INDEX
List of Articles Pages No.
An in Vitro Correlative Study of Sella Turcica Dr. Priyanka 1 - 6 Roofing and Dental Anomalies Chintaman Saokar
Effect of Platelet Rich Plasma on Osseo Integration of Dental Implants by Texture Based Evaluation of Patient’s Dental Dr. Guljot Singh 7 - 14 Panoramic Radiographs - An In Vivo Study
Low Level Laser Therapy for Dentinal Hypersensitivity Dr. Piyush Pareek 15 - 22 - A Review
Chronic Osteomyelitis of Jaw Dr. Dhawal Goyal 23 - 27
Surgical Periodontal Therapy using as a Dr. Kamal Garg 28 - 35 Different Scalpel
Role of Laser Bioactivation in Surgical Periodontal Therapy: Dr. Rajni Aggarwal 36 - 41 An Update
Efficacy of Locally Delivered Antimicrobials in the Management of Periodontal Pocket Dr. Guljot Singh 42 - 49 - A Clinical Evaluation
Endodontic Management of Bayonet Shaped Canals in Single and Multirooted Second Dr. Navdeep Jethi 50 - 54 Premolar – Case Series.
An in Vitro Correlative Study of Sella Turcica Roofing and Dental Anomalies
Dr. Priyanka Chintaman Saokar, 1 Dr. Akshai Shetty, 2 Dr. Dinesh M.R., 3 Dr. Sudhir Navale 4
1. Dr. Priyanka Chintaman Saokar Senior Lecturer, Department of Orthodontics, YCMMRDF Dental College and Hospital, Vadgaon Guptaa, Ahmednagar, Maharashtra, India 2. Dr. Akshai Shetty Associate Professor, D.A.P. M. R.V. College and Hospital, Bangalore, Karnataka, India 3. Dr. Dinesh M.R. Head of Department, D.A.P. M. R.V. College and Hospital, Bangalore, Karnataka, India 4. Dr. Sudhir Navale Associate Professor, Bharati Vidyapeeth Pune, Katraj, Pune.
Abstract Objective: The objectives of the present study were to find out the association between the Sella Turcica Bridging with dental anomalies and incidence of most common type of bridging in local population. Material and Methods: For the study, 50 pretreatment lateral cephalometric radiographs showing complete Sella Turcica Bridging and 50 pretreatment lateral cephalogram without Sella Turcica Bridging were taken. After collection of the samples, retrospective study was performed with analysis of patient’s records that included case history, orthodontic study models, orthopantomograms, intraoral periapical radiograph, occlusal radiograph, intraoral and extraoral photographs. The purpose of this analysis was to assess the associated dental anomalies. Result: The results of the present study indicated that there was a significant association between the presence of Sella Turcica Bridging with dental anomalies Conclusion: Incidence of dental anomalies was found to be higher in patients with Sella Turcica Bridging as compared to those without Sella Turcica Bridging. There was no significant difference in incidence of patients having Type A and Type B Sella Turcica Bridging. Keywords: Sella Turcica Bridging, Neural Crestal Cells, Lateral Cephalogram, Pituitary Gland
INTRODUCTION with a significant problem in other system. With the introduction of cephalometer by Interestingly, some of these findings are detectable Broadbent in 1931 orthodontist were given a very early in life and often precede other signs or valuable tool for investigation of facial and cranial symptoms in syndromes. Therefore, in some cases, growth which helped the practicing orthodontist in they could potentially be valuable for an early clinical evaluation and treatment planning for diagnosis. 2 patients. However, orthodontist also have the The sella turcica is an important anatomical responsibility to carefully examine the structure for cephalometric assessment because of cephalometric radiograph, not only to observe its central landmark. The sella turcica lies on the facial patterns or verify accuracy of tracing but also intracranial surface of the body of the sphenoid and to determine if other abnormalities are present. We consists of a central pituitary fossa . Two anterior must not forget that the field of orthodontics is and two posterior clinoid processes project over the concerned with the health of entire individual.1 pituitary fossa. Fusion of the posterior and anterior Most of these pathologic conditions, developmental clinoid processes is known as a sella turcica bridge. abnormalities, or normal variants are associated 1 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 There are two types of bridging depending on their For the present study, 50 pretreatment lateral radiographic appearances. 3 cephalometric radiographs showing complete Sella Formation and development of the sella turcica and Turcica Bridging were retrieved from the 500 teeth share, in common, the involvement of neural existing case records. Control group consisted of 50 crest cells. In fact, the anterior part of the sella pretreatment lateral cephalogram without Sella turcica is believed to develop mainly from neural Turcica Bridging; retrieved from same case records crest cells and in tooth development; dental by using simple random sampling. After collection epithelial progenitor cells differentiate through of sample, retrospective study was performed with sequential and reciprocal interaction with neural analysis of patient records that include case history, crest-derived mesenchyme. 4 orthodontic study models, orthopantomograms, Recently some studies have been done to establish intraoral and extaoral photographs, intraoral association of craniofacial skeletal anomalies with periapical radiographs and occlusal radiogrophs. dental anomalies. This relationship may be based The purpose of this analysis was to assess any on the involvement of neural crest cells and/or associated dental anomaly in patients with Sella homeobox or hox genes during the development Turcica Bridging and patients without Sella Turcica stage. It appears that tooth formation and their Bridging. Considering Shafer’s classification eruption and sella turcica bridge calcification, as morphological variations in size, shape, structure, well as neck and shoulder skeletal development, are number and eruption of teeth were analyzed. influenced by neural crest cells.2 Correlation between Sella Turcica Bridging and So, the main purpose of this study is to elucidate dental anomalies was evaluated. 5 relationship between Sella Turcica Bridging and To determine most common type of the Sella dental anomalies in local population. Other purpose Turcica Bridging; two different morphological of this study is to find out most common type of appearances of sella bridging (Type-A and Type- Sella Turcica Bridging in local population. B) were used and compared with the current study. MATERIAL AND METHODOS Type-A: that manifest ribbon like fusion In the present study, pretreatment cephalometric Type-B: that manifest extension of anterior and/or radiographs of 100 patients of local population of posterior clinoid process, where these two meet Karnataka; aged 7-30 years were taken. They were either anteriorly, posteriorly or in the middle, with grouped in to two groups based on presence or thinner fusion.6 (Photograph 1, 2) absence of Sella Turcica Bridging. Statistical Method: Group 1: Fifty Subjects with Sella Turcica Chi-Square test and z-test were used in this study. Bridging 1. Chi-Square test:7 Group 2: Fifty Subjects without Sella Turcica A chi-square test was used for: Bridging. To find out association of dental anomalies in the Armamentarium: group with Sella Turcica Bridging and without 1. High quality radiographs which were taken by Sella Turcica Bridging. trained radiographic technicians in a 2.Z test:8 standardized manner with clearest Z test was used to compare the different reproduction of sella turcica area. morphological variations of Sella Turcica Bridging 2. High quality orthodontic study models i.e. Type-A and Type-B. 3. High quality orthopantomograms It is used to test significance of difference in means 4. High quality intraoral periapical radiographs for large samples (>30) 5. High quality occlusal radiographs Statistical software: 6. High quality intraoral and extraoral The Statistical software namely SPSS 11.0 and photographs Systat 8.0 were used for the analysis of the data and 7. Case history records of patients Microsoft word and Excel have been used to generate graphs, tables etc.
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Photograph: 1 Photograph:2 Sella Turcica Bridging-Type: A Sella Turcica Bridging-Type: B (Ribbon like fusion) (Thinner fusion with extension of anterior and/or posterior clinoid process)
RESULTS patients with Sella Turcica Bridging compared to In the present study, association of Sella Turcica those without Sella Turcica Bridging. This Bridging with dental anomalies was studied. The association was statistically highly significant (P- sample constituted 50 cases with Sella Turcica value: <0.001). Bridging and 50 controls without Sella Turcica 2. Distribution of type of bridging: (Table 2, Bridging. The gender distribution in the present Graph2) study was found to be 36 males and 64 females. One of the objectives of this study was to find out Results obtained in the study are as follows: most common type of Sella Turcica Bridging in 1. Association of Sella Turcica Bridging and local population. Z test was carried out to compare dental anomalies: (Table 1, Graph1) the proportions of patient with Type- A and Type- As the main objective of this study was to find out B Sella Turcica Bridging. 46 % cases had Type-A association between Sella Turcica Bridging and Sella Turcica Bridging and 54% cases had Type-B dental anomalies; chi square test was carried out. Sella Turcica Bridging. No statistically significant 90% cases with Sella Turcica Bridging showed difference was found between the proportions of presence of anomalies and 38% cases without Sella patients having Type A and Type B bridging in the Turcica Bridging showed presence of anomalies. study sample (P value: >0.05). Presence of anomalies was found to be higher in
Table No. 1: Comparison of the presence of anomalies in cases with bridging and without bridging: With Bridging Without Bridging Anomaly Total Chi-sq P-Value N % N %
Present 45 90.00 19 38.00 64
Absent 5 10.00 31 62.00 36 29.340 <0.001**
Total 50 100 50 100 100
** Highly significant
3 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 Graph No. 1: Presence of anomalies in patient with bridging and without bridging:
Table No. 2: Distribution of type of bridging in study sample: Bridging Type N % Z P-Value
Type A 23 46.00
Type B 27 54.00 -0.800 0.422
Total 50 100
Graph No. 2: Distribution of type of bridging in study sample:
DISCUSSION development and then ossifies in very early Calcification of diaphragma sellae, which childhood. According to this theory, a sella turcica radiologically has been described as ‘roofing’ or bridge should be considered as a developmental ‘bridging’ of the sella, in the absence of clinical anomaly.10,11 Moreover, as the area anterior to the signs or symptoms, is considered as a normal sella turcica in the early embryonic period develops variant of the sella turcica.9 Although many predominantly from neural crest cells, any pathological conditions can be associated with this structural deviations in the anterior wall are calcification. As far as the etiology is concerned, it believed to be related to specific deviations in the has been suggested that an inter cliniod ligament is facial skeleton. 12 laid down in cartilage at an early stage of
4 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 Hochstetter and Kier postulated that osseous Mutations of several genes are associated with interclinoid ligament was a developmental anomaly syndromic tooth agenesis. To date, the familial and and they showed the existence of the foramen sporadic forms of tooth agenesis have been formed by this ligament in fetus and infant skull.13 associated with mutations in MSX1 and PAX9.24 It was concluded that cartilagenous interclinoid Interestingly, MSX1- and PAX9-deficient mice taeina were extremely rare hence could not be exhibited several other craniofacial regarded as routine occurrences.14 abnormalities.25,26 In the present study, association of Sella Turcica Knowledge of sella turcica morphology is of great Bridging with dental anomalies was studied in 50 importance for orthodontic diagnosis and treatment cases with bridging and 50 controls without planning because orthodontists regularly analyze bridging. The statistical analysis showed highly considerable number of profile radiographs. significant association between the presence of Orthodontists will be in many cases the first to anomalies and the Sella Turcica Bridging register minor malformations of sella turcica. (P<0.001). Presence of anomalies was found to be Insight into the sella turcica malformations and higher in patients with bridging as compared to information about the etiological background of those without bridging. In this study, incidence of such malformations is very important. dental anomalies was 90 per cent with Sella As one of the objectives of this study was to find Turcica Bridging and 38 percent without Sella out the most common type of Sella Turcica Turcica Bridging. This is in accordance with the Bridging in local population, the results showed no studies done by Rosalia Leonardi, Ersilia Barbato, statistically significant difference between the Maurizio Vichi and Mario Caltabiano.4 This proportions of patients having Type A and Type B finding is also consistent with the study done by bridging in the study samples (P>0.05). But there Sandham A, Horsewell B, Kjaer I, where they was an overall increased incidence of Type-B Sella found that skeletal anomalies or normal variant Turcica Bridging (54%) when compared with seen in cephalometric radiograph are associated Type-A (44%) sella turcica brigding. This finding with dental anomalies15,16,17 is in accordance with the study done by R.M.Jones, One of the possible etiologies for the increased A. Faqir, D.T. Millett, Jonas P. Becktor, Sanna occurrence dental anomalies with Sella Turcica Einnerson.3 Bridging could be that the formation of Sella From a clinical point of view, these skeletal Turcica Bridging and the development of the teeth, anomalies and /or normal variants may be share in common the involvement of neural crest considered as risk factors that could enable the cells. In fact, the anterior part of the sella turcica is clinician to make an early diagnosis and thus treat believed to develop mainly from neural crest cells. the dental anomalies at an early stage. Because In the initial period of embryogenesis, the primitive many of these skeletal anomalies and normal oral cavity is lined by oral ectoderm; most of the variant present early in life, their early detection connective tissue cells underlying the oral ectoderm can be used to forecast the presence of dental are of neural crest cells. These cells are thought to anomalies later in life, enabling the clinician to instruct or induce the overlying ectoderm to start adopt preventive measures. tooth development.18 Dental epithelial progenitor CONCLUSIONS cells differentiate through sequential and reciprocal The conclusions from this study were: interaction with neural crest-derived mesenchyme. 1. Incidence of dental anomalies was found to be 19,20 higher in patients with Sella Turcica Bridging Molecular studies of odontogenesis, using the as compared to those without Sella Turcica mouse tooth as a model, have shown that the tooth Bridging. development is under strict genetic control, which 2. There was no significant difference in determines tooth position, number, size, and shape incidence of patients having Type A and Type .21,22,23 The majority of cases involving hypodontia B Sella Turcica Bridging. and oligodontia are due to genetic factors. 5 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 REFERENCES
1. Stuart B, Fred A.L. Abnormalities found on 14. Lang J. Skull base and related structures: Atlas of cephalometric radiographs. Angle Orthod Oct1976. clinical anatomy. Stuttgart: Schattauer, 1995;175 Vol 46. No 4:381-386. 15. Sandham A. Cervical vertebral anomalies in cleft 2. Rosalia L,Ersilia B, Maurizio V, Mario C. Skeletal lip and cleft palate . Cleft Palate J.1986. Vol:23, Anomalies and Normal Variants in Patients with 206-214 Palatally Displaced Canines. Angle Orthod 2009. 16. Horsewell B B,The incidence and relationship of Vol 79. No 4:727–732. cervical spine anomalies in patient with cleft lip 3. Jones R.M., Faqir A., D. T. Millett D. T, Moos K. and cleft palate. J Oral Maxillofacial Surg. 1991. F, McHugh S. Bridging and Dimensions of Sella vol: 49. 693-697 Turcica in Subjects Treated by Surgical- 17. Kjaer I, Fischer Hansen, Keeling J W, Reintoft I. orthodontic Means or Orthodontics Only. Angle Pituitary gland and axial skeletal malformations in Orthod 2005. Vol75. No 5: 714–718. human faetuses with spina bifida. Eur J Pediatr 4. Rosalia L, Esralia B, Maurizio V, Mario C. Sella Surg. 1999. Vol:9: 354-358.) turcica bridge in subject with dental anomalies.Eur 18. Orban. Orban’s oral histology and embryology. J. orthod 2006. Vol 28:580-5853. 12th edition. Elsevier publication;2008. 5. Shafer W.G, Hine M.K, Levy B.M. A textbook of 19. Miletich I, Sharpe P T neural crest contribution to oral pathology. 4th edition. Elsevier mammalian tooth formation. Birth defect research. publication;1997. Part C, Embryo Today. 2004. Vol 72: 200-212 6. Inger K, Karin B. B, Lisson J, Charlotte G, Russel 20. Mortoni T et al. in vitro differentiation of dental B.G. Face, palate and craniofacial morphology in epithelial progenitor cells through epithelial patients with solitary median maxillary central mesenchymal interactions. Archives of oral incisor. Eur J. orthod 2001. Vol 23: 63-73. biology2005. Vol: 50, 695- 705 7. Park K. Park’s textbook of preventive and social 21. Thesleff I. The genetic basis of normal and medicine. 18th edition. Banarasidas Bhanot abnormal craniofacial development. Acta publication; 2005. Odontologica Scandinavica 1998. Vol :56. 321- 8. Soben P. Essentials of preventive and community 325. dentistry. 4th edition. Arya publication;2009. 22. Vastardis H. The genetics of human tooth agenesis: 9. Kantor M L, Nortan L A,. Normal radiographic new discoveries of understanding human tooth anatomy and common anomalies seen in anomalies. Am J Orthod Dentofacial Orthop 2000. cephalometric films. Am J Orthod Dentofacial Vol: 117. 650-656. Orthop 1987. Vol: 91. 414-426 23. Peters H, Balling R. Teeth: where and how to 10. Lang J. Sructure and postnatal organisation of make them. Trends in genetics. 1999. Vol 59. 59- heterofore uninvestigated and infrequent 65 association of sella turcica region. Acta Anatomica 24. Mostowska A,Kobielak A, Trzesiac W H. 1977. Vol: 99: 121-139 Molecular basis of nonsyndromic tooth agenesis: 11. Inoue T, Rhoton AL, Barry M E. Surgical mutations of MSX1 and PAX 9 reflect their role in approaches to cavernous sinus: a microsurgical patterning human dentition. Eur J. Of Oral study. Neurosurgery 1990. Vol: 26. 903-932 Sciences 2003. Vol 111. 365-370 12. Kjar I, Keeling J W, Reintoft I, Nolting D, Fischer 25. Satokota I, Mass R. MSX1 deficient mice exhibit Hansen B. Pituitary gland and sella turcica in cleft palate and abnormalities of craniofacial and human trisomy 21 fetuses related to axial skeletal tooth development. Nature Genetics 1994. Vol: 6. development. American journal of Medical 348-356 Genetics 1998. Vol : 80. 494-500 26. Peter H, Neubuser A, Kratochwil K, Balling R,. 13. Kier E L. Embryology of normal optic canal and its PAX9 deficient mice lack pharyngeal pouch anomalies. An anatomic and roentgenographic derivatives and teeth and exhibit craniofacial and study. Invest. Radiol. 1966. Vol: 1. 346-362 limb abnormalities. Genes And Development 1998. Vol : 12. 2735-2747.
