Dental march 2011

IJMD’s Editorial Panel

Associate Editor N Aravindha Babu

Editor-in-Chief KMK Masthan

Executive Editor S Bhuminathan

Indian Journal of

Multidisciplinary DentistryIndian Journal of

Multidisciplinary Dentistry

IJMD Advisory BoardProsthodontics Mahesh Verma Srinisha J Raghavendra Jayesh S Sanjna Nayar

Conservative Dentistry/Endodontics Sukumaran VG Subbiya A Swaminathan S (Singapore)

Implantology John W Thurmond (USA)

Genetics Aravind Ramanathan

Oncology Abraham Kuriakose M

Oral and Maxillofacial Surgery Ramakrishna Shenoi Vijay Ebnezer Raj Kutta (USA)

Oral Pathology and Microbiology Vinay K Hazarey Ipe Vargese V Puneet Ahuja

Orthodontics Krishna Nayak US Dhandapani G Murali RV Deepak C

Pharmacology Muthiah NS Elumalai M

General Medicine Rajendran SM

Periodontics Chandrasekaran SC Ash Vasanthan (USA)

Oral Medicine and Radiology Selva Muthu Kumar SC Nalini Aswath

Pedodontics Krishan Gauba Ashima Gauba

Biochemistry Julius A

Microbiology Mahalakshmi K

IJCP’s Editorial PanelDr KK Aggarwal

CMD, Publisher and Group Editor-in-Chief

Dr Veena AggarwalJoint MD & Group Executive Editor

Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean

Harvard Medical SchoolGroup Consultant Editor

Anand Gopal Bhatnagar Editorial Anchor

Dr Deepak ChopraChief Editorial Advisor

Volume 1, Issue 2January-February 2011

Advisory BodiesHeart Care Foundation of India, Non-Resident Indians Chamber of Commerce & Industry, World Fellowship of Religions

IJMD is included in the databases of Genamics JournalSeek along with Ulrich International periodical directory and Index Copernicus International, Ltd.

IJCP’S EDItORIAl & BuSInESS OffICESDelhi Mumbai Kolkata Bangalore Chennai Hyderabad

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SubscriptionDinesh: [email protected]: 09831363901

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Dr Veena Aggarwal9811036687

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ContentsFrom the editor-in-chieF 64

From the desk oF iJcP GrouP editor-in-chieFSucroseContentofSelectedPediatricMedications 65

review articleCBCT-AParadigmShiftintheManagementofDentalImpactions 67

PsychosomaticDisturbanceinRelationtoPeriodontium 74

AnemiaofChronicDiseaseandPeriodontitis:TheMissingLink 82

Three-DimensionalMiniplateFixationinMandibularAngleFractures 89

FibrousDysplasiaoftheMaxilla-ReportofTwoCaseswithReview 100

ClinicalandPathologicalEvaluationofOralChangesinLeprosy 105

case rePortSimpleMeansofManagementofTeethwithForeignBodyinRootCanal 78

ExtrusionofFracturedAnteriorTooth-AnInvisibleApproach 96

oriGinal researchComparisonofEnzymeb-glucuronidaseLevelsAroundHealthyandDiseasedImplants:AClinicalStudy 93

Cutting Efficiency, Surface Change and Hardness: EZ-fill Safe Sider Instruments vs K Files 110

Oral Hygiene Status, Knowledge, Attitude and Practices of Oral Health among Rural Children of Kanchipuram District 115

clinical studyASurveyonBiomedicalWasteManagement 86

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Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 2, Jan-Feb 201164

From the editor-in-chieF

The first issue came out well and in time due to the exceptional coordination from IJCP especially Ms. Chitra Mohan and Ms. Kamya. There was more cream on top of the cake in the form of the encouraging message from The President, Dental Council of India, Dr Mahesh Verma. The response

of the readers who spoke, wrote, mailed or smsed acted as the boost for the second issue works. Most were congratulatory since it was the first issue, some were pouring out with suggestions and a few were critical. The critics amazed me because I realized they were the ones who read the journal cover-to-cover, made notes of lapses that had occurred and took the time and effort to communicate what they thought. My wholehearted thanks for their ideas which helped me not to repeat the same kind of mistakes and I hope they continue to criticize and help to refine our journal to great standards.

The authors were to be congratulated for their patience since I wore them down with my repeated requests for final corrections and proof readings. Many of the responses from the readers were of specific nature regarding a particular article which I have forwarded to the relevant authors. I hope they respond to the reader and thereby create an interactive scientific community.

Following the tradition of several international journals and to utilize the left over spaces at the end of the articles we have planned to include book reviews, academic event coverage write ups and ‘Did you know? on Dentistry. The readers are most welcome to contribute such items.

Online version of our journal is available at http://ebook.ijcpgroup.com/ijmd/index.htm from the first issue onwards. An indexed journal needs to link all articles printed in previous issues for easy search and find, and hence our Group Editor-in-Chief Dr KK Aggarwal has kindly consented to let us avail this facility. I convey him my thanks for helping this journal grow.

My sincere thanks to the Executive Editor Dr S Bhuminathan who has visions of making this journal a hundred plus pages issue and with color photographs.

Best Wishes...

Dr KMK MasthanProfessor and Head

Department of Oral Pathology and Microbiology Sree Balaji Dental College and Hospital, Chennai

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65Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 2, Jan-Feb 2011

From the desk oF iJcP GrouP editor-in-chieF

Many drugs may contain high dose of sucrose. Here is a slit fro US formulations. Same will be true for most India formulations.

Dr KK AggarwalPadma Shri and Dr BC Roy National Awardee

Sr Physician and Cardiologist, Moolchand MedcityPresident, Heart Care Foundation of India

Group Editor-in-Chief, IJCP Group Editor-in-chief, eMedinewS

Chairman Ethical Committee, Delhi Medical CouncilDirector, IMA AKN Sinha Institute (08-09)

Hony. Finance Secretary, IMA (07-08)Chairman, IMA AMS (06-07)

President, Delhi Medical Association (05-06)[email protected]

http://twitter.com/DrKKAggarwalKrishan Kumar Aggarwal (Facebook)

Drug Sucrose content (gms/5 ml)Paracetamol/AcetaminophenTylenol children’s elixir 1.6Tylenol children’s suspension 3.7Tylenol maximum strength liquid 5.5Acetaminophen/codeineTylenol elixir with codeine 3AmoxicillinAmoxicillin 125 suspension 2Amoxicillin 250 suspension 3Trimox suspension 3.3AzithromycinZithromax 100 suspension 3.9Zithromax 200 suspension 3.9CarbamazepineTegretol suspension 2CefadroxilDuricef 125 suspension 2.5Duricef 250 suspension 2.4

Sucrose Content of Selected Pediatric Medications

Cont’d...


Drug Sucrose content (gms/5 ml)CephalexinCephalexin 125 suspension 1.4Cephalexin 250 suspension 1Cephalexin 125 suspension 2.6Keflex oral suspension 3ClarithromycinBiaxin 125 suspension 3Biaxin 250 suspension 2.3ferrous gluconateFergon 2ferrous sulfateFer-in-sol drops 1.9Fer-in-sol syrup 3Fer-Gen-Sol 2Griseofulvin Grifulvin V oral suspension 3.5Multivitamins Iberet 500 liquid 0.6Theragran liquid 1.78Vi-Daylin liquid 0.8Advanced Formula Centrum liquid 1.7Nystatin oral suspension 2.5Ni stat oral suspension 3Penicillin VK Veetids 3.5Penicillin VK 125 suspension 2.4Phenobarbital Phenobarbital elixir 0.6Prednisolone Prelone syrup 1.8Prednisone Prednisone solution 1.8Sulfisoxazole Gantrisin pediatric suspension 2.8trimethoprim/sulfamethoxazole Bactrim pediatric suspension 2.5

Pediatric Dosage Handbook, 7th ed., Taketomo CK, Hodding JH, Kraus DM (Eds.), Lexicomp, Cleveland 2000:1228.

Happy reading…

From the desk oF iJcP GrouP editor-in-chieF

...Cont’d


Traditional two-dimensional (2D) imaging of three-dimensional (3D) anatomic structures has long posed a problem in the diagnosis and

consequently the management of dental impactions. Localization of these teeth were traditionally done using the buccal object rule (SLOB), as well as, taking two radiographic images at right angles to one another, most often a periapical and an occlusal view.1 Diagnosis and treatment planning often gets complicated with the presence of one or more impacted teeth that may be present at unusual relationships to the erupted dentition.

Cone beam computed tomography (CBCT) as a dedicated 3D imaging tool in dentistry has improved the maxillofacial surgeons’ access to advanced imaging, while significantly reducing the radiation dose to the patient, as complicated diagnostic challenges were often sent for medical CT evaluation in the past. Moreover, the method offers the advantage that it can also be used in the dental practice, taking the existing radiation protection regulations into account. This

guarantees optimum patient and user friendliness, because referral to a specialized CT facility is thus no longer necessary in most cases. In the first 12 months of the trials of the Planmeca Promax 3D at the Dept. of Dental Surgery and Radiology of the University Clinic for Oral and Maxillofacial Medicine in Graz, the overwhelming majority of referrals for CBCT (almost 90%) was concerned with the field of oral surgery and implantology. Oral surgical questions mainly covered aspects of wisdom tooth anatomy, position of impacted canines, premolars and mesiodents, as well as cystic lesions. Diagnoses of the maxillary sinuses and the area of tooth preservation represented further indications.2

CBCT can show the location of the impacted teeth, their relationship and effect on the surrounding dentition.3 Data acquired during imaging can be reformatted to show sequential slices through the oral and maxillofacial complex in the axial, coronal and sagittal planes. These data can be further be manipulated to produce precise 3D reconstructions of the area of interest, giving the maxillofacial surgeon a clear picture of the exact location of the teeth in question.

In addition, panoramic reconstruction of data from CBCT can be performed at various slice thicknesses,

abstract

Radiographic interpretation and diagnosis of dental impactions have always posed a great challenge to the oral surgeon; this could largely be attributed to the limitations posed by the conventional two-dimensional (2D) imaging modalities. Dental impactions, which can occur due to pathologic or developmental factors, can be evaluated accurately using cone beam computed tomography (CBCT) three-dimensional (3D) imaging. 3D localization of the impacted teeth and determination of the type of impaction can be performed using multiplanar reformats from the CBCT data and this data will help the oral surgeon to get a sense of a 3D position of the teeth and its relation to the adjacent anatomic structures. Most importantly 3D images from the CBCT machine allows the surgeon to accurately plan the appropriate treatment strategy as he will be able to visualize the proximity of vital structures and thickness of bone covering the impacted teeth. The teeth most commonly impacted are the mandibular impacted teeth followed by the maxillary canines. Surgical removal of mandibular impacted teeth pose a high risk, as the lingual nerve and the inferior alveolar nerve and vessels pass close to the teeth. The advent of CBCT as contemporary diagnostic aid in craniofacial imaging has brought in a paradigm shift in the diagnosis and management of dental impactions in the field of oral and maxillofacial surgery.

