240 -5252 1. Goranko Prpic, Mehicic, Nada Galic. 6. Tara Renton, Dental (Odentogenic) Pain, ODONTOGENIC PAIN.Rad 507, Medical Reviews in pain, vol.5 – no.1 March 2011 Sciences,34(2010):43-54 7. John I-Ingle and Dudley H.Glick, Differential 2. Veynon BJ. Psychological components of pain diagnosis and treatment of dental pain, ch-7 perception.Dent Clin Nort Am.1978,22:101 8. Polly E. Bijur, Wenly Silver, John Gallagher. 3. Kureishi A, Chow AW. The tender tooth. Reliability of the Visual Anolog Scale for Dentoalveolar, periocoronal, and periodontal measurement of acute pain. Academic infections. Infect Dis Clin north Am1988; Emergency Medicine, Dec. 2001, Vol.8, N0.12 2(1):163 – 82 9. Oral gel for relief of tooth pain. Wo 4. Nagassapa DN .Comparison of functional 2014087420 A 1 characteristics of interdental A and C nerve 10. Jeff Urges,Arlen Meyers. Pain management in fibres in dental pain. East Africa Med Dentistry Medcape – Nov. 19, 2014 Journal.1996,73(3):207-9 5. Gillian A. Hawker, Samra Mian, Tetyana Kendzershoa, Melissa French. Measures of Adult pain, Arthritis Care and Research – Vol.

33 CULTURAL COMPETENCY AMONGST DENTAL Original Article PRACTITIONERS IN MUMBAI – A KAP STUDY.

Suyog Chandrashekhar Savant*, Sahana Hegde**, Ravi V. Shirahatti***, Deepti Agarwal**** ABSTRACT Background: Mumbai consists of culturally diverse people whose views and requirements of the dental treatment vary widely and can be influenced by cultural factors. The objective: Hence a need was felt to know whether the dentists have knowledge, attitude and appreciate the importance of providing culturally sensitive oral health care to their patients while making oral health care provision. Basic research design: A cross sectional study design with a self administered structured questionnaire was used which had questions on to knowledge, attitude and practice. 420 dental participants from Mumbai responded to the questionnaire. Results: It was found that 45% of the participants could not define culturally sensitive oral health care provision. However, more than 95% claimed to provide culturally sensitive health care provision. Conclusion: The knowledge, attitude and practices of the dental practitioners was found to be poor although they gave importance to cultural competency. KEYWORDS: Cultural competency, Cultural sensitivity, Oral health care. Received: 14-03-2016; Review Completed: 02-05-2016; Accepted: 30-05-2016

INTRODUCTION: values and beliefs, the development of empathy for Mumbai, is the most populous city in India and is people viewing the world through a different the second most populous city in the world. cultural lens, and the application of specific According to extrapolations carried out by the communication and interaction skills that can be World Gazetteer in 2010 census, the population of learned and integrated into clinical encounters Mumbai was 11,914,398 with diverse culture (Bennett et al, 2005). This definition focuses on an loving people, living in either fully integrated or outcome, and includes attention to obvious multicultural societies. The number of migrants to language differences in the consultation, as well as Mumbai from outside Maharashtra during the how culture influences attitudes, expressions of 1991–2001 decade was 1.12 million, which distress, and helps seeking practices (Formicola et amounted to 54.8% of the net addition to the al, 2003). Consequently, it is suggested that clinical population of Mumbai. Sixteen major languages of procedures and policies should reflect these. India are spoken here, the official language being Showing respect for patients' cultural beliefs and Marathi. Other languages are Hindi, Gujarati and attitudes is an important component, especially English. The religions represented in Mumbai when their views opposes or differs from the include Hindus (67.39%), Muslims (18.56%), professionals' views. Emphasis should be given to a Buddhists (5.22%), Jains (3.99%), Christians genuine willingness and desire to learn about other (3.72%), Sikhs (0.58%), with Parsis and Jews cultures, rather than simply being a managerial making up the rest of the population. Individuals’ requirement (Bhui et al, 2007). views and requirements of the dental treatment vary Health professionals are more aware of the widely and can be influenced by cultural factors challenges they face while providing health care to a (Egede, 2006). As increase in the exposure to culturally and racially diverse population (Bhui et diversity occurs, health care providers may al, 2007). Studies revealed that cultural competency therefore need to develop skills in intercultural has an important role to play if one has to get to the competency and sensitivity. roots of health care disparities (Nowak et al, 2004; “Cultural competency” is the ability to identify Hewlett et al, 2007; Lopez et al, 2008; Melamed et and challenge one’s own cultural assumptions, al, 2008; Pilcher et al, 2008; Rubin et al, 2008). Despite concerns about ethnic disparities of access

*Asso. Prof, **Prof and Head, ***Reader, **** Reader DEPARTMENT OF PUBLIC HEALTH DENTISTRY, BHARTI VIDYAPEETH DENTAL COLLEGE, NAVI MUMBAI.

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. SUYOG CHANDRASHEKHAR SAVANT, TEL: +91 9920747899

34 Suyog Chandrashekhar Savant et. al. : Cultural competency amongst dental practitioners in Mumbai – A KAP study. to culturally appropriate health care, and calls for questionnaire. Pre-testing also helped to interpret cultural competency training to be mandatory, there the meaning of each question in an appropriate is little information about the effectiveness of manner. The questions had multiple choices and the cultural competency training in health settings participants had to select from suitable options. (Bhui et al, 2007). Moreover it is well established Reliability estimates, calculated from the full set of that in order to provide culturally competent care, responses to the questionnaire using Cronbach’s knowledge of cultural beliefs, values and practices coefficient alpha with the use of SPSS (version is necessary, otherwise health practitioners can 10.0) was found to be 0.92 after which study was easily fall prey to inappropriate management and conducted. A calibrated clerk was asked to deliver poor compliance by the patients. and get the completely filled questionnaire back for Due to lack of previous studies conducted in data analysis. After getting the approval from the this regard in Mumbai, this study was intended to ethical committee of Dr. D.Y. Patil Dental College know if the dental practitioners in Mumbai were and Hospital the study was undertaken. Number and culturally competent enough to treat the patients of percentage distribution of participants’ responses diverse culture. The study focused on the were calculated based on responses. knowledge, attitude and practices of dental RESULTS practitioners based on cultural diversity of their Out of 457 self administered questionnaires, 420 patients while making oral health care provision. questionnaires were completed and included for the METHODS analysis. 346 participants had Bachelor’s degree A structured, self administered questionnaire with (BDS) and 74 participants had Master’s degree 16 questions was used to assess the knowledge, (MDS) in dentistry. 37 questionnaires were attitude and practices of 420 dental practitioners out excluded from data analysis as they were of 840. Participants who were registered under the incompletely filled. The response rate was 91.90%. Indian Dental Association (IDA) from Mumbai Table 1 shows the results of questionnaire study branch were selected through convenience which assessed the knowledge, attitude and sampling. There were 5 questions on knowledge, 6 practices of 420 dental practitioners based on questions on practice and 5 questions on attitude. cultural diversity of their patients while making oral The questionnaire was exclusively developed based health care provision. on the textbook (Scully and Wilson, 2006) which DISCUSSION gave importance to culture of the patients, discussed the importance of differences which existed The results of the self administered questionnaire between the health care provider and recipients, were based on participants’ knowledge and attitude which was vital for providing the quality health care about cultural competence and importance they that met patients’ needs. The questionnaire study gave while practicing in a multicultural society. was conducted with participants consent and When the participants were asked about what assurance of confidentiality. Name and professional comprised culturally sensitive oral health care, only qualification about the participants was noted. The 45% of participants provided all the relevant replies survey instrument (questionnaire) was checked for stating that providing education, respectful care and its face and content validity by a panel of six subject informing them about the health issues was experts from Department of Preventive and Social important.. The reason might be because there Medicine of Dr. D. Y. Patil Medical College, Pune might not be genuine willingness and desire to learn and four experts from Dr. D. Y. Patil Dental College about other cultures when there are difference of and Hospital, Pune. Based on the content validity opinions between the dentist and patient (Bhui et al, ratio of 0.62, the items in the questionnaire were 2007). A similar study revealed that dental students modified or deleted. Pre-testing of the could not identify a cultural group which they felt questionnaire was done on 10 participants chosen they knew well in terms of oral health status from the IDA list through convenience sampling. (Wagner and Redford-Badwal, 2008). This opinion Pre-testing was done to check the wording, clarity was also voiced in other studies by (Scully and as well as comprehensibility of the adopted Wilson, 2006; Bhui et al, 2007) which stated that