6 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 Effect of Platelet Rich Plasma on Osseo Integration of Dental Implants by Texture Based Evaluation of Patient’s Dental Panoramic Radiographs - An In Vivo Study
Dr. Guljot Singh, 1 Dr. Sabiya Sheikh, 2 Dr. Shivani Jain, 3 Dr. Kalyani P Goswami, 4 Dr. Jyoti Beniwal 5
1. Dr. Guljot Singh Principal and Head, Department of Periodontology & Implantology, Daswani Dental College & Research Centre, Kota, Rajasthan, India. 2. Dr. Sabiya Sheikh PG Student, Department of Periodontics & Implantology, Daswani Dental College & Research Centre, Kota, Rajasthan, India. 3. Dr. Shivani Jain Senior Lecturer, Department of Periodontics & Implantology, Daswani Dental College & Research Centre, Kota, Rajasthan, India. 4. Dr. Kalyani P Goswami PG Student, Department of Periodontics & Implantology, Daswani Dental College & Research Centre, Kota, Rajasthan, India. 5. Dr. Jyoti Beniwal Research Assistant, Dr. Harvansh Singh Judge Institute of Dental Sciences Hospital, Sector 25, South Campus, Panjab University, Chandigarh
Abstract Aim: To analyse the effect of application of autologous Platelet-Rich-Plasma (PRP) on the osseointegration of implants using texture -based analysis of the patient’s sequential dental panoramic radiographs. Methods: Twenty Partially edentulous patients without any localized or generalized pathology in the implant region were selected for this randomised control clinical trial. Patients were equally alloted in two treatment groups: Group A [ test group] included 10 patients, who received endosseous implants exposed to autologously extracted platelet rich plasma and GROUP B [control group] included 10 patients, in whom endosseous implants NOT exposed to autologously extracted platelet rich plasma were placed. Effect of PRP application on the peri-implant bone regeneration and osseointegration of the implant was analysed by texture- based analysis of orthopantomograph at baseline, 3months and 6 months postoperatively. Following recording of sequential radiographs, Spatial Gray Level Dependance Method was used to analyse the radiographic difference in the osseointegration of implants belonging to the test and control groups. Results: The study revealed that no significant difference was demonstrated between the osseointegration of an implant placed conventionally in a freshly created osteotomy site and treatment of the implant surface with platelet rich plasma extracted autologously from the patient’s own venous blood sample. Conclusion: Exposure of an implant surface to autologously generated PRP extract does not have a significant effect on the osseointegration of implants. Keywords: Dental Implants, Osseointegration, Platelet Rich Plasma, Panoramic Radiographs
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INTRODUCTION Formal consent was taken for all patients Implant treatment mainly aims at functional participating in the study with due explanation of restoration of stomatognathic system which all underlying procedures within the study such as provides comfort and health for the patient. implant surgery, radiography, implant prosthetic Osseointegration forms basis of implant success. superstructure clinical procedures, etc. The study Platelet plays a fundamental role in the early stages utilised orthopantomography (OPG) as a of wound healing and bone regenaration by comparative sample for the analysis of efficacy of releasing growth factors and other molecules. osseointegration for the two patient groups at Platelet rich plasma is one such autologous source, baseline, 3 months and 6 months postoperatively. rich in various growth factors whose release Sequentially recorded radiographs of each subject continues for 7 days. were evaluated for differences in peri-implant bone This study evaluates the use of PRP in regeneration in the test and control groups via osseointegrated implant sites & the study effect Spatial Gray Level Dependance Method (SGLDM) was analysed using the Spatial Gray Level involving texture based analysis of the radiographs Dependence Method (SGLDM) involving texture- . This involved a vertical pixel to pixel comparative based analysis of the patient’s sequential dental analysis of the gray level segregation of the panoramic radiograph. radiographic image through comparison of the MATERIAL AND METHODOLOGY spatial distribution of gray focus levels in the The present study was conducted on 20 patients regions of interest i.e. the immediate 500-1000µm who reported the OP department (OPD) of the radius around the placed implant length. The ROI Department of Periodontics & Implantology, values were then tabulated for statistical analysis. Daswani Dental College & Research Centre, Kota RANDOMISATION - patients were randomly for replacement of missing teeth. All the patients assigned in one of the 2 groups included in the study fulfilled the eligibility criteria Group A [TEST GROUP]- 10 partially edentulous INCLUSION CRITERIA - Inclusion criteria was patient were subjected for endosseous implant relatively open ended so as case selection could be exposed to autologous platelet rich plasma. possible within the limits of standardization. Age Group B [ CONTROL GROUP]- 10 partially limit was 18 years to 60 years to encompass all edentulous patient were subjected for endosseous common causes of tooth loss requiring implant implant NOT exposed to platelet rich plasma. therapy for replacement such as gross decay, PROCEDURE trauma, bone loss as well as age related tooth loss. GROUP A - subjects were required to provide 5ml To prevent any compromise in the prosthetic sample of venous blood prior to implant placement superstructure fabrication, the mesiodistal surgery for harvesting the autologous PRP. diameter of the edentulous span was defined to an Steps in PRP Preparation: 8 to 10mm range to cover both anterior and 1. With sterile gauze and injection 5 ml Venous posterior jaw regions. Good to fair oral hygiene blood was drawn into a test tube containing an was considered (OHI-S: 0.0 to 2.0), as described by anticoagulant to avoid platelet activation and Green et al (1964). Bone height for implant degranulation. placement was kept in the range of 8mm to 15mm 2. The test tube carrying the processed blood to include all/most possible implant sizes sample was then placed in the centrifuge with EXCLUSION CRITERIA - Patients with adverse another test tube placed contralaterally with occlusal habits such as bruxism were excluded to the same metric quantity of saline for prevent possible future implant overload. Patients centrifugal balance. with higher values of OHI-S along with 3. The first cycle of centrifugation was then periodontally, Medically, psychiatrically and performed, called the "soft spin[1]” at 3000rpm physically compromised patients as well as for 10 mins. pregnant subjects were excluded. 8 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 4. Centrifuged blood sample was Separated in atop it and the surgical flap was sutured back three layers, bottom-most RBC layer (55% of into place with the implant submerged under total volume), top most acellular plasma layer the soft tissue [fig 1.D] & [ fig 2.D]. A called PPP (platelet poor plasma) (40% of protective surgical pack was then placed over total volume), and an intermediate PRP layer the implant site to prevent trauma or food (5% of total volume) called the "buffy coat" lodgement and contamination to the site and occurred at this stage. the sutures. 5. Using a sterile syringe, the PPP, PRP and b) Second Stage Surgery: After the healing some RBCs were then transferred into another period, incision was placed over the implant tube without an anticoagulant site and soft tissue reflected sufficiently to 6. This test tube was now subjected to a second allow removal of cover screw. Healing centrifugation, which was longer and faster abutments were placed and gingival tissue than the first, called a "hard spin". This was sutured around it. Later, the healing allowed the platelets (PRP) to settle at the abutments were removed and final abutments bottom of the tube with a very few RBCs, were placed on which implant prosthesis was which explains the red tinge of the final PRP fabricated following prosthetic superstructure preparation. The acellular plasma, PPP (80% fabrication steps. of the volume), was found at the top. c) Radiographic Examination: Parameters 7. Most of the PPP was removed with a syringe were recorded with IOPAR (Intra-Oral Peri- and discarded, and the remaining PRP was Apical Radiograph) and OPG shaken well for homogenisation. (Orthopantomograph immediately following 8. This extracted PRP was then mixed with the implant procedure at baseline, at 90 days bovine thrombin and calcium chloride at the & at 180 days post-operatively by. Following time of application (This results in gelling of recording of sequential radiographs, the the platelet concentrate. Calcium chloride Spatial Gray Level Dependence Method nullifies the effect of the citrate anticoagulant (SGLDM) was used to analyse the used, and thrombin helps in activating the radiographic difference in the fibrinogen, which is converted to fibrin and osseointegration of implants belonging to the cross-linked[2]) test and control groups. Difference in the 9. The extracted PRP was then loaded into a radiographic gray level saturation of the syringe and manually coated onto the implant control and test group were then analysed for being placed into the freshly prepared notable differences. osteotomy site for group A patients. RESULTS SURGICAL TECHNIQUE The effect of application of autologous Platelet- The surgical procedure was same for both the Rich Plasma (PRP) on the osseointegration of the groups and was divided into two stages: implant using texture based analysis of the a) First Stage Surgery: After assessing the pre- patient’s dental panoramic radiographs recorded on treatment records, and fabricating a surgical the day of implant placement [fig.3A, 3.B], and at stent, crestal incision was given[fig1.A] &[fig 180 days (6 month) [fig. 3.C, 3.D] postoperatively 2 A]and full thickness flap was raised at the was analysed. The null hypothesis for the present proposed implant placement site[fig1.B] &[ study stated that there is no significant relation fig.2.B] Implant site was then prepared by between the osseointegration of an implant placed sequential drilling to prepare the osteotomy conventionally in a freshly created osteotomy site site to receive the implant [fig. 2.C]. The and treatment of the implant surface with platelet implant fixture (untreated for Group B and rich plasma(PRP) extracted autologously from the treated with autologous PRP for Group A) [fig patient’s own venous blood sample. Based on the 1.C] was then placed into the osteotomy site, values obtained and the results hence calculated, following which a cover screw was placed statistical analysis using means and Paired ‘t’ Test 9 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 reveals that the ‘t’ value for all test and control By conventional criteria, this difference is group evaluations approached 0.0000 along with a considered to be not statistically significant. statistically insignificant p value (p>0.05). GROUP B: [90 days] P value and statistical Statistical Analysis: - the clinical data was significance: The P value equals 1.0023 by analysed statistically by paired t test. conventional criteria, this difference is considered STATISTICAL RESULTS BASED ON THE to be not statistically significant. ANALYSIS OF AVAILABLE DATA (PAIRED GROUP C: [180 days] P value and statistical ‘T’ TEST): significance: The P value equals 1.0008 By GROUP A: [0 days] P value and statistical conventional criteria, this difference is considered significance: The P value equals 1.0000. to be not statistically significant.
Group Test Control Group Test Control Group Test Control (0) (0) (0) (0) (0) (0) Mean 77.6 76.8 Mean 83.6 83.2 Mean 85.7 86.2 SD 1.03 0.63 SD 1.08 0.59 SD 1.02 0.88 SEM 0.33 0.20 SEM 0.41 0.28 SEM 0.36 0.22 N 10 10 N 10 10 N 10 10
Fig. 1: Evaluation of Mean
Fig.1 [A]Crestal Incision for Mucoperiosteal Flap (Test Group-A). [B] Full Thickness Flap reflected. [C]Application of Autologously Extracted PRP onto Implant Fixture Surface. [D]Implant Fixture placed in Freshly Prepared Osteotomy site.
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Fig 2[A] Crestal Incision for Mucoperiosteal Flap(Control Group-B)[B] Reflection of Full Thickness Flap.[C]: Sequential Drilling for Endosseous Implant Placement.[D] Implant Hexed into Osteotomy Site with Cover Screw
Fig 3[A] ROI Analysis of Test Sample at 0 Days[B] ROI Analysis of Control Sample at 0 Days [C] : ROI Analysis of Test Sample at 180 Days.[D] ROI Analysis of Control
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Graph 1: Representation of Evaluation of Means of Test and Control Group ROI Values
DISCUSSION compared to that of an implant placed without The restoration of missing teeth is an important treatment with platelet rich plasma. aspect of modern dentistry. As teeth are lost to The study design used the orthopantomography decay or periodontal disease, there is a definitive (OPG) as a comparative sample for the analysis of demand for replacement of aesthetics or efficacy of osseointegration for the two patient function.The concept of replacement of missing groups as it provides a standardized method of teeth with dental implants allows the clinician to radiographic imaging based on well-defined rehabilitate the patient’s edentulism in a near skeletal landmarks, at the same time minimizing physiologic manner as a biologic union is expected the patient’s radiologic exposure[4] . A relatively to occur between the dental implant and the low voltage of 66 kV & current of 9 mA, with a patient’s alveolar bone . This biologic union is minimalistic exposure time of 16s restricts the referred as osseointegration, a term coined by patient’s radiologic exposure to a maximum of Dr.Per-Ingvar Branemark, the father of modern 0.010mSv. The method of comparison used to implantology. As the process of osseointegration analyse the effect of the application of platelet rich is primarily a result of a positive tissue response to plasma on the implant surface on the a biocompatible bone friendly substance, it is also osseointegration of the implant was chosen to be affected by a variety of natural and physiological the Spatial Gray Level Dependence Method factors. One very rich source of these growth (SGLDM) as described by Lee et al (1992). It is a factors that are known to positively enhance bone radiographic analytic technique based on formation and growth, is platelet rich plasma evaluation of 2-dimensional distribution of gray (PRP), which contains platelet derived growth level matrices on panoramic radiographs in factor (PDGF), transforming growth factor (TGF) specific parts of the radiographic image denoted as and many other such bone growth inducing plasma the study areas and known as regions of derivatives[3]. interest(ROIs), Based on the number of The present study was conducted to study the effect occurrences of gray matrices belonging to various of the application of this platelet rich plasma onto levels of saturation on a scale of 0.0 to 1.0, density the surface of an implant at the time of implant of the ROIs signifies increased radiopacity at a placement in a freshly prepared osteotomy site on microscopic level comparing the subsequent bone the subsequent osseointegration of the implant as formation as a result of osseointegration . Haralick
12 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 et al (2014) have compared SGLDM with other correlation could be found between radiographic analytic techniques like Pixel Based submicroscopic apposition of bone in the Texture Analysis (PBTA), Computational osseointegration of implants treated with PRP. Algorithm for Analysis of Image Saturation Ultramicroscopic evaluation and comparison of (CAIS), etc and concluded that SGLDM provides osteoblastic activity revealed a present but a more defined interpretation and gives a definitive statistically insignificant improvement in result when a comparison of near equal values of osseointegration of the samples belonging to the radiographic saturation is required. test group [5]. Ullas33 et al (2008) postulated that The desired physiologic effects of the growth early bone apposition following implant placement factors present in PRP were expected to enhance may be encouraged by exposure to PRP but the the osteo-inductive and conductive environment longterm bone response was similar in both the test and appositional bone growth occurring upon and and control groups, rendering the study result around the implant. But, comparison of the level of inconclusive[6]. Ketabi et al (2015) used Periotest osseointegration of the subsequent implant versus to compare the effect of local appli-cation of an implant placed without PRP treatment, analysed platelet-rich plasma (PRP) on osseointegration of using SGLDM involving texture- based analysis of implants placed in the mandible of edentulous the patient’s sequential dental panoramic patients. They concluded that no additional effect radiographs, did not reveal a statistically on implant stability was observed in the test group significant difference in a grayscale- based patients, although beneficial effects in improving measurement of predetermined pixel locations of soft and hard tissue healing were definitely radiographic regions of interest (ROIs) around the observed [7]. Several other such studies have implant at all three defined durations, viz. 0 days, arrived at similar lines of resultant research. 90 days and 180 days. A comparative evaluation of However, there is definitely a much wider scope of the grayscale saturation levels thus recorded research in the direction of acceptance of a positive revealed that the test values for both the sample effect of PRP on the osseointegration of dental groups were more or less similar. implants. Georgekapoulos et al (2014) The region of interest (ROI) values for implants demonstrated a significantly positive effect on placed in the test group patients demonstrated a bone formation in implants treated with PRP using mean ROI value of 82.3 units, whereas that of a radiographic analysis that utilizes couccurance of implants placed in the patients in the control group gray level matrices around healing implants[8]. was demonstrated to be 82.6 units. To prevent the Kundu24 et al (2014) demonstrated that a possibility that a sample ROI might include some synergistic effect of PRP was observed on pixels from the dental implant, leading to an improved implant stability and bone levels. additive effect on the grayscale saturation values, However, they also concluded that this effect was the grayscale saturation of bone regions not as markedly observed on implants placed in inconsequent to the implant site were also areas with perpendicular buttress osteocyte activity recorded, to define a credible range of bone surface such as the posterior maxilla. This allowed for grayscale saturation. reflection upon the effect of buttress arrangement As the study is entirely based on a comparison of on implant osseointegration.[9] In Study by these ROIs to arrive at a rejection or acceptance of Monov5 et al (2005), post placement implant the null hypothesis, it is imperative to consider the stability measurements were made by means of effect of the errors in demarcation on the resultant resonance frequency analysis at different time sample values. Although the evidence presented intervals, in implants placed with and without above describes various lines of reasoning as to exposure to PRP. study concluded that improved why the effect of PRP on the osseointegration of an resonance frequencies were noted in implants implant may not always be evident, direct studies exposed to PRP[10]. scientific evidence exists both supporting the result of this study are also in in favor of and against the result of the present abundance. Attia32 et al (2019) concluded that no study, it is only tactical to conclude that further 13 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 research in the field of submicroscopic, histologic CONCLUSION and radiographic interpretation of osseous changes Study reveals that no correlation was or regeneration that occur following the creation of demonstrated between the osseointegration of an an osteotomy site for the placement of an implant implant placed conventionally in a freshly created that may better allow a detailed analysis of the osteotomy site and treatment of the implant surface effect of osteoinductive and conductive with platelet rich plasma (PRP) extracted components of blood and its products may allow autologously from the patient’s own venous blood more light to be shed on a clearer correlation sample. between the said criteria. Conflicts of Interest: None.
REFERENCES
1. Froum S, Wallace S, Tarnow D, Cho S. “Effect of Augmentation:Implant Survival and Success Platelet-Rich Plasma on Bone Growth and Rates”. Journal Clin Med 2019;9:382-391. Osseointegration in Human Maxillary Sinus 6. SatyaS, Dhayanand V , Sangeetha S, Prakash PSG. Grafts: Three Bilateral Case Reports”. Int Journal “Plasma Rich Plasma In Periodontal Therapy”. J. of Periodont & Rest Dent 2002;22(1):45-53. Pharm. Sci. & Res. Vol. 9(6), 2017, 965-971. 2. Sebastian F, Olmeido D, Lineras J, Guglimote M. 7. Ketabi M, Fahami, Amini S. “Effect of Platelet- “Effect of Platelet-Rich Plasma on the Periimplant rich Plasma on Implant Stability in the Mandible”. Bone Response: An Experimental Study”. Imp Journal Periodont Imp Dent 2015;7(2):50-54. Dent 2004;13(1):73-78. 8. Georgakopoulos I, Tsantis S, Korfiatis P, Fanti 3. G Weibrich, Hansen T, Kleis W, Buch R, Hitzler E“The impact of platelet-rich-plasma(prp) on W. “Effect of platelet concentration in platelet-rich osseointegration of oral implants in dental plasma on peri-implant bone regeneration”. Bone panoramic radiography: A texture based 2004;34(4):665-71. evaluation”. Clin Min Met 2014 Jan;11(1):59-66. 4. 4.Ito K, Yamada Y, Naiki T, Ueda M. 9. Kundu R, Rathee M. “Effect of Platelet-Rich- “Simultaneous implant placement and bone Plasma (PRP) and Implant Surface Topography on regeneration around dental implants using tissue- Implant Stability and Bone”. Journal Clin Diag engineered bone with fibrin glue, mesenchymal Res 2014Jun;8(6):ZC26-ZC30. stem cells and platelet-rich plasma”. Clin Oral Imp 10. Monov G, Fuerst G, Tepper G, Watzak G. “The Res 2006 oct;17(5):579–86. effect of platelet‐rich plasma upon implant 5. Attia S, Narberhaus C, Schaaf H, Streckbein P. stability measured by resonance frequency “Long-Term Influence of Platelet-Rich Plasma analysis in the lower anterior mandibles”. Clin (PRP) on Dental Implants after Maxillary Oral Imp. Res 2005;16(4):461–5.