Key words: CBCT, dental impactions, 2D and 3D imaging modalities

CBCT - A Paradigm Shift in the Management of Dental ImpactionsC Deepak*, B Saravanan**, S Kishore Kumar†

*Professor**Senior Lecturer†Associate ProfessorDept. of OrthodonticsSree Balaji Dental College and Hospital, Chennai Address for correspondence E-mail: [email protected]

review article


review article

giving the maxillofacial surgeon a familiar radiographic environment to evaluate; without the presence of distortion, magnification or superimposition, all of which are usually associated with conventional 2D panoramic imaging.

For 3D reconstruction, CBCT images are converted from axial slices into a 3D image in a series of steps. The first step is called the thresholding, where a Hounsfield range (HU) of the desired anatomy is specified. For example, if one is segmenting the mandible, a threshold between 300 HU and 1800 HU is selected. This thresholding will exclude soft tissue and air from the images. The resulting segmentation will contain some artifact due to scatter from metal objects and fillings. This artifact is cleaned up in the next step, where the operator goes through the images one by one, taking away the artifacts and extraneous objects from the images. The next step is called the ‘region growing’, where the operator selects a seed point within the structure of interest that has been already been segmented in the first two steps. That seed point will grow into the complete region of interest (ROI). Finally, the resulting segmentation of the individual

slices is combined together by an interpretation creating a 3D reconstruction.4

Etiology of Dental Impactions

A tooth is said to be impacted after it fails to erupt after the completion of its root formation and the chronological age of eruption.

Dental impactions occur commonly due to: 1) Developmental, namely jaw-toothsize discrepancy, eruption pattern of teeth, supernumerary teeth, presence of retained teeth or ankylosis and 2) pathological, namely a tumor cyst or a systemic or local bone pathology that could displace or impede the eruption of the tooth. Determining the exact cause of impaction greatly influences the treatment planning, as an appropriate surgical approach can be devised to minimize the postsurgical morbidity.

Developmental factors

The teeth most commonly impacted are the third molars followed by the maxillary canines.5 Orthopantomography (panoramic radiography) has been used for the study of measurements involving particularly the prediction of the eruption of impacted lower third molars and analyses of measurements of the ramus and head of mandible. The discrepancy involved with the projection of this radiographic image has stimulated the search for further ways to use it, particularly in orthodontic treatments and oral and maxillofacial surgeries. The author proposes a graphimetric method for the mandible, based on panoramic radiography. The results are expressed in linear and angular measurements, aiming at bilateral comparisons as well as the determination of the proportion of skeletal and dental structures, indivi-dually and among themselves as a whole. The method has been named panorametry, and allows measurement of the mandible (mandibular panorametry) or the posterior mandibular teeth (dental panorametry). When combining mandible and maxilla, it should be referred to as total panorametry. It may also be used, in the future, with CBCT images, and in this case it may be mentioned as CT panorametry.6,7

Canine Impaction

Canine impaction is a common occurrence, and clinicians must be prepared to manage it. With early

figure 1. A, Left and B, Right views showing mesioangular impactions of the mandibular third molars.


review article

detection, timely interception and well-managed surgical and orthodontic treatment, impacted maxillary canines can be erupted and guided to an appropriate location in the dental arch.8-10 A novel method of gauging the difficulty of impaction and the potential efficacy of treatment (KPG index), has been devised for canine impactions using 3D images from the CBCT.

Depending on its anatomical location, the cusp tip and the root tip are each given a number 0-5 in 3D taken from a pretreatment image. The sum of the cusp tip and root tip scores in the three views dictates the anticipated difficulty of treatment.11

figure 2. Traditional 2D data set for evaluating impacted teeth.

Root Resorption

Root resorption of maxillary lateral incisors caused by impacted canines is well-known and a relatively common phenomenon. However, much debate and conflicting evidence exists with regard to the actual resorption trigger and potential etiological factors involved. Consequently, there are no obvious clinical clues concerning prevention and diagnosis as well as subsequent treatment decisions.

The introduction of CBCT has recently allowed drawing a new and much more documented light on the diagnostic and therapeutic strategies involved in managing such complex cases.12-14


review article

Jaw Size Discrepancy

The size of the jaw and length of the arch determines the amount of space the dentition has, to align itself into occlusion.15 The tube shift method (also known as the parallax technique) has traditionally been the method of locating impacted teeth and provides an arbitrary position and approximation of the level of difficulty for the management of these teeth. In addition, the extent of the pathology caused by ectopic teeth and their surrounding structures has also been evaluated by these radiographs.16 A recent report found that the use of CBCT technology

figure 3. 3D data set consists of A, axial image, B, panoramic image, C, series of single cross sections, D, 3D reconstructions.

could add value to the management of patients with such anomalies. The authors used the technology to precisely locate ectopic canines and design treatment strategies that allowed minimally invasive surgery to be performed and helped develop an effective orthodontic treatment plan.17

Supernumerary teeth

The presence of supernumerary teeth, maybe or may not be associated with an impacted teeth, this depends on the arch length and alignment of the rest of the dentition. The commonest site for a single

BA

C D


review article

figure 4. 3D and panoramic reconstruction of mandible showing relationship of impacted molars to inferior alveolar nerve canal (IAN).

section can be done without superimposition of the adjacent teeth and structures.

Ankylosis

Another important cause of impaction is ankylosis, which is characterized radiologically by a discontinuity of the PDL space surrounding the tooth. This creates a rigid union between the tooth and bone thereby effectively causing the affected tooth to become impacted or remain submerged.18 Ankylosis also remains as one of the major complications associated with impacted teeth in children. Orthodontically-assisted eruption of an ankylosed tooth may intrude or displace the adjacent teeth. Children who undergo orthodontically assisted eruption should be followed closely to ensure that movement of an impacted tooth is occurring. In general, the removal or assisted eruption of impacted teeth in children requires a thoughtful interdisciplinary evaluation between the surgeon and orthodontist/primary dental care provider. Factors that must be considered include operative feasibility, orthodontic management, future growth and psychosocial considerations. The use of emerging technology, such as CBCT and skeletal anchorage, should better equip surgeons to navigate the anatomy 3D and provide assistance in management of difficult cases.19

Types of Impaction

Impactions are generally evaluated based on the position of the long axis of the impacted teeth to that of the long axis of teeth present in the rest of the dentition. Therefore, the teeth could be horizontally, vertically, buccally or palatally impacted. Further, if the crown of the impacted teeth lies towards the adjacent teeth then it is classified as mesioangularly impacted and if the crown of the impacted tooth lies away from the adjacent tooth then is classified as distoangularly impacted.20

A horizontally impacted tooth may sometimes be oriented in such a manner that it aligns the axis of the tooth at a right angle to the dentition (i.e. buccolingually), thus making the evaluation of these impacted more complicated, using a plain film radiography. The need for advanced imaging techniques in the management of such impactions becomes even more pertinent.21

figure 5. Buccolingual position.

R L

supernumerary tooth is the maxillary incisor region and multiple supernumerary teeth occur frequently in the premolar region, usually the mandible.

3D data from CBCT can be beneficial in localization of these supernumerary teeth in relation the surrounding teeth and other structures by reformatting the data acquired in three anatomical planes, thereby vastly improving the diagnostic process. The prime advantage is that, buccolingual evaluation of each individual


review article

Effect of Impacted Teeth on Surrounding Structures

Impacted teeth may displace, impede the eruption, and/or cause external resorption of adjacent teeth. Instances of cases showing evidence of root resorption of the adjacent teeth using conventional 3D CT scans have been reported.22 If the impacted tooth is partially impacted, it may attract plague, thereby facilitating caries in it and the adjacent tooth.

Treatment Planning for Impacted Teeth

Once surgical intervention has been decided, a thorough radiographic examination is needed to determine the position of the adjacent teeth and the important anatomical structures. The proximity of the tooth to a cortex (buccal or lingual) will determine the approach the surgeon will take. The area must be examined for proximity to nerve and vessel canals (the incisive canal/foramen of the anterior maxilla, the inferior alveolar nerve canal and mental foramen for mandibular third molar and premolar.

When viewing the anatomic relation between the inferior alveolar nerve (IAN) and mandibular third molar root apices using dental 3D-CT, contact of the two anatomic structures results in an increased risk for IAN exposure or injury.23-26 The ability of CBCT to project these structures in three different planes decreases the chances of injuring them and remaining teeth in the dentition. The axial plane allows for buccolingual assessment of the tooth position. The coronal shows the mesiodistal inclination of the anterior teeth in addition to providing sequential cross-sections, through the IAN canal. The sagittal plane can show the mesiodistal inclination of the posterior teeth

and the proximity of IAN canal to the roots of the impacted teeth.20 The use of 3D data from a CBCT machine, gives valuable information regarding the impacted teeth, like, type of impaction, proximity to surrounding vital anatomical structures and resorption of adjacent teeth. Familiarity with the technology and information garnered will help the Maxillofacial Surgeon make an appropriate treatment decision.

ReferencesWhite SC, Pharoah MJ. Oral radiology, principles and interpretation. Philadelphia, Mosby, 2004. Rugani P, Kirnbauer B, Arnetzl GV, Jakse N. Cone beam computerized tomography: basics for digital planning in oral surgery and implantology. Int J Comput Dent 2009;12(2):131-45.Cevidanes LH, Styner MA, Proffit WR. Image analysis and superimposition of 3-dimensional cone-beam computed tomography models. Am J Orthod Dentofacial Orthop 2006;129(5):611-8.Bankman IN. Handbook of Medical Imaging. Processing and Analysis. San Diego Academic Press, 2000.Bedova MM, Park JH. A review of the diagnosis and management of impacted canines. J Am Dent Assoc 2009;140(12):1485-93.Kau CH, Richmond S, Palomo JM, Hans MG. Three-dimensional cone beam computerized tomography in orthodontics. J Orthod 2005;32(4):282-93.Puricelli E. Panorametry: suggestion of a method for mandibular measurements on panoramic radiographs. Head Face Med 2009;23:5-19. Maverna R, Gracco A. Different diagnostic tools for the localization of impacted maxillary canines: clinical considerations. Prog Orthod 2007;8(1):28-44.Liu DG, Zhang WL, Zhang ZY, Wu YT, Ma XC. Localization of impacted maxillary canines and observation of adjacent incisor resorption with cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105(1):91-8. Hechler SL. Cone-beam CT: applications in ortho-dontics. Dent Clin North Am 2008;52(4):809-23, vii.Kau CH, Pan P, Gallerano RL, English JD. A novel 3D classification system for canine impactions - the KPG index. Int J Med Robot 2009;5(3):291-6.Alqerban A, Jacobs R, Lambrechts P, Loozen G, Willems G. Root resorption of the maxillary lateral incisor caused by impacted canine: a literature review. Clin Oral Investig 2009;13(3):247-55. Alqerban A, Jacobs R, Souza PC, Willems G. In-vitro comparison of 2 cone-beam computed tomography

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figure 6. Root resorption.


review article

systems and panoramic imaging for detecting simulated canine impaction-induced external root resorption in maxillary lateral incisors. Am J Orthod Dentofacial Orthop 2009;136(6):764.e1-11; discussion 764-5.Curley A, Hatcher DC. Cone beam CT - anatomic assessment and legal issues: the new standards of care. J Calif Dent Assoc 2009;37(9):653-62. Fonseca LC, Kodama NK, Nunes FC, Maciel DH, Fonseca FA, Roitberg M, et al. Radiographic assessment of Gardner`s syndrome. Dentomaxillofac Radiol 2007; 36(2):121-4.Chaushu S, Chaushu G, Becker A. The role of digital volume tomography in the imaging of impacted teeth.World J Orthod 2004;5(2):120-32.Mah J, Enciso R, Jorgensen M. Management of impacted cuspids using 3-D volumetric imaging. J Calif Dental Assoc 2003;31(11):835-41.Mc Donald RE, Avery DR, Dean JA. Dentistry for the child and adolescent. Philadelphia, Mosby, 2004.Tiwana PS, Kushner GM. Management of impacted teeth in children. Oral Maxillofac Surg Clin North Am 2005;17(4):365-73.Tamimi D, Elsaid K. Cone-beam computed tomography in the assessment of dental impactions. Sem Orthodont 2009;15(1):57-62.Suomalainen A, Ventá I, Mattila M, Tuetola L, Vehmas T, Peltola JS. Reliability of CBCT and other radiographic methods in preoperative evaluation of

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lower third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(2):276-84.Ericson S, Kurol PJ. Resorption of incisors after ectopic eruption of maxillary canines: a CT study. Angle Orthod 2000;70(6):415-23.