35 Suyog Chandrashekhar Savant et. al. : Cultural competency amongst dental practitioners in Mumbai – A KAP study. meeting patients’ personal, religious, cultural needs dental practice was important (Rowland et al, and enabling patients to make their choices and 2006), but they lacked knowledge about the cultural respecting them was important for dental groups they were likely to see in practice (Wagner practitioners. and Redford-Badwal, 2008). Incorporating 97% of participants overwhelmingly stated concepts of cultural competency into dentistry and that they observed diverse culture among the teaching it in dental school environment might be patients who visited them. However this response an important step in resolving these issues. contradicted with the answers they chose as the 95% of participants considered cultural factors indicators of culture. Participants were able to and cultural background while providing acknowledge, accept and value the importance of acceptable oral care to patients. There is a growing diverse culture but they did not know what body of evidence of studies which supports the need comprised culturally sensitive oral health care. for cultural competence among health professionals Dress, lifestyle, language and diet were chosen as to positively influence clinical consultations and the correct indicators of culture (Scully and Wilson, health outcomes (Bennett et al, 2005). Studies have 2006) by only 9.02% of participants. Some dress revealed that beliefs, values and traditions are codes are specific to certain cultures. Muslim males critical factors in etiology of illness and disease and prefer to wear kameez or purdah in females, Hindu those related to health and healing (Wagner and ladies prefer to wear saris, Sikh- the turbans and so Redford-Badwal, 2008). on. Similarly, lifestyle is also a relative indicator of 93% of participants replied that cultural different cultures. Some diseases like oral cancer concerns of patients were important. This opinion are related to lifestyle. Use of tobacco is a common was similar to the report provided by The Institute lifestyle in South Asians. Areca nut chewing is of Medicine (IOM) ‘Unequal Treatment: common in people from South and South East Asian Confronting Racial and Ethnic Disparities in Health population (Scully and Wilson, 2006). Care’ which recommended that cross-cultural 28% dentists indicated language as a part of education should be integrated into the training of cultural indicator. When patients and providers all current and future health professionals speak the same native language, patients are more (Formicola et al, 2003; Pilcher et al, 2008). If the likely to report positive physical and mental health cultural issues of the patients were not addressed outcomes. Alternatively, patients' inability to properly, then it might lead to patients’ communicate in their native language could lead to dissatisfaction, poor adherence and adverse health delays in care, fewer or missed appointments, non out¬comes. In addition, lack of empathy for adherence to therapy, and medical error (Taylor, patient’s cultural values can result in stereotyping 2004). Moreover studies have supported the fact and biased treatment by a health care provider that language forms an important part of the cultural (Melamed et al, 2008). competency (Rubin, 2004; Taylor, 2004; Lopez et Only 24% of participants were aware of the al, 2008; Melamed et al, 2008; Pilcher et al, 2008). commonly used agents of animal derivatives. Hence there is a need to increase dentists’ However, 99% and 82% of participants replied perception in this regard. correctly the presence of animal derivatives in bone The fourth indicator was diet because culture graft and suture materials and waxes respectively. plays an important role in diet. Scully and Wilson, Alginates, analgesics, bone fillers, mouth washes, (2006) stated that people with low intake of well haemostatic materials, tooth pastes, waxes, nourished food like green leafy vegetables or fruits periodontal brushes and prophylactic pastes, may have acute ulcerative gingivitis. Also vitamin B12 contain animal derivatives (Scully and Wilson, deficiency was most commonly seen in Hindus. 2006). The reason may be dental products are The results suggested that the participants were mostly categorized into cosmetic category as a able to acknowledge, accept and value the result of which they do not undergo rigorous trials importance of cultural competency but were not unlike the pharmaceutical products which are able to identify the indicators completely. Dental meant for human consumption. participants believed that cultural sensitivity in Only 8% of 92% participants prescribed

36 Suyog Chandrashekhar Savant et. al. : Cultural competency amongst dental practitioners in Mumbai – A KAP study. alcohol containing products (mouth wash/ mouth it was relevant to reveal the information regarding rinse) to patients based on cultural background. The the animal and alcohol content of the dental reason may be some of the religious groups object to products which might be sensitive to ones cultural some constituents present in dental health care beliefs. products that are not accepted but are not barred The studies on cultural competency were in either if the product is designed to enhance health. relation to ethnic and racial diversity (Formicola et These objectionable oral health products are al, 2003; Mouradian et al, 2003; Novak et al, 2004; licensed as pharmaceutical products to avoid Taylor, 2004; Egede, 2006; Rowland et al, 2006; religious and ethnic group restrictions. Example of Scully and Wilson, 2006; Bhui et al, 2007; Hewlett it are alcohol containing mouthwashes. (Scully and et al, 2007; Gregorczyk and Bailit; 2008; Melamed Wilson, 2006) have stated briefly the objections that et al, 2008; Rubin et al, 2008, Wagner and Redford- different religions may have in this regard. Badwal, 2008). and communication skills 87% of participants checked the contents of (Formicola et al, 2003; Rowland et al, 2006; Scully dental products and its derivatives before treating and Wilson, 2006; Gregorczyk and Bailit 2008; patients. 13% of participants did not check contents. Melamed et al, 2008; Pilcher et al, 2008; Rubin et al, However only 15% of participants replied that 2008; Wagner et al, 2008; Hewlett et al, 2009) dental products had specifications which Questions on social behavior, religion and ethnicity contradicted the previous response of 87% which that form important part of the culture were not stated that they checked the dental specifications. discussed in the study. The results of the study has Had they checked the specifications, most of the external validity and can be generalized. However participants would have known that the dental since there was paucity of literature comparison of products of animal origin do not have mention of the the present study with other studies could not be derivatives written on the product. The reason was done. None of the studies reviewed had questions alcohol containing mouthwashes and dental related to alcohol and animal derivatives present in products like sutures and waxes fell into cosmetic the dental products. There were lack of references category which did not undergo rigorous trials for studies which were carried out to test the (Scully and Wilson, 2006). No studies were found to knowledge, attitude and practices of the dentists in compare with the mentioned results. relation to the use and knowledge about the dental 32% of participants replied that their patients products. expressed concerns regarding the content of dental CONCLUSION products used that might be detrimental to their The knowledge of the dental practitioners about the cultural beliefs. This question was asked as patients’ culturally sensitive oral health care was found to be views, reactions to illness, health needs and poor. Although they gave importance to provide expectations of treatment were influenced by many culturally sensitive health care provision, they factors of which cultural beliefs are one (Scully and could not replicate it in practice due to the lack of Wilson, 2006). knowledge. 6% of participants stated they prescribed RECOMMENDATIONS alcohol containing mouthwash/ mouth rinse against alcohol free products with animal derivatives in If dentistry has to reduce oral health disparities dental prescriptions even if they were against the related to cultural diversity, then dentistry will also cultural belief of the patients. This reply was based need to recognize how its systems of care and its on the fact that although convictions and beliefs individual practitioners are influenced by bias, govern a patients’ life and health care providers stereotyping, and beliefs about minorities resulting should be sensitive to it, but when there are conflicts due to lack of cultural competency (Formicola, in religious beliefs, patients beliefs and health care 2003). Dental educators should partner with social providers’ beliefs then, the interest of the patients scientists, anthropologists and researchers to must be put first and foremost (Scully and Wilson, develop and evaluate educational programs to 2006). improve the cultural competence of health professionals (Saha et al, 2008). Cultural For the last question, 92% of participants stated

37 Suyog Chandrashekhar Savant et. al. : Cultural competency amongst dental practitioners in Mumbai – A KAP study. competency training (Rubin, 2004; Wagner JA and Redford-Badwal, 2008) should be started at an undergraduate college level and should be included in their curriculum (Hewlett 2009) which will help the dental practitioners to cope better with future challenges in training and practice (Melamed et al, 2008).

Questionnaire to assess knowledge, attitude and practices of 420 dental practitioners based on cultural diversity of their patients while making oral health care provision.

Numbers Percentages 1. What comprises of culturally sensitive oral health care? a. Provide respectful care, educate and inform the patients on health issues. 371 88.33% b. Meet patients' personal, religious, cultural needs. 344 81.90% c. Enable patients to make own choice and respect them. 233 55.47% d. Participants who selected the first three options 192 45.71%* e. Don't know. 4 0.95% 2. Do you observe diverse culture among the patients who visit you? a. Yes 409 97.38%* b. No 11 2.62% If yes, are any one/these the indicators? a. Dress 105 25% b. Lifestyle 215 51.90% c. Language 116 27.61% d. Work profile 100 23.80% e. Diet 387 92.14% f. Don't know 6 1.42% Correct responses (a,b,c,e) 38 9.04%* 3. Do you consider the cultural factors while treating the patients? a. Yes 400 95.23%* b. No 20 4.77% 4. Should the cultural background of patients be considered while providing acceptable oral care to patients? a. Yes 400 95.23%* b. No 20 4.77% c. Don't know/did not understand 1 0.24% 5. Should cultural concerns come in the way of oral health care provision? a. Yes 392 93.34% b. No 27 6.42%* c. Don't know 1 0.24% 6. Are you aware of commonly used agents of animal derivation in dentistry? a. Yes 100 23.8%* b. No 312 74.29% c. Don't know 8 1.91% 7. Which of these products may contain animal derivatives? a. Bone graft and suture material. 418 99.52%* b. Alginate. 17 4.04% c. Wax. 344 81.90%* d. Mouthwash and toothpastes. 5 1.19% e. All of above 3 0.71%

38 Suyog Chandrashekhar Savant et. al. : Cultural competency amongst dental practitioners in Mumbai – A KAP study.

8. Do you prescribe alcohol containing products (mouth wash / mouth rinse) to your patients based on cultural background? a. Yes 34 8.1% b. No 385 91.67%* c. Did not understand 1 0.23% 9. Are you aware of alcohol free mouthwash / mouth rinse? a. Yes 409 97.38%* b. No 11 2.62% 10. Do you check contents of dental products and its derivatives before treating patients? a. Yes 368 87.61%* b. No 52 12.39% 11. Do the dental products have specifications whether the dental products contain derivatives of animal origin? a. Yes 61 14.52%* b. No 205 48.81% c. don't know 154 36.67% 12. Has any of your patients expressed concerns regarding the content of dental products that might be detrimental to their cultural beliefs? a. Yes 134 31.90%* b. No 286 68.10% 13. Do you make patients aware of the kind of treatment provided to them that might be detrimental to their cultural beliefs? 400 95.23% a. Yes 20 4.77%* b. No 14. If the cultural belief is against the use of alcohol would you still prescribe alcohol containing mouthwash/ mouth rinse against alcohol free mouthwash? a. Yes 26 6.19% b. No 393 93.57%* c. Did not understand 1 0.24% 15. Do you prescribe the products containing animal derivatives in dental prescriptions to your patients? a. Yes 26 6.19% b. No 390 92.86%* c. Don't know 4 0.95% 16. Is it relevant to reveal the information regarding the animal and alcohol content of the dental products which might be sensitive to ones cultural beliefs? a. Yes 385 91.67%* b. No 6 1.43% c. Don't know 10 2.38% d. Not necessary 10 2.38%

*Highlighted results are discussed in the discussion.