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Low Level Laser Therapy for Dentinal Hypersensitivity - A Review
Dr. Kamal Garg, 1 Dr. Rajni Aggarwal, 2 Dr. Piyush Pareek 3
1. Dr. Kamal Garg Professor and HOD, Surendera Dental College and Research Institute, Sri Ganga Nagar. Rajasthan 2. Dr. Rajni Aggarwal Reader , Surendera Dental College and Research Institute, Sri Ganga Nagar. Rajasthan 3. Dr. Piyush Pareek Post Graduate Student. Surendera Dental College and Research Institute, Sri Ganga Nagar. Rajasthan
Abstract Dentinal hypersensitivity (DH) is characterized by a nonspontaneous, acute short- or long-lasting pain originating from exposure of the dentinal tubules or dentine to the thermal, chemical, mechanical, or osmotic stimuli, which cannot be ascribed to any other dental defect or pathology. There are various treatment modalities, one amongst them is lasers. Lasers have been shown to fulfill the requirements of Grossman’s criteria by being nonirritating to the pulp. Different lasers have been used for the treatment of dentine hypersensitivity i.e, Low output power (low-level) lasers like (HeNe) helium-neon and (GaAlAs) gallium-aluminumarsenide (diode) lasers and high output laser i.e, (Carbon Dioxide Laser (CO2), neodymium- or erbium-doped yttriumaluminum garnet (Nd:YAG, Er:YAG lasers) and erbium, chromium doped: yttrium, scandium, gallium and garnet (Er,Cr:YSGG) lasers). Each laser has different mechanism of action in causing a reduction in dentinal hypersensitivity. In case of low level lasers, a small fraction of the lasers energy is transmitted through enamel or dentin to reach the pulp tissue. Low-power laser therapy is an appropriate treatment strategy to promote biomodulatory effects, minimize pain and reduce inflammatory processes. The low-level lasers produce their effects from photobiostimulation effect within the tissues and do not cause temperature elevation within the tissues. The output powers range from 50 to 500 mW with wavelengths in the red and near infrared of the electromagnetic spectrum, from 630 to 980 nm with pulsed or continuous-wave emission. The application of LLLT has become popular in the clinical application for dentinal hypersensitivity. The aim of this paper is to review low-level laser therapy in dentin hypersensitivity. Keywords: Dentinal hypersensitivity, low level laser therapy.
INTRODUCTION both the sexes with no significant difference and Dentine hypersensitivity associated with the neck the most affected age group is 20–30 years old.2 of the tooth is the enigma amongst all the Cervical areas of buccal surface of canines and odontological problems associated with pain which premolars have a larger frequency of occurrence of has a difficult solution for the dentist. Dentine this disorder than other teeth.3 The occurrence of Hypersensitivity (DH) is an abnormal response of DH is due to the denudation or alteration of the the exposed vital dentine to thermal, chemical, or outer layer of the tooth i.e enamel and / or root tactile stimuli, and which cannot be ascribed to any cementum by processes that include attrition, other form of dental defect or pathology.1 DH abrasion and erosion, or by radicular denudation as affects one in every seven adult patients, affecting
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National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 a result of gingival recession, any periodontal tubules after recrystallization of the dentinal disease or any post periodontal surgery.4 surface. According to hydrodynamic theory, such Although different theories have been proposed for occlusion could mediate stimulus transmission the mechanism involved in DH etiology like neural from the dental surface to the pulp.9 Low-level theory, odontoblastic theory but recent studies gave laser therapy (LLLT) is a sensitizing method to support to Brannstrom’s hydrodynamic theory, promote biomodulatory effects, minimize pain and which states that, a stimulus applied to open reduce inflammatory processes that shows a great dentinal tubules, increases the flow of dentinal promise. This treatment induces alterations within tubular fluid, with mechanical deformation of the the net of nerve transmission of the dental pulp, nerves located into the inner ends of the tubules or instead of altering the exposed dentinal surface, as in the outer layers of the pulp. Type A delta fibers in most other types of treatment. LLLT has been are supposed to be responsible for dentinal used for DH since the 1980s. Studies using the sensitivity being probably activated by the gallium aluminum arsenide (GaAlAs) laser showed hydrodynamic process.5-6 DH reduction in the range of 60%–98%. The aim In order to eliminate such discomfort for patients, of this paper is to review effects and critically different treatment modalities having several discuss most relevant aspects related to LLLT( Low substances like desensitizing pastes, varnishes, level laser therapy) in minimizing dentinal pain. sealants (i.e for both home and office technique) LLLT and its Clinical Applications iontophoresis, fillings have been tested. Most of the The application of low-level lasers in medicine was treatment modalities have aimed to block exposed introduced in the 1980s. Since then considerable dentinal tubules, but none of these treatments has scientific work including the use of cell cultures, produced consistently effective or long-lasting animal models and clinical studies has been results without any black points. Seeking a solution undertaken to evaluate its potentially beneficial for this problem, keeping in mind all the effects. The application of LLLT has become requirements and black points of the previously popular in a variety of clinical applications, used treatment solutions or agents and also including promotion of wound healing and considering the technological development, the reduction of pain. Low level laser applications in laser therapy was introduced as an alternative for dentistry include the promotion of wound healing the management of dentin hypersensitivity. in a range of sites, like surgical wounds, extraction Laser ( acronym for LIGHT AMPLIFICATION sites, recurrent aphthous ulcerations, etc. BY STIMULATED EMISSION OF RADIATION) Applications of LLLT in dental and periodontal therapy was first introduced as a potential method treatments represent the subject of many in vivo for treating DH in the mid-1980s.8 Various types of and in vitro studies, which recommend the use of laser used in treatment such as low-power lasers are laser therapy after gingivectomy and gingivoplasty He-Ne (632.5 nm), diode lasers (DLs) with various procedures due to its ability to speed up the healing wavelengths 810, 940, and 980 nm, and process. medium-power lasers as Nd: YAG (1064 nm), CO2 The low-level lasers facilitate fibroblast and (10600 nm), Er: YAG (2940 nm), and Er, Cr: keratinocyte motility, collagen synthesis, YSGG (2780 nm). In these lasers, He-Ne (632.5 angiogenesis and growth factors release, thus nm) and Diode Lasers have analgesic effect, they facilitating the healing process. This therapy has can have effect alone or in combination with been used in pain management protocols following desensitizing agents. gingivectomies, and as an adjunct treatment in The desensitizing effect of the high power laser is nonsurgical periodontal procedures.13-14 Low-level thought to be related to the occlusion or narrowing laser therapy (LLLT) has also been considered as of the dentinal tubules. These effects of these lasers an alternative treatment option for pain in dentinal are related to an increase in surface temperature hypersensitivity. Kimura et al. summarized the which can result in the complete closure of dentinal current knowledge regarding laser applications for
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National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 the treatment of dentin hypersensitivity.15 Several This was found to be a long-lasting effect, inducing other studies evaluated the effectiveness of the an increase in the size of nerve action potential for clinical use of diode lasers for the treatment of more than 8 months after cessation of irradiation. dentin hypersensitivity and reported their use as He-Ne laser irradiation at 6 mW does not affect the effective in reducing dentinal hypersensitivity.16-22 enamel or dentin surface morphologically, but a Three wavelengths (780, 830, and 900 nm), all small fraction of the laser energy is transmitted within the infrared spectrum of (galium-aluminium- through enamel or dentin to reach the pulp tissue. arsenide) GaAlAs diode laser, have been used for With low power-output lasers, there is no danger of the treatment of dentin hypersensitivity. causing skin burns or damaging cells.29-31 Different Low Level Lasers for Dentinal Hypersensitivity Low power output laser therapy was initially used to support wound healing . Subsequently, in the 1980s, the benefit of LLLT delivery systems were used as an anti-inflammatory tool. After that, it was demonstrated that LLLT systems stimulates nerve cells in a clinical environment.23-25 The low level lasers used for the treatment of dentinal hypersensitivity are of two types:
1. (He-Ne) Helium neon laser (632nm) Fig 1: He-Ne laser device 2. (Ga-Al-As) Gallium aluminium arsenide or Indications: Mild cervical dentin hypersensitivity diode laser (655nm to 980nm) (score 1) is only one indication (acc. To VAS (He-Ne) Helium neon laser (632nm) score). In the cases of moderate or severe dentin The first low-level laser introduced was helium- hypersensitivity (score 2 or 3), the effects cannot be neon (He-Ne), which combined a gaseous mixture expected. to produce a wavelength in the visible light Parameters: 6 mW and 5 Hz or continuous wave spectrum (λ = 632.8 nm) and low power output (CW) mode for 2 to 5 minutes. (ranging from 5 mW to 30 mW). Since the Technique: The laser tip has to be placed as close wavelength produced by He-Ne laser was highly as possible to the tooth surface in non contact absorbed by soft tissues, its penetration was mode. The irradiation is applied to the same tooth limited. The first use of this laser for the treatment surface without scanning. The examination of of dentine hypersensitivity was reported by Senda change of dentin hypersensitivity is carried out et al. (1985), then, consecutively by several other every 30 minutes until the dentin hypersensitivity 26 investigators. Irradiation modes were two types: decreases.32-38 pulsed (5 Hz only) and continuous wave (CW) (GaAlAs) Gallium-Aluminium-Arsenide laser or mode. The laser tip has to be placed as close as Diode laser possible to the tooth surface in noncontact mode. Diode lasers are usually variants of The mechanism involved is mostly unknown. gallium:aluminum:arsenide (GaAlAs), which emit Treatment effectiveness rates of He-Ne laser ranges in the near infrared spectrum (780 nm, 830 nm, and from 5.2%– 100% based on different studies. 900 nm; power output from 20 to 100 mW), or According to physiological experiments, He-Ne indium:gallium:arsenide:phosphorus (In:Ga:As:P) laser irradiation does not affect peripheral A-delta devices, which emit wavelengths in the red or C-fiber nociceptors, but does affect electric spectrum of visible light (600 to 680 nm, power activity (action potential) which in the healthy output from 1 to 50 mW). In their early stages of nerve increased by 33% following a single development, GaAs systems were difficult to run 27-28 transcutaneous irradiation. for long periods in a CW mode because of the propensity of the chip to overheat. However, by 17
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1979, experiments using a new diode were looking therapy lasers stimulate nerve cells, interfering with very promising. This new chip, which used wafer- the polarity of cell membranes by increasing the thin crystals of GaAlAs, could produce a variety of amplitude of the action potentials of cellular wavelengths from 720 to 904 nm, all within the membranes, thus blocking the transmission of pain infrared spectrum. It could also generate a stimuli in hypersensitive dentin. It seems that the continuous wave with no likelihood of overheating. low output lasers mediate analgesic effects due to Mainly four wavelengths (780, 790, 830, and 900 depressed nerve transmission.39-40 nm) of GaAlAs laser have been used for the Also according to the recent literatures, the low treatment of dentin hypersensitivity. New diode absorbed energy by the dentin surface (via its lasers were developed in the attempt to obtain mineral such as phosphate and carbonate) leads to slightly higher power output and wavelengths that heat accumulation, which gradually increases the could penetrate soft tissues without damaging them. surface temperature (Ying, Gao et al., 2013).41 This Indications: Mild and moderate dentin results in denaturation and modification of organic hypersensitivity (score 1 and 2) are indications. matrix layer with an amorphous form and hence Parameters: The laser devices of 3 W with the DTs sealing (Marchesan, Brugnera-Junior et al., wavelength of 810 nm (Osada, Tokyo, Japan) and 2008).42 0.5- 20 W with the wavelength of 805 nm DISCUSSION (Panasonic, Osaka, Japan) are sold now. The 3 W Low-power laser therapy is an appropriate power output device is a CW laser device, and the treatment strategy to promote biomodulatory 0.5-20 W power output device is CW or pulsed effects, minimize pain and reduce inflammatory mode, with a pulse width range from 0.003 to 0.2 s. processes. Its use has been widely accepted and As the guide beam, a semiconductor laser of the approved due to satisfactory results reported in the 635 nm wavelength and 1 mW power is used. literatures. Although the desensitization Technique: In order to prevent thermal damage to mechanisms produced by HLLT i.e high-power the dental pulp by lasers, the laser tip is kept more lasers, such as the carbon dioxide, Nd:YAG, than 5 cm from the tooth surface. Furthermore, Er:YAG and Er,Cr:YSGG lasers have been widely when the patient feels pain, the laser tip has to be discussed, are related to an increase in surface scanned quickly over the tooth surface. Sometimes, temperature which can result in the complete the air spray is also used for preventing a closure of dentinal tubules and image analysis also temperature rise on the surface during laser detected obliteration of tubules after laser irradiation. irradiation.43 Specials concern when deciding to use laser irradiation in the management of hypersensitive dentin are the precise irradiation parameters required for therapeutic laser effects and standardization of treatment protocols. Defined and appropriate parameters are extremely important to produce the effects desired. Different outcomes may be produced depending on the parameters employed.44-47 Low-level laser therapy is more effective than high energy irradiation. LLLT have no adverse effects Fig 2: GaAlAs laser (Diode Laser) have been reported with the use of such therapy to treat hypersensitive teeth. In addition to the Mechanism of pain reduction by Low Level biological effect of increasing the potential of Lasers action of the pulp tissue, authors emphasize that The desensitizing mechanism obtained with LLLT low energy wavelengths produced by LLLT are is as yet elusive. It is believed that low-level safer to the pulp because they stimulate circulation
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National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 and cellular activity. However, LLLT does not application time and more quickly for the patient. produce any changes in mineralized tooth substrate. In most of the articles, fluoride gel or desensitizing Due to the individual differences observed in substances used in combination with LLLT can response to the laser therapy, additional sessions of potentiate effects. The same line of reasoning is LLLT may be necessary in order to obtain a considered valid for the association with positive result. Since low-level energy irradiation is desensitizing pastes. New substances as mostly related to biostimulation and analgesia, it cyanoacrylate, glutaraldehyde and potassium seems obvious that such effects are mainly binoxalate are spreading for the properties to temporary. The role of the “soft laser” as a stimulate laser beneficial effects and they can be therapeutic tool is a contentious issue. According to used alone as preventative measures in patients WilderSmith, clinical trials demonstrated no with mild hypersensitivity. However, the advantage in replacing conventional treatment of effectiveness of these treatments has clashed hypersensitive dentin with low-level laser therapy, sometimes with the existence of a placebo effect. In despite its positive effect on patient attitude toward the majority of studies, patients have a decrease in treatment. Contrasting results, however, have VAS from baseline both immediately and over supported LLLT. WilderSmith reported that more time, till six months after treatment. The diode laser positive effects were observed right after the first appears to be the most widely used in everyday low-level laser irradiation, whereas cumulative practice by dental hygienists and dentists. Studies effects and a gradual improvement from visit to are clarifying the follow-up results within the visit should be expected.48-51 interference of the placebo effect. However, in vitro In double-blinded studies this may be particularly studies confirm a real effectiveness of these lasers. true, when information given at the beginning of Thanks to the SEM analysis, the percentage of the study may influence patient’s perception toward occlusion appears to be complete and the diameter the treatment. Pulpal effects of the laser devices of dentinal tubules reduced. previously discussed have been investigated in CONCLUSION various studies. The GaAlAs laser at a wavelength LLLT, due to its reduced side effects can be of 780 nm, and a power output of 30 mW for 3 min considered as an effective treatment for the dentinal caused no thermal or other damage to pulp tissues hypersensitivity. All the parameters for the in monkeys.52 According to an in vitro treatment are already set up by the manufacturer thermometric study, GaAlAs laser irradiation at the and supplied with specific protocols for each parameters of 30 mW (CW) at 780 nm wavelength, treatment. In consideration with all the literatures, it 60 mW (CW) at 830 nm wavelength, and 10 W can be said that low level laser is an innovative and (pulsed) at 900 nm wavelength do not cause faster treatment both in terms of therapy time and significant intrapulpal temperature rises.53 results, with minimal side effects and greater The LLLT assisted treatment of dentine comfort for patients, which appear more satisfied hypersensitivity is a good method to solve with traditional methods. Although it would seem immediate and long term pain, compared to that the LLLT effectively reduces pain symptoms, conventional desensitizing topical agents and the further studies and more suitable follow-ups are high level laser treatment. It is although more necessary. expensive but leads to rapid results with less
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24. Kimura Y, Takebayashi H, Iwase T, Morioka T. 36. Wilder-Smith P. The soft laser: therapeutic tool or The enhancement of transforming growth factor-ß popular placebo? Oral Surg Oral Med Oral Pathol activity by helium-neon laser on wound healing in 1888;66:654-658. rats. Lasers Life Sci 1993;5:209-217. 37. Matsumoto K, Nishihama R, Onodera A, 25. Kimura Y, Iwase T, Morioka T, Wilder-Smith P. Wakabayashi H. Study on treatment of Possible plateletderived growth factor involvement hypersensitive dentine by He-Ne laser. J Showa on helium-neon laser stimulated wound healing in Univ Dent Soc 1988;8:180-184. rats. Lasers Life Sci 1997;7:267-284. 38. Mezawa S, Shiono M, Sato K, Mikami T, Hayashi 26. Gomi, A., Kamiya, K., Yamashita, H., Ban,Y., M, Maeda K, Ogawa M, Saito T. The effect of low- Senda, A., Hara, G., Yamaguchi, M., Narita, T. & power laser irradiation on hypersensitive dentin: Hasegawa, J. (1986) A clinical study on ‘‘Soft differing effect according to the irradiated area. J Laser 632’’, a HeNe low energy medical laser. Japan Soc Laser Dent 1992;3:87-91. Aichi-Gakuin Journal of Dental Science 24, 390– 39. Gillam DG, Mordan NJ, Newman HN. The dentin 399. disc surface: a plausible model for dentin 27. Rochkind S, Nissan M, Razon N, Schwartz M, physiology and dentin sensitivity evaluation. Adv Bartal A. Electrophysiological effect of HeNe laser Dent Res 1997;11:487-501.I on normal and injured sciatic nerve in the rat. Acta 40. Gerschman JA, Ruben J, Gerbart-Eaglemont J. Neurochir (Wien) 1986;83:125-130. Low level laser therapy for dentinal tooth 28. Rochkind S, Nissan M, Barr-Nea L, Razon N, hypersensitivity. Am Dent J 1994; 39:353-357. Schwartz M, Bartal A. Response of peripheral 41. Ying, L., Gao, J., Gao, Y., Shuaimei, X., Zhan, nerve to He-Ne laser: experimental studies. Lasers X.and Wu, B. (2013) "In vitro study of dentin Surg Med 1987;7:441-443. hypersensitivity treated by 980-nm diode laser." 29. Kimura Y, Wilder-Smith P, Yonaga K, Matsumoto Journal of lasers in medical sciences 4(3): 111. K. Treatment of dentine hypersensitivity by lasers: 42. Marchesan, M.A., Brugnera-Junior, A., Souza- a review. J Clin Periodontol. 2000 Oct; 27(10):715- Gabriel, A. E., Correa-Silva, S.R. and Sousa-Neto, 21. M.D. (2008) "Ultrastructural analysis of root canal 30. Matsumoto K, Kimura Y. Laser Therapy of Dentin dentine irradiated with 980-nm diode laser energy Hypersensitivity. J Oral Laser Application 2007; 7: at different parameters." Photomedicine and laser 7-25. surgery 26(3): 235-240. 31. Ladalardo TC, Pinheiro A, Campos RA, Brugnera 43. Aranha A, Eduardo C. Effects of Er:YAG and Júnior A, Zanin F, Albernaz PL, Laser therapy in Er,Cr:YSGG lasers on dentine hypersensitivity. the treatment of dentine hypersensitivity. Braz. Short-term clinical evaluation. Lasers Med Sci Dent. J. 2004; 15 (2): 144-150. 2012; 27:813–818. 32. Senda A, Gomi A, Tani T, Yoshino H, Hara G, 44. Walsh LJ. The current status of low level laser Yamaguchi M, Matsumoto T, Narita T, Hasegawa therapy in dentistry. Part 2. Hard tissue J. A clinical study on “Soft Laser 632”, a He-Ne applications. Austr Dent J 1997; 42:302-306 low energy medical laser. Aichi-Gakuin J Dent Sci 45. Goodis HE, White JM, Marshall Jr GW, Yee K, 1985;23:773-780. Fuller N, Gee L, Marshall SJ. Effects of Nd: and 33. Matsumoto K, Nakamura G, Tomonari H. Study on Ho: Yttrium-Aluminum-Garnet lasers on human the treatment of hypersensitive dentine by He-Ne dentine fluid flow and dental pulp chamber laser irradiation. Japan J Conserv Dent temperature in vitro. Arch Oral Biol 1997;42:845- 1986;29:312-317. 854 34. Gomi A, Kamiya K, Yamashita H, Ban Y, Senda 46. Liu HC, Lin CP, Lan WH. Sealing depth of A, Hara G, Yamaguchi M, Narita T, Hasegawa J. A Nd:YAG laser on human dentinal tubules. J Endod clinical study on “Soft Laser 632”, a He-Ne low 1997;23:691-693 energy medical laser. Aichi-Gakuin J Dent Sci 47. Pashley EL, Horner JÁ, Liu M, Kim S, Pashley 1986;24:390-399. DH. Effects of CO2 laser energy on dentin 35. Kanamura N, Saitoh H, Uematsu N, Morimoto I, permeability. J Endod 1992;18:257- Takeda G, Hori N. Pain-relieving effects of soft 48. Wilder-Smith P. The soft laser: therapeutic tool or laser (He-Ne) irradiation on various oral lesions. popular placebo? Oral Surg Oral Med Oral Pathol Japan J Conserv Dent 1986;29:1548-1555. 1988;66:654-658.