Flygare L, Ohman A. Preoperative imaging procedures for lower wisdom teeth removal. Clin Oral Investig 2008;12(4):291-302.

Ghaeminia H, Meijer GJ, Soehardi A, Borstlap WA, Mulder J, Bergé SJ. Position of the impacted third molar in relation to the mandibular canal. Diagnostic accuracy of cone beam computed tomography compared with panoramic radiography. Int J Oral Maxillofac Surg 2009;38(9):964-71.

Nakayama K, Nonoyama M, Takaki Y, Kagawa T, Yuasa K, Izumi K, Ozeki S, Ikebe T. Assessment of the relationship between impacted mandibular third molars and inferior alveolar nerve with dental 3-dimensional computed tomography. J Oral Maxillofac Surg 2009;67(12):2587-91.

Neugebauer J, Shirani R, Mischkowski RA, Ritter L, Scheer M, Keeve E, Zöller JE. Comparison of cone-beam volumetric imaging and combined plain radiographs for localization of the mandibular canal before removal of impacted lower third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105(5):633-42; discussion 643.

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74 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 2, Jan-Feb 2011

The etiology of inflammatory periodontal disease is complex. The etiological significance of biological and behavioral risk factors,

including systemic conditions, smoking, oral hygiene and age has been demonstrated. However, a significant proportion of the variation in disease severity cannot be explained by taking only these factors into consideration.

Harmful effects that result from psychic influence on the organic control of tissues are known as psycho-somatic disorders.

There are two ways, in which psychosomatic disorder may be induced in the oral cavity:

Through the development of habits that are injurious to the periodontiumBy the direct effect of the autonomic nervous system on the physiologic tissue balance.

ClassificationOral hygiene negligenceChanges in dietary intakeSmoking and other harmful habitsOral habitsBruxismGingival circulationAlteration in salivary flow and componentsEndocrine changes

Lowered host resistanceStress

Possible Mechanism of Action of Psychosocial Factors on Periodontal Tissues

Oral Hygiene negligence

It is obvious that proper oral hygiene is partially- dependent on the mental health status of the patient. Some patients may be disturbed or distracted psychologically so that personal hygiene is neglected. Other patients may intentionally ignore oral hygiene to fulfill deep neurotic needs.

Moulton and Ewen1 (1952) suggested that oral hygiene may be neglected during depression, deep anxiety and rebellion against authority. The dentist’s instructions concerning oral hygiene may be ignored as a form of ‘Parental defiance’ (Sword 1970).

It has been reported that psychological disturbances can lead patients to neglect oral hygiene and the resultant accumulation of plaque is detrimental to the periodontal tissues.

Changes in Dietary Intake

Emotional conditions are thought to modify dietary intake, thus indirectly affecting periodontal status (Moulton2 et al 1995, Meyer2 1989). This can involve for instance, the consumption of excessive quantities of refined carbohydrates and softer diets, requiring less vigorous mastication and therefore predisposing to plaque accumulation at the proximal risk sites (Newman 1974).

*Senior Lecturer**ProfessorDept. of PeriodonticsThai Moogambigai Dental College and HospitalMogappair, Chennai Address for correspondenceE-mail: [email protected]

abstract

Is a pattern of disruptive psychological and physiological functioning that occurs when an environmental event is appraised as a threat to important goals and one’s ability to cope.

Key words: Psychosocial stress, stress in peridontium, stress goals and management

Psychosomatic Disturbance in Relation to PeriodontiumV Shankar Ram*, P Jaya Kumar**

review article


review article

SmokingTobacco smoking has a direct toxic effect on the gingiva.Vascular or other changes are induced by nicotine or other substance.Smoking and acute necrotic acute necrotizing ulcerative gingivitis (ANUG) are both reflections of stress.

Kenney3 et al mentioned that the circulating nicotine have following effect:

Vasoconstriction, produced by the release of adrenaline and nonadrenaline, which is supposed to result in lack of nutrients for the periodontal tissue.Suppression of secondary antibody responses.Inhibition of oral neutrophil functions.

Bruxism

Bruxism is the clenching or grinding of the teeth when the individual is not chewing or swallowing (Ramfjord4 et al. 1966). Bruxism can occur as brief, rhythmic strong contractions of the jaw muscles during eccentric lateral jaw movement or in maximum intercuspation, which is called clenching. (Clark5 et al, 1993). Olkinuera6 (1972) divided bruxers into two categories:

Those associated with stressful eventsThose without any association of stress.

There is little evidence to suggest that bruxists have personality derangement or mental illness. But it has been proved that brain-damaged children and mentally retarded individuals have a higher prevalence for bruxism.

Gingival Circulation

The tonus of smooth muscle of blood vessels may be altered by the emotions by way of the autonomic nervous system. For e.g. prolonged contraction could alter the supply of oxygen and nutrients to the tissues. In a study by Manhold7 et al, a lower ability of the tissues was found in rats under stress to utilize oxygen.

Smoking and stress have been implicated in reducing gingival blood flow which in turn could increase the possibility of necrosis of tissues, with subsequent reduced resistance to plaque (Clark et al, 1981).

Alterations in Salivary flow and Components

Psychologic factors are known to influence the rate of secretion and composition of saliva. Mental activity, stress, muscular effects or emotional disturbances produce a transient reduction of salivary flow and changes in the salivary enzyme count.

Saliva in turn, relates to plaque formation, calculus deposition and antibacterial and proteolytic activities, all of which may have a bearing on periodontal disease. These relationships between salivary physiology and psychologic status do not necessarily demonstrate the causes of periodontal disease but may show a pathway in which periodontal health is influenced by salivary changes.

lowered Host Resistance

Stress and its biochemical mediators may modify the immune response to microbial challenge, which is an important defense against periodontal disease. Under stress, the release of adrenaline and nonadrenaline may not only induce a decrease in blood flow, but possibly also in those blood elements necessary for maintaining resistance to disease-related microbes Cojen et al, (1983) found ANUG patients compared to controls presented:

Depressed polymorphonucleocyte chemotaxis and phagocytosisReduced proliferation of lymphocytes upon stimulation by a nonspecific mitogen. They also suggested that depression of some host defense mechanisms, under stress conditions, might be important in the pathogenesis of ANUG.

ANUG and Psychosomatic Factors

Psychologic factors appear to be important in the etiology of ANUG. The disease often occurs in association with stress situation. Psychological disturbances, as well as increased adrenocortical secretion are common in patients with the disease.

Effects of Stress on Periodontium

Periodontal diseases are infections associated with specific pathogenic bacteria that colonize the subgingival area. However, as with many chronic infections, the onset and progression of periodontal infections are clearly modified by local and systemic host conditions


review article

or risk factors that markedly affect the resistance of the host to infecting periodontal organisms. Psychosocial factors may represent another group of modifiers that can alter the host’s capacity to contend effectively with these noxious bacteria. There is a growing evidence linking stress to periodontal disease, however little has been done to asses the mechanism by which psychosocial stress, distress and coping influence periodontal disease.

Role of the HPA Axis in Stress

The hypothalamus-pituitary-adrenal (HPA) axis is a grouping of responses to stress by the brain and the pituitary and adrenal glands. First, the hypothalamus (a central part of the brain) releases a compound called corticotropin-releasing factor (CRF), which was discovered in 1981. The CRF then travels to the pituitary gland, where it triggers the release of a hormone, adrenocorticotropic hormone (ACTH). The ACTH is released into the bloodstream and causes the cortex of the adrenal gland to release the stress hormones, particularly cortisol, which is a corticosteroid.

Stress Wound Healing

The cellular immune response plays a major role in wound healing. Not only it protects the wound site from infection, it also prepares the wound for healing and regulates its repair.

Cytokines such as IL-1, IL-8 and tumor necrosis factor are extremely important in recruiting phagocytic cells to clear away the damaged tissue and to regulate the rebuilding by fibroblasts and epithelial cells. A decrease in expression in any of these cytokines could impair wound healing.

Management of Stress

Stress Reduction Protocol

The stress reduction protocol includes two series of procedures that when used either individually or collectively, act to minimize stress to the patient during treatment and thereby decrease the degree of risk presented to the patient.

Stress reduction protocol for normal, healthy anxious patients (ASA I).Stress reduction protocol for medical risk patient (ASA II, III, IV)

normal Protocol ReductionRecognition of medical risk and anxietyMedical consultationPremedicationAntianxiety or sedative-hypnotic drugs triazolam or flurazepam either one night before the appointment or one hour before appointment. Other drugs like diazepam, oxazepam and promethazine can also be used.Appointment schedulingMinimized waiting timeVital signs monitoring: Blood pressure, heart rate, rhythm and respiratory ratePsychosedation

GA or nondrug sedation such as iatrosedation and hypnosis pharmacosedation-oral, inhalation, IM or IV.

Stress Management by PatientsExerciseMeditation

Stress at a GlanceStress is a normal part of life that can either help us learn and grow or can cause us significant problems. Stress releases powerful neurochemicals and hormones that prepare us for action (to fight or flee).If we don’t take action, the stress response can lead to health problems.Prolonged, uninterrupted, unexpected and unmanageable stress are the most damaging types of stress.Early separation from a mother can lead to altered stress responses and depression later in life.The stresses of the mother can affect the stress response of the fetus, and perhaps predispose the child to psychiatric illness later in life.Stress can be managed by regular exercise, meditation or other relaxation techniques, structured timeouts and learning new coping strategies to create predictability in our lives.Many of our ways in dealing with stress - drugs, pain medicines, alcohol, smoking and eating -


review article

actually worsen the stress and can make us more reactive (sensitive) to further stress.While there are promising treatments for stress, the management of stress is mostly dependent on the willingness of a person to make the changes necessary for a healthy lifestyle.