39 Suyog Chandrashekhar Savant et. al. : Cultural competency amongst dental practitioners in Mumbai – A KAP study.

REFERENCES: Primary Care Medical Practitioners in Children's Oral Health. Journal of Dental Education 72(5), Bennett, D.L.; Chown P.; Kang, M.S.L. (2005): 860-868. Cultural diversity in adolescent health care. The Medical Journal of Australia 183(8), 436-438. Pilcher, E.S.; Charles, L.T.; Lancaster, C.J. (2008): Development and Assessment of a Cultural Bhui, K.; Warfa, N.; Patricia Edonya, P.; McKenzie, Competency Curriculum. Journal of Dental K.; Bhugra, D. (2007): Cultural competence in Education 72(9), 1020-1028. mental health care: a review of model evaluations. BMC Health Services Research 7(15), 1-10. Rowland, M.L.; Bean, C.Y.; Casamassimo, P.S. (2006):A Snapshot of Cultural Competency Egede, L.E. (2006): Race, Ethnicity, Culture, and Education in U.S. Dental Schools. Journal of Dental Disparities in Health care. Journal of General Education 70(9), 982-990. Internal Medicine 21(6), 667-669. Rubin, R.W.; Rustveld, L.O.; Weyant, R.J.; Close, Formicola, A.J.; Stavisky, J.; Lewy, R. (2003): J.M. (2008): Exploring Dental Students' Cultural Competency: Dentistry and Medicine Perceptions of Cultural Competence and Social Learning from One Another. Journal of Dental Responsibility. Journal of Dental Education Education 67(8), 869-875. 72(10), 1114-1121. Gregorczyk, S.M.; Bailit, H.L. (2008):Assessing the Cultural Competency of Dental Students and Rubin, R.W.(2004):Developing Cultural Residents. Journal of Dental Education 72(10), Competence and Social Responsibility in 1122-1127. Preclinical Dental Students. Journal of Dental Education 68(4), 460-467. Hewlett, E.R.; Davidson, P.L.; Nakazono, T.T.; Carreon, D.C.; Gutierrez, J.J.; Afifi, A. (2009): Scully, W. and Wilson, N (2006): Culturally Revision to dental school curricula: Effects of the Sensitive Oral Healthcare. Edn p Quintessence Pipeline Program. Journal of Dental Education Publishing Co Ltd London. 73(2), 259-268. Saha, S., Beach, M.C.; Cooper, L.A. (2008): Patient Hewlett, E.R.; Davidson, P.L.; Nakazono,T.T.; Centeredness, Cultural Competence and Healthcare Baumeister, S.E.; Carreon, D.C.; Freed, J.R. Quality. Journal of the National Medical (2007): Effect of School Environment on Dental Association 100(11), 1275–1285. Students' Perceptions of Cultural Competency Taylor, S.L. (2004):The Role of Culturally Curricula and Preparedness to Care for Diverse Competent Communication in Reducing Ethnic and Populations. Journal of Dental Education 71(6), Racial Healthcare Disparities. American Journal of 810-818. Managed Care 10, 1-4. Lopez, L.; Vranceanu, A.M.; Cohen, A.P.; Wagner, J.A.; Redford-Badwal, D. (2008):Dental Betancourt, J.; Weissman, J.S. (2008): Personal Students' Beliefs About Culture in Patient Care: Characteristics Associated with Resident Self-Reported Knowledge and Importance. Journal Physicians' Self Perceptions of Preparedness to of Dental Education 72(5), 571-576. Deliver Cross-Cultural Care. Journal of General Internal Medicine 23(12), 1953–1958. Wagner, J.; Arteaga, S.; D'Ambrosio, J.; Hodge, C.; Ioannidou, E.; Pfeiffer, C.A.; Reisine, S. (2008): Melamed, E.;Wyatt, L.E.; Padilla, T.; Ferry, R.J. Dental Students' Attitudes Toward Treating Diverse (2008): Patient-based Cultural Competency Patients: Effects of a Cross-Cultural Patient- Curriculum for Pre-Health Professionals. Family Instructor Program. Journal of Dental Education Medicine Journal 40(10), 726-33. 72(10), 1128-1134. Mouradian, W.E.; Berg, H.E.; Somerman, M.J. (2003):Addressing Disparities Through Dental- Medical Collaborations, Part 1.The Role of Cultural Competency in Health Disparities: Training of

40 RADICULAR CYST: A REPORT OF TWO CASES A Case Report

Yesha Jani*, Abhishek Barot**, Twinkal Patel***, Manisha Lalwani**** ABSTRACT The maxillofacial region is affected by more cysts than any other part of the body. They are the most common odontogenic cyst of inflammatory origin. Radicular cysts are usually asymptomatic, hence they are often discovered incidentally on routine radiographs as round, well corticated radiolucency at the apex of root. However, the clinical and radiographic picture may vary. This is a report of two cases of radicular cyst, with different clinical and radiographic features necessitating different lines of treatment. KEYWORDS: Odontogenic cyst, radicular cyst, periapical cyst, jaw cysts Received: 08-02-2016; Review Completed: 06-06-2016; Accepted: 29-06-2016 INTRODUCTION: mediated by prostaglandins and cytokines.5 A cyst is a space-occupying lesion with an outer It is the most common of all the jaw cysts and wall of fibrous connective tissue that surrounds a comprises about 52% to 68% of all the cyst central cavity called the cyst lumen. On the inner affecting the human jaw.6 Almost all radicular cysts aspect of the wall is a lining of epithelium, most are lined partially or completely by non-keratinized commonly stratified squamous epithelium.1 stratified squamous epithelium.3 Odontogenic cysts are the most common form of Radicular cyst's prevalence is highest among cystic lesions that affect the maxillofacial region. patients in their third decade of life, and higher They are classified into an inflammatory group among men than women.1 These cysts can occur in including radicular cysts and a developmental the periapical area of any tooth, at any age but are group, which includes keratocysts and dentigerous 2 seldom seen associated with the primary dentition. cysts. A radicular cyst is generally defined as a cyst Anatomically, the apical cysts occur in all tooth- arising from epithelial residual cells (cell rests of bearing sites of the jaws but are more frequent in Malassez) in the periapical periodontal ligament as maxillary than mandibular teeth.1,4 a consequence of inflammation, usually following the death of dental pulp.1,3,4 Most of the radicular cysts are symptomless and are discovered when periapical radiographs are taken Radicular cysts are believed to be formed from of teeth with non-vital pulps.1,3 Radiographically, epithelial cell rests of Malassez (ERM), which are most radicular cyst appear as round or pear shaped remnants of Hertwig's epithelial root sheath, unilocular radiolucent lesion in the periapical present within the periodontal ligament. region, particularly those over 2 cm in size.1,3 Root- Proliferation of these epithelial cell rests is end filling materials are applied after surgical root frequently associated with stimuli from periapical 1,5 canal treatment to achieve a good apical seal that periodontal inflammation secondary to pulpitis. prevents egress of potential contaminants into peri- During periapical inflammation, host cells in the radicular tissue.7 periapical tissues release many inflammatory mediators, pro-inflammatory cytokines, and These two cases have totally different clinical and growth factors which induce proliferation of the radiographic picture with different treatment ERM in all directions to form a three dimensional modalities. ball mass. As the epithelial mass grows, the central CASE REPORT cells move further away from their source of CASE 1 nutrition and undergo necrosis and liquefaction A 55 year old male Hindu patient came to the OPD degeneration, forming a central cystic cavity lined 5 of Oral Medicine and Radiology department of the by epithelial wall. Following its formation, institute with the complaint of swelling in the palate radicular cysts grow by periapical bone resorption

* Senior Lecturer, ** Senior Lecturer, *** PG Student, **** PG Student ORAL MEDICINE & RADIOLOGY DEPARTMENT, AHMEDABAD DENTAL COLLEGE & HOSPITAL, GUJARAT.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Twinkal Patel, TEL: +91 9714802656

41 Yesha Jani et. al. : Radicular Cyst: A Report of Two Cases since last 4 days. Patient had a history of trauma before 20 years due to an accidental fall from the bike leading to a blow to his face. There was bleeding from maxillary anterior region of mouth. Since then, he was asymptomatic until he noticed a swelling in the anterior hard palate region before a week. Before 4 days, patient noticed an increase in size of the swelling [Figure 1].

Figure 2: Maxillary anterior occlusal radiograph showing round radiolucency in 11,12 region

[Figure 3] FNAC macroscopic examination Figure 1: Intraoral photograph showing swelling showed blood tinged yellow coloured fluid with on hard palate approximate 1.5 ml volume. [Figure 4] Patient had a habit of smoking 20-25 bidis per day since last 40 years. On examination, a mesiodens was present. Also, there was a single, round swelling measuring 1 cm in diameter on right side of the hard palate extending mesio-distally from mesial of 11 to distal of 14 and antero-posteriorly from the level of maxillary canine to second premolar. The overlying mucosa was red without any sinus tract or fistula. On palpation, the swelling was non-warm, tender, soft in consistency, non- Figure 3: Orthopantomograph showing compressible & non-fluctuant. Provisional radiolucency with radioopaque borders related diagnosis for this case was infected radicular cyst in with roots of 12,13 relation to 11, 12 On pulp vitality testing, there was no response in relation to 11, 12. Maxillary occlusal radiograph showed a single, oval, well defined radiolucency with, 1 x 1.5 cm size present on the right side of hard palate not crossing the midline. [Figure 2] It was surrounded by a thin radiopaque corticated border involving the 1/3rd of root apex of 12, apex of 11 and extending to the distal of the 16. Orthopantomogram shows a single round 2 cm diameter sized radiolucency with corticated borders centered over the apical third of roots of 12 and 13. Figure 4: Macroscopic examination showing blood tinged yellow fluid

42 Yesha Jani et. al. : Radicular Cyst: A Report of Two Cases

The patient was advised root canal treatment for 11, [Figure 6] However, none were tender on 12 & 13 followed by apicoectomy for cyst percussion. A provisional diagnosis of chronic enucleation. The specimen was sent for irreversible pulpitis in relation to 36 was given. histopathological examination. On checking vitality there was no response in Histopathological examination showed that the relation to 36. IOPA of 36 showed a radiolucency epithelium was stratified squamous in nature with involving enamel and dentin reaching pulp. Also, underlying connective tissue stroma showing dense radiopaque gutta purcha cones were present in collagen fibers with fibroblasts, large number of mesio-buccal and mesio-lingual canals of 36. inflammatory cells & blood filled capillaries. Periapically, a single, round, well defined [Figure 5] radiolucency 1 cm in diameter was present on the apex of mesial and distal roots which was surrounded by well-defined radiopaque corticated border.