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49. Wakabayashi H, Matsumoto K. Treatment of 52. Matsumoto K, Wakabayashi H, Funato A, dentine hypersensitivity by GaAlAs soft laser Shirasuka T. Histopathological findings of dental irradiation [abstract 554]. J Dent Res 1988;67:182. pulp irradiated by GaAlAs laser diode. Japan J 50. Gelskey SC, White JM, Pruthi VK. The Conserv Dent 1985;28:1361-1365 effectiveness of the Nd:YAG laser in the treatment 53. Arrastia AMA, Machida T, Wilder-Smith P, of dental hypersensitivity. J Can Dent Assoc Matsumoto K. Comparative study of the thermal 1993;59:377-386. effects of four semiconductor lasers on the enamel 51. Marsilio AL, Rodrigues JJ, Borges AB. Effect of and pulp chamber of a human tooth. Lasers Surg the clinical application of the GaAlAs laser in the Med 1994;15:382-389. treatment of dentine hypersensitivity. J Clin Laser Med Surg 2003;21:291-296.
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Chronic Osteomyelitis of Jaw
Dr. Dhawal Goyal, 1 Dr. Nilima Malik, 2 Dr. Neha Gupta, 3 Dr. Manoj Agarwal, 4 Dr. Rajani Kalla, 5 Dr. Sanyam Agarwal 6
1. Dr. Dhawal Goyal MDS, Oral Private Practitioner 2. Dr. Nilima Malik MDS Oral and Maxillofacial Surgery 3. Dr. Neha Gupta Assistant Professor, Dept. of Prosthodontics, RUHS College of Dental Sciences, Jaipur 4. Dr. Manoj Agarwal Assistant Professor, Dept. of Conservative Dentistry & Endodontics, RUHS College of Dental Sciences, Jaipur 5. Dr. Rajani Kalla Assistant Professor, Dept. of Prosthodontics, RUHS College of Dental Sciences, Jaipur 6. Dr. Sanyam Agarwal Medical Officer, Dept. of Conservative Dentistry & Endodontics, RUHS College of Dental Sciences, Jaipur
The prevalence of osteomyelitis of jaws in third Cultures, bone biopsy, conventional radiography, world country is still at a higher rate despite newer scintigraphy, CT scan are used to diagnose chronic and powerful antibiotics and advances in dental osteomyelitis of jaws. Computed Tomograph helps care. This may be due to low socio-economical in determination of cortex and medullary status, unavailability of primary health care involvement of diseased bone better as compared to services, and poor nutritional status in the rural conventional radiograph. areas. Therapy for osteomyelitis of jaws requires a Osteomyelitis may be defined as an inflammatory multidisciplinary approach. A precise condition of the bone that usually begins as an microbiologic diagnosis and adequate debridement infection of the medullary cavity, rapidly involves of necrotic tissue are essential. Acute the Haversian system and quickly extends to hematogenous osteomyelitis usually responds to periosteum of the affected area. The infection then antimicrobial therapy. becomes established in the cortical portion of the However, chronic osteomyelitis of jaws usually bone, creating ischemia and eventually causing requires surgical debridement. Surgical exploration necrosis of bone. Osteomyelitis of jaws develops and sequestrectomy & saucerization are most after a chronic odontogenic infection or a variety of frequently used to treat these cases. Radical surgery other reasons like tuberculosis or fungal infection. such as decorticotomy or resection is effective in An underlying alteration in host defence is present the treatment of extensive cases of chronic in majority of patients with osteomyelitis of jaws. osteomyelitis of the jaws. Hyperbaric oxygen is Osteomyelitis has been noted in patients with often recommended as an adjuvant in treatment of diabetes, autoimmune disease, agranulocytosis, chronic osteomyelitis of jaws. leukaemia, severe anaemia, malnutrition, syphilis, In present study, we have analyzed the etiological cancer chemotherapy, steroid drug use, sickle cell factors, age and sex prediction, site of occurence, disease, acquired immunodeficiency syndrome1 and role of CT scan and various treatment modalities with the habit of tobacco and alcohol followed in our institute over a period of 3 yrs. consumption.2 23
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Aims and Objectives of our study are- 3. Infantile osteomyelitis. 1. To study the various etiological factors of B. Non Suppurative Osteomyelitis chronic osteomyelitis. 1. Diffuse sclerosing osteomyelitis 2. To study the role of systemic conditions as a 2. Focal sclerosing osteomyelitis (condensing predisposing factors in chronic osteomyelitis of osteitis) jaw. 3. Proliferative periostitis (Garre's sclerosing 3. To discuss various treatment modalities osteomyelitis, periostitis ossificans) (surgical & nonsurgical) for management of 4. Osteoradionecrosis chronic osteomyelitis of jaws. Osteomyelitis of maxilla is less frequent than Topazian (2002) has classified osteomyelitis as: mandible because maxillary blood supply is more A. Suppurative osteomyelitis extensive. Thin cortical plate and a relative paucity 1. Acute suppurative osteomyelitis of medullary tissues in the maxilla preclude 2. Chronic suppurative osteomyelitis: confinement of infections within bone and permit (a) Primary- no acute phase preceding the dissipation of oedema and pus into soft tissue (b) Secondary –follows acute phase and paranasal sinuses.
Acute inflammation Pus, organism (edema, pus formation) extension
Increased intramedullary Haversian system Pressure involvement
Vascular collapse Elevation of periosteum (Stasis, ischemia of bone)
Avascular bone Disrupted blood supply
In Tuberculous osteomyelitis of the maxilla or Management of osteomyelitis of jaws depends on - mandible there are 3 possible methods of • Etiology of the disease inoculation of bacteria into the bone, • Predisposing factors like altered immune status 1. Direct inoculation of bacilli into the oral mucosa of host, vascularity of bone etc. through an ulcer or a breach in continuity of the • Site and extent of the lesion. mucosa or through periodontal membrane. Osteomyelitis of jaws usually requires medical and 2. Spread to the bone through an extraction socket surgical treatment, although occasionally antibiotic or an infected fracture line. therapy alone is successful. 3. Hematogenous spreads from primary focus Chronic osteomyelitis of jaw bones can be elsewhere in the body. This primary focus may be managed by active or quiescent, apparent or latent either in the 1. Medical management lungs or in the lymph glands of the mediastenum, 2. Surgical management mesentery, and cervical region or in the kidney or in other viscera. MEDICAL MANAGEMENT: It includes- MANAGEMENT • Adequate fluid and dietary intake 24
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• Evaluation and correction of host immune - Osteomyelitis is more common in mandible system deficiencies due to odontogenic infection as compared to • Systemic Antibiotic therapy maxilla, whereas fungal osteomyelitis was • Anti tubercular therapy-Whenever required more common in maxilla (which confirms its • Antifungal therapy- Whenever required route of transmission ie. Inhalation) as • Hyperbaric oxygen therapy compared to mandible. Tuberculous SURGICAL MANAGEMENT: It includes osteomyelitis was seen only in mandible. One • Local antibiotic therapy- Closed wound case of diffuse sclerosing osteomyelitis or irrigation-suction & Antibiotic impregnated primary chronic osteomyelitis was seen in the beads mandible. - Retrospective correlation between CT scan • Sequestrectomy and Saucerization finding and surgical intervention was carried • Decortication out. It was suggestive that patients whose CT • Resection and Reconstruction scan showed sclerosis pattern, they underwent RESULTS decortication and patients with mixed pattern The study was conducted in the department of Oral CT scan underwent curettage. One resection and Maxillofacial surgery, Nair Hospital Dental was carried out in mixed pattern patient. College, Mumbai. 40 patients were examined. 32 CASE REPORT patients out of 40 were suffering from osteomyelitis A 55 years old female patient reported to due to odontogenic cause. Three patients had Maxillofacial Dept., Nair Hospital Dental College etiologic factor as fungal infection, whereas 4 with the chief complaint of discharge of pus from patients had tuberculous osteomyelitis of jaw. One right infraorbital region and discharge of pus patient had primary chronic osteomyelitis of intraorally since 8 months. mandible and etiology was unknown. There was h/o extraction of upper molar tooth on In our study right side, later patient noticed extraoral - Mandible was more commonly affected as discharging sinus in right infraobital region and compared to maxilla. Both bones had discharge of pus intraorally in right upper buccal predilection for right side more as compared to vestibule. She had consulted to family doctor for left side the same and taken treatment for 3 months but there - Patients having systemic disorders required was no improvement in symptoms. Then patient more time for recovery as compared to patients was referred to Nair Hospital Dental College for who did not have any systemic disorders definite management. - Surgical method used primarily for Patient gave past history of diabetes since 6 years osteomyelitis was sequestrectomy and and was on Inj. Human insulin 10 units before saucerization. It was carried out in 19 patients breakfast, 8 units before dinner subcutaneously. and curettage was carried out in only 16 She gave H/O hypertension and was taking Tab. patients. Decortication was carried out in 4 Amlodipine 5 mg in morning. There was no other patients and one patient underwent resection significant past medical history. Patient was a home followed by reconstruction. maker. - CT scans of 20 patients were evaluated. The Patient’s general condition was fair. Vital CT scan pattern showed was classified into 4 parameters were brought within normal limits. Face categories; sclerotic, lytic, mixed and was asymmetrical. One extraoral discharging sinus sequestrum. The most common pattern seen was seen in right infraorbital region. On intra oral was mixed pattern. 9 patients had mixed CT examination, necrotic maxilla could be appreciated scan pattern and 5 patients had lytic pattern and extending from right tuberosity and crossing 3 patients each showed sclerosis and midline till 25. Grade II mobile teeth sequestrum pattern. 11,12,13,21,22,23,24, 25 were noted. Mouth
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National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 opening was adequate. Patient`s oral hygiene was powder which was supposed to be mixed with 200 very poor. ml of normal saline and infused over 2 to 3 hrs. OPG showed various grades of radiolucency and Special attention was maintain hydration of patient. radio-opacity with a large sequestrum extending 200 ml of normal saline was rapidly infused before from right tuberosity and crossing midline till 25. slow infusion of Amphotericin –B and once Opacification was noted in right maxillary sinus. Amphotericin –B infusion was over, again 200 ml CT scan showed the area of erosion and cortical of normal saline was flushed rapidly. discontinuity with destruction of antero-lateral and Patients input and output chart was maintained to postero-lateral wall of right maxillary sinus. monitor renal function and after infusion patients Necrosis of alveolar bone was seen extending from serum electrolytes were checked. After every 3rd right tuberosity crossing midline up to left side day renal function tests were assessed. Inj. Avil premolar. 25mg and Inj. Paracetamol 300mg were given Bone scintigraphy showed increased radiotracer before infusion to prevent the episode of fever and 99mTc-MDP uptake in right and left maxilla. No chills which could occur during infusion. To similar lesion was found in other bones of body. prevent photosensitivity reaction to the drug I.V. Diagnosis was made as chronic suppurative set and infusion bottle were covered with yellow osteomyelitis of right maxilla. Patient was started paper. on Tab. Doxy 100 mg OD and meantime patient Wound responded well to surgical intervention was worked up for general anesthesia and blood which was followed by sugar and blood pressure were brought within Inj. Amphotericin - B therapy. normal limit. Pus for culture and antibiotic CONCLUSION sensitivity test was repeatedly sent but there was no The clinician should consider patient’s immune organism seen. Mantoux test and sputum for AFB compromised status and treat any compromising were negative. condition and the condition that alter the Finally patient was posted for surgery under vascularity of bone and predispose the patient to general anesthesia and large sequestrum of maxilla the onset of osteomyelitis of jaws, concomitantly was removed via Weber-Fergusson approach. with the orofacial infection. With the increased Thorough curettage of the defect was done. Extra number of immunocompromised patients seeking oral sinus tract present in infra- orbital region was health care services, one might as a direct removed with help of 11 no. blade. Granulation consequence expect the incidence of osteomyelitis tissue and necrosed bone were sent for biopsy and to increase. culture and sensitivity test. Almost all the avenues and pathways have been Patient was started on Inj. Ampiclox and Inj. explored, but still a lot has to be learnt. It is true Gentamicin. Report of pus for culture and that the dread of morbidity and mortality due to sensitivity test was suggestive of fungal infection. osteomyelitis has been conquered, but we still can On KOH smear filamentous fungi were seen. not boast of a positive and accurate approach to the Growth on Saburaund media was suggestive of multitude of problems presented by chronic Aspergillus. Amphotericin –B was started on day osteomyelitis of jaws. (1) 25mg, day (2) 37.5mg then 50mg/day till 3 weeks followed by oral fluconazole for 6 weeks. The dose of Amphotericin –B varies from 0.5mg/kg to 1.5 mg/kg according to severity of infection. Amphotericin –B was available as dry
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REFERENCES 1. A.A.Olaian, J.T.Amuda & E.O.Adekeye: 13. R.M.Borle et al: Osteomyelitis of the Osteomyelitis of mandible in sickle cell zygomatic bone: A case report; JOMS disease: Brit. JOMS 1997, 35:190·192. 1992:50:296-298. 2. A.Duncan Fisher: Osteomyelitis of mandible 14. R.Van Merkesteyn, R.H. Groot, J. Bras and in a child JOS, 1977; Vol. 35, Jan. DJ Baker: Diffuse sclerosing Osteomyelitis of 3. H. T. Davies, R. J. Carr: Osteomyelitis of the the mandible clinical, radiographic & mandible: a complication of routine dental Histologic Findings in 27 patients. JOMS extractions in alcoholics: British JOMS 1990; 1988, 46:825-829 28:185-188. 15. Richard Topazian, Goldberg & Hupp,Oral & 4. H. William Sippel, Charlos Nyborg & Harry Maxillofacial Surgery Infection:214-242:W.B. Alvis: HBO as an adjunct to the treatment of Saunders,2002. chronic Osteomyelitis of the mandible: Report 16. Sten Graffman et al. Scintigraphy in diagnosis of case JOS: Sep 1969 of osteomyelitis of the jaws: IJOMS:1977 5. J.O.Daramola and Ajagbe; chronic 6;247-250. osteomyelitis of the mandible in adults: A 17. Stern K., Nesasisan et al: Eikenella clinical study of 34 cases. British journal of osteomyelitis of mandible associated with Oral surg; 1982, 20: 58-62. anemia of chronic disease. J of Oral Surg: 6. J. W. Hudson: Osteomyelitis of Jaws. A 50 1978:36:285-292. year perspective JOS: 1993:51:129:41, 301. 18. Su-Gwan Kim & Hyun Seon Jang: Treatment 7. Jacobsson, G. Dahlen, et al: Bacteriologic and of chronic Osteomyelitis in Korea: 000 2001: serologic investigation in diffuse sclerosing 92:394-80. osteomyelitis of the mandible. J of Oral Surg 19. Thomas kerley & Mader et al: The effect of 1982:54:506-512. adjunctive hyperbaric oxygen on bone 8. Jacobsson S.& Hollender L.: Treatment and regeneration in mandibular Osteomyelitis: prognosis of diffuse sclerosing Osteomyelitis report of a case: J Oral Surg 1981: 39; 619-23. of mandible: Oral surgery, 1980; 49: 7-14. 20. Tony canosa, mark cohen et al.Osteomyelitis 9. Madeleine Rohlin et al . Diagnostic value of of the maxilla causesd by Methicillin- bone scintigraphy in osteomyelitis of the Resistant staphyloacoccus aureus. mandible. OOO: 1993:75:650-7. JOMS;2003;61;387-390 10. Marx, R. E.: A new concept in the treatment 21. Yoshikazu, Tanimoto et al. possible identity of osteroradionecrosis. J. Oral Maxillofac. of diffuse sclerosing osteomyelitis and Surg. 1983b: 41: 351-357. chronic recurrent multifocal 11. Marx RE, Eric Carlson et al: Isolation of osteomyelitis.OOO:1995;80;401-8. Actinomyces Species and Eikenella corrodens 22. Yoshikazu Suei, Keiji Tanimoto: Partial from Patients with Chronic Diffuse Sclerosing Resection of the mandible for the treatment of Osteomyelitis: J Oral Maxillofac Sur: 52:.26- DSO. Report of four cases. JOMS 1997: 33. 1994 55:410-141 12. R. Benoliel and J. Asquith: Actinomycosis of Jaws: 2 cases report Int. JOS 1985:14; 195- 199.
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Surgical Periodontal Therapy using as a Different Scalpel
Dr. Kamal Garg, 1 Dr. Rajni Aggarwal, 2 Dr. Puneet Kalra, 3 Dr. Amit Khunger 4
1. Dr. Kamal Garg Professor and Head, Department of periodontology and Oral Implantology, Surendera Dental College and Research Institute. Sri Ganganagar. Rajasthan 2. Dr. Rajni Aggarwal Reader, Department of periodontology and Oral Implantology, Surendera Dental College and Research Institute. Sri Ganganagar. Rajasthan 3. Dr. Puneet Kalra Post-Graduate Student. Department of periodontology and Oral Implantology, Surendera Dental College and Research Institute. Sri Ganganagar. Rajasthan 4. Dr. Amit Khunger Senior Lecturer. Department of periodontology and Oral Implantology, Surendera Dental College and Research Institute. Sri Ganganagar. Rajasthan
Surgeries are considered as traumatic procedures in dental field. Fear of bleeding, delayed Abstract healing, post–operative trauma or complications are the major factors which the most challenging questions are asked by patients before periodontal surgeries. To overcome these, LASERS were introduced and very much appreciated both by the patients and dental professionals. LASERS have overcome complications of many dental surgical procedures. In this review article, all these factors are explained along with other author studies. Keywords - LASERS, Frenectomy, Gingivectomy, Depigmentation, Periodontal Flap, LANAP, Dental implants.