Stress-related Diseases and ConditionAlcohol abuse and alcoholismAsthmaAsthma complexitiesDepressionHigh blood pressureHoliday depression and stressJet lagMigraine headachePanic disorderPost-traumatic stress disorder

Conclusion

Studies to date strongly suggest that stress, distress and inadequate coping are important risk indicators for periodontal diseases. It is likely that systemic disease associated with periodontal disease such as diabetes, cardiovascular disease, preterm delivery, and osteoporosis may share psychosocial stress as a

common risk factor. These early beginnings will require extensive study to fully understand the molecular and cellular basis of the role of stress as a contributor to periodontal disease.

ReferencesVettore MV, Leáo AT, Monterio Da Silva AM, Quintanilha RS, Lamarca GA. The relationship of stress and anxiety with chronic periodontitis. J Clin Periodontol 2003;30(5):394-402.Deinzer R, Kottmann W, Foster P, Herforth A, Stiller-winkler R, Idel H. After-effects of stress on crevicular interleukin-1 beta. J Clin Periodontol 2000;27(1):74-7.Sakki TK, Knuuttila ML, Anttila SS. Lifestyle, gender and occupational status as determinants of dental health behavior. J Clin Periodontol 1998;25(7):566-70.Monteiro da Silva AM, Newman HN, Oakley DA, O’Leary R. Psychosocial factors, dental plaque levels and smoking in periodontitis patients. J Clin Periodontol 1998;25(6):517-23.Giannopoulou C, Kamma JJ, Mombelli A. Effect of inflammation, smoking and stress on gingival crevicular fluid cytokine level. J Clin Periodontol 2003; 30(2):145-53.Dolic M, Bailer J, Stachle HJ, Eickholz P. Psychosocial factors as risk indicators of periodontitis. J Clin Periodontol 2005;32(11):1134-40.Puleo DA, Thomas MV. Implant Surfaces. Dent Clin North Am 2006;50(3):323-38.

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oot canal procedure is a difficult procedure in itself; but when canal is obstructed by a foreign body it may become more taxing. At

times, objects get lodged inside the pulp chamber or root canal of a tooth. This is more likely to occur in teeth with open pulp chambers. Fracture teeth or teeth with incomplete endodontic treatment in which canals are left open for drainage and in the case of open carious lesion; foreign object may become a potent source of pain and focus of infection. These objects can be retrieved with some ease if they are located within the pulp chamber, but once the object has been pushed apically retrieval may be more complicated.

Clinically open pulp cavity is seen in teeth with fracture, incomplete endodontic treatment with dislodged temporary filling or deep carious lesions. Earlier it was a common practice to leave pulp chamber open for drainage and still followed by some practitioners.

This case report describes three cases where patient reported with various foreign bodies in the canal of their teeth.

*Professor and Head **Postgraduate StudentDept. of Conservative Dentistry and EndodonticsVSPM’s Dental College and Research Centre, Dighdoh Hills NagpurAddress for correspondenceDr Pratima Shenoi301, Abhinav ResidencyB-1, Laxmi Nagar, Nagpur - 440 022, MaharashtraE-mail: [email protected]

abstract

Root canal procedure is a difficult procedure in itself; but when canal is obstructed by a foreign body it becomes more taxing. This is more likely to occur in teeth with open pulp chambers. Fractured teeth or teeth with incomplete endodontic treatment in which canals are open for drainage and in the case of open carious lesion; foreign objects may become a potent source of pain and focus of infection. These objects can be retrieved with some ease if they are located within the pulp chamber, but once the object has been pushed apically retrieval may become more complicated. In the present cases, the foreign object was located within the root canal and retrieved successfully by simple nonsurgical techniques.

Key words: Open root canal, foreign body

Simple Means of Management of Teeth with Foreign Body in Root CanalPratima Shenoi*, Archana Kandhari**, Mohit Gunwal**

Case Report

Case 1

A 22-year-old male patient reported to the OPD of Dept. of Conservative Dentistry and Endodontics of the College with discolored lower anterior teeth with an extraoral draining sinus. The intraoral periapical radiograph revealed a radio-opaque object in the canal. On careful history from the patient, it was revealed that the patient had inserted a piece of common pin in the open pulp chamber of the lower central incisor. He had sustained trauma approximately three years back and after 2-3 months of pin insertion the sinus tract appeared. After a conventional access cavity the pin was bypassed using No. 8, 10 and 15 K files with ethylenediaminetetraacetic acid (EDTA). Once bypassed the pin was successfully removed using 15# H file by engaging the pin. Biomechanical preparation of the canals was then done followed by obturation.

Case 2

A 35-year-old male patient reported to the OPD of the department with discolored lower left canine. The case history revealed that the tooth had been treated up till biomechanical preparation seven years back. Patient did not report for obturation to the clinician and later a gingival abscess developed with the same tooth along with pain. The patient removed the temporary and pushed a piece of clove in the canal. The clove being radiolucent could not be appreciated

R

case rePort


case rePort

figure 1 A. Intraoral periapical radiograph revealed a radio- opaque object in the canal.

figure 2 A. Discolored tooth in lower left quadrant.

figure 1 B. Piece of common pin.

figure 2 B. Clove removed from the canal with file.

figure 2 C. Working length intraoral periapical radiograph showing deviation of instrument in root canal.

figure 1 C. Intraoral periapical radiograph after obturation.

on radiograph. With the help of small size K-file and EDTA the clove was removed in small pieces. Following this once sufficient amount of clove was removed H file was used on with circumferential filing and clove was removed from root canal walls.

Case 3

A 45-year-old male patient reported to the OPD of the department with pain in lower left posterior region. The case history revealed that endodontic treatment with the tooth had been initiated two years back. Patient left the treatment in between and now reported with pain.

Intraoral periapical radiograph was taken and broken root canal instrument was seen. The instrument was bypassed using No. 8 K flex file, canal orifice was enlarged with the help of gate glidden drill and the instrument was removed using 25 gauge needle by engaging the tip of needle on the instrument. After that canals were enlarged with protaper system and obturation was done.


case rePort

figure 2 D. H file in canal showing no deviation of instru-ment file.

figure 2 E. Postobturation intraoral periapical radiograph.

figure 3 A. Intraoral periapical radiograph showing broken pin.

figure 3 B. Intraoral periapical radiograph after removal of pin.

figure 3 C. Intraoral periapical radiograph postobturation.

Discussion

Various foreign objects were reported to be lodged in the root canals and the pulp chamber, which ranged from pencil leads, darning needles, metal screws, to beads and stapler pins. Grossman reported retrieval of inedible ink pencil tips, tooth pick, adsorbent points and even a tomato seed from the root canals of anterior teeth left open for drainage.

Earlier a common procedure employed during emergency root canal treatment involved leaving the pulp chamber open when pus continued to discharge through the canal. Such a procedure may place the patient at risk of foreign body lodgment in the canal.

Foreign bodies in root canals may act as obstructions for the smooth passage of endodontic instruments. A radiograph can be of diagnostic significance especially if the foreign body is radio-opaque. McAuliffe1 described the case of an 11-year-old boy who presented with a staple lodged in the root canal of the maxillary left permanent central incisor. This staple was localized

using parallax techniques and successfully removed from the canal. Specialized radiographic techniques such as radiovisiography, 3D CAT (computerized axial tomography) scans can play a pivotal role in the localization of the exact position of these foreign objects.

Retrieval of the object may become difficult when it is lodged in the periapical region. Shrivastav and Vineeta2


case rePort

have suggested periapical surgery or intentional reimplantation to remove such objects. Prabhakar also, suggested the successful retrieval of a foreign object located in the apical portion of an immature root canal by simple orthograde techniques, avoiding the need for surgery or intentional reimplantation.3

Nadkarni4 reported with case of 12-year-old boy presented with a fractured sewing needle within the palatal root canal of a nonvital permanent maxillary first molar. The patient admitted that he had often placed a sewing needle in the tooth to relieve discomfort associated with it. The fractured needle was removed with a tweezers that had long, narrow beaks. Use of this simple technique allowed the object to be removed from the root canal with minimal damage to internal tooth structure.

Foreign bodies in root canal can act as focus of infection. Foreign bodies pushed through root canal into the sinus are one of the causes of chronic maxillary sinusitis of dental origin. Foreign bodies in root canals should be carefully evaluated to determine their nature, position, size and the degree of difficulty that may be encountered during retrieval. Patience, care and appropriate techniques may be helpful in retrieving foreign bodies and avoiding periapical surgery. Complicated crown fractures should be managed promptly, and prolonged open drainage avoided in children if the risks of foreign body impaction are to be minimized.

Retrieval of foreign objects lying in the pulp chamber or canal can be done using simple method using needle by engaging it with instrument and pulling it out or by the costly instruments like ultrasonic instruments, the Masserann Kit, etc. Steglitz forceps is a specialized instrument with a narrow beak used to retrieve instruments from the coronal portion of canal.

The use of an operating microscope is also beneficial. The microscope gives light and illumination inside the canal and provides the clinician with the ability to visualize any intraradicular obstruction and

locate its position in relation to surrounding root canal walls.

In cases of weeping canals when giving a closed dressing is at all feasible, an open dressing may be given to the patient with instruction to avoid eating grains and food that may block the canal. He should be instructed to report the next day for receiving a closed dressing. The patient should be well-educated about the treatment and motivated to complete it.

Conclusion

As a foreign object can act as a source of pain and cause difficulty in the elimination of infection from the root canal, prompt but cautious attempts should be made to retrieve it first by simple nonsurgical means. Removal of foreign objects from the root canal is often a very difficult procedure. The procedure is even more complicated if the foreign body is unusual.5

If the foreign object resists all efforts for removal and when a strong possibility of failure exists, a surgical procedure may be the only viable alternative. In the present cases, the foreign object was located within the root canal and retrieved successfully by a simple nonsurgical technique.

ReferencesMcAuliffe N, Drage NA, Hunter B. Staple diet: a foreign body in tooth. Int J Paediatr Dent 2005; 15(6):468-71.Srivastava N, Vineeta N. Foreign body in the periradi-cular area. J Endod 2001;27(9):593-4.Prabhakar AR, Namineni S, Subhadra HN. Foreign body in the apical portion of a root canal in a tooth with an immature apex: a case report. Int Endod J 2008;41(10): 920-7.Nadkarni UM, Munshi A, Damle SG, Kalaskar RR. Retrieval of a foreign object from palatal root canal of a permanent maxillary first molar: a case report. Quintessence Int 2002;33(8):609-12.Walvekar SV, Al-Duwairi Y, Al-Kandari AM, Al-Quoud OA. Unusual foreign objects in the root canal. J Endod. 1995;21(10):526-7.