Figure 5: Microphotograph showing stratified squamous epithelium & connective tissue [Figure 7] Orthopantomogram shows a single CASE 2 round radiolucency with radiopaque borders from A 48 year old Hindu female patient came to the OPD mesial aspect of root of 36 to mesial aspect of root of Oral Medicine and Radiology department of the 37 and supero-inferiorly from 1/3rd of root to institute with complaint of decay in lower left back mandibular canal. [Figure 8] tooth region of jaw since last 1 year. Patient had undergone silver amalgam restoration before 3 – 4 years as she noticed caries in that tooth. Then the restoration got dislodged by itself before 2 years. Patient also had a habit of chewing 3 – 4 betel nuts per day since last 15 to 20 years. On examination, 36 was grossly carious.

The patient was advised extraction followed by cyst enucleation. The specimen was sent for histopathological examination. [Figure 9] Histopathological examination showed stratified squamous epithelial in arcading pattern with loosely arranged underlying connective tissue stroma. Large number of inflammatory cells were also evident. Figure 6: Intraoral photograph showing grossly carious 36

43 Yesha Jani et. al. : Radicular Cyst: A Report of Two Cases

DISCUSSION present with non-vital tooth and in second case there The radicular cyst has been classified as was symptomless carious non-vital tooth. inflammatory, because in the majority of cases it is a Radiographically, most radicular cysts appear as consequence to pulpal necrosis following caries, round or pear shaped unilocular radiolucent lesion with an associated periapical inflammatory in the periapical region.2 In first case radiolucency response.3 It is also called radicular cyst, apical was pear shaped at periapical region of 12 and in periodontal cyst or dental cyst.8 A radicular cyst is second case radiolucency was round in shape at associated with carious, non-vital, discoloured or periapical region of 36. 4 fracture tooth. Position of the maxillary anterior Macroscopically, fluid aspirated from the periapical teeth makes them more prone to injury and 5 cysts is of yellowish-white in color and contained subsequent pulp necrosis. In the first case, trauma cholesterol crystals.5 This is in accordance with the to maxillary anterior teeth was the cause. Periapical findings of the first case. inflammation and pulpitis secondary to dental caries is another cause of formation of radicular The treatment options for large periapical lesions cyst.5 In the second case, grossly carious tooth was range from conventional non-surgical root canal the cause for developing radicular cyst. treatment with long treatment with long term calcium hydroxide therapy to various surgical Few studies in the UK and the South African interventions.6 The first case was treated by root population have shown that radicular cysts occur canal treatment followed by apicoectomy which is more commonly between the third and fifth decades the ideal plan of treatment for large cysts involving of life, more common in males than females, and multiple teeth whereas the second case required more frequently found in the anterior maxilla than 2,3 extraction because much of the involved tooth had other parts of the mouth. In the first case age of the already lost its crown structure due to carious patient was 55 years, but the trauma occurred before destruction over a period of time. 20 years while in the second case the patient was aged 48 years. CONCLUSION The initial swellings of these radicular cysts are Radicular cyst is the most commonly occurring usually bony hard, but as they increase in size, the cyst. Different type of cases is differentiated by covering bone may become very thin despite initial radiographically and histopathological sub-periosteal bone deposition.2,3 Most of the examination. So, preoperative radiograph should be radicular cyst are symptomless and are discovered taken whenever needed whether the patient is when periapical radiograph is taken of teeth with asymptomatic or symptomatic. This will does help non-vital pulps.1 Patient often complains of slowly to provide an inadequate diagnosis and does proper enlarging swellings.1 In the first case swelling was treatment plan for the patient.

REFERENCES: radicular cysts of maxilla: Steps in diagnosis & 1. Nainani P, Sidhu G. Radicular cyst – An update review of management. J Bio Innov 2015; 4(1): with emphasis on pathogenesis. J Adv Med 1-11. Dent Sci Res 2014; 2(3): 97-101. 6. Ghezta N. Surgical enucleation of large 2. Banu GK, Belir A, Mehmet AE. Odontogenic radicular cyst – Case report. J Dentofac Sci cyst: A clinical study of 90 cases. J Oral Sci 2012; 1(2): 29-32. 2004; 46(4): 253-7. 7. Shahriar S, Hamid Y, Saeed R, Mahsa E, Sahar 3. Dexter B, Madhusudan AS, Gayathri R, Brave S, Mahsa U. Comparison of the sealing ability VR. Radicular cyst of anterior maxilla. Int J of mineral trioxide aggregate and portland Dent Clin 2011; 3(2): 16-17. cement used as root-end filling materials. J Oral Sci 2011; 53(4): 517-22. 4. Niyanta J, Sujan S, Rachappa M. Unusual case report of bilateral mandibular radicular cysts. 8. Nilesh K, Sameer Z, Mohan S. Peripheral Contemp Clin Dent 2011; 2(1): 59-62. presentation of periapical cyst: A rare finding. J Oral Maxillofac Pathol 2015; 6(1): 565-7. 5. Kumar N, Anuj D, Pramod C. Unusually large

44 AMELOGENESIS IMPERFECTA IN SIBLINGS A Case Report – A REPORT OF TWO CASES.

Roseline Patel*, Rutu Jani**, Prutha Nemade***, Abhinandan Gokhroo**** ABSTRACT Amelogenesis imperfecta (AI) is a diverse collection of inherited diseases that exhibit quantitative or qualitative tooth enamel defects in the absence of systemic manifestations. This defect is entirely ectodermal, since mesodermal components of the teeth are basically normal. The AI trait can be transmitted by either autosomal dominant, autosomal recessive, or X- linked modes of inheritance with more than one person affected in the family. This article describes amelogenesis imperfecta in two sisters with detailed clinical and radiological findings. KEYWORDS: Amelogenesis imperfecta, hypoplastic type, familial type. Received: 09-03-2016; Review Completed: 31-05-2016; Accepted: 01-07-2016

INTRODUCTION: forms.3,5 This enamel anomaly may affect both the 3,6 Dental enamel, the highly mineralized structure in primary and permanent dentition. This article the human body, is formed within a unique, describes amelogenesis imperfecta in two sisters extracellular matrix derived through the synthesis with detailed clinical and radiological findings. and secretion of proteins by the ameloblast cells.1,9 CASE REPORT – 1 Dental enamel formation is divided into secretory, A female patient of age 18 belonging to low socio transition and maturation stages. During the economic status reported to the outpatient secretory stage, enamel crystals grow primarily in department of oral medicine and radiology with length. The crystallites lengthen at a mineralization chief complaint of yellowish discoloration of teeth front formed near the secretory surfaces of the since childhood. Family history revealed presence ameloblast cells. During the maturation stage, of same type of teeth in her younger sister (Case 2), mineral is deposited exclusively on the sides of the while one elder sister and two younger brothers crystallites, which grows in width and thickness to 1,9 were not affected. None of the parents and other coalesce with adjacent crystals. family members from maternal and paternal side The final composition of enamel is a reflection of had the history of discoloration of teeth. Her the unique molecular and cellular activities that take primary dentition was also discolored. Patient did place during its amelogenesis. Deviation from this not have disturbance in eruption of any tooth. pattern may lead to amelogenesis imperfecta (AI).2 Medical history was non contributory. AI is also known by varied names such as hereditary enamel dysplasia, hereditary brown enamel, hereditary brown opalescent teeth.1,11 AI is caused by mutations in genes that control amelogenesis and follows inheritance patterns of autosomal- dominant, autosomal recessive or X-linked modes of transmission.2,6,8,10,11 Genes implicated in autosomal forms are genes encoding enamel matrix proteins, namely: enamelin and ameloblastin, tuftelin, MMP-20 and kallikrein – 4.2 AI results in poor development or complete absence of enamel of the teeth caused due to improper differentiation of ameloblasts. The enamel defects Figure1: Profile photographs patients showing of this condition are clinically divided into bilateral facial symmetry in Case 1 & Case 2 hypoplastic, hypocalcified and hypomineralized Extraoral examination (Figure 1) did not reveal any

* Sr Lecturer, ** Sr Lecturer, *** Post Graduate Student, **** Post Graduate Student DEPARTMENT OF ORAL MEDICINE & RADIOLOGY DEPARTMENT, AHMEDABAD DENTAL COLLEGE & HOSPITAL.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Prutha Nemade, TEL: +91 9978275740

45 Roseline Patel et. al. : Amelogenesis Imperfecta in siblings – A report of two cases. relevant findings. On intraoral examination, all teeth were present (Figure 2) except 46 which had been extracted before 2 months due to caries.