INTRODUCTION resulted in decrease in pain and enhanced the wound Surgical techniques such as subgingival curettage, healing and thus enhance patient comfort. gingivectomy, and flap surgeries have been studied Stated best by Apfelberg in 1987, lasers are a "new in the attempt of reducing probing pocket depth (PD) and different scalpel," (optical knife, light scalpel). and gaining clinical attachment level (CAL). Other When used correctly in proven applications, lasers treatment options aiming to regenerate tissues offer an acceptable and impressive alternative include guided tissue regeneration (GTR), or the within the field of periodontics and other dental application of growth factors, which have field. Therefore, LASERS in periodontal therapy demonstrated varying degrees of success and can be used for various surgeries like, frenectomy, predictability. Regardless of the treatment modality, gingivectomy, depigmentation, flap surgeries, surgical periodontal therapy is often associated with second stage implant surgery. pain and discomfort.1 Lasers in Frenectomy Procedure In the last decade or so, the use of LASER (Light Laser-assisted frenectomy is much more amplification by stimulated emission of radiation) comfortable for the patient because it is painless, has occupied part of the dialogue within does not require suture and immediate haemostasis periodontology due to several proposed advantages. can be achieved. Frenectomy can be done using CO2 Several researches have shown that use of lasers for laser with 4 to 5 W and in slightly defocused mode. surgical or non surgical periodontal therapy have While in case of diode laser 0.8 W in continuous wave mode in contact mode is used. Argon laser can 28 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 be used for frenectomy procedure at 1.0 to 2.25 W removal of phenytoin hyperplasia in twelve patients. in continuous wave delivery; water spray may be The results showed lack of haemorrhage, used .1 sterilization of the surgical area, prompt healing, In maxillary and mandibular frenectomy, the frenum minimal post operative discomfort, and minimal is simply vaporised with the laser. In lingual time spent to perform the procedure. Shankar et al. frenectomy, the tip of the tongue is grasped, tension 20126 performed gingivectomy using diode laser in is placed, and from the greatest concavity of the three patients undergoing orthodontic treatment. frenum moving posteriorly, the frenum is simply The authors concluded that diode lasers showed no vaporized until the desired effect is achieved. Few post- operative pain , swelling, excellent more studies which supports the use of LASER as a haemostasis and patient acceptance. Funde S et al. surgical blade in frenectomy. Haytac MC et al.20062 20157 Compared Laser, Electrocautery and Scalpel compared the degree of postoperative pain, such as in the Treatment of Drug-Induced Gingival discomfort and functional complications (eating and Overgrowth in a forty six old male patient. The speech), experienced by patients after two result showed that healing with scalpel was best frenectomy operation techniques. Forty patients among all three with minimal inflammation. Healing requiring frenectomy were randomly assigned to with electrocautery was worst among all with have treatment either with a conventional technique uneven healing and incomplete surface or with a carbon dioxide (CO2) laser. The results epithelization. Healing with laser was better than indicated patients treated with the CO2 laser had less electrocautery. postoperative pain and fewer functional Lasers in De-Pigmentation Procedure complications (speaking and chewing) and required Various treatment options are in practice for fewer analgesics compared to patients treated with depigmentation which includes scalpel technique, the conventional technique. Olivi G et al. 20103 free gingival graft surgery, use of chemicals (90% evaluated the efficacy of an Er, Cr: YSGG laser in phenol and 95% alcohol), bur abrasion, removing the labial frenum in an adolescent and pre- electrocautery, cryosurgery and lasers. Among these pubescent population. Using an Er, Cr: YSGG laser techniques laser offers a promising therapeutic at a power setting of 1.5 W or less and 20–30 pulses option since it is simple, painless and predictable. It per second, a total of 156 frenectomies were has many advantages over conventional treatment. performed on 143 children. Patient acceptance was Diode laser can be used at 1.5 to 2 W in continuous very high, and no postoperative adverse events were wave mode in contact method. CO2 laser can be reported. Aldelaimi TN et al. 20144 conducted laser- used in superpulsed wave (10 watts, 0.8 mm spot assisted frenectomy on twenty five patients using size, 20 Hz, 10 milliseconds) or at 2 to 4 W 980nm diode laser. The postoperative advantages, continuous pulsed wave mode.1 i.e., lack of swelling, bleeding, pain or, scar tissue Er: YAG laser (Versa wave) can also be used in formation, the good wound healing and overall depigmentation procedure. The laser beam set up at satisfaction were observed in the clinical application 1000 mj, 45 Hz per second in defocused mode to of laser-assisted frenectomy. produce a 3 mm diameter circle, thus reducing the Lasers in Gingivectomy Procedure beam penetration while increasing the treated Gingivectomy is performed using diode laser at 1W surface. After every 2 minutes the gingiva is wiped in continuous wave mode in contact method. CO2 off by wet sterile gauze soaked with 1% normal laser can also be used at 4 to 10W depending on the saline, then depigmentation continued until no thickness of the gingival and the beam is used in pigment remained. Er: YAG can also be used at both the focused and defocused mode. Argon laser settings of 250 mJ, 15 Hz, with water and air in can also be used for gingivectomy procedure using defocused mode. There are many other studies 300μm fibre in contact mode at 1.0 to 1.8 W in which also suggest the LASERS are safe. continuous wave with water spray.1 Other studies Astawasuwan et al .20008 presented the use of which also suggest that use of LASER is safe and Nd:YAG laser for gingival depigmentation in three reliable. Pick et al. 19855 used CO2 laser for the cases .Nd:YAG laser was set at 6watt 29 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021
,60millijoules/pulse and 100 pulse /second in periodontal attachment lost to disease.'-6 New contact mode. The results showed that ablation of connective tissue attachment and cementum gingival hyperpigmentation was accomplished regeneration can be achieved by cells originating without any bleeding complication or post-operative from the periodontal ligament. Many attempts to pain. Azzeh M 20079 treated gingival prevent apical migration of epithelial cells include: hyperpigmentation by Erbium-Doped: Yttrium subgingival curettage, cryotherapy, chemical Aluminum Garnet Laser for esthetic purposes. In six substance application (e.g., phenol camphor, and patients laser ablation was performed by an erbium- antiformin13), free palatal grafts, and different types doped: yttrium, aluminum, and garnet (Er: YAG) of incision, biological barrier membranes and laser (settings: 250 mJ, 15 Hz, with water and air and carbon dioxide laser. using the defocused mode) without using topical or Lasers block the epithelial downgrowth by forming local anesthesia. The results showed that, no patient the necrotic layer on the wound area that gives time discomfort, pain, or bleeding complications were for cells of the periodontal ligament to repopulate found Ablated wounds healed almost completely the root surface and form a new attachment. within 4 days. No recurrence of gingival Carbondioxide laser has the potential to de- hyperpigmentation was found during the follow-up epithelialize tissue. Biologic tissue, regardless of periods.The authors concluded that depigmentation pigmentation or vascularity, absorbs CO2 laser of melanin hyperpigmented gingiva by the Er: YAG energy because the target of interaction is water. laser is a reliable and satisfactory procedure Singh et This feature virtually assures no heat conduction to al.201210 did comparative evaluation of gingival deeper soft tissue layers. Recent research suggests depigmentation by diode laser and cryosurgery that gingiva can be totally de-epithelialized using using tetrafluoroethane.20 patients were divided CO2 laser while leaving the connective tissue into two groups ,group A (diode laser) and group B basically undisturbed in monkeys and in humans. (tetrafluoroethane). The laser beam was set at 0.70 CO2 laser treatment of flaps at the time of surgery W powers, 200 J energy, in continuous mode. The delayed epithelial downgrowth along the root authors concluded that the depigmentation achieved surface for up to 14 days longer than conventional using both the techniques were found equivalent and techniques. Therefore CO2 laser can be used at 8W satisfactory. Grover HS et al.201411 evaluated in pulsed and focused mode for de-epithelialization. patient response and recurrence of pigmentation Similarly diode a soft tissue laser can be used for de- following gingival depigmentation carried out with epithelialization at 2 to 4 W continuous wave in a surgical blade and diode laser. A split mouth contact mode.1 Rossmann et al.199214 conducted a approach was used for 20patients wherein one side study to examine whether controlled de- received laser and the other side scalpel surgery. The epithelialization with CO2 laser would retard the results of this study indicated that both scalpel and apical migration of the epithelium and thereby laser were efficient for gingival depigmentation. increase the amount of connective tissue Butchibabu K et al.201512 did comparative attachments. Elastics were placed on the maxillary evaluation of the gingival depigmentation by using premolars and incisors of 7 cynomolgous monkeys a surgical blade and a diode laser. Four systemically to create periodontal defects. On experimental side healthy patients were treated with different gingival the oral epithelium was removed by CO2 laser depigmentation techniques. Diode laser and surgical irradiation. The results showed less epithelium and blade was used for the depigmentation in either of more connective tissue on the experimental side. the arches. The results showed that diode laser were Therefore carbondioxide lasers may be useful to esthetically pleasing with great patient comfort, less retard epithelium and enhance new connective tissue bleeding and no pain as compared to surgical blade. attachment. Centty et al.199715 compared Lasers used in Flap Procedures conventional periodontal surgery combined with In periodontal surgery, tissue healing may be carbondioxide laser and conventional periodontal accompanied by apical migration of epithelial cells, surgery alone with respect to epithelial elimination thus preventing the regeneration and restoration of and degree of necrosis of mucoperiosteal flaps. Five 30 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 patients with at least two comparable bilateral 3) Sealing the pocket orifice with a “thermal fibrin periodontal defects needing pocket elimination clot” surgery participated in this study. The test site 4) Creating a physical barrier (such as a barrier received a sulcular incision and carbondioxide laser membrane), preventing down growth of de-epithelialization of the outer and inner aspect of epithelium. the flap. The control group received reverse bevel 5) Promoting healing from the bottom up rather incision only. The results showed significant than the top down by stimulating the release of differences between the carbondioxide laser and pluripotential cells from the PDL and alveolar reverse bevel incision with respect to sulcular and bone. gingival(external) flap surface epithelial elimination The hallmark of LANAP is pocket reduction, new and tissue necrosis. The carbondioxide laser tissue attachment and a lack of tissue recession eliminated sulcular and gingival (external) Yukna R et al. 200718 presented histologic results in epithelium without disturbing underlying human following a laser assisted new attachement connective tissue. Rossmann and Israel .200016 procedure (LANAP) for the treatment of periodontal conducted animal and human studies on laser de- pocket. Six pairs of single rooted teeth with epithelialization for enhanced guided tissue moderate to advanced chronic peridontitis regeneration and concluded that the histologic associated with subgingival deposits were treated. results of using membranes and the laser procedure One of each pair of teeth received treatment of the enhanced the wound healing and regeneration of inner pocket wall with free running pulsed Nd: YAG new bone compared with defects using the laser to remove the pocket epithelium and test membrane alone. pocket was lased second time to seal the pocket .The LANAP (Laser Assisted New Attachment results concluded that LANAP treated teeth showed Procedure) greater reduction in pocket depth and gain in clinical The LANAP (laser-assisted new attachment attachment level than the control teeth. All LANAP procedure) is a protocol that deals with treated specimens showed new cementum and new inflammation, the infectious process, occlusion, connective tissue attachment. Pope J et al. 201419 tooth mobility, and an osseous component. It is a reported a novel approach to the treatment of severe surgical laser procedure designed for the treatment chronic periodontitis using a carbon dioxide (CO2) of periodontitis through regeneration rather than laser in combination with scaling and root planning resection. Regeneration is a rather complex event (SRP). This study presents the findings of 17 and, as seen with guided tissue regeneration or patients that were compared in a split-mouth design scaling and root planning alone, can be very and followed for 3 months. The authors concluded unpredictable, whereas LANAP is predictable. that sites treated with the CO2 laser tended to show The concept of LANAP was born in 1989 with Drs. a greater decrease in probing depths, greater Robert Gregg and Del McCarthy. They were amounts of recession, and greater gains in clinical involved in the early use of Nd: YAG lasers in attachment levels, but the results were not dentistry. LANAP utilizes a free-running (10- 6 statistically significantly better than SRP alone. seconds) pulsed Nd: YAG laser in place of a scalpel. Lasers in Implant Surgery Originally referred to as Laser-ENAP, LANAP has One of the most interesting uses of lasers in implant evolved to provide a minimally invasive alternative dentistry is when lasers are used for uncovering in to flap surgeries.17 second stage implant surgery providing less The potential for regeneration by LANAP postoperative pain, less bleeding, and faster healing. procedure is facilitated by17 The fundamental key to success in implant 1) Delivering intense, precise, and selective placement is the apposition of normal healing bone energy to the affected area (periodontal onto the implant surface. The preparation of the pocket), without damage to adjacent tissues. osteotomy site demands a technique whereby the 2) Being bactericidal to pigmented periodontal local temperature does not exceed 47ᵒC.Since laser pathogens. use results in the conversion of incident 31 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 electromagnetic energy into heat energy, this heat the impression-taking process. The use of laser can energy should not damage the implant surface. greatly expedite this procedure because the implant Research into the use of this laser as an adjunctive can be uncovered and the impressions can be to implantology, drew conclusions that the obtained at the same appointment. This is possible penetrating and high peak heat energy effects because the laser allows for a bloodless field. Based produced during soft tissue and peri-implant on laser tissue interaction characteristics, all laser treatment, caused damage to both the implant wavelengths are suitable, provided care is exercised surface and the surrounding bone. This led to a to avoid contact with the implant body. The ablation general deprecation of laser use in connection with of soft tissue lead to precise and predictable healing implants, which remained for several years. With the and often this procedure can be carried out using further development of other laser wavelengths, topical anaesthesia. Suggested energy levels of one investigations were carried out to establish whether to two watt (Continuous wave diode), 150 mJ/ 15pps these new lasers would cause damage. The general (Nd: YAG), 200-250 mJ/10 pp(erbium group) and parameters would include the emission mode of the one to two watts (CO2), appear to be appropriate in laser, the nature of the target tissue and type of laser- removing gingival tissue overlying the implant cove tissue interaction. Other investigation centred on the screw.2 material used in implant manufacture, its Different lasers which can be use in second stage reflectivity, whether the titanium was coated and implant surgery are diode, Nd: YAG and Erbium generally, the conductive effects of heat through the family. But various studies conclude that diode implant into surrounding bone. lasers are more beneficial and cause less damage to Titanium as a metal exhibits reflectivity to incident the implant surface. Kreisler et al. 200220 compared light energy. With regard to the wavelengths of the effects of various laser wavelengths on titanium current lasers, the reflectivity is lowest in the range implants and concluded that NdYAG and HoYAG 780-900nm,rising as the wavelength increases lasers are contraindicated on osseointegrated towards 10,600nm.This would suggest that shorter implant surface irrespective of power output, the Er: wavelengths are most damaging, as the low YAG and CO2 output powers must be limited to reflectivity would allow greater heat effects to build avoid implant damaging while (Gallium- up, and is keeping with studies carried out with the AluminumArsenide (GaAlAs)) are safely used as no Nd:YAG laser. However, there is evidence to structural damage to the implant surface was suggest that the diode wavelength group, delivered occurred after laser irradiation. in low power continuous wave (1-2 Watts average The diode wavelength is poorly absorbed by power) cause minimal damage to the implant or titanium and the implant body temperature did not surrounding bone. While Nd: YAG, Er, Cr: YSGG elevate significantly during laser exposure. The and Er: YAG results in high peak values and heat ability of the diode laser not to effect neither production (> several hundred ᵒC) .2It should be polished titaniumn was confirmed by Stubinger et noted that despite concerns about overheating and al.201021. He also showed that the, diode lasers seem surface changes during laser usage, the experience to be the only laser systems offering surface of the past few years seems to support the idea that preservation and safely used with Zirconia implants. the risks can be minimized with proper technique Diode Lasers and control of laser parameters. Diode laser of 970 nm wavelength in a power of 3 Soft Tissue Management associated with W can be used effectively at second stage surgery Implants instead of scalpel; the laser cuts precisely without Following the placement of an implant and its infiltrative anesthesia and excellent homeostasis will integration into the osseous substrate, the current be resulted and seems to minimize post operative method of treatment is to surgically uncover the pain. The gingival contours remain stable after laser implant, wait for the tissues to heal, and then implant recovery procedure. The great proceed with impressions and the fabrication of the decontamination capability of diode laser permits to restoration. The reason for this delay is to facilitate work in an almost sterile operative field (a 98% 32 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 reduction of pathogenic bacteria), with clear healing pattern of peri-implantitis lesions following advantages for rapid the wound healing and non-surgical treatment with an Er: YAG laser decreasing possibilities for post-operative (ERL).The study concluded that a single course of infections. When there is no harm for the soft tissue, non-surgical treatment of peri-implantitis using Er: there is no retraction of the tissue, so the impressions YAG may not be sufficient for the maintenance of can be taken as soon as possible without delay. failing implants. Kholey EL. 2013 22 conducted a study to assess if Volkan et al. 201527 did a radiographic and dental implant uncovering is possible with a diode microbiologic split-mouth clinical trial, to evaluate laser without anaesthesia, compare its performance the efficacy of a diode laser as an adjunct to with traditional cold scalpel surgery. For the study conventional scaling in the nonsurgical treatment of group, second-stage implant surgery was done with peri-implantitis. In addition to conventional scaling a 970 nm diode laser. For the control group, the and debridement (control