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nemia of chronic disease (ACD) defined as the anemia occurring in chronic infections and inflammatory conditions is not due to marrow

deficiencies or other diseases and occurs in the presence of adequate iron stores and vitamins.¹ The ACD is a prevalent, poorly understood condition that afflicts patients with a wide variety of diseases, including infections, malignancies and rheumatologic disorders. It is characterized by blunted erythropoietin response by erythroid precursors, decreased red blood cell survival and a defect in iron absorption and macrophage iron retention, which interrupts iron delivery to erythroid precursor cells.

Pathogenesis of Anemia of Chronic Disease

Cartwright (1966) postulated the three pathologic processes involved in ACD:

Shortened erythrocyte survivalFailure of the bone marrow to increase red blood cells production to compensate for this increased demandImpaired release of iron from the reticulo-endothelial system.²

The low serum iron and accumulation of iron in the reticuloendothelial cells of the patient is the result from the retention of iron by reticuloendothelial macrophages and decreased intestinal iron absorption.This impairment of iron delivery by macrophages and enterocytes is the part of a host defence mechanism to fight infection and cancer. Early in their course, patients with the anemia of chronic disease have normal body iron stores and a mild normocytic anemia that results from impaired iron cycling. Over time the impaired intestinal iron absorption associated with anemia of chronic disease leads to iron deficiency and the anemia becomes microcytic. Cytokines such as interleukin-1 (IL-1), IL-6, tumor necrosis factor-alpha (TNF-α) and interferons are hypothesized to be involved in the maintenance of red blood cell production or stability.³

Inflammation and Acute Phase Response

Acute inflammatory disease is classically accompanied by signs and symptoms such as fever, anorexia and somnolence. The endocrine and metabolic response to acute inflammation includes the release of hormones which induce catabolism and gluconeogenesis such as glucagon, insulin, adrenocorticotropic hormone, growth hormone, thyroxine and catecholamines. The concentrations of iron and zinc in plasma decrease while those of copper increase. The hematopoietic response includes leukocytosis, thrombocytosis and anemia secondary to decreased erythropoiesis.4

Surgical trauma induces a state of inflammation with an acute-phase reaction and anemia. The severity of this response is related to the extent of trauma. When

*Reader**Head†Postgraduate StudentDept. of PeriodonticsSree Balaji Dental College and Hospital, ChennaiAddress for correspondenceDr Nithya AnandE-mail: [email protected]

abstract

Anemia of chronic disease (ACD), the second most prevalent form of anemia after iron deficiency anemia, is a condition associated with chronic diseases. Increasingly referred to as ‘Anemia of inflammation’, this type of anemia is to a large extent immune driven and cytokine mediated. This article reviews the various factors interlinking periodontitis, a chronic inflammatory condition with the pathogenesis of ACD.

Key words: Anemia of chronic disease, cytokine-mediated, periodontitis

Anemia of Chronic Disease and Periodontitis: The Missing Linknithya Anand*, SC Chandrasekar**, Garima Dembla†

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the hemoglobin (Hb) concentration acutely decreases in patients with normal renal function, erythropoietin secretion is increased for 4-10 days. The reactive increase in erythropoietin secretion is diminished in patients undergoing an acute-phase response which has been attributed to inhibition of erythropoietin secretion by pro-inflammatory cytokines.

A narrow definition of the acute-phase response to inflammation is based on the characteristic changes in the concentrations of several plasma proteins secondary to altered hepatic transcription and synthesis of excretory proteins. The plasma concentrations of the two major human acute-phase proteins, C-reactive protein (CRP) and serum amyloidal A, increase 100-1,000 fold in response to severe infections. The concentrations of other positive acute-phase proteins increases less e.g., complement factors, fibrinogen, ferritin, haptoglobin and α1 protease inhibitor. Among the negative acute-phase synthesis and secretion is decreased are albumin, transferrin, α-fetoprotein and transthyretin. The acute-phase response is regulated by a number of pro-inflammatory cytokines such as IL-1, TNF-α, IL-6, b- and γ-interferon. The cytokines are to a large extent produced locally by tissue macrophages, but in severe inflammation, systemic effects occur as well.

Periodontitis: An Inflammatory Disease

Periodontitis is an inflammatory disease of the support-ing tissues of the tooth which is caused by specific micro-organisms in a susceptible host. Gram-negative anaerobic bacteria are most commonly associated with the initiation of periodontitis. The bacteria and their products evoke an immunoinflammatory reaction in the host tissue. Though this process is intended to eliminate the microbial challenge, it often results in damage to the host tissue.

The sulcular epithelium acts as a protective barrier and prevents entry of micro-organisms and other irritants into the systemic circulation. The host-microbial interaction in periodontitis leads to ulceration of sulcular epithelium. The ulcerated epithelium acts as a portal of entry for the bacteria to enter the connective tissue and thus into the systemic circulation. Bacteremia has been observed in patients with periodontitis and has been directly related to the severity of inflammation. The subgingival microbiota in patients

with periodontitis poses a significant and persistent gram-negative bacterial challenge to the host. Acute- phase proteins like the CRP has been shown to be elevated in patients with periodontitis. This suggests a possible influence of periodontitis on systemic status of an individual. Studies have associated periodontitis with atherosclerosis, cardiovascular diseases and stroke. These studies indicate that periodontitis leads to a low grade systemic inflammation.

Anemia of Inflammation: The Cytokine-hepcidin Link

The anemia of inflammation, commonly observed in patients with chronic infections, malignancy, trauma and inflammatory disorders, is a well-know clinical entity. It now appears that the inflammatory cytokine IL-6 induces production of hepcidin, an iron- regulatory hormone that may be responsible for most or all of the features of this disorder.

Hepcidin: The Iron Regulatory Hormone

Hepcidin is a 20-, 22- or 25-amino acid peptide that is cleaved from a larger precursor. It is produced in the liver and detectable in the serum and urine.5 Hepcidin has intrinsic antimicrobial activity and its expression increases in response to inflammatory stimuli. Hepcidin was first isolated from human urine and named on the basis of its site of synthesis (hep) and its in vitro antibacterial properties (-cidin). In human urine, the predominant form contains 25-amino acids, although shorter 22 and 20 amino acid peptides are also present.

The main peptide is notable for containing eight cysteine residues linked as four disulphide bridges resulting in a molecule with a simple hairpin structure is characteristic of peptides capable of disrupting bacterial membranes and is similar to other antimicrobial peptides.⁶ The existence of an iron regulatory hormone was postulated primarily to account for the observed interactions between the anatomically distinct sites of iron absorption, recycling and utilization. There was no indication that it had additional role in iron metabolism until 2001, when mouse studies were published showing that hepatic hepcidin mRNA synthesis was induced by iron loading.


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Effects on Erythropoiesis

The erythropoiesis-suppressing effect of inflammation is mainly due to increased activity of the pro-inflam-matory cytokines.⁷ In vivo, the cytokines act in concert to affect precursor cells at different stages of erythropoiesis. TNF-α and IL-1 are extensively studied. In experimental animal studies and in humans administration of both cytokines causes

a hypoproliferative anemia by direct action on erythroid progenitor cells or indirectly by stimulating production. Despite the overall suppressive effect on erythropoiesis, some studies have shown that TNF-α and IL-1 stimulate the growth of early progenitors (burst forming units-erythroid [BFU-E]), while suppressing the growth of later stages (colony-forming units-erythroid [CFU-E]).

The inhibitory effect of TNF-α and IL-1 on erythropoiesis can be overcome in a dose-dependent fashion by administering epoetin.

Effects on Erythrocyte Survival

Macrophages normally remove senescent erythrocytes from the circulation. Erythocytes coated with immunoglobulins or immune complexes are cleared more efficiently from the circulation.⁸ Macrophages, activated by inflammatory signals, are responsible for accelerated disposal of erythrocytes, shortening of the life-span of erythrocytes and decreasing the Hb concentration.

Effects on Iron Metabolism

Inflammation and the acute-phase response interact with iron metabolism at several levels. Inflammation reduces the serum concentrations of iron and transferrin.Kooistra et al found that iron absorption from the gut was impaired in patients with renal failure and elevated serum CRP levels (>8 mg/l). This is consistent with the notion that the synthesis of transferrin is reduced during the acute-phase response. Less apotransferrin is secreted in the bile and delivered to the gut. As a result less iron is delivered to the transferring receptors of the mucosal cells. Functional iron deficiency is defined as low availability of iron for erythropoiesis despite normal or high iron stores in the body. A state of functional iron deficiency often occurs when erythropoiesis is stimulated by erythropoietin, but the rate of iron delivery to the bone marrow is insufficient.

Theoretically, functional iron deficiency may occur in one of the two ways:

When high doses of epoetin stimulate eryth-ropoiesis so much that it exceeds the maximal capacity to deliver ironWhen the delivery of iron from the reticuloendothelial cells to hematopoietic cells is inhibited or blocked.

Induction of liver hepcidin synthesis decreases iron export from absorptive cells (enterocytes) recycling cells (macrophages) and storage cells (hepatocytes).

Hepatic iron Fe/Tf

HepcidinAbsorption

Recycling

StorageCyto

kines

Inflammation Infection

Down-regulation of liver hepcidin synthesis increases iron export from absorptive cells (enterocytes) recycling cells (macrophages) and storage cells (hepatocytes).

HFE and non-HFE hem [Not FP disease]

Anemia Hypoxia

Hepcidin

Absorption

Recycling

Storage

Inflammation

Macrophage IL-6 Hepatocyte Hepcidin

Macrophage iron release

Intestinal iron absorption

Role of Hepcidin and IL-6

IL-6 acts directly on hepatocytes to stimulate hepcidin production. Hepcidin, in turn, acts as a negative regulator of intestinal iron absorption and macrophage iron release.


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Serum ferritin is an acute-phase protein and increases two- to four-fold in response to inflammation. IL-1 and TNF-α cause an increase in ferritin synthesis directly at the transcriptional level. Cytokines may also induce ferritin synthesis indirectly by increasing iron uptake into hepatocytes. The increase in ferritin synthesis by hepatocytes and reticuloendothelial cells underlies the increase in the iron storage pool during inflammation.The circulating ferritin contains only minute amounts of iron and its role in iron metabolism is uncertain. It may have protective detoxifying effect by taking up free iron at sites of inflammation.

Lactoferrin is present in polymorphonuclear leukocytes and acts as an iron scavenger with bactericidal activity. As a part of the acute-phase reaction, lactoferrin synthesis increases during inflammation. It can bind large amounts of free iron. The iron bound to lactoferrin is taken up by activated macrophages, which express specific lactoferrin receptors. During inflammation, this causes iron deprivation of erythroid precursors, which fail to express lactoferrin receptors.

Iron is essential for the growth of some microbes and sequestration of iron in the form of insoluble compounds, such as lactoferrin and hemosiderin is thought to be part of the host defence against bacterial and viral infections. However, a decrease in erythropoiesis may also reflect a relative deficit of erythropoiesis in the face of an increased demand to produce neutrophil granulocytes and other immunocompetent cells.