Figure 3: OPG and Hand Wrist Radiographs of Figure2: Intraoral photographs showing mottled Case 1. OPG shows generalized enamel structure loss enamel in Case 1 Radiographic investigations (Figure 3) included The teeth, in general, exhibited a yellowish brown orthopantomogram (OPG) and hand wrist discoloration, with diffuse pitting present on almost radiograph. Examination of radiographs revealed all surfaces of all teeth, more prominent on labial that enamel was almost half its expected thickness, and buccal surfaces. The surfaces of teeth were but was of normal density i.e it was more radiodense rough. The thickness of enamel was reduced than the dentin. Loss of cuspal height and open exposing the dentin on almost all teeth except 11, proximal contacts in posterior teeth were noted. 13, 16, 21, 23, 26. Pulp chambers were normal with no sign of A provisional clinical diagnosis of amelogenesis obliteration of root canals in any teeth. OPG also imperfecta and differential diagnosis of revealed same features in all teeth including environmental enamel hypoplasia (dental unerupted 28, 38, 48 and absence of 18. OPG also fluorosis), dentinogenesis imperfect and dentin showed normal bone and joints. Hand wrist dysplasia were considered. radiograph showed normal bones, joints and skeletal maturation. Correlating history, clinical features and radiographic features diagnosis of Type 1 hypoplastic amelogenesis imperfecta was considered and patient was referred to the department of prosthodontia for full mouth rehabilitation. CASE REPORT – 2 A female patient of age 16 years belonging to low socio economic status reported to the outpatient department of oral medicine and radiology with

46 Roseline Patel et. al. : Amelogenesis Imperfecta in siblings – A report of two cases. chief complain of yellowish discoloration of teeth A provisional clinical diagnosis of amelogenesis since childhood. Family history revealed presence imperfecta and differential diagnosis of of same type of teeth in one of her elder sister (Case environmental enamel hypoplasia (dental 1) while the other elder sister and two younger fluorosis), dentinogenesis imperfect and dentin brothers were not affected. None of the parents and dysplasia were considered. other family members from maternal or paternal Radiographic investigations (Figure 5) done side had the same history of discoloration of teeth. included orthopantomogram (OPG). Examination Her primary dentition was also discolored. Patient of OPG revealed a missing 18 and normal pulp did not have disturbance in eruption of any tooth. chambers and root canals with no sign of Medical history was non contributory. obliteration in any teeth. Multiple teeth showed loss Extraoral examination (Figure 1) did not reveal any of enamel structure. OPG also showed normal bone relevant findings. On intraoral examination (Figure and joints. There was presence of unerupted 28, 38 4) all the teeth were present. The teeth, in general, and 48. exhibited a yellowish brown discoloration, with diffuse pitting present on almost all surfaces of all teeth, more prominent on labial and buccal surfaces. The surfaces of teeth are rough. The thickness of enamel was reduced exposing the dentin on almost all teeth.

Figure 5: OPG of Case 2 showing generalized enamel structure loss Correlating history, clinical features and radiographic features diagnosis of Type 1 hypoplastic amelogenesis imperfecta was considered and patient was referred to the department of prosthodontia for full mouth rehabilitation. DISCUSSION Amelogenesis imperfecta (AI) encompasses a complicated group of conditions that demonstrate developmental alterations in the structure of enamel in the absence of systemic disorder. The prevalence of this condition range from 1 in 718 to 1 in 14,000, depending on the population.1,2,11 The most widely accepted classification is that proposed by Witkop and Sank in 1976. Witkop and Rao (1971) classified AI broadly based on Figure 4: Intraoral photographs showing mottled phenotype and style of inheritance into three enamel in Case 2 categories: hypoplastic variety, hypocalcified variety, and hypomaturation variety. Later in 1989 Witkop gave the classification shown in table 1.1,2

47 Roseline Patel et. al. : Amelogenesis Imperfecta in siblings – A report of two cases.

Table - 1

Type I Hypoplastic

IA Hypoplastic, pitted autosomal dominant

IB Hypoplastic, local autosomal dominant

IC Hypoplastic, local autosomal recessive

ID Hypoplastic, smooth, autosomal dominant

IE Hypoplastic, smooth X- linked dominant

IF Hypoplastic, rough autosomal dominant

IG Enamel agenesis, autosomal recessive Type II Hypomaturation

IIA Hypomaturation, pigmented autosomal recessive

IIB Hypomaturation, X- linked recessive

IIC Snowcapped teeth, autosomal dominant Type III Hypocalcified

IIIA Autosomal dominant

IIIB Autosomal recessive

Type IV Hypomaturation- hypoplastic with taurodontism IVA Hypomaturation-hypoplastic with taurodontism, autosomal dominant

IVB Hypoplastic-hypomaturation with taurodontism, autosomal dominant

Hypoplastic AI represents 60-73% of all cases; on the trait to the offspring of either sex.2 The cases hypomaturation AI represents 20-40%, and hypo- in this report had hypoplastic autosomal recessive calcification AI represents 7% of all cases.4,5,11 (Type IC) type AI. The first clear descriptions of X-linked hypoplastic AI is sometimes associated with syndromes like, AI AI were those of Schulze and Lenz and Schulze, with taurodontism, trichodentoosseous syndrome, who recognized the different manifestations in AI with nephrocalcinosis and cone-rod dystrophy affected males and females. This was confirmed with AI.6,7 The commonest differential diagnosis and expanded upon by Schulze in a monograph, which should be kept in mind during the clinical detailing families from a geographically discrete assessment is environmental enamel dysplasia area in Germany. The inheritance pattern of X- (dental fluorosis) and dentinogenesis imperfecta. linked disorders dictates that male-to-male Dental fluorosis may present with areas of transmission cannot occur. Conversely, all female horizontal white banding corresponding to periods offspring's of an affected male must be affected. of more intense fluoride intake and may show the Affected females have a 50% probability of passing premolars or second permanent molars to be spared

48 Roseline Patel et. al. : Amelogenesis Imperfecta in siblings – A report of two cases.

(chronological distribution). The variability of this complexity of the condition requires an condition, from mild white flecking of enamel to interdisciplinary approach for optimal treatment profoundly dense white coloration with random, outcomes.3 The treatment approach should be disfiguring areas of staining and hypoplasia, ideally be developed keeping in mind the specific requires careful questioning to distinguish from AI. AI type and underlying defect. The treatment of In the latter case, the history will often reveal these patients has been usually done in two phases, excessive fluoride intake either in terms of a habit, temporary phase followed by transitory phase. such as eating toothpaste in childhood, or related to Adhesive restorative techniques, over dentures, a local water supply.1,4 In the present cases, there is fixed partial dentures, full porcelain crowns, no such history is given by patient. Also the OPG porcelain fused to metal crowns, and inlay/onlay shows the affected enamel formation in unerupted restorations constitute the contemporary treatment third molars and shows normal bones, joints and modalities.4 skeletal maturation in hand wrist radiograph. CONCLUSION Dentinogenesis imperfecta can be differentiated from AI in our cases by the presence of bulbous A dentist should diagnose Amelogenesis imperfecta crowns and narrow roots, the relatively normal (AI) as early as possible for timely intervention and density of any remaining enamel, and on proper treatment planning for long term survival of radiographs the obliteration of pulp chambers and the restorations. Dental practitioners should root canals is seen, in the absence of marked consider the social implications for these patients attrition.7 and intervene to relieve their suffering. Thus this article is an attempt to improve the clinicians Treatment planning for patients with AI is related to knowledge about clinical and radiological many factors: the age and socioeconomic status of diagnosis of AI as well as the intervention required the patient, the type and severity of the disorder. The for such a condition.

REFERENCES: Sabina PB, Eduardo AO, Ricardo DC. Amelogenesis imperfecta and nephrocalcinosis 1. Sumathy C, Ashokan KA, Ashokan SC, Ganesh syndrome: A case report and review of the M. Literature review of amelogenesis literature. Nephron Physiol 2011; 118: 62-5. imperfect with case report. J Indian Acad Oral Med Radiol 2012; 24(1): 83-7. 7. Yogesh C, Apurv J, Aditi L, Shubha R. Case report on hypoplastic amelogenesis imperfecta 2. Mayur C, Shweta D, Asha S, Sanket K. with multiple impacted teeth. J Dent Med Sci Amelogenesis imperfecta: Report of a case and 2014; 13: 79-82. review of literature. J Oral Maxillofac Pathol 2009; 13(2): 70-8. 8. Narendranath R, Siva PR. Ann Essences Dent 2010; 2(1): 3-8. 3. Emin M, Peruze C, Murat Y, Selcen Z. Amelogenesis imperfecta, hypoplastic type 9. Godoy ML, Sergio RP. The genetics of associated with some dental abnormalities: A amelogenesis imperfect – A review of the case report. Braz Dent J 2010; 21(2): 170-4. literature. J Appl Oral Sci 2005; 13(3): 212-7. 4. Nuzula B, Gowri B, Raghavendra K, Vathsala 10. Peter C, Michael A, Zupan AB. Amelogenesis N, Rashmi L, Carol S. Amelogenesis imperfect. Orphanet J Rare Dis 2007; 2(17): 1- imperfecta: A series of case reports. Int J Adv 11. Health Sci 2015; 2(1): 17-21. 11. Anar P, Anjani C, Bhavin D, Naresh S, 5. Nigam P, Singh VP, Prasad KD, Tak J. Abhishek B. Amelogenesis imperfecta. J Amelogenesis imperfecta: A case report and Ahmedabad Dent Col 2011; 2(1): 39-43. review of literature. Int J Sci Stud 2015; 2(10): 146-9. 6. Júnior HM, Pedro EN, Sibele NA, Carolina CO,

49 LOWER LIP SUCKING HABIT TREATED WITH A Case Report A LIP BUMPER APPLIANCE

Hiral Vayeda*, Vijay Bhaskar**, Bhumi Sarvaiya ***, Rajal Pathak****, Tithi Acharya***** ABSTRACT The patient was a 12-year-old girl with a lower lip sucking habit with increased Overjet and mandibular incisor irregularity. Hyperactivity of the mentalis muscle and deepening of the labiomental sulcus because of the abnormal sucking habit was observed. Interceptive treatment was started with a lip bumper appliance to break the lower lip sucking habit. The lip bumper appliance therapy resulted in the elimination of the lower lip sucking habit, musculus mentalis hyperactivity, and labiomental strain and improvement of the lower incisor inclinations, and overjet reduction. KEYWORDS: Lip sucking; Habit; Mentalis hyperactivity; Lip bumper Received: 04-04-2016; Review Completed: 06-06-2016; Accepted: 04-07-2016 INTRODUCTION: habit with a mandibular lip bumper appliance Oral habit is a part of normal development in CASE REPORT children. Habits are the learned patterns of muscle A 12-year-old girl came to the Department of contraction with complex nature. Oral habits are Pedodontics and Preventive Dentistry with the chief repetitive act seen commonly from infancy and 1 complaint of lower lip sucking habit since 4-5 years. should finish automatically as age advances . The patient used to get indulge in the habit The position and stability of the dentition are particularly at the time of watching TV and at the influenced by the equilibrium between their night during sleep. Her medical history showed no surrounding muscular forces 2. Extraoral forces contraindication to the habit breaking appliance. exerted by the orbicularis oris and buccinator Facial photographs showed an orthognathic profile muscles are balanced by the opposing forces of the with mentalis muscle hyperactivity and a deep tongue 3. Any prolonged change in this balanced labiomental sulcus caused by her abnormal habit. muscle function caused by parafunctions, such as Her intraoral examination revealed a Class I molar lip sucking, lip biting, tongue thrusting, can alter the relationship with an overjet of 10 mm. The equilibrium, initiate morphologic change in the maxillary anterior teeth were protruded with normal configuration of the teeth and supporting diastemata between them. The mandibular anterior bone, and result in a malocclusion4,5. The teeth were lingually collapsed. Symmetrical upper manifestation of an acquired malocclusion varies and lower midlines were noted. according to the type, localization, severity, frequency, and longevity of the habit, but elimination of the abnormal habit is fundamental for treatment and future stability. In cases with a lip sucking habit, the lip bumper appliance is a good treatment alternative for breaking the habit and correcting the resultant malocclusion. Treatment effects of the mandibular lip bumper appliance, such as gain in arch length, control of molar rotation, and anchorage, are well discussed in several studies 6-9. However, its use in correcting the lower lip sucking habit has not been demonstrated Pre- operative and intra-oral photographs of the patient previously. The purpose of this case report was to present the treatment for a patient having a lower lip sucking