group), crevicular sulci implants were exposed with a surgical blade. The and the corresponding surfaces of 24 random use of the diode laser obviated the need for local implants were laced by a diode laser running at 1.0 anaesthesia; there was a significant difference W power at the pulsed mode. The authors concluded between the two groups regarding the need for that adjunct use of diode laser did not yield any anaesthesia. Raghavan R et al. 201423 presented a additional positive influence on the peri-implant clinical report comparing efficacy of laser and healing compared with conventional scaling alone. electrocautery in second stage implant surgery and Papadopoulos et al. 201528 compared the concluded that both lasers and electrosurgery units effectiveness of open flap debridement used alone, work well for simple cutting of oral soft tissues as with an approach employing the additional use of a opposed to the use of scalpel. diode laser for the treatment of peri-implantitis. Management of Peri-implantitis with Lasers Nineteen patients were divided into two groups and Among the various procedures to manage peri treated for peri-implantitis. The test group was implantitis, the use of lasers have evolved as a new irradiated with diode laser. The authors concluded technique. Laser can be used for decontamination of that surgical treatment of peri-implantitis by access different implant surfaces which also depends on flaps leads to improvement of all clinical parameters power intensities. It has been reported that, bacteria studied while the additional use of diode laser does kill-rates of up to 99.4% have been attained through not seem to have an extra beneficiary effect. the use of lasers. The semiconductor 809-nm, the SUMMARY CO2 and Er: YAG lasers are recommended, since it With the beneficial properties over conventional appears that they do not exert a negative impact on scalpel that includes relative ease of ablation of soft the implant surface while Nd: YAG laser is not tissue, hemostasis ,instant sterilization, reduced suitable for implant therapy, since it easily ablates bacteraemia, little wound contraction ,reduced the titanium irrespective of output energy. Schwarz edema, minimal scarring, reduced mechanical et al.200324 observed that the Er:YAG laser at 100 trauma, less operative and post-operative pain, faster mJ/pulse (energy out put of 85 mJ/pulse, calculated healing, increased patient acceptance, no sutures and energy density 10.3 J/cm2 per pulse) and 10 Hz requiring no or topical anaesthesia, soft tissue under water irrigation does not damage titanium lasers(CO2,Nd:YAG ,diode ,Er:YAG and surfaces and does not affect the attachment of Er:YSGG) are being widely used as a tool for osteoblast- like cells. Schwarz F et al .200425 gingival soft tissue procedures.22 showed that nonsurgical treatment of peri- Performance of lasers differs depending on their implantitis with an Er: YAG laser at 100 mJ/pulse penetration depth and hence may possibly damage and 10 Hz (energy density 12.7 J/cm2 per pulse) the underlying tissues by thermal effects. In CO2, under water spray led to a statistically significant Er: YAG and Er, Cr: YSGG laser, laser light is reduction in pocket depth and gain in clinical absorbed in superficial layers and hence is attachment level. Schwarz et al .200626 conducted a advantageous, with rapid and simple vaporization of study to assess clinical and histo-pathological soft tissues. However, deeply penetrating Nd: YAG 33 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 and diode lasers having greater thermal effects, had been suggested to retard its downward growth, leave a thicker coagulation area on treated surface and studies have shown effective removal of and hence used similar to electrosurgical epithelium from gingival tissues without damaging procedures. Epithelial exclusion using CO2 laser the underlying connective tissues.22
REFERENCES 1. Miserendino L, Pick RM Lasers in Dentistry. gingival depigmentation using a surgical blade and Quintessence publishing. Chicago1995. a diode laser. J Dent Lasers 2014;8:202-5. 2. Haytac MC and Ozcelik O. Evaluation of Patient 13. Mainman TH. Stimulated optical radiation in ruby Perceptions After Frenectomy Operations: A nature 1960;187:493-494. Comparison of Carbon Dioxide Laser andScalpel 14. Rossman J,McQuade M,Turunen D.Retardation of Techniques.J Periodontol .2006;77:1815-1819. epithelial migration in monkeys using a 3. Olivi G , Chaumanet G n Genovese MD, Beneduce carbondioxide laser.J Periodontal .1992;63:902. C, Andreana S. Er,Cr:YSGG laser labial 15. Cenntty IG,Blank LW,Levy BA, Romberg E and frenectomy: A clinical retrospective evaluation of Barnes D. Carbondioxide Laser for De- 156 consecutive cases. Academy of General epithelialization of Periodontal Flaps. J Dentistry .2010;126-133. Periodontal.1997;68:763-769. 4. Aldelaimi1 TN and Mahmood AS. Laser-Assisted 16. Rossmann JA and Israel M.Laser de- Frenectomy Using 980nm Diode Laser. J Dent Oral epithelialization for enhanced guided tissue Disord Ther .2014;2(4): 1-6 regeneration.A Paradigm shift.Dent Clin North 5. Pick RM, Bernard C. Pecaro , Silberman CJ. The Am.2000;44(4):793-809. Laser Gingivectomy The Use of the CO2 Laser for 17. Khadtare Y, Chaudhari A, Waghmare P, Prashant S. the Removal of Phenytoin Hyperplasia. J. The LANAP Protocol (laser- assisted new Periodontol.1985;56(8):492-496. attachment procedure) A Minimally Invasive 6. Shankar BS, Ramadevi T, Neetha M S, Reddy P S Bladeless Procedure. J Periodontol Med Clin Pract K, Saritha G, Reddy J M. Chronic Inflammatory .2014;1: 264-271. Gingival Overgrowths: Laser Gingivectomy & 18. Yukna R, Carr R and Evans G. Histologic Gingivoplasty. J Int Oral Health 2013; 5(1):83-87. Evaluation of an Nd:YAG laser Assisted New 7. Funde S ,Dixit M B , Pimpale SK. Comparison Attachment Procedure in Humans.The International between Laser, Electrocautery and Scalpel in the Journal of Periodontics and Restorative Treatment of Drug-Induced Gingival Overgrowth: Dentistry.2007;27(6):577-587. A Case Report. IJSS .2015; 1(10):27-30. 19. Pope J, Rossmann JA, Kerns D, Beach MM and 8. Astawasuwan P,Greenthong K,Nimmanon V. Cipher D.Use of a Carbon Dioxide Laser as an Treatment of Gingival Hyperpigmentation for Adjunct to Scaling and Root Planing for Clinical Esthetic Pupose by Nd:YAG Laser:Report of 4 New Attachment: A Case Series. Clin Adv cases.J Periodontol.2000;71:315-321. Periodontics .2014;4:209-215. 9. Azzeh MM.Treatment of Gingival 20. M. Kreisler, H. Gotz and H. Duschner. Effect of Hyperpigmentation by Erbium-Doped:Yttrium, Nd:YAG, Ho: YAG, Er:YAG,CO2, and GaAIAs Aluminum, and Garnet Laser for Esthetic Purposes. laser irradiation on surface properties of endosseous J Periodontol.2007;78(1):177-184. dental implants, Int J Oral Maxillofac 10. Singh V, Bhat SG, Kumar S and Bhat M. Implants.2002; 17 : 202-211. Comparative Evaluation of Gingival 21. Stubinger S, Etter C , Miskiewicz M , Homann F, Depigmentation by Diode Laser and Cryosurgery Saldamli B, Wieland M and Sader R. Surface Using Tetrafluoroethane: 18-Month Follow-Up. alterations of polished and sandblasted and acid- Clin Adv Periodontics .2012; 2:129-134. etched titanium implants after Er:YAG, carbon 11. Grover HS, Dadlani H, Bhardwaj A, Yadav A, Lal dioxide, and diode laser irradiation. Int J Oral S. Evaluation of patient response and recurrence of Maxillofac Implants2010;25(1) :104-111. pigmentation following gingival depigmentation 22. Kholey EL.Efficacy and safety of a diode laser in using laser and scalpel technique: A clinical study. J second-stage implant surgery: A comparative Indian Soc Periodontol .2014;18:586-92. study.Int J Oral Maxillofac Surg. 2013;43(5):633- 12. Butchibabu K, Koppolu P, Tupili MK, Hussain W, 638. Bolla VL, Patakota KR. Comparative evaluation of 34 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021
23. Raghavan R , Shajahan PA , Koruthu A , Sukumar 26. Schwarz F ,Bieling K , Nuesry E , , Sculean A and B , Nair A , Divakar KP . Second stage surgery: a Becker J. Clinical and histological healing pattern of clinical report comparing efficacy of laser and peri-implantitis lesions following non-surgical electrocautery. International Journal of Dental treatment with an Er:YAG laser. Lasers Surg Research. 2014 ;2 (1) :26-28. Med.2006;38(7):663-671. 24. Schwarz F, Rothamel D, Sculean A, Georg T, 27. Arısan Volkan, Karabuda Zihni Cüneyt, Arıcı Scerbaum W, Becker J. Effects of an Er:YAG laser Selahattin Volkan, Topçuoğlu Nursen, and Külekçi and the Vector ultrasonic system on the Güven. Photomed Laser Surg. 2015;33(11): 547- biocompatibility of titanium implants in cultures of 554. human osteoblast-like cells. Clin Oral Implants Res. 28. Papadopoulos A, Vouros I, Menexes, 2003; 14: 784–792. Konstantinidis A. The utilization of a diode laser in 25. Schwarz F, Sculean A, Rothamel D, Schwenzer K, the surgical treatment of peri-implantitis. A Georg T, Becker J. Clinical evaluation of an randomized clinical trial. Clin Oral Er:YAG laser fornonsurgical periodontal therapy Investig.2015;19(8):1851-1860. surgical treatment of peri-implantitis. A pilot study. Clin Oral Implants Res 2004; 15.701-711.
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Role of Laser Bioactivation in Surgical Periodontal Therapy: An Update
Dr. Rajni Aggarwal, 1 Dr. Kamal Garg, 2 Dr. Puneet Kalra, 3 Dr. Amit Khunger 4 1. Dr. Rajni Aggarwal Reader, Department of periodontology and Oral Implantology, Surendera Dental College and Research Institute. Sri Ganganagar. Rajasthan 2. Dr. Kamal Garg Professor and Head, Department of periodontology and Oral Implantology, Surendera Dental College and Research Institute. Sri Ganganagar. Rajasthan 3. Dr. Puneet Kalra Post-Graduate Student. Department of periodontology and Oral Implantology, Surendera Dental College and Research Institute. Sri Ganganagar. Rajasthan 4. Dr. Amit Khunger Senior Lecturer. Department of periodontology and Oral Implantology, Surendera Dental College and Research Institute. Sri Ganganagar. Rajasthan
Abstract Low level Laser therapy (LLT) is the safest therapy which is used from past many decades. This therapy doesn’t increase the temperature of the treated tissues and therefore also called as soft laser therapy. Application of LLT is commonly used in dental treatments and its application in periodontal filed are inflammatory process, wound healing, periodontal therapy, various types of grafts, periodontal flaps. The present study shows the role of LLT in periodontal aspects. Keywords LASERS, low level laser therapy, periodontal therapy, wound healing, gingivectomy, connective tissue graft
INTRODUCTION cellular signalling, and cellular functions are Low- level laser therapy (LLLT) is a light source secondary reactions resulting in faster cell division, treatment that generates light of a single wavelength. proliferation rate, migration of fibroblasts and rapid The phrase “therapeutic laser” has also been used to matrix production.1 suggest the purpose and intent of the treatment. A Primary reactions after light absorption more appropriate designation of the phenomenon There are various theories to explain the mechanism might be “LASER PHOTOBIOMODULATION or of therapeutic lasers.1 LASER BIOACTIVATION.” 1 1. Singlet oxygen hypothesis (1981) MECHANISM OF ACTION OF LOW LEVEL 2. Redox properties alteration hypothesis. LASERS (1988) Bio-stimulatory effect of laser irradiation represents 3. Nitrogen oxide hypothesis (1992) a set of structural, biochemical and functional 4. Transient local heating hypothesis. (1992) changes in living microorganisms. It supplies direct 5. Superoxide anion (1993) bio-stimulation light energy to the body cells. 6. Photochemical theory (1999) Cellular photoreceptors (e.g. Cytochromophores The most recognized theory to explain the effects and antenna pigments) can absorb low-level laser and mechanism of therapeutic lasers is the light and pass it on to mitochondria, which promptly photochemical theory. According to this theory, the produce Adenosine-triphosphate (ATP). The light is absorbed by certain molecules, followed by alterations in photo-acceptor function are the a cascade of biologic events. Suggested primary reactions and subsequent alterations in photoreceptors are the endogenous porphyrins and
36 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 molecules in the respiratory chain. (Cytochrome c- responsible for cleaving collagen fibres. Studies oxidase, leading to increased ATP production) In have shown that low-level laser may lower IL-1ß; addition, the conversion of some of the incident and this effect depends on radiation duration. In the energy into heat would suggest an increase in local meantime, it can reduce IFN-γ, while having micro-circulation through vasodilation. Therefore stimulating effect in the production of PDGF and the stimulatory effects of LLLT include the TGF-ß. All these changes would result in anti- following: inflammatory effect of low-level laser. In brief, low- • Proliferation of macrophages level laser affects COX2, IL-1ß, MMP-8, PDGF, • Proliferation of lymphocytes TGF-ß, bFGF, and plasminogen expressions.2 • Proliferation of fibroblasts Low Level Laser Therapy in Wound Healing • Proliferation of endothelial cells Periodontal wound healing is necessary when • Proliferation of kerantinocytes periodontitis and gingivitis, or trauma, have affected • Increased cell respiration /ATP synthesis the composition and integrity of the periodontal • Release of growth factors and other cytokines structures. LLLT has been shown to cause vasodilation, with increased local blood flow. LLLT • Transformation of fibroblasts into causes the relaxation of smooth muscle associated myofibroblasts with endothelium. This vasodilation brings in • Increase in fibroblast growth factor (FGF) oxygen and also allows for greater traffic of immune • Collagen synthesis cells into tissue. These two effects contribute to The most popularly described treatment benefit of accelerated healing.2 LLLT is wound healing. Mester et al (1971) did Wound healing consists of several distinct phases, electron microscopic examination and showed all of which can be affected at the cellular level by evidence of accumulated collagen fibrils and LLLT. Faster wound closure is of great importance electrondense vesicles intra-cytoplasmatically in compromised patients, such as diabetics, and within the laser-stimulated fibroblasts as compared patients undergoing treatment for malignancies. with untreated areas. The range of radiation doses at Because LLLT can enhance the release of growth which stimulation of fibroblast proliferation has factors from fibroblasts, and can stimulate cell been observed is wide (0.45-60 J/cm2). proliferation, it is able to improve wound healing in The mechanisms of action underlying the analgesic such compromised patients. Histological studies effects are unclear, despite the implicit treatment have demonstrated that laser irradiation improves benefits. There is evidence suggesting that LLLT wound epithelialization, cellular content, may have significant neuropharmacologic effects on granulation tissue formation, and collagen the synthesis, release, and metabolism of a range of deposition in laser-treated wounds, compared to neurochemicals, including serotonin and untreated sites .These findings have been confirmed acetylcholine at the central level and histamine and in oral mucosal wound healing in clinical studies in prostaglandin at the peripheral level. The pain humans.(Marie et al.1997)3 influence has also been explained by the LLLT LLLT benefits can be performed with various effect on enhanced synthesis of endorphin, wavelengths and units with different outputs. decreased c-fiber activity, bradykinin, and altered Usually, the therapeutic window for sub-thermal pain threshold.1 tissue interaction is 1 to 500 mW, but surgical lasers Low Level Laser Therapy in The Periodontal can be defocused and used as a low level laser. The Inflammatory Process most popular lasers are relatively inexpensive diode Low-level laser is capable of reducing inflammation units that were developed in the 1980s. The GaAs and appearance of MMP8 (Matrix (gallium-arsenide; 904 nm) diode laser was Metallopeptidase8) following scaling. It can also developed in the early 1980s and was typically 1 to prevent plasminogen increased activity, and 4 mW. Pulse-train modulated GaAs lasers entered prostaglandin synthesis. Plasminogen activity is the market in the late 1980s.1 capable of activating latent collagenase, the enzyme
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Application of low laser therapy in periodontal involving at least three teeth in each quadrant were therapy recruited for the study. Afterwards, SRP quadrants Bearing in mind the suitable sub-cellular absorption were randomly assigned for 10 sessions of LLLT. and the cellular-vascular impacts, low-level laser The results showed that SRP+LLLT (10 sessions, may be a treatment of choice for soft tissues. Low- 830 nm, 100 mW, 3 J per point, 3 J/cm2) exhibited level lasers is recommended in surgical periodontal greater reductions in PPD at 5 weeks and 3 months therapy or as an adjunct to nonsurgical periodontal but not at 6 months. Further, SRP+LLLT-treated therapy for its pain –reducing, wound healing sites had a statistically significant increase in mean promoter and anti-inflammatory effects1 radiographic bone density when comparing 6- and Qadri et al. 20054 conducted a split-mouth, double- 12-month data and overall from baseline to 12 blind controlled clinical trial to study the effects of months. There was also reduction in interleukin low-level lasers as an adjunctive treatment of (IL)-1β but the difference between control and laser inflamed gingival tissue. In seventeen patients with sites was not statistically significant. moderate periodontitis, samples of Gingival Obradovic R et al. 20127 conducted a study to Crevicular Fluid (GCF) and subgingival plaque evaluate the effects of low-level laser therapy were taken one week after SRP. The laser therapy (LLLT) by exfoliative cytology in patients with was started 1 week later and continued once a week Diabetes mellitus (DM) and gingival inflammation. for 6 weeks. One side of the upper jaw was treated Three hundred patients were divided in three equal with active laser and the other with a placebo. The groups: Group 1 consisted of patients with test side was treated with two low-level lasers periodontitis and type 1 DM, Group 2 of patients having wavelengths of 635 and 830 nm. The GCF with periodontitis and type 2 DM, and Group 3 of samples obtained were analysed for elastase patients with periodontitis (control group). After activity,IL-1β and MMP-8. The results showed that, oral examination, smears were taken from gingival the probing pocket depth, plaque and gingival tissue. Full-mouth scaling and root planning was indices were reduced more on the laser side than on done. A split-mouth design was applied; on the right the placebo one. The decrease in GCF volume was side of jaws GaAlAs LLLT (670 nm, 5 mW, 14 also greater on the laser side. Elastase activity, IL- min/day) was applied for five consecutive days. 1beta concentration and the microbiological After the therapy was completed, smears from both analyses showed no significant differences between sides of jaws were taken. The results showed that the the laser and placebo sides while there was decrease investigated parameters were significantly low after in MMP-8 on the laser side. therapy compared with values before therapy. Pejcic A et al. 20105 analyzed the effects of low Therefore it was concluded that LLLT as an adjunct level laser irradiation treatment and conservative in periodontal therapy reduces gingival treatment on gingival inflammation. All patients in inflammation in patients with DM and periodontitis. the study underwent conservative treatment. After Low-Level Laser and Gingivectomy conservative therapy, the patients from the Gingivectomy is used to remove the supra-bony experimental group were subjected to 10 low level periodontal pockets, or the pockets not extending laser treatment sessions. The results of this study from the Muco-gingival junction. Following showed that the with laser therapy values of indexes gingivectomy, an open wound is formed whose decreased steadily, whereas with conservative repair may take more than five weeks; the period in therapy they increased up to a certain point, but did which the patient may experience pain due to the not reach the pre-therapy values. open wound and secondary repair. Therefore, there Makhlouf et al. 20126 conducted a split-mouth, have been studies through which drugs, antibiotics, double blinded, short-term, controlled clinical trial and amino acids are used to reduce pain and speed to study the effect of low-level laser therapy (LLLT) up repair. Recently studies were conducted to as an adjunct to scaling and root planing (SRP) for evaluate the effect of LLLT on healing and reduction treatment of chronic periodontitis. Sixteen patients of pain after gingivectomy procedure.1 with a probing pocket depth (PPD) of 4–6 mm 38 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021