Serum CRP Predicts Epoetin Resistance

CRP is secreted by the liver and inflammation causes a rapid increase in its serum concentration. It plays a role in host defence by interacting with complement. It is simple, reliable readily available and in expensive test. It is also a long-term predicator of cardiovascular risk and mortality in the general population and in chronic renal failure patients. About one-third of patients with chronic renal failure have serum CRP concentrations >10 mg/l. In dialysis patients, high CRP levels are associated with low Hb levels and or epotein resistance

Discussion

Anemia is one of the most common global public health problem in recent times. Globally, anemia affects 1.62 billion people, which is 24.8% of the total population. Evidence indicates that ACD is seen in rheumatoid arthritis and chronic periodontitis, though

the etiologic factors of both the diseases are different, stating that long-standing chronic inflammation can lead to anemia. Various studies have found associations between ACD and periodontitis. The pro-inflammatory cytokines released in periodontitis interact with hepcidin the iron regulating hormone and down regulate erythropoiesis. Siegel et al reported a depression in the number of erythrocytes secondary to periodontal disease.⁹ Hutter et al suggested that periodontitis also needs to be considered as a chronic disease which may cause lower number of erythrocytes and consequently lower Hb levels.¹⁰

Conclusion

The growing field of periodontal medicine has evidence interlinking periodontitis with cardiovascular disease, preterm low-birth-weight, diabetes and chronic obstructive pulmonary disease. The association between ACD and periodontitis with hepcidin being the key factor as new emerging concepts with wide reaching ramification needs more evidence and research.

ReferencesSneha R, Sumanth S, Padhye AM. Evaluation of blood parameters in patients with chronic periodontitis for signs of anemia. J Periodontol 2010;81(8):1202-6.Cartwright GE. The anemia of chronic disorders. Semin Hematol 1966;3(4):351-75.Means RT Jr. The anemia of infection. Baillieres Best Pract Res Clin Haematol 2000;13(2):151-62.Trey JE, Kushner I. The acute phase response and the hematopoietic system: the role of cytokines. Crit Rev Oncol Hematol 1995;21(1-3):1-18.Park CH, Valore EV, Waring AJ, Ganz T. Hepcidin, a urinary antimicrobial peptide synthesized in the liver. J Biol Chem 2001;276(11):7806-10.Ganz T. Hepicidin, a key regulator of iron metabolism and mediator of anemia of inflammation. Blood 2003;102(3):783-8.Means RT Jr. Advances in anemia of chronic disease. Int J Hematol 1999;90:7-12.Jurado RL. Iron, infections and anemia of inflammation. Clin Infect Dis 1997;25(4):888-95.Siegel EH. Total erythrocyte, leucocyte and differential white cell counts of blood in chronic periodontal disease. J Dent Res 1945;24:270-71. Hutter JW, Van der Velden U, Varoufaki A, Huffels RA, Hoek FJ, Loos BG. Lower numbers of hemoglobin in periodontitis patients compared to control subjects J Clin Periodontol 2001;28(10):930-6.

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ll human activities produce waste and these wastes are dangerous and need safe disposal. Industrial waste, sewage and agricultural waste

pollute water, soil and air and it can also be dangerous to human beings and environment. Similarly, hospitals and other healthcare facilities generate lots of waste, which can transmit infections particularly HIV, hepatitis B and C and tetanus to the people who handle it or come in contact with it.1,2 To protect the environment and community health, The Ministry of Environment and Forest has notified, biomedical waste (management and handling) rules in 1998 that urges all hospitals, clinics, nursing homes and laboratories to ensure safe and environmentally sound management of waste produced by them.3

Biomedical waste is any waste generated during the diagnosis, treatment or immunization of human beings or any research activity. Biomedical waste generated in the hospital falls under two major categories:

Non hazardousBiohazardous

Non hazardous waste includes non infected plastics, cardboard, packing material, paper, etc. Biohazardous waste again falls into two types.

Type I: (Infectious waste) - Sharps, non-sharps, plastics disposables, liquid waste, etc.

Type II: (Noninfectious waste) - Radioactive waste, discarded glass, chemical waste, cytotoxic waste, etc.

Approximately 75-90% of the biomedical wastes are non hazardous and as harmless as any other municipal waste. The remaining 10-25% is hazardous and can be injurious to humans or animals and deleterious to environment.4 In the present study, a questionnaire survey was carried out to determine the awareness about biomedical waste management policy, practices and to assess the attitude towards it. The objective was to identify the major lacunas and to make recommendations in order to improve the facilities for current requirements.

Material and Methods

The data collection was done through standard set of questionnaire, which was developed after literature search and review. The questions recorded the degree of awareness and the attitude of the various respondents present towards the bio-waste management. The respondents of the survey comprising of doctors, house surgeons, students and paramedical staff provided the complete impression of that hospital.

Total sample size: 1000

Details of the sample:Doctors : 550Students : 250Paramedical staff : 200

A Survey on Biomedical Waste Management

R Mensudar*, A Karthick**, D Amutha†, P Vivekanandhan‡

abstract

Dental practitioners are becoming increasingly concerned about the potential impact of dentistry on the environment and often take voluntary measures to reduce the production and release of environmentally unfriendly wastes from their practices. So it is important for the dentist to know how to manage and prevent by securing basic knowledge of biohazards components.

Key words: Biomedical waste, color coding, safe disposal, segregation

*Reader **Senior Lecturer†Lecturer‡ProfessorDept. of Conservative Dentistry and EndodonticsSree Balaji Dental College and Hospital, ChennaiAddress for correspondenceDr R Mensudar25/8, Thandavarayan Street, Old Washermenpet, Chennai - 600 021E-mail: [email protected]

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this, dentists are likely to be exposed to various biological health hazards. Of 80-85% waste generated in a hospital, infectious waste accounts for only a small fraction (10-15%). However, this small fraction is of biggest concern as it poses direct threat to the health and hygiene of the human beings by transmitting viral, bacterial, fungal and parasitic disease.

Biomedical Waste Management Process

Handling, segregation, mutilation, disinfection, storage, transportation and final disposal are the vital steps for safe and scientific management of biomedical waste in any establishment. The key to minimization and effective management of biomedical waste is segregation (separation) and identification of the waste. The most appropriate way of identifying the categories of biomedical waste is by sorting the waste into color coded plastic bags or containers.

Categorization of Biomedical Wastes

Biomedical wastes have been categorized into 10 different categories as mentioned below:

Category No. 1: Human anatomical (human tissues, organs, body wastes parts)

Category No. 2: Animal wastes (animal tissues, organs, body parts carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generated by veterinary hospitals, discharge from hospitals, animals houses)

Category No. 3: Microbiology and Biotechnology waste (waste from laboratory cultures, stocks or specimens of micro-organisms live or attenuated vaccines, human and animal cell culture used in research and infectious agents from research and industrial laboratories, waste from production of biological, toxins, dishes and devices used for transfer of cultures).

Category No. 4: Waste sharps (needles, syringes, scalpels, blades, glass, etc. that may cause puncture and cuts. This includes both used and unused sharps).

Category No. 5: Discarded medicines (waste comprising of outdated contaminated and discarded medicines).

Category No. 6: Solid waste (items contaminated with blood, and body fluids including cotton, dressings, solid linen, plaster casts, linen, beddings, other material contaminated with blood).

Result

All the persons interviewed were in the age group 25-40 years. The results of the survey were tabulated and percentile analysis was carried out. Eighty percent of them accepted that their healthcare setting have a waste management facility and all of them agreed that the biomedical waste that is generated from the hospital set up has to be segregated before they are disposed. But they were not sure who has to segregate the waste and 80% of them stated that it was the duty of the auxiliary staff to segregate the waste. But according to the rule and literature, it is the duty of every personal who generate the biomedical waste. Though around 80% of the respondent were aware of the bio-hazard symbol, majority of them were not aware of the classification of biomedical wastes and its segregation methods, which indicates that they have neither undergone a training program nor been updated on it.

In the present survey, an overwhelming response of all the participants stated that they would wish to take up the training program to keep them updated. A majority of participants (92%) agreed that the premier hospital is severely lacking in action to dispose its waste and uphold its statutory responsibilities. This is due to the lack of education, awareness and trained personnel to manage the waste in the hospital, as well as the paucity of the funds available for proper waste management system.

Regarding the attitude assessment around 96% agreed that the biomedical waste management is a serious issue and the waste has to be properly handled and disposed. They also accepted (90%) that it is just not the government responsibility, but the duty of every personal who are involved in the process of creating biomedical waste. Around 97% of them accepted that this is neither an extra burden on the regular duty work nor it increases the financial burden on the hospital management. However, in the present survey all (100%) of them accepted that the success of the waste management is a team work and not a single persons’ issue.

Discussion

Dentistry is a profession dedicated to promoting and enhancing oral health well-being. While accomplishing


clinical study

Category No. 7: Solid waste (wastes generated from disposable items other than the waste sharps such as tubing’s, catheters, intravenous sets, etc.).

Category No. 8: Liquid waste (waste generated from laboratory and washing, cleaning, housekeeping and disinfecting activities).

Category No. 9: Incineration ash (ash from incineration of any biomedical waste).

Category No.10: Chemical waste (chemicals used in production of biological, chemicals used in disinfection, as insecticides, etc.).

Steps in Waste Management

Medical waste should be managed according to its type and characteristics. For waste management to be effective, the waste should be managed at every step, from acquisition to disposal. The following are the elements of a comprehensive waste management system:

Waste survey: The survey should differentiate and quantify the waste generated. This helps to determine the method of disposal.

Waste segregation: This consists of placing different kinds of wastes in different containers or coded bags at the point of generation. It helps to reduce the bulk of infectious waste as well as treatment costs. Segregation also helps to contain the spread of infection and reduces the chances of infecting other healthcare workers.

Waste accumulation and storage: Waste accumulation and storage occurs between the point of waste generation and site of waste treatment and disposal.

Waste transportation: When medical waste is not treated on site, untreated waste must be transported from the generation facility to another site for treatment and disposal.

Waste treatment: Treatment is mainly required to disinfect or decontaminate the waste, right at source so that it is no longer the source of pathogenic organisms.

Waste disposal: The waste disposal methods vary in their capabilities, cost, availability to generation and impacts on the environment. The various disposal

methods include incineration, autoclaving, chemical methods, thermal methods (low and high), ionizing radiation process, deep burial and microwaving.

Thus, the hospital waste must be collected, segregated and disposed off using proper method.5,6 Even if a small amount of infectious waste gets mixed with general waste it can contaminate the entire waste collected. A policy needs to be formulated based on reduce, reuse and recycle the biomedical waste.