* PG Student, ** Professor & HOD, *** Reader, **** Sr Lecturer, ***** Sr Lecturer DEPARTMENT OF PEDODONTICS AND PREVENTIVE DENTISTRY DEPARTMENT, AHMEDABAD DENTAL COLLEGE & HOSPITAL, AHMEDABAD, GUJARAT, INDIA.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Hiral Vayeda, TEL: +91 8511108890

50 Hiral Vayeda et. al. : Lower Lip Sucking Habit Treated With A Lip Bumper Appliance

TREATMENT construction of the appliance was easy. The patient Treatment objective included the elimination of became acclimated to it in a short time period and lower lip sucking habit. The treatment was initiated she did not have serious complaints while chewing. with preventive therapy like oral prophylaxis There are fixed and removable lip bumpers. A fixed followed by pit & fissure sealants in all first appliance was prepared as the success of the permanent molars. Band pinching was done on both removable type depends on patient cooperation. lower first molars (36, 46) followed by alginate The fixed lip bumper was used for 24 hours and the impression following which a prefabricated lip habit was eliminated in a short period of time. When the habit was completely eliminated the appliance bumper appliance was placed at the level of the 11 gingiva two to three mm in front of the lower was removed . incisors and four to five mm away from the buccal Lip bumpers have been used to gain arch length for segments. The appliance was fixed to the molar to the alignment of mild to moderately crowded dental eliminate any risk of patient compliance. Further, arches8, to correct molar rotations7, to control the maxillary arch impression was made using anchorage loss, to improve labialis muscle activity, alginate impression material & dental cast was and to eliminate lower lip biting habit12 . In the case obtained. Hawley's appliance was fabricated in the in this study, a lip bumper appliance was used to upper arch. eliminate the lower lip sucking habit and improve Patient was followed up every 15 days till 4 months labialis and mentalis muscle activity. The sucking after which the lower lip sucking habit was habit was prevented by the labial shield of the completely eliminated. appliance. After treatment, the lower lip position was improved. The lower incisors inclined labially and the overjet was corrected because of the elimination of the lower labialis and mentalis muscle forces in response to unopposed pressure from the tongue. Similar dental changes after lip bumper therapy have been reported in other studies4-8,13 In the present case, lip bumper therapy led to desirable results within four months. Treatment time with the mandibular lip bumper appliance is reported to range between six to 33 months in previous studies 4-6,14,15 .The relatively shorter period of treatment time in the case in this study might be Post–operative and intra-oral photographs of the patient because of the use of a fixed appliance, which eliminated the patient compliance problems. DISCUSSION CONCLUSION The lip bumper is a simple functional appliance and usually well tolerated by the patient. Various forms Although all other treatment options are available, a of treatment have been instituted in an attempt to fixed lip bumper appliance is very beneficial in prevent lip biting10. In the present case, a lip bumper eliminating the lower lip sucking habit in the was preferred as it has some advantages. The children and thereby restoring the function REFERENCES: 3. Graber TM. Orthodontics: Principles and Practice. Philadelphia, Pa: WB Saunders; 1. Brodie AG. Muscular forces in diagnosis, 1972:139–145. treatment, and retention.Angle Orthod. 1953;1:16–35. 4. Graber TM. The ''three M's'': muscles, malformation and malocclusion. Am J Orthod. 2. Weinstein S. Minimal forces in tooth 1963;49:418–450. movement. Am J Orthod. 1967;53:881–903. 5. Jacobson A. Psychology and early orthodontic

51 Hiral Vayeda et. al. : Lower Lip Sucking Habit Treated With A Lip Bumper Appliance

treatment. Am J Orthod. 1979;76:511–529. 11. Karacay F, Guven G, Sa⁄Dic1 A, Bafiak F Treatment Of Habitual Lip Biting: A Case 6. Bergersen EO. A cephalometric study of the Report Turk J Med Sci 2006; 36 (3): 187-189 clinical use of the mandibular labial bumper. Am J Orthod. 1972;61:578–602. 12. Chaiwat J, Deckunakorn S. Bite jumping appliance with lower lip bumper. J Dent Assoc 7. Bjerregaard J, Bundgaard AM, Melson B. The Thai. 1991;41:66–77. effect of the mandibular lip bumper and maxillary biteplate on tooth movement, 13. Davidovitch M, McInnis D, Lindauer SJ. The occlusion, and space conditions in the lower effects of lip bumper therapy in the mixed dental arch. Eur J Orthod. 1980;2:257265. dentition. Am J Orthod Dentofacial Orthop. 1997;111:52–58. 8. Nevant CT, Buschang PH, Alexander RG, Steffen JM. Lip bumper therapy for gaining 14. Soo ND, Moore RN. A technique for arch length. Am J Orthod Dentofacial Orthop. measurement of intraoral lip pressures with lip 1991;100:330–336. bumper therapy. Am J Orthod Dentofacial Orthop. 1991;99:409–417. 9. Osborn WS, Nanda RM, Currier GF. Mandibular arch perimeter changes with lip 15. Klocke A, Nanda RS, Ghosh J. Muscle activity bumper treatment. Am J Orthod Dentofacial with the mandibular lip bumper. Am J Orthod Dentofacial Orthop. 2000;117:384–390 10. Chen L, Liu F. Successful treatment of self inflicted oral mutilation using an acrylic splint retained by a head gear. Pediatr Dent 1996; 18: 408-410.

52 MANAGEMENT OF HIGHLY PLACED PERMANENT A Case Report MAXILLARY CANINES USING CANTILEVER SPRINGS

Anushree Guru*, Hiten Pandav**, Aatman Joshipura ***, Arth Patel**** ABSTRACT Simplified approach in correction of highly placed canines are necessary to place the teeth in correct ideal position without disturbing the other teeth or occlusion. Prudent treatment planning is necessary to achieve the various treatment goals. This case report describes the orthodontic management of a 13-year-old female patient with bilateral labially highly placed permanent maxillary canines. Received: 05-04-2016; Review Completed: 07-06-2016; Accepted: 01-07-2016

INTRODUCTION: Eruptive disturbances are alterations of normal mesocephalic head & mesoprosopic face with tooth eruption, including accelerated, delayed, interlabial gape of 4 mm [Figure - 1]. Intraoral failed, or deviated in the direction of tooth eruption.1 examination [Figure - 2] showed bilaterally labially Because of overretained deciduous teeth, highly placed permanent canines and retained permanent teeth don't get enough space In the arch deciduous canines and well aligned lower arch. In so it ultimately disturbs the eruptive path of that the occlusion, she had a 50% overbite and a 4 mm teeth. overjet. The molar relationship was Class I. The dental midlines were concordant with each other Impaction is the total or partial lack of eruption of a 2 and with the face, and no mandibular shift was tooth well after the normal age of eruption. detected on closure. There was no relevant history Between 25% and 50% of the general population of any medical problem. are affected by impacted teeth, with the incidence of upper canine impaction reportedly ranging from 0.92% to 4.3%, respectively.3,4 Maxillary canine impactions are twice more common in females (1.17%) than in males (0.51%).5 Eight percent of patients with impacted maxillary canines have bilateral impactions.5 Impaction of a maxillary canine is a common problem because it has the longest period of development, the deepest area of development, and the long eruption path of all the teeth.3 They are also the teeth that frequently require surgical and orthodontic intervention for their eruption. FIGURE-1 According to Kokich and Mathews the cause of labial impaction of the canines probably is related to either a retained deciduous tooth, diversion of the canine tooth bud, or idiopathic failure of eruption of unknown origin.6 CASE REPORT A 13-year-old female presented for orthodontic treatment with the chief complaint of impaired facial esthetics during smile due to irregular upper front teeth. She had a grossly symmetric,

* Senior Lecturer, ** PG Student, *** Senior Lecturer, **** Senior Lecturer DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS DEPARTMENT, AHMEDABAD DENTAL COLLEGE AND HOSPITAL.

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. HITEN PANDAV , TEL: +91 98791 20365

53 Anushree Guru Et. Al. : Management of Highly Placed Permanent Maxillary Canines Using Cantilever Springs

Within 2 months of active orthodontic treatment using cantilever springs both the side canines were come nearly straight occlusal plane [figure -4]. In this case bite opening was required, so after that we bonded the remaining teeth and continuous Ni-ti wire including all teeth [figure -5].