Amorim JF et al. 20068 conducted a study to Low-Level Laser and Periodontal Flaps investigate gingival healing after gingivectomy and Gingival recession is a ubiquitous finding in adjunctive use of low-level laser therapy (LLLT). periodontal visits, which can lead to root sensitivity, Twenty patients with periodontal disease were aesthetic problems, and caries. There are numerous selected. After surgery; one side was submitted to ways for the treatment of gingival recession, one of LLLT using a 685-nm wavelength, output power of which is Coronally Advanced Flap (CAF). 50 mW, and energy density of 4 J/cm2. The other Numerous models have been suggested to increase side was used as the control and did not receive laser the CAF potential as a treatment protocol, one of irradiation. Healing was evaluated, clinically and which is the low-level laser. biometrically, immediately post-surgery and at days Ozturan, et al. 201111 conducted a study on 3, 7, 14, 21, 28, and 35. The results showed coronally advanced flap adjunct with low intensity significant improvement in healing for the laser laser therapy. In this split mouth study, after CAF, group at 21 and 28 days. and before suturing, laser was radiated to the Ozcelik O et al. 20089 conducted a split-mouth targeted area. The laser parameters used included a controlled clinical trial to assess the effects of LLLT wavelength of 588nm, with a power of 120mW, on healing of gingiva after gingivectomy and continuous mode, and 5 minutes radiation duration. gingivoplasty. Twenty patients with inflammatory Following suturing, the targeted area was radiated gingival hyperplasia on their symmetrical teeth were with laser. No dressing was used. The patients included in this study. After gingivectomy and underwent laser therapy everyday for 5 minutes for gingivoplasty, a diode laser (588 nm) was randomly 7 days. In the control group, following CAF surgery, applied to one side of the operation area for 7 days. laser (in switched off form) was used. Significant The surgical areas were disclosed by a solution differences were found for the width, and depth of (Mira-2-tones) to visualize the areas in which the the gingival recession, keratinized gingival epithelium is absent. The results showed that LLLT- thickness, and finally clinical attachment level and applied sites had significantly lower stained areas complete root coating in the test group was more compared with the controls on the post-operative than that of the control group. third, seventh and 15th day. Javier et al. 201312 conducted a single-masked pilot Martu S et al .201210 evaluated the efficiency of clinical study to compare the tissue response and laser therapy in healing, regeneration and repair postoperative pain after the use of a diode laser (810 processes located in the superficial periodontium nm) (DL) as an adjunct to modified Widman flap after gingivectomy procedures. The study group (MWF) surgery to that of MWF alone. Statistically consisted of 38 patients without any systemic significant differences were seen for tissue edema diseases presenting with gingival hypertrophy and pain scale assessment. The study concluded that developed exclusively within the clinical context of the use of an 810-nm diode laser provided additional gingivitis and/or periodontitis. 17 patients were benefits to MWF surgery in terms of less edema and treated only through gingivectomy procedures. For postoperative pain. 21 patients, gingivectomy was associated with laser Doshi et al. 201413conducted a randomized therapy, applied every day for seven days. Gingival controlled double-blinded split mouth study to mucosa fragments were taken on day 1 and on day compare the levels of dentinal hypersensitivity (DH) 21, and routinely processed for the microscopic and pain after 660 nm laser irradiation in test and exam. This study showed morphological differences control sites following periodontal flap surgery. at the gingival epithelium level and subjacent lamina There was statistically significant decrease in both propria in laser group i.e there was decrease in the DH and pain in the laser-irradiated site on the 7th inflammatory infiltrate located in the lamina propria day following periodontal flap surgery, as compared and diminished number of lymphocytes and with the control site. macrophages which determine a lower production of Jayachandran et al. 201514 analyzed the pre and chemical mediators interfering with the sequences post–operative results obtained between of the healing process. conventional periodontal flap surgery and diode 39 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 laser assisted periodontal flap surgery. According to (CTG) alone or in combination with low-level laser this study clinically significant improvement in therapy. The test group presented more complete probing pocket depth and clinical attachment levels root coverage than the control group Dentine were observed in both the surgical sites. Patient sensitivity decreased significantly after 6 months in acceptance and comfort were more in laser treated both groups. Therefore the authors concluded that sites compared to conventional surgical sites. Low-level laser therapy may increase the percentage Low-Level Laser and Free Gingival Graft of complete root coverage when associated with Moslemi et al. 201415 conducted a randomized CTG. controlled clinical trial to evaluate the effect of SUMMARY 660nm low power laser on pain and healing in The use of LLLT helps to control the symptoms and palatal donor site. In the test group, following the condition of periodontitis. The anti-inflammatory free gingival graft ops, the Diode laser with 660 nm effect slows or stops the deterioration of periodontal and a power of 200 mW was applied to the targeted tissues and reduces the swelling to facilitate the site for 32 seconds, which was repeated on days 1, hygiene in conjunction with other scaling, root 2, 4, and 7 post-op .On day 14, the palatal wound in planning, curettage, or surgical treatment. As a the laser-applied group was significantly better result, there is an accelerated healing and less post- healed than the control group regarding clinical op discomfort. It is non-invasive, non- repair and epithelialization; and in day 21, the pharmaceutical, and economical. These benefits epithelialization amount was significantly much may help generate interest among more clinicians, better in the laser-applied group than the control researchers, and manufacturers to study and gain group. The authors concluded that low-level laser more knowledge on how best to use this may heal the wound in the palatal graft site. phenomenon. Developing the equipment and Lasers and Connective Tissue Graft treatment protocols and training the general Stephanie et al. 201416 evaluated the treatment of educators and health practitioners is essential for gingival recession with a connective tissue graft improving health services and treatment outcomes.1
REFERENCES 1. Papadopoulos A, Vouros I, Menexes, 7. Makhlouf M, Dahaba MM, Tuner J, Eissa SA et al. Konstantinidis A. The utilization of a diode laser in Effect of adjunctive low level laser therapy (lllt) on the surgical treatment of peri-implantitis. A nonsurgical treatment of chronic periodontitis. randomized clinical trial. Clin Oral Investig2015; Photomed Laser Surg 2012; 30(3): 160-66. 19(8):1851-60. 8. Carla DA, Greghi SL, Adriana CP, Sant A, 2. Sobouti F, Khatami M, Heydari M, Barati M. The Passanezi E, Taga R. Histomorphometric Study of role of low-level laser in periodontal surgeries. J the healing of human oral mucosa after Lasers Med Sci 2015; 6(2):45-50. gingivoplasty and low-level laser therapy. Lasers 3. Surendranath P, Arjun kumar R. Low level laser Surg Med2004; 35:377–84. therapy – A Review. J Dent Med Sci2013;12(5);56- 9. Amorim JF, De Sousa GR , Silveira LB, Prates RA, 9. Pinotti M, Ribeiro MS. Clinical Study of the gingiva 4. Marei MK, Abdel-Meguid SH, Mokhtar SA, Rizk healing after gingivectomy and low-level laser SA. Effect of low-energy laser application in the therapy . Photomed Laser Surg 2006, 24(5): 588-94. treatment of denture-induced mucosal lesions. J 10. Ozcelik O, Haytac MC, Kunin A, Seydaoglu G. Prosthet Dent 1997; 77(3):256-64. Improved wound healing by low-level laser 5. Ribeiro WJ, Michyele C, Brana S, Esper LA, irradiation after gingivectomy operations: a Almeida A. Evaluation of the Effect of the GaAlAs controlled clinical pilot study. J Clin Periodontol Laser on Subgingival scaling and root 2008; 35(3):250-54. planing.Photomed Laser Surg 2008; 26(4): 387-91 11. Sobouti F, Rakhshan V, Chiniforush N, Khatami M. 6. Aykol G, Baser U, Maden I, Kazak Z, Onan U, Effects of laser-assisted cosmetic smile lift Sevda TK et al. The Effect of low-level laser therapy gingivectomy on postoperative bleeding and pain in as an adjunct to non-surgical periodontal treatment. fixed orthodontic patients: a controlled clinical trial. J Periodontol 2011;82:481-8. Prog Orthod 2014;15(1):66. 40 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021
12. Ozturan S, Durukan SA, Ozcelik O, Seydaoglu G, combination promotes periodontal regeneration in Haytac MC. Coronally advanced flap adjunct with fenestration defects: A Preliminary in vivo study. J low intensity laser therapy: a randomized controlled Periodontol 2014;85:770-78. clinical pilot study. J Clin Periodontol 2011; 38(11): 15. Almeida AL, Esper LA, Sbrana MC, Ribeiro IW, 1055-62. Kaizer RO. Utilization of low-intensity laser during 13. Sanz-Moliner JD, Nart J, Cohen RE, Ciancio SG. healing of free gingival grafts. Photomed Laser Surg The Effect of an 810 nm Diode Laser on 2009; 27(4):561-4. Postoperative Pain and Tissue Response Following 16. Moslemi N, Heidari, M, Fekrazad R, Modified Widman Flap Surgery: A Pilot Study in Nokhbatolfoghahaie H, Yaghobee S, Shamshiri A et Humans. J Periodontol 2013; 84(2):152-8. al. Evaluation of the effect of 660nm low power 14. Maria NJ, Campos N, Messora MR, Pola NM, laser on pain and healing in palatal donor site: a Santinoni CS, Bomfim SR et al. Platelet-rich randomized controlled clinical trial. J Dent Med- plasma, low-level laser therapy, or their Tehran Univ Med Sci 2014. 27(1): 71-7.
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Efficacy of Locally Delivered Antimicrobials in the Management of Periodontal Pocket – A Clinical Evaluation”
Dr. Guljot Singh, 1 Dr. Umang Jamwal, 2 Dr. Nikhat Fatima, 3 Dr. Nikhil Hole, 4 Dr. Ritika Jain 5
1. Dr. Guljot Singh Principal and Head, Department Of Periodontology & Implantology, Daswani Dental College & Research Centre, Kota, Rajasthan, India. 2. Dr. Umang Jamwal PG Student, Department of Periodontics & Implantology, Daswani Dental College & Research Centre, Kota, Rajasthan, India. 3. Dr. Nikhat Fatima Reader, Department of Periodontics& Implantology, Daswani Dental College & Research Centre, Kota, Rajasthan, India. 4. Dr. Nikhil Hole PG Student, Department of Periodontics & Implantology, Daswani Dental College & Research Centre, Kota, Rajasthan, India. 5. Dr. Ritika Jain Reader, Department of Pediatric Dentistry & Preventive Dentistry, Daswani Dental College & Research Centre, Kota, Rajasthan, India
Abstract Aim: To evaluate the effectiveness of local delivery of antimicrobial agents in the management of periodontal pocket” Materials and Methods: 30 Patients with persistent periodontal pockets of probing depth ≥5 mm with bleeding on probing were selected and included in this 3 month follow up randomized comparative clinical study. Subjects were divided into three groups, Group I (Scaling and Root planning), Group II(Scaling + Simvastatin gel) and Group III(Scaling + Chitosan hydrogel with tetracycline). clinical parameters like Plaque Index (PI), Gingival index (GI), pocket probing depth (PPD) and clinical attachment level(CAL) were assessed. paired t test & One way ANOVA was used to analyse the significance of changes in clinical parameters over time between and within the groups. Results: On intragroup comparison, all three groups showed significant PI and GI reduction (P < 0.001) after treatment at 3months. In intergroup comparisons, PPD reduction and CAL gain were more significant in test Groups 2(Scaling + Simvastatin gel) at 1 month & 3 month from baseline. Clinical parameters were significantly reduced in test sites. Conclusion: Local application of simvastatin gel and chitosan hydrogel with tetracycline subgingivally resulted in significant improvement clinically therefore local drug delivery proved to be more convenient, easy-to-use and more effective than only scaling and root planning. These devices also do not probe the risk of overdose or systemic overload, simple for formulation, affordable and easily available. Keywords: Antimicrobials, Periodontal Pocket, Chronic Periodontitis, Local Drug delivery system, Clinical and Microbiological Study.
INTRODUCTION conditions are characterized by destruction of the Periodontal disease is a general term which periodontal ligament, resorption of alveolar bone encompasses several pathological conditions and migration of the junctional epithelium along the affecting the tooth supporting structures. These tooth surface. The clinical signs of periodontitis are, 42 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 changes in the morphology of gingival tissue, inflammatory, wound healing, hemostasis and bone bleeding upon probing, as well as periodontal pocket repair.6 formation. This pocket provides an ideal The current study is a controlled clinical trial to environment for the growth and proliferation of evaluate the efficacy of 1.2% Simvastatin and anaerobic pathogenic bacteria.1 Chitosan hydrogel with tetracycline as local drug Non-surgical and surgical therapy are both delivery in adjunct to scaling and root planning for applicable in the treatment of periodontal disease. the treatment of chronic periodontitis. The gold standard in the treatment of periodontitis is MATERIALS AND METHODS mechanical debridement of the pockets by scaling 30 Patients were selected from the Outpatient and root planning (SRP).2This approach is a Department of Periodontics, Daswani Dental demanding therapeutic procedure and it has College & Research Centre, Kota, Rajasthan. The limitations, mainly related to the inability to access procedures, possible risks/discomforts and benefits deep pockets and furcations and elimination of were fully explained to the participants. All the pathogens. To overcome these limitations, different patients included in the study satisfied the following adjunctive therapies have been proposed, mainly the inclusion and exclusion criteria. use of systemic or local antimicrobial agents.3 Inclusion Criteria Local drug delivery systems with controlled release Patients with periodontitis, pocket depth >5mm, All properties have the potential to be used as a medically healthy patients with no recurrent history therapeutic component in the management of of any systemic disease. periodontal disease. The principal requirement for Exclusion Criteria: effectiveness of this form of therapy is that the agent Patients with smoking and drinking habits, receiving should reach the base of the pocket and is maintained surgical treatments, systemic diseases, undergone there for an adequate time for the antimicrobial periodontal treatment in last six months period, effect to occur. In view of their beneficial properties, Pregnant and lactating female undergoing antibiotic statins and chitosan hydrogels have been presented therapy. as new potential candidates for improving Randomization periodontal therapy outcomes.4 Statins have anti- After enrollment, the patients were randomly inflammatory and bone stimulating properties assigned into 3 groups: Statins are beneficial in the primary prevention of 1. Group 1 will received Phase I periodontal cardiovascular disease in patients with elevated therapy i.e. Scaling and Root Planning (SRP). CRP, but relatively low cholesterol levels. Bone 2. Group 2 will received Phase I periodontal anabolism regulated by statins can be ascribed to therapy and SIMVASTATIN(SMV)GEL as an three aspects Promoting osteogenesis, inhibiting adjunct to SRP. osteoblast apoptosis and Suppressing 3. Group 3 will received Phase I periodontal osteoclastogenesis.5 therapy and CHITOSAN HYDROGEL with Hydrogels are high-water content materials prepared tetracycline as an adjunct to SRP. from cross-linked polymers that are able to provide Treatment Procedure sustained, local delivery of a variety of therapeutic At Baseline visit, after thorough Scaling and root agents. The advanced development of chitosan planning (to achieve a smooth and clean root hydrogels has led to new drug delivery systems that surface), LDD was performed by a operator using a release their payloads under varying environmental blunt cannula syringe (26 gauge), injecting 0.1 ml of stimuli. Chitosan hydrogel is an excellent excipient the prepared placebo/1.2%simvastatin /1.2% because it is non-toxic, stable, biodegradable, and chitosan gel with tetracycline into the periodontal can be sterilized & are able to provide sustained, pocket. Following delivery, periodontal dressing local delivery of a variety of therapeutic agents that was placed. may positively affect chronic periodontitis. Clinical Evaluation Properties of chitosan that are perhaps the most Clinical parameters were assessed after thorough important to dentistry are bioactivity, anti- SRP at baseline, 1 month & at 3 month using: 43 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021
1. Plaque Index (Sillness and Loe)7 kept for hydration for 12 hours. The solution was 2. Gingival index (Loe and Sillness)7 mixed in overhead stirrer for 3 hours. 2ml 3. Clinical attachment level to be measured with gluteraldehyde solution (1%w/v) was added William’s Periodontal probe.8 dropwise to this solution with continuous stirring for Preparation of Simvastatin Gel 1hour. Thereafter the solution was poured into petri Simvastatin gel was prepared by adding 2.5 g of dishes and allowed to dry in an oven at 45oc. methylcellulose to 100 g of distilled water slowly Post-LDD, patients were instructed to avoid and stirring continuously to attain the gel chewing on sticky/hard foodstuff or using consistency. Once this was prepared, 1.2 g of toothbrush/interdental aids near the treated areas for Simvastatin was added slowly with continuous 1 week. All patients received the same post- stirring to get the preparation operative instructions and no mouthwashes or Preapration of Chitosan Hygrogel antibiotics were prescribed after treatment. 1gram chitosan powder and 2 gram lactic acid were dissolved in 40ml water (ph between 3-5) and was
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RESULT month to 3 months was significantly more among The collected data was subjected to statistical Group 2 (Scaling + Simvastin gel, 1.50± 0.23mm, analysis. Based on the distribution of data, the 2.15 ± 0.33mm, 0.66± 0.32 mm respectively) in appropriate statistical test was used. The mean PI, GI comparison to Group 3 (Scaling + Chitosan and CAL were compared between pre-test and post- hydrogel with tetracycline 1.13± 0.10mm, test in each study group using paired t-test within the 1.76±0.22, 0.64± 0.11respectively) which was group. One way ANOVA was used to analyze the significantly more than Group 1 (Scaling and Root significance of changes in PI and GI over time planning Mean± S.D 0.79±0.03mm, 1.30± 0.12mm, between groups. 0.51±0.20mm respectively).(Graph 2,Table 2) The mean difference in plaque index from baseline The mean difference in CAL from baseline to 1 to 1 month and from baseline to 3 months was month, from baseline to 3 months and from 1 month significantly more among Group 2 (Scaling + to 3 months was significantly more among Group 2 Simvastatin gel, MEAN±S.D; 1.59± 0.08, 2.29±0.05 (Scaling + Simvastin gel, 0.89 ± 0.29 mm, 2.18 ± respectively) in comparison to Group 3 (Scaling + 0.36mm, 1.48± 0.41 mm respectively) in Chitosan hydrogel with tetracycline, comparison to Group 3 (Scaling + Chitosan MEAN±S.D;1.20±0.21, 0.97+- 0.04; 1.90+- 0.08 hydrogel with tetracycline 0.61 ± 0.15mm, respectively) which was significantly more than 1.12±0.32, 0.98 ± 0.18 respectively) which was Group 1 (Scaling and Root planning, MEAN±S.D; significantly more than Group 1 (Scaling and Root 0.78± 0.02, 0.97±0.04 respectively) (Graph planning Mean± S.D 0.30 ±0.06mm, 0.60± 0.11mm, 1,Table1). 0.62±0.19mm respectively)(Graph 3,Table 3). The mean difference in gingival index from baseline to 1 month, from baseline to 3 months and from 1
Graph. 1
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Graph. 2
Graph. 3
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Table. 1 Plaque Mean Std. F-value p-value index Deviation At baseline Group 1 (Scaling and Root planning) 2.86 0.05 2.399 0.311 Group 2 (Scaling + Simvastatin gel) 2.92 0.02 Group 3 (Scaling + Chitosan 2.89 0.10 hydrogel with tetracycline) At 1 month Group 1 (Scaling and Root planning) 2.08 0.05 55.3655 <0.001 Group 2 (Scaling + Simvastatin gel) 1.33 0.06 Group 3 (Scaling + Chitosan 1.69 0.25 hydrogel with tetracycline) At 3 months Group 1 (Scaling and Root planning) 1.89 0.05 1.062.269 <0.001 Group 2 (Scaling + Simvastatin gel) 0.64 0.06 Group 3 (Scaling + Chitosan 1.00 0.07 hydrogel with tetracycline)