Conclusion

Within the limitation of the study, it was analyzed that low awareness level were seen in all the categories of participants. The participants seemed to be following hospital protocol for waste managements without concrete understanding or training. Thus, the result of the survey enforces the need for strict action to create a better environmental management system for the disposal of biomedical waste in all the hospitals. It should be supported through appropriate education training and the commitment of the healthcare staff, management and healthcare management with an effective policy and legislative framework.4,7

ReferencesSantappa M, Kumar RV. Hospital. Waste Management Committee and Salient features of biomedical wastes, Proceedings of Southern Regional Conference on Biomedical Waste Management organized by Tamil Nadu Pollution Control Board, Chennai, 1999. Manual on Hospital Waste Management. Central Pollution Control Board, New Delhi, 2000.Da Silva CE, Hoppe AE, Ravenello MM, Mello N. Medical wastes management in the south of Brazil. Waste Manag 2005;25(6):600-5.Rao SK, Ranyal RK, Bhatia SS, Sharma VR. Biomedical waste management: an infrastructural survey of hospital. MJAFI 2004;60:379-82.Harrison B, Nicosia J. States act to regulate medical waste. J Am Dent Assoc 1991;122(9):118-20. Radha KV, Kalaivani K, Lavanya R. Case study of biomedical waste management in hospitals. Global J Health Sci 2009;1(1):82-8.Park K. Hospital Waste Management. In: Park’s Textbook of Preventive and Social Medicine. 18th edition, New Delhi 595-8.

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The mandibular angle is one of the most frequent site of fractures of the lower jaw accounting for around 20-30% of all fractures occurring

in the mandible.1,2 The use of a single miniplate for fixation of angle fractures of the mandible has been debated over years. The conventional rigid fixation technique employs thick compression plate along the lower border of the mandible which negated the forces of torsion and shear, but had the disadvantage of bicortical screws, whereas, the Champy’s osteosynthesis principle produced a natural strain of compression along the lower border of the mandible caused due to mastication. These drawbacks of rigid and semirigid fixation led to the development of three-dimensional (3D) miniplate consisting of two miniplates joined by interconnecting struts.3 These plates are highly malleable, offer good resistance against torque forces and most importantly low profile, and their stability doesn’t derive from thickness of the plate. The aim of this study is to evaluate the results of open reduction and internal fixation of mandibular angle fractures

*Professor and Head**Associate Professor Dept. of Oral and Maxillofacial Surgery Sree Balaji Dental College and Hospital, ChennaiAddress for correspondenceVijay Ebenezer Professor and Head Dept. of Oral and Maxillofacial Surgery Sree Balaji Dental College and Hospital Pallikaranai, Chennai - 600 100 E-mail: [email protected]

abstract

The aim of the study was to evaluate the clinical efficacy of three-dimensional (3D) miniplate for monocortical fixation of mandibular angle fractures. The 3D plating system is based on the principle of obtaining support through geometrically stable configuration. The quadrangle geometry of plate assures stability in the 3D of the fracture sites when compared to the conventional miniplates. Twenty-two patients were included in the study with a minimum follow-up period of 18 months. Patients with either isolated mandibular angle fractures or other associated fractures in the mandible were selected. Standard extraoral and intraoral approaches were employed for reduction of fractures. None of the patients were subjected to intermaxillary fixation. All patients in our study had early recovery of normal jaw function. Primary healing and good union of the fracture site with minimal weight loss due to early reinstatement of masticatory function were the other advantages.

Key words: Mandibular angle fracture, three-dimensional miniplate

Three-Dimensional Miniplate Fixation in Mandibular Angle FracturesVijay Ebenezer*, Balakrishnan Ramalingam**

either isolated or with other associated fractures of the lower jaw, using 3D miniplates.

Methods

Twenty-two patients, who reported to the Dept. of Oral and Maxillofacial Surgery, Sree Balaji Dental College and Hospital with mandibular angle fractures either isolated or with other fractures of the mandible were included in our study. The etiology of 80% patients was road traffic accidents. The age group of patients ranged from 20 to 35. Ethical Committee clearance from the institution was obtained prior to the study. Patients were administered intravenous antibiotic immediately on admission. Amoxicillin/clavulanic acid 1.2 gs IV twice-daily was started and continued for three days after surgery. All patients were treated between 1st to 4th day following injury. Standard submandibular or modified submandibular approaches were selected in cases where the intraoral approach was not feasible. The choice of anesthesia was decided depending on the approach, all extraoral approaches were operated under general anesthesia. Radiological examination was performed with orthopantomogram (OPG), the findings included status of dentition, whether dentulous or edentulous, presence of tooth in the line of fracture, presence of any other associated fractures in the mandible, the extent of displacement of the fragments, derangement of occlusion and relationship of the fracture to the neurovascular bundle. Postoperative radiographs were taken before discharging the patient, and then at

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Fracture site exposed.

Postoperative OPG.

Case Report 1

3D plate fixation.

monthly intervals for a period of six months and once in three months for the next 12 months.

Results

Twenty-two patients were selected to participate in the clinical study. The patients selected were within age group of 20-35 years. Seventeen patients were male (77%) and five were females (33%). Two out of 22 patients (9%) were edentulous, eight patients (36%) were partially edentulous and 12 patients (55%) were completely dentate. Seventeen patients (77%) in the study had sustained the injury due to road traffic accidents, three patients (14%) injured due to interpersonal violence, two patients (9%) had the injuries due to work- related mishaps.

Out of 22 patients; 16 patients (72%) had fractures in other sites of the mandible, the most common was the contralateral parasymphysis followed by the condyle on the contralateral side. Tooth in the line of fracture was encountered in eight cases (36%), but did not require removal during surgery. Intermaxillary fixation was used only to stabilize the occlusion and was removed before extubation. Guiding elastics were used in two patients (9%) for minor correction of occlusal discrepancies. Intraoral wound dehiscence occurred in one patient (4%), which was treated with metronidazole washes, which healed asymptomatically. No case of nonunion was encountered in this study, but in one patient (4%) the plate fractured eight months following fixation, which was detected during routine radiographic examination, but still remained symptomless and was removed later. The 1-year postoperative radiographs showed complete healing in all 22 cases. Four patients (18%) had sensory deficit in the first two postoperative weeks, which gradually improved over the next six months. In one patient (4%) there was a complete paresthesia on the affected nerve but recovered after 1-year.

Discussion

The treatment of mandibular angle fractures has evolved over a period of time from old methods of bandaging and splinting which are forms of closed reduction to the more recent methods of open reduction.4 General acceptance of open osteosynthesis did not appear in maxillofacial literature until an organized research was done by the AO group in 1950.5 Even in open osteosynthesis technique there has


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Case Report 2

been a metamorphosis and change in trends from rigid fixation in 1968 to semirigid fixation in 1973.6 Rigid fixation using dynamic compression plate had its own disadvantages such as need of very wide incision, bulky nature of plates and the procedure itself which was technique sensitive.7 Michelet (1973)8 ended the search for simple osteosynthesis that would guarantee fracture healing without compression. This was modified, developed and put to practical use by Champy in 1978.9 During the last decade significant attention has been placed in the fixation of fracture mandible using a combination of transorally placed small plates secured with monocortical screws. Fixation using such plates has been shown to simplify surgery and reduce surgical morbidity, however, they have failed to surpass the predictability of rigid fixation using 2.4 mm compression and reconstruction plates.10 Farmand11 developed the concept of 3D miniplates. Their shape is based in the principle of Quadrangle as a geometrically stable configuration for support. Since, the stability

Graph 1. Gender

Female 23%

Male 77%

Graph 2. Etiology

Work-related mishaps (9%)

Inter personal violence 14%

RTA-77%

Postoperative OPG.

3D plate fixation.

Fracture site exposed.


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achieved by the geometric shape of these plates surpasses the standard miniplates, the thickness can be reduced to 1 mm. The basic form is quadrangular with 2 × 2 holed square plates and 3 × 2 (or) 2 × 2 rectangular plate. The 3D miniplates itself was a misnomer as the plates themselves were not 3D, but holds the fracture segments rigidly by resisting the 3D forces namely shearing, bending and torsional forces occurring on the fracture site in function. The present study showed that the 3D plate allows no movement at the superior and inferior borders with maximal torsional and bending forces as opposed to a single linear plate applied to superior border area. When only one linear plate is placed at the superior border area, torsional and bending forces usually cause movement along the axis of the plate with buccolingual splaying and gap formation at the inferior border, respectively. In 3D plate system the screws are placed in the box configuration on both sides of fracture rather than on a single line and broad platform is created that may increase the resistance to torsional forces along the axis of the plate. Because of the design, the 3D plate is conceptually that of two linear plates connected by reinforcing vertical struts. Strut plates may therefore provide greater resistance against gap opening at the inferior border with biting forces compared to a single plated applied at the external oblique ridge or superior lateral border. Wilternberg12 found that displacement forces acting on the 3D plate, were comparable to those of reconstruction plate. Mustafa Farmand13 suggested that tissue dissection is to be done only in the vicinity of the planned osteotomy or fracture line, the 3D plates are positioned parallel to the osteotomy or fracture line and the connecting arms of the plate should be positioned rectangular to the osteotomy or fracture line. In conclusion, the results from the study suggest that fixation of mandibular fracture with 3D miniplate provides 3D stability because of its design, ease of technique during fixation of fracture fragments and carries low morbidity and infection rates that may prove to be comparable to the

standard plating systems. The only probable limitation of these plates may be excessive implant material due to the extravertical bars incorporated for countering the torque forces.

ReferencesFridrich KL, Pena-Velasco G, Olson RA. Changing trends with mandibular fractures: a review of 1,067 cases. J Oral Maxillofac Surg 1992;50(6):586-9.Ogundare BO, Bonnick A, Bayley N. Pattern of mandibular fractures in an urban major trauma center. J Oral Maxillofac Surg 2003;61(6):713-8.Farmand M. Experiences with the 3-D miniplate osteosynthesis in mandibular fractures. Fortschr Kiefer Gesichtschir 1996;41:85-7.Fonseca RJ: Vol-1, 2nd Edition-474-5.Ward Booth. Maxillofacial Surgery. Vol. 1, 2nd edition.Kruger Eberhard and Schilli: Text book of oral maxillofacial surgery, 6th edition.Iizuka T, Fujimoto H, Ono T. A new material (single crystal sapphire screw) for internal fixation of the mandibular ramus. J Craniomaxillofac Surg 1987;15(1):24-7.Michelet: Rigid skeletal fixation of fractures. J Oral Maxillofac Surg 1973;51:163-73.Champy M, Loddé JP, Schmitt R, Jaegor JH, Müster D. Mandibular osteosynthesis by miniature plates via buccal approach. J Maxillofac Surg 1978; 6(1):14-21.Guimond C, Johnson JV, Marchena JM. Fixation of mandibular angle fractures with a 2.0-mm 3-dimensional curved angle strut plate. J Oral Maxillofac Surg 2005;63(2):209-14.Farmand M, Dupoinrieux L. The value of 3-dimensional plates in maxillofacial surgery. Rev Stomatol Chir Maxillofac 1992;93(6):353-7.Wittenberg JM, Mukherjee DP, Smith BR, Kruse RN. Biomechanical evaluation of new fixation devices for mandibular angle fractures. Int J Oral Maxillofac Surg 1997;26(1):68-73.Farmand M. The 3-D plating system in maxillofacial surgery. J Oral Maxillofac Surg 1993;S1(Suppl 3):166.