FIGURE-2 TREATMENT OBJECTIVES AND PLAN The objectives of orthodontic treatment for the FIGURE-4 patient were to extract the deciduous maxillary canines and the labially highly maxillary canines placed in proper position, then level and align the arches, obtain normal overjet, and overbite, and achieve a well-intercuspated bilateral Class I canine and molar occlusion. It was decided to use cantilever springs bilaterally to pull the highly placed canines downwards in nearly maximum occlusal plane then bond the other remaining teeth and continuous Niti wire were given including all teeth. TREATMENT PROGRESS Both the side first molar banding and maxillary canine bonding were done. Cantilever spring fabricated from 17*25 TMA wire and attached FIGURE-5 actively to canine bracket on both side. [figure – 3] TREATMENT RESULTS DISCUSSION Maxillary permanent canines are important for an attractive smile and are also essential for a functional occlusion. The cantilever spring was easy to fabricate and biomechanically efficient for occlusal movement of buccaly placed canine. When tied to the braided ligature strands, the stored energy in the spring generated optimum eruptive force in the occlusal FIGURE-3 direction. When the canines show the occlusal movement, the deciduous canines were extracted because up to that time they were an act as natural space maintainer.

54 Anushree Guru Et. Al. : Management of Highly Placed Permanent Maxillary Canines Using Cantilever Springs

The segmental beta-titanium alloy cantilever spring CONCLUSION was used to provide a point force application to the Understanding the biologic principles and proper canine, a low load-deflection rate, and a large range application of the biomechanics enable us to carry of activation. In this statically determinate force out challenging tooth movements. Best treatment system, the buccal segments were more efficiently goals can be achieved in limited time using the managed, and intrusive side-effects were magical effect of cantilever spring without distributed over a wider area to minimize the 7 interfering the other teeth or occlusion and provide clinical side effects. good orthodontic treatment outcome.

REFERENCES: 5. Bishara SE. Impacted maxillary canines: A review. Am J OrthodDentofacialOrthop 1. Brin I, Zilberman Y, Azaz B. The unerupted 1992;101:159-71. maxillary central incisor: Review of its etiology and treatment. ASDC J Dent Child 6. Kokich VG, Mathews DP. Surgical and 1982;49:352-6. orthodontic management of impacted teeth. Dent Clin North Am 1993;37:181-204. 2. Orthodontic Glossary. St. Louis: American Association of Orthodontics; 1993 7. Lindauer SJ, Isaacson RJ. One-couple orthodontic appliance systems. SeminOrthod 3. Jacoby H. The etiology of maxillary canine 1995;1:12-24. impactions. Am J Orthod 1983;84:125-32. 4. Ngan P, Hornbrook R, Weaver B. Early timely management of ectopically erupting maxillary canines. SeminOrthod 2005;11:152-63.

55 REHABILITATION OF OCULAR DEFECT USING CUSTOM A Case Report MADE OCULAR PROSTHESIS- A CASE REPORT

Darshana Shah*, Chirag Chauhan**, Foram Sutaria ***, Jenish Solanki**** ABSTRACT As eye is a vital and important organ, loss of eye can lead to crippling effect on the facial appearance and affects the psychology of the patient. In such cases Ocular Prosthesis is probably the only alternative to rehabilitate the anophthalmic patients. After enucleation, evisceration and exenteration of the eye the main purpose of the ocular prosthesis is to maintain the volume of eye socket and create an illusion of a healthy eye and surrounding tissues. When compared to Stock Eye, Customized Eye Prosthesis provides more aesthetic and precise result. Here is the case report presenting, sequential steps for the construction of the custom made ocular prosthesis in a simplified cost effective manner. Key words: Ocular Defect, Customised Ocular Prosthesis, Ocular Rehabilitation Received: 17-04-2016; Review Completed: 15-06-2016; Accepted: 02-07-2016 INTRODUCTION: disadvantage is the erosion of the overlying tissue, Loss or removal of this organ can occur in cases of a resulting in the exposure of the implant or contamination of the implants at the time of congenital abnormality, severe trauma, disease such 5 as an infection, a tumour or malignancy, insertion. Other side, an ocular prosthesis can be sympathetic ophthalmia or in suspected cases for either readymade (stock) or custom-made. Stock the histological confirmation for diagnosis.1 prosthesis comes in standard sizes, shapes, and colours. They can be used for interim or Surgical procedures adopted for the removal of an 6,7,8 eye are classified by Peyman, Saunders and postoperative purposes. Custom made eyes have Goldberg (1987) into three general categories: several advantages including better mobility, even enucleation, evisceration and exenteration. distribution of pressure due to equal movement According to Scoll (1982) enucleation is a surgical thereby, reducing the incidence of ulceration, procedure in which the globe and the attached comfort, tissue adaptation, improved facial portion of the optic nerve are excised from the orbit. contours, improved fit and enhanced gained from the control over the size of the iris, pupil and colour Evisceration is removal of the contents of globe 9 while leaving the sclera and extra ocular muscles of the iris & sclera. Thus the ideally constructed intact. Exenteration is the most radical of the three prosthesis must duplicate the missing features so procedures and involves removal of the eye, precisely that the casual observer notices nothing adnexa, and the part of the bony orbit.2 that would draw attention to the prosthetic reconstruction.10 The disfigurement resulting from loss of an eye can cause significant physical, psychological as well as Case Report social consequences. Replacement of the lost eye as A 74 years old male patient reported to the Dept. soon as possible is necessary to promote physical of Prosthodontics, Ahmedabad dental college and and psychological healing for the patient and to hospital with chief complain of difficulty in eating. improve social acceptance.3 Early management of Intra oral examination revealed completely an anophthalmic socket prevents loss of volume in edentulous maxillary and mandibular arches, while the anterior orbital area and facial asymmetry. A extra oral examination revealed loss of left eye due multidisciplinary management and team approach to measles infection acquired at the age of 5 years are essential in providing accurate and effective and he had been wearing pre-fabricated eye rehabilitation and follow-up care for the patient.4 prosthesis since 50 years. The mucosa of the eye Frequently, an implant is placed in the tissue bed to socket appeared healthy with intact tissue bed. [Fig- facilitate the construction of an ocular prosthesis. 1] So according to the present condition and However, apart from its cost, principal economic reasons, rehabilitation of the ocular

* Professor and Head, ** Professor, *** Post Graduate Student, **** Post Graduate Student DEPARTMENT OF PROSTHODONTICS, CROWN AND BRIDGE AND ORAL IMPLANTOLOGY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL, GANDHINAGAR, GUJARAT- 382115, INDIA

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. DARSHANA SHAH , TEL: +91 9824510309

56 Darshana Shah et. al. : Rehabilitation Of Ocular Defect Using Custom Made Ocular Prosthesis- A Case Report defect by fabricating a custom made ocular Gujarat, India) was mixed and poured to produce prosthesis was planned, to replace the missing eye the internal surface details of the final impression and surrounding structures, after thorough and to make the lower (first) half of the mould. explanation of the procedure to the patient with Before the stone sets, the indexing grooves were obtained consent. made for re-orientation. After the application of the Primary Impression Procedure: separating media over the lower half, the upper (second) half of the mould was poured with type III An ophthalmic topical anaesthesia was applied to dental stone (Gold Stone, Asian Chemicals, the socket to increase the patient's comfort for the Gujarat, India), which covers the external surface of entire procedure. A primary impression of an the final impression and a funnel shaped hole was anopthalmic socket was made by using alginate left unfilled around the stem of the tray for the impression material (Mari flex, Septodont passage of the molten wax. Healthcare India Pvt Ltd., Class A, Type II: Normal setting). A thin mix of the material was being flowed Fabrication and Try in of Scleral Wax Pattern : into the socket by using a disposable syringe (Dispo The molten modelling wax was poured into the two- van 5 ml, Hindustan syringes & medical devices piece mould through the hole as described above, Ltd). Patient was seated, with the head tilted at the allowed to chill and removed from the mould angle of 45 0 to the floor and then asked to perform carefully. Then the wax pattern was properly various eye movements like closing, opening, up- contoured and carved till it fitted properly into the down and lateral movements of the contralateral socket. To insert the wax pattern, upper eye lid was eye. The set alginate impression was then supported lifted up, placing the superior edge of the pattern and retrieved from socket by using 19 gauge behind the lid and gently pushed upward. While the orthodontic wire loop [Fig-2] and poured with type lower lid was drawn down, the inferior border of the III dental stone (Gold Stone, Asian Chemicals, pattern was seated in the inferior fornix and lower Gujarat, India) from which a self-cure acrylic resin lid was released. The wax pattern was checked for (Pyrax polymars, India) special tray was fabricated. the size, support from the tissues, simulation of The tray was perforated centrally, for the functional eye movements, and eyelid coverage attachment to the syringe nob and at the periphery, until it resembled patient's natural eye. for the excess material to get flowed through, during Selection and Placement of Iris on the scleral final impression. [Fig-3] Wax Pattern: Final Impression Procedure: An iris, closely matching to the natural eye's shade For the final impression, the disinfected special tray and size, was selected from the stock eye. For the was tried in patient's eye socket to check for the centralization and correct placement of iris on the extensions. Additional silicone light body material scleral wax pattern, parallel lines were marked on (Photosil, DPI) was homogenously mixed, loaded the patient's face, surrounding the natural eye and and carried out in a disposable syringe. The material the distance between the lines were measured: from was then injected into the socket and was supported the midline of the face to the medial canthus, from by the special tray attached to the syringe nob. [Fig- medial canthus to the centre of the iris and from the 4] Patient was then asked to perform muscular centre of iris to the lateral canthus. The same movements of the contralateral eye ball in all markings and measurements were transferred on directions to allow the material to flow in all the the defect side eye. [Fig-7] The contralateral eye areas of socket, as well as on the outer surface of the side measurements were used for comparison and tray to record the movements of eye lids also. The the iris position was located on the wax pattern set final impression was then carefully picked up accordingly, with an indelible marking pen. The from the socket and was checked to ensure the fine pupil was used as the center of the eye ball. Once the surface details. [Fig-5] position was verified, the wax pattern was removed. Pouring of The Final Impression and Selected iris from the stock eye was trimmed Fabrication Of Two-piece Mould: [Fig-6] carefully and placed into scleral wax pattern according to measurements [Fig-8] and the wax Type IV dental stone (Pearl stone, Asian Chemicals, pattern was again tried and verified with iris in