Table. 2 Plaque Mean Std. F-value p-value index Deviation At Baseline Group 1 (Scaling and Root planning) 2.79 0.02 1.505 0.241 Group 2 (Scaling + Simvastatin gel) 2.81 0.03 Group 3 (Scaling + Chitosan hydrogel 2.84 0.10 with tetracycline) At 1 Month Group 1 (Scaling and Root planning) 2.01 0.05 43.443 <0.001 Group 2 (Scaling + Simvastatin gel) 1.32 0.02 Group 3 (Scaling + Chitosan 1.71 0.27 hydrogel with tetracycline) At 3 Months Group 1 (Scaling and Root planning) 1.50 0.05 322.941 <0.001 Group 2 (Scaling + Simvastatin gel) 0.66 0.08 Group 3 (Scaling + Chitosan 1.08 0.08 hydrogel with tetracycline
Table. 3 Plaque Mean Std. F-value p-value index Deviation At Baseline Group 1 (Scaling and Root planning) 3.69 0.42 0.133 0.876 Group 2 (Scaling + Simvastatin gel) 3.74 0.40 Group 3 (Scaling + Chitosan 3.78 0.29 hydrogel with tetracycline) At 1 Month Group 1 (Scaling and Root planing) 3.39 0.41 4.096 0.028 Group 2 (Scaling + Simvastatin gel) 2.85 0.51 Group 3 (Scaling + Chitosan 3.17 0.32 hydrogel with tetracycline) At 3 Months Group 1 (Scaling and Root planing) 3.11 0.36 16.777 0.001 Group 2 (Scaling + Simvastatin gel) 2.26 0.36 Group 3 (Scaling + Chitosan 2.80 0.26 hydrogel with with tetracycline 47 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021
DISCUSSION found to decrease the secretion of MMP-1, MMP- 2, Mechanical debridement of periodontal pockets by MMP-3 and MMP-9 in vitro. scaling and root planing is the standard treatment for As mentioned, the ideal objective for using local chronic periodontitis. However, role of mechanical drug delivery is to control the host-mediated tissue debridement is limited for eliminating pathogens in destruction and to regain the lost periodontium. furcations and deep pockets because these sites are Thus, new drugs have been found to have such difficult to access. Locally delivered antibiotics can effects, out of them statins are opening a new era of be incorporated directly into the pocket. Hung and interest. Lindy et. al. examined the association of Douglass stated that nonsurgical periodontal therapy statin use and clinical markers of chronic in combination with drugs locally will provide better periodontitis and concluded that patients on statin clinical outcomes compared to only non-surgical medication exhibit fewer signs of periodontal periodontal therapy.9 inflammatory injury than subjects without the statin Tetracycline is a wide spectrum antibiotic which regimen. Saxlin et.al. reported that statin medication may affect anaerobic bacteria. Sachdeva and appears to have an effect on the periodontium that is Agarwal in research on the use of tetracyclines dependent on the inflammatory condition of the adjunct to scaling and root planing showed a periodontium. 10The results of Pradeep et al. decrease in pocket depth and attachment of Subramanian et al. are similar to the results obtained epithelium. However, chronic periodontitis is not by Lindy et al. regarding the anti-inflammatory only an infectious process but also involves effects of the statins. Statins possess potential inflammation and tissue loss. Consequently, the use pleiotropic effects which seem to be beneficial in of tetracycline to control infection is not sufficient; periodontics. These beneficial effects, include anti- therefore, in our study a combination of tetracycline inflammatory, immune-modulatory, antioxidant, with chitosan to enhance tissue regeneration. antithrombotic, and endothelium stabilization Chitosan, a non toxic, biodegradable, actions. biocompatible, inexpensive substance, with or The adjunctive use of subgingivally delivered without antibiotics has demonstrated effectiveness biodegradable chitosan base 3% with tetracycline in the treatment of chronic periodontitis. gel 1% and 1.2% Simvastatin gel evaluated in this Chitosan has mucoadhesive properties, a study is safe and provides statistically significant preliminary requirement for prolonged release of the results. Findings of the study state that both, the PI drug at the site and the ability of gelling at low pH and GI revealed a significant progressive regression state. In addition to that chitosan has a antacid and during the entire study period at 1 and 3 months (P< antiulcer properties that may reduce the irritation of 0.001) in all 3 groups. drug. Chitin and chitosan have been investigated as On intergroup comparision the mean difference in antimicrobial agents against a broad range of target CAL from baseline to 1 month, from baseline to 3 microorganisms has proven in vitro antimicrobial months and from 1 month to 3 months was activity against various pathogenic oral cavities significantly more among Group 2 (Scaling + directly involved in plaque formation and Simvastin gel, 0.89 ± 0.29 mm, 2.18 ± 0.36mm, periodontal disease such as Actinobacillus 1.48± 0.41 mm respectively) in comparison to actinomycetemcomitans, Streptococcus mutans and Group 3 (Scaling + Chitosan hydrogel with P. gingivalis. tetracycline 0.61 ± 0.15mm, 1.12±0.32, 0.98 ± 0.18 Due to concerns regarding the increasing bacterial respectively) which was significantly more than resistance, antibiotics do not meet widespread Group 1 (Scaling and Root planning Mean± S.D acceptance; thus, non-antibiotic alternatives may be 0.30 ±0.06mm, 0.60± 0.11mm, 0.62±0.19mm a more reasonable approach. respectively). Cytokines, matrixmetalloproteinases (MMPs) are This study was in accordance to the cross sectional responsible for degradation of extracellular matrix study carried out by Sangwan et al. in which the molecules in periodontal disease. Statins have been participants underwent periodontal examination which included plaque index, gingival bleeding 48 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 index, probing depth and clinical attachment level, effects. This suggests that this group of drugs might the study concluded that statins have a positive have a great potential to improve the outcomes in the effect on periodontal health. treatment of periodontitis since they are safe and not Also, our study was in concordance with the study costly. However, they cannot substitute the standard conducted by Pradeep et al. (2013) who investigated periodontal treatment, which consists of removing the effectiveness of Simvastatin (SMV), 1.2 mg, and microorganisms, considered to be the primary reported that there was a greater decrease in gingival aetiologic factor of the disease. Thus, on the basis of index and probing depth and more CAL gain with this study, it can be said that local SMV therapy significant bone fill at sites treated with SRP plus markedly improves the benefits of SRP, clinically. locally delivered SMV in patients with chronic By the use of these classes of drugs, the threshold for periodontitis.The results were comparable to the surgical periodontal therapy might move toward work of Pradeep &Thorat who investigated the deeper pockets where better and additional effects efficacy of a 1.2% simvastatin gel as an adjunct to might be expected with their use as local delivery scaling and root planing on chronic PD treatment. drugs. Local therapy with various controlled release The authors concluded that in the sites with chronic system can be evaluated for maximum benefits. PD treated with scaling and root planing and local Long-term benefits and safety of the same also need application of simvastatin gel there was a greater to be evaluated. gain of clinical attachment with significant bone fill. CONCLUSION Kinra et al. 107 in his study showed that Sustained release systems prevent the recolonization combination of allograft with a solution of of pathogens for long period and reduces simvastatin leads to significantly greater reduction inflammation. From the findings of the study, we in probing depth, gain in clinical attachment level, elucidate that treating chronic periodontitis with and linear defect fill than when the graft is used subgingivally delivered Simvastatin and Chitosan alone in the treatment of human periodontal hydrogel as an adjunct to scaling and root planning infrabony defects. demonstrated positive results clinically. Clinical There are very few studies on applicability of statins parameters were significantly reduced in test sites. in chronic periodontitis in the literature, but results Conflicts of Interest: None of this study indicate that statins hold beneficial
REFERENCES 1. ”Cobb C Non surgical pocket therapy-mechanical. 7. Soben Peter. “Indices in dental epidemiology. Ann Periodontol.” 1996;1:443–490. Essentials of preventive and community 2. “Cobb C et al Clinical significance of non-surgical dentistry.”4th ed. New Delhi: Arya Publishing periodontal therapy: An evidence-based perspective house; 2009. p.321-26. of scaling and root planing. J. Clin. Periodontol.” 8. Carranza FA, Takei HH, Cochran DL. Clinical 2:6-16 diagnosis. In: Newman MG, TakeiHH, Klokkevold 3. Pragati S, Ashok S. “Recent advances in periodontal PR, Caranza FA, editors. Carranza’s Clinical drug delivery systems. Int. J. Drug Deliv 2009;1:1– Periodontology. 10th ed.Noida:Saunders, Reed 14. Elsevier India Private Limited; 2006. p.551-53. 4. Purushotham S, D'Souza ML, Purushotham R. 9. “Hung and Douglass Local delivery of antimicrobial Statin:” A boon in periodontal therapy.” SRMJ Res agents for the treatment of periodontal disease” Dent Sci 2015;6: 243-9. August 50(1):83-99. 5. Gazzerro P, Proto MC, Gangemi G, Malfitano AM, 10. Tuomas Saxlin 1, Liisa Suominen-Taipale, Matti Ciaglia E, Pisanti S, et al. Pharmacol Rev. 2012 Knuuttila, Pirkko Alha, Pekka YlöstaloJ Clin Jan;64(1):102-46. Periodontol;2009 Dec;36(12):997-1003. 6. Karthiga Devi , Sathish Kumar K, Arivalagan K.” Microwave assisted nanoparticles for drug delivery systems.” Int J Pharma Pharma Sci 2014;6:118-23.
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Endodontic Management of Bayonet Shaped Canals in Single and Multirooted Second Premolar – Case Series
Dr. Navdeep Jethi, 1 Dr. Jyoti Beniwal, 2 Dr. Falak Ashraf, 3 Dr. Vikram J. Nain, 4 Ish Singla 5
1. Dr. Navdeep Jethi Senior Lecturer, Department of Conservative Dentistry and Endodontics, Daswani Dental Collage and Research Centre, Kota, Rajasthan. 2. Dr. Jyoti Beniwal Prosthodontist, Dr. Harvansh Singh Judge Institute of Dental Sciences Hospital, Sector 25, South Campus, Panjab University, Chandigarh 3. Dr. Falak Ashraf MDS Oral pathology, Daswani Dental Collage and Research Centre, Kota, Rajasthan 4. Dr. Vikram J. Nain MDS (Prosthodontist), Shah Satnamji Speciality Hospitals, Sirsa 5. Dr. Ish Singla Private Practitioner, Sirsa
Abstract A good knowledge of root canal anatomy is necessary to deal with challenging cases in endodontic treatment. Often, two curvatures are seen in maxillary premolars in the same root canals, this two curvature root canal anatomy is referred as S shaped canals or Bayonet shaped root canals. Procedural errors such as ledges, fractured instruments, canal blockages, zip and elbow creations are common causes of failure in such cases. So a deep insight in the internal anatomy of the teeth before commencement of the treatment is necessary and routine IOPA can be used to assess the proper shape, form and morphology of the teeth, but sometimes an extra root may be not properly visible in them, so multiangled radiographs are essential for the diagnosis of such case. Here are two cases of endodontic treatment in Bayonet shaped root canals diagnosed, prepared and obturation with two different techniques. Keywords: Bayonet shaped canals, S shaped canals, Vertucci classification, Maxillary second premolars, extra roots, Guttaflow.
INTRODUCTION stabbing blade which may be fixed to the muzzle of Root canal system of Maxillary second premolar a rifle for use in hand-to-hand fighting. Bayonet demonstrates high variability and according to a shaped canals involve at least two curves, with the study it was the only tooth to show all eight apical curve having maximum deviations in Vertucci’s canal configurations.1 According to anatomy.7 Others teeth in which S-shaped canals Vertucci, maxillary second premolars shows are commonly found are maxillary lateral incisors, maximum variations and bayonet shaped canal is maxillary canines, maxillary first premolars, and one of such variations which is very difficult to mandibular molars.5 negotiate.3, 4 The incidence of Vertucci’s type II S-shaped or bayonet shaped canals pose a big (two canal orifices end in one apical foramen,) and challenge while endodontic therapy.6 If they cross type IV (two canal orifices end in two separate in mesiodistal direction, these double curvatures apical foramina is very common in case of second can be easily identified in radiographs but multi maxillary premolar.2 Bayonet is a sword-like angled radiographs are needed when they traverse
50 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021 in a buccolingual direction, and other chances to file. The Canal was negotiated using K files (6, 8, diagnose these canals is that when the initial file is and 10), an unrestricted approach to the first curve removed out of the canal and multiple curvatures is necessary, and the shape of the removed files are seen in it.5For optimal biomechanical showed curvatures too. The working length was preparation of S-shaped canals, evaluation to the estimated from pre operative radiograph. In the multiple concavities along the external surfaces of middle third of the root first patency file (10 k file) the root and three dimensional visualization of root was binding with dentinal walls. To lessen the canal anatomy is necessary because failure may degree of the curvature, anti curvature filing was leads to procedural errors.7This paper includes two done. Once the entire canal was negotiated, first, to case reports of bayonet shaped canals in Maxillary facilitate biomechanical preparation of the apical second premolars , diagnose, prepared and curve, passive shaping of the coronal curve was obturated with two different methods one with done. Constant recapitulation with small files along Guttaflow obturation in single root canal and other with EDTA lubrication was used with double deals with Bayonet shaped canals in double rooted flaring technique for chemo mechanical maxillary second premolar obturated with lateral preparation. Copious irrigation with saline and condensation. NaOCl was necessary to prevent blockage and CASE REPORT 1: Aesthetic Obturation ledging in the apical curve. Pre curving of the with Guttaflow apical 3 mm of the file aids in maintaining the A 45 year old female patient was reported to curvature of the canal. Obturation was done using department of conservative dentistry and Gutta flow, which is a silicon based obturation endodontics in Daswani Dental College, Kota, with material, a combination of sealer and gutta percha. chief complaint of pain in posterior teeth region of Initially a GP master cone was seated up to the upper jaw on chewing of food and sensitivity to apical third of the canal. Following the hot, cold and sweet beverage. Pain was severe, manufacturer’s instructions, guttaflow was mixed boring, throbbing in nature which increases with in the capsule and the canal tip was placed onto the hot stimulus. Tooth was tender on percussion and capsule, and the capsule into the dispensing gun. pulp was vital, confirmed with pulp tester. Small amount of guttaflow was dispensed over a Radiographic findings include double curvature in pad to check the pink colour and ensure the proper root of the second premolar (15). After the mixing of the material before placing into the canal. informed consent the patient was anesthetised with The final obturation of the root canal was done L.A. and isolated properly with the help of rubber using last apical file used to apply a small amount dam. Access was opened using round bur and of the GuttaFlow into the root canal, master cone refined using Endo Z bur. After flaring the canal was seated, and backfilling was done with orifice was opened and enlarged using Sx Protaper GuttaFlow.
a) Pre Operative Radiograph b) Canal Negotiation
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c) Working Length d) Obturation: Gutta Flow
Fig 1: Guttaflow obturation of the S shaped canals in Maxillary second premolar.
CASE REPORT 2: Bayonet Shaped Canals any other root, when evaluated in preoperative in Double Rooted Maxillary Second IOPA. The patient was anesthetised with local Premolar Obturated with Lateral anaesthesia and isolation in the oral cavity was Condensation done with a rubber dam. The access was prepared using no 2 and 4 round bur and while flaring of the A 35 years old patient was reported to our tooth, the dentinal map revealed two canal orifices. department with a chief complaint of severe pain in The orifices were enlarged using GG drills and Sx second quadrant of maxillary jaw. Radiographic protaper file was used for initial coronal flaring of interpretation of a S shaped root canal anatomy was both the canals. easy and double flare in the root was obvious in the IOPA. It was very difficult to say that this tooth had
Fig 2: Radiographic evaluation of a Bayonet shaped canals in double rooted maxillary second premolar
Canals were negotiated with no 6, 8, and 10 files. The working length was confirmed radio The curvature was clearly visible on the files graphically and copious irrigation with NaOCl and removed from each of the canals as they were saline was admitted during chemomechanical bayonet shaped. But confusion was about the fact, preparation with NiTi 15K-35 K files in both the that under which type the tooth morphology falls canals. After initial coronal flaring, the apical according to Vertucci’s classification, the portion was prepared. Step back technique of canal confirmation was done with changed angulations preparation was used during the procedure, anti radiographs. The Digital radiographs revealed two curvature filing was done to straighten the separated roots in the tooth and both had double curvatures. Recapitulation was done along with curvatures. irrigation. After proper preparation lateral condensation obturation technique was applied using GP cones and AH plus sealer. 52 National Research Denticon, Vol-10 Issue No. 1, Jan. - Mar. 2021
Fig 3: a) Working Length taken b) Master cone RVG c) Obturation Done
DISCUSSION about the incidence of extra roots in the maxillary Due to double curvature, negotiation of S shaped premolars teeth are quite rare.9 Mandibular canals is very difficult.1, 6 these are highly prone to premolars have the most aberrant anatomy. A chances of strip formation. 5 Guttman suggested the number of reports of root canal variations in these preflaring of coronal 1/3rd of the canal to reduce the teeth have been reported in the literature. 2,10 angle of the curvature.3 The access will make the Vertucci reported 2.5% incidence of a second approach to second curve much easier if we reduce canal, in his series of studies conducted on the curvature.5 Preflaring was done with Sx file in extracted teeth. 11 11.7% occurrence of two canals both the cases and once it was done the apex was and 0.4% of three canals is reported by Zilich and easily negotiable. For the preparation of the apical Dawson. 12 Harty has reported 11% possibility of portion of the canals NiTi files were used. The second canal. In most instances they have had one apical enlargement was done up to 35 k as further canal, 13,14,15,16,17 In studies on extracted maxillary enlargement can leads to iatrogenic error. 3 second premolars ,it was found that 35.4% of them Guttaflow is a silicone based sealer5 and had two root canals at the apex. In Indians shows a endodontic treatment of the complex anatomy of higher incidence of type II configuration (33.6%) in the root canal can now be completed with the the root canal morphology of the maxillary second precise filling and sealing. Guttaflow has easy premolar. The finding of additional type, namely application technique along with its ability to type XIX (2-1-2-1), is rare. Highly variable expand, flow, and fill the 3D space in the canal anatomic structures in case of maxillary second makes it an excellent option for the permanent premolars highly influence the clinical outcome of obturation of root canals.18 It is a mixture of endodontic therapy. 19 Silicone with GP powder to form, a “two in one” CONCLUSION cold filling system. It is supplied in unidose capsule Successful endodontic therapy in S–shaped canals & is injected after mixing or carried to canal on GP. depend upon: After mixing GuttaFlow has a working time of 15 • Proper understanding of tooth morphology minutes and sets completely in 25 to 30 minutes. It • Correct radiographic technique and evaluation is radiopaque in a final radiograph which should be • Choosing appropriate technique for cleaning taken after the completion of the root canal and shaping of canals. 18 obturation. • Choosing a good obturation technique. Literature is plentiful with the reports of extra canals in mandibular second premolars, but reports
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