57 Darshana Shah et. al. : Rehabilitation Of Ocular Defect Using Custom Made Ocular Prosthesis- A Case Report place. [Fig-9] Investing, flasking and dewaxing of scleral wax pattern: [Fig-10] The final carved and adjusted scleral wax pattern with the iris was then invested and flasked in a conventional manner with an attachment in place, made up of clear self-cure acrylic resin (Pyrax polymars, India), fixed to the iris, to secure its Fig.1: Pre-treatment Fig.2: Primary Impression, placement to the counter-flask while flasking and View: Ocular Defect With Alginate dewaxing was done in a usual manner. Packing and Characterization: The heat cure tooth moulding material (DPI tooth moulding powder, The bombay Burmah trading Corporation Ltd, Mubai, India), matching the shade of the natural eye sclera was selected for packing. First, trial closure was done by using a thin polythene sheet and after separating the flasks, characterization was performed to mimic red veins, Fig.3: Fabrication Of by incorporating red fibers, collected from Lucitone Special Tray heat cure denture base resin, (Dentspy, Germany) with the help of heat cure monomer liquid. After that the heat cure acrylic resin was processed in a usual manner. Processing time can be reduced as less bulk of the resin is used to be cured. So, 20 minutes in boiling water was sufficient. After processing, the flask was bench cooled and the prosthesis was retrieved from the mould. The converted heat cured ocular prosthesis was finished Fig.4: Final Impression Making and polished with the pumice. [Fig-12] Delivery of customised ocular prosthesis: [Fig- 14] The final polished ocular prosthesis was then disinfected (0.5% Chlorhexidine gluconate solution + 70% isopropyl alcohol) for five minutes. After Fig.5: Final Impression Fig.6: Fabrication Of disinfection the prosthesis was rinsed with sterile For Eye Prosthesis Two-piece Mould saline to avoid chemical irritation and was lubricated to improve smooth functional eye movements. The fit of the artificial eye and the lid configurations of both eyes were compared and evaluated by visual observation. Post treatment instructions for placement, removal, cleaning and maintenance of the prosthesis were given and need of regular follow up was explained.

Fig.7: Wax Pattern Trial Fig.8: Placement Of Iris With Measurements In Wax Pattern For Iris Placement

58 Darshana Shah et. al. : Rehabilitation Of Ocular Defect Using Custom Made Ocular Prosthesis- A Case Report

to granuloma formation), poor aesthetics and poor eye movements.11 Moreover, the voids in the prefabricated prosthesis collect mucus and debris, which can irritate mucosa and act as a potential source of infection, which are minimized in custom- made prosthesis.11,12 However, custom-made prosthetic eye fabrication involves complex painting procedures in various Fig.9: Final Trial Of Fig.10: Flasking stages that are quite difficult and based purely on Wax Pattern And Dewaxing painting skills of the operator.13 The technique used, With Iris In Place to fabricate ocular prosthesis in this case report, modifies a pre-fabricated eye prosthesis to a custom-made fit with improved aesthetics. Thus using a combination technique, in which iris button was attained from the prefabricated eye and customized scleral portion was created from the impression of the socket, can help us to overcome the disadvantages of a prefabricated eye prosthesis. Fig.11: Old Pre-fabricated Fig.12: Customised The technique is relatively easy to perform, saves Eye Prosthesis Ocular Prosthesis the laboratory time, restores the opening as well as various degrees of eye movements correctly and supports the eyelid. Instead of having various advantages, limitations of this technique are, the clinician is dependent on the availability of the prefabricated eye with properly matching the iris size and shade. Also, the long-term colour stability of the heat-cured acrylic and the strength of its union with the stock iris will have to be closely evaluated with regular follow up.9 CONCLUSION: As the main purpose of the maxillary facial Fig.13: Pre-treatment Fig.14: Post-treatment prosthesis is to mimic nature, the technique discussed in the above-reported case ensure that the DISCUSSION: use of customized ocular prosthesis has been a boon The art of making artificial eyes has been practiced to the patients who cannot afford for the implant since ancient times. The first ocular prosthesis was placements. The custom made ocular prosthesis made by Romans and Egyptian priests as early as also permits the finished prosthesis to generate an the fifth century BC. Artificial eyes were made of equal distribution of pressure and intimate enamel, metal or painted clay and attached to cloth adaptation to the tissue bed, which enhances the and worn outside the socket. In the 15th century, the patient's comfort and confidence by increased first in-socket artificial eye was made using gold adaptiveness and natural appearance, and also 11 with coloured enamel. Thus fabrication of ocular maintains its orientation during various eye prosthesis has been known to human being since movements. Although the vision is the main aspect times immemorial. of the eye, prosthodontist cannot replace this aspect, Except ocular implants, two other options are but can definitely restore the most beautiful aspect available for artificial eye prosthesis, one is a pre- of the life, esthetics and facial expressions, which fabricated ocular prosthesis and the other is custom- allow the patient to face the world confidently. made. Pre-fabricated prosthesis carries potential disadvantages of poor fit (which endangers the eye

59 Darshana Shah et. al. : Rehabilitation Of Ocular Defect Using Custom Made Ocular Prosthesis- A Case Report

REFERENCES: 1969;17:266-9. 1. Raflo GT. Enucleation and evisceration. In 7. El-Dakkak M. Problem solving technique in Tasmun W, Jaeger E (Eds.), Duane's clinical ocular prosthetic reconstruction. Saudi Dent J ophthalmology, Revised ed, Vol. 5. 1990;2:7-10. Philadelphia: Lippincott-Raven, 1995: 1-25. 8. Smith RM. Relining an Ocular Prosthesis: A 2. Sunil Kumar Mishra and Chowdhary Ramesh. Case Report. J Prosthodont 1995;4:160-3 Reproduction of custom made eye prosthesis 9. Dr. Hardik K Ram, Dr. Rupal J Shah. Simplified maneuver: A case report. Journal of Dentistry method for Ocular Rehabilitation: - A Case and Oral Hygiene December 2009; Vol. 1(5): Report. IOSR Journal of Dental and Medical 59-63 Sciences. Jan.- Feb. 2013; Volume 3(4):10-13 3. Artopoulou II, Montogomery PC, Wesley PJ, 10. Naeem Ahmad, Aruna J Bhandari, U Pai , S.A. Lemon JC. Digital imaging in the fabrication Gangadhar. Prosthetic Management of a patient of ocular prosthesis. J Prosthet Dent 2006; 95: with an Ocular Defect. Pravara Med Rev 2009; 327-30. 1(2) 4. Nafij Bin Jamayet, Theerathavaj Srithavaj, 11. Cain JR. Custom Ocular Prosthesis. J Prosthet Mohammad Khursheed Alam. A Complete Dent 1982; 48: 690-4 Procedure of Ocular Prosthesis: A Case Report. International Medical Journal. December 2013; 12. Grisius MM, Robert L. Treatment of Vol. 20(6): 729 - 730 lagophthalmos of the eye with a custom prosthesis. J Prosthet Dent 1993;70:333-5. 5. Beumer J, Zlotolow I. Restoration of facial defects. In: Beumer J, editor. maxillofacial 13. Allen L, Webster HE. Modified impression method of artificial eye fitting. Am J rehabilitation - prosthodontic and surgical Ophthalmol 1969;67:189-218. considerations 1st ed. St. Louis: C. V. Mosby publishers; 1996. p. 350-64. 14. Doshi PJ, Aruna B. Prosthetic management of patient with ocular defect. J Ind Prosthodont 6. Goel BS, Kumar D. Evaluation of ocular Soc 2005; 5: 37-38. prosthesis. J All India Ophthalmol Soc

60 DEPARTMENT OF PERIODONTICS: Dr. Balaji Manohar Dr. Pravin Kudva Dr. Bela Dave DEPARTMENT OF CONSERVATIVE DENTISTRY: Dr. Sunita Garg Dr. Medha Jain DEPARTMENT OF PROSTHODONTICS: Dr. Sunilkumar M. V. Dr. Rajesh Seturaman Dr. Saumil Mathur Dr. Keval Shah DEPARTMENT OF ORAL MEDICINE & RADIOLOGY: Dr. F. R. Karjodkar Dr. Jigna Shah DEPARTMENT OF ORAL PATHOLOGY: Dr. Raksha Shah Dr. B. Sivapathasundra DEPARTMENT OF ORTHODONTIA: Dr. A. F. Bhatia Dr. N. Daruwala DEPARTMENT OF ORAL SURGERY: Dr. Bhagvandas Rai Dr. Anisha Maria Dr. Kiran Desai Dr. Babu Parmar DEPARTMENT OF PEDODONTICS: Dr. Rashmin Naik Dr. Vaishali Nandiniprashad DEPARTMENT OF PUBLIC HEALTH DENTISTRY: Dr. Ajith Krishnan Dr. Janki Shah Dr. Sujal Parkar

Mr. P. K. Kulkarni Ex. Deputy Director, Senior Grade Stastatician, National Institute of Occupational Health, Gujarat

61 ETHICS COMMITTEE

CHAIRPERSON Dr. Mahendra K. Joshi Advocate & Medico Legal Advisor DEPUTY CHAIRPERSON

Dr. Mahadev Desai Professor & Head, Dept of General Medicine, ADCH.

MEMBER SECRETARY Dr. Rupal Vaidya Professor & H.O.D Conservative Dentistry & Endodontics, ADCH.

COMMITTEE MEMBERS Dr. Darshana Shah Professor & H.O.D Dept of Prosthodontics & Crown & Bridge, ADCH

Dr. Dolly Patel Professor & H.O.D Orthodontics & Dentofacial Orthopedics, GDCH.

Dr. Chetana Desai Professor Dept of Pharmacology BJMC, Ahmedabad.

Dr. G. C. Patel Statistician

Dr. Harsh Shah Reader Department of Public Health Dentistry, ADCH.

Dr. Dilip Zaveri Director Biocare Research (India) Pvt. Ltd. Paldi, Ahmedabad.

COMMUNITY REPRESENTATIVE / SOCIAL WORKER Mr. Ashish Shah

Dr. Janki Vasant NGO. Samvedna

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