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Dental implants play a promising role in replacing lost tooth structures. The success of dental implant supported prosthesis depends

on both the operator and patient. A successful implant osseointegrates with the bone and a sulcus develops around the tooth structure simulating the natural tooth. The sulcus formed around the prosthesis of the implant is termed as ‘peri-implant sulcus’ and the fluid found in this sulcus is called ‘peri-implant sulcular fluid’. It has been found through different studies that the peri-implant sulcus simulates the gingival sulcus and the peri-implant sulcular fluid contents are nearly similar to that of the gingival sulcular fluid .

1

Periodontal diseases including those affecting the implants, is recognized as a group of inflammatory disorders whose pathophysiology is related to accumulated microbial plaque and the host response to these accumulations. The role of bacteria in

the initiation of periodontal diseases, resulting in connective tissue and alveolar bone destruction has been well-documented.2

One of the hallmarks of current periodontal research is the search for a diagnostic test to assess periodontal disease activity through potential biomarkers that would be more predictive. Efforts to develop diagnostic tests based on host factors have focused entirely on the analysis of sulcular fluid.3 Analysis of the peri-implant sulcular fluid provides a means by which different aspects of the multifaceted host response in inflammatory diseases of implants can be studied. This provides a noninvasive means of evaluating the role of host response in periodontal disease. The analysis of sulcular fluid for periodontal diagnosis has been the subject of interest. This fluid contains locally and systemically derived markers of periodontal disease and hence may offer the basis for a patient-specific diagnostic test for diseases affecting the supporting apparatus.2

Among the various enzyme systems that are released by inflammatory cells, b-glucuronidase is considered to be a marker for primary granule release by neutro- phils. b-glucuronidase is a polymorphonuclear (PMN) derived lysosomal acid hydrolase which is stored

*Associate ProfessorDept. of Periodontics Tagore Dental College and Hospital, Chennai**Professor Dept. of Periodontics Meenakshi Ammal Dental College and Hospital, ChennaiAddress for correspondenceDr MN Prabhu253, III Main Road, TNHB, Velachery, Chennai - 600 042E-mail: [email protected]

abstract

The sulcus formed around the prosthesis of the implant is termed as ‘peri-implant sulcus’ and the fluid found in this sulcus is called ‘peri-implant sulcular fluid’. b-glucuronidase enzyme is an indicator of polymorphonuclear (PMN) influx into the sulcus. b-glucuronidase together with hyaluronidase is involved in the catabolism of proteoglycans. The purpose of this study was to compare the levels of enzyme b-glucuronidase between healthy and diseased implants. Fifty male subjects with implant prosthesis were screened postoperatively and 19 was selected based on the following inclusion and exclusion criteria. Selections of healthy and diseased implants were based on visual inspection of the gingiva and clinical records obtained within a period of six months prior to sampling. Plaque and gingivitis levels were recorded for the healthy and diseased implants. Filter-paper strips were used for obtaining the sulcular fluid and was assayed for the levels of enzyme b-glucuronidase. Despite the small number of implants evaluated in this study, the levels of b-glucuronidase were significantly higher around failing implants compared to healthy implants. From the results of this study, it can be inferred that the increased b-glucuronidase levels can be an important biomarker and a good predictor of implant failure.

Key words: b-glucuronidase, peri-implant sulcus, peri-implant sulcular fluid

Comparison of Enzyme b-glucuronidase Levels Around Healthy and Diseased Implants: A Clinical StudyMn Prabhu*, Jaideep Mahendra**

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in primary azurophil granules. This enzyme is an indicator of PMN influx into the sulcus. b-glucuronidase together with hyaluronidase is involved in the catabolism of proteoglycans. The endoglycosidase hyaluronidase cleaves hexosa-minidic linkage producing tetrasaccharides. This tetrasaccharide is further degraded by b-glucuronidase. Therefore, b-glucuronidase most likely contributes to non-collagenous matrix degradation in periodontal diseases. It has been proved in a number of clinical studies that changes occur in the b-glucuronidase levels found in the gingival sulcular fluid, with changes in the health status of the periodontium surrounding the normal tooth.3 A similar finding is likely to occur around implants. In lieu of above, the present study was undertaken to estimate the levels of enzyme b-glucuronidase in peri-implant sulcular fluid surrounding healthy and diseased implants.


Fifty male subjects with implant prosthesis were screened postoperatively and 19 was selected based on the following inclusion and exclusion criteria. Inclusion criteria includes the patients having placed the prosthesis over the implant at least or before a period of six months, patient age should be within 20-60 years and the patient should not have any oral lesions. The subjects with the history of periodontal treatment in the preceding six months, intake of non steroidal anti-inflammatory drugs, immunosuppressive drugs, corticosteroids, antihypertensive drugs, antibiotic therapy and antiseptic therapy for the preceding six months, smokers and any underlying systemic conditions2 were excluded from the present investigation.

Selections of healthy and diseased implants were based on visual inspection of the gingiva and clinical records obtained within a period of six months prior to sampling. Failing implants were evidenced by mobility of the implant, the presence of fistulae or exposed implant threads or hydroxyapatite coatings.4

Before the collection of the peri-implant sulcular fluid, all supragingival plaque was removed from each sampled site. The sites chosen for sample collection were isolated with cotton roles. The fluid was collected using standardized filter-paper strips held within the

crevice. The strip was inserted into the sulcus or pocket until slight resistance is felt and was left in place for 20 seconds. Then, it was transferred immediately into plastic vials containing 300 µl of saline with 0.1% polysorbate. The fluid was later eluted from the paper strips by vortexing the sample at 3500 rpm for a period 30 minutes. The strips were then removed from the vials and the vials were sealed and frozen at 80°C for subsequent laboratory analysis.5

β-glucuronidase Assay

The presence of b-glucuronidase was determined according to Boutros M et al, in this study. Briefly our method includes the identification of b-glucuronidase by the release of 4-methylumbelliferone from hydrolysis 4-methylumbelliferyl-b D-glucuronide. Twenty-five microliter of sample, 10 µl of substrate and 65 µl of acetate buffer were incubated for one hour at 37°C. Blanks were prepared as described above, except that 25 µl of sample was replaced with 25 µl of saline. Following incubation 2.4 µl of glycine buffer was added to each sample and to blank. Five nanograms per milliliter and 1 ng/ml standards of 4-methylumbelliferone were prepared while the sample and blanks were incubated. These two standards were prepared each time the assay was run to detect changes not only in the buffers used but in fluorometer. Only one standard is needed to set the fluorometer maximum on the computerized amino-Bowman series 2 fluorometer. Fluoroscence was read at an excitation wavelength of 365 nm and emission wavelength of 450 nm.5

Statistical Analysis

The result obtained was statistically analysed by using SPSS PC (Statistical Package for Social Science). Correlation analysis was done to estimate the strength of linear relationship between b-glucuronidase present in each study group.

Results

The b-glucuronidase levels in the control group consisting of 10 well-integrated implants were found to be 2.8211 ± 0.622 (measured in nanograms per site).

The b-glucuronidase levels in the experimental group consisting of nine failing implants were found to be 5.734 ± 1.102 (measured in nanograms per site).


oriGinal research

The results are represented diagrammatically using bar graphs (Fig. 1). The results were found to be statistically significant. The results clearly indicate that the peri-implant sulcular fluid in the diseased implants have an increased amount of b-glucuronidase than that in the healthy implants.

Discussion

Beta-glucuronidase is an important component of the primary granules of PMN. It is a lysosomal acid hydrolase enzyme which is capable of breaking down connective tissue ground substances.6 During the inflammatory process the enzyme b-glucuronidase is released by the degranulation of activated PMNs. b-glucuronidase together with hyaluronidase is involved in the catabolism of proteoglycans. The endoglycosidase hyaluronidase cleaves hexosaminidic linkages, producing tetrasaccharides with the structure of (GlcUA-b1, 3-GlcNAc b1, 4). This tetrasaccharide is further degraded by b-glucuronidase and b-N-acetyl hexosaminidase. b-glucuronidase is an exoglycosidase that removes GlcUA from nonreducing ends of tetrasaccharides or larger polysaccharides. Its substrates include dermatan sulfate, heparan sulfate, chondroitin sulfate and hyaluronic acid. Therefore b-glucuronidase most likely contributes to noncollagenous matrix degradation in periodontal diseases.5-7

The results of the present study indicates clearly that when compared to successful implants, the failing implants were found to have more amount of b-glucuronidase in their sulcular fluid.8 This result

is in correlation with the results of, Pippin et al3 and Lamster et al.9 The studies done by them also indicated an increase in b-glucuronidase levels in case of diseased when compared to healthy sites.3,9

It can be inferred from the present study that b-glucuronidase is a potential biomarker of tissue destruction, as its level increases with disease.9 The increased b-glucuronidase levels can be an important biomarker and a good predictor of implant failure.10

ReferencesCao CF, Smith QT. Crevicular fluid myeloperoxidase at healthy, gingivitis and periodontitis sites. J Clin Periodontol 1989;16(1):17-20.Newman MG, Flemming TF. Periodontal considerations of implants and associated microbiota. J Dent Educ 1988;52(12):737-44. Pippin DJ, Cobb CM, Feil P. Increased intracellular levels of lysosomal beta-glucuronidase in peripheral blood PMNs from humans with rapidly progressive periodontitis. J Periodontal Res 1995;30(1):42-50.Rams TE, Link CC Jr. Microbiology of failing dental implants in humans: electron microscopic observations. J Oral Implantol 1983;11(1):93-100.Boutros M, Michalowicz BS, Smith QT, Aeppli DM. Crevicular fluid enzymes from endosseous dental implants and natural teeth. Int J Oral Maxillofac Implants 1996;11(3):322-30.Lamster IB, Hardey LJ, Oshrain RL, Gondon JM. Evaluation and modification of spectrophotometric procedures for analysis of lactate dehydrogenase and beta-glucuronidase and arylsulphatase in human gingival crevicular fluid collected with filter-paper strips. Arch Oral Biol 1985;30(3):235-42.Lamster IB, Oshrain RL, Gordon JM. Enzyme activity in human gingival crevicular fluid: considerations in data reporting based on analysis of individual crevicular sites. J Clin Periodontol 1986;13(8):799-804.Smith QT, Geegan SJ. Repeated measurement of crevicular fluid parameters at different sites. J Clin Periodontol 1991;18(3):171-6.Lamster IB, Holmes, Gross KB, Oshrain RL, Cohen DW, Rose LF, et al. The relationship of beta-glucuronidase activity in crevicular fluid to probing attachment loss in patients with adult periodontitis. J Clin Periodontol 1995;22(1):36-44.Rams TE, Roberts TW, Tatum H Jr, Keyes PH. The subgingival microbial flora associated with human dental implants. J Prosthet dent 1984;51(4):529-34.

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figure 1. Control b-glucuronidase levels around healthy implants 2.8211 ± 0.622. Experimental b-glucuronidase levels around diseased implants 5.734 ± 1.102.

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Tooth traction (extrusion) was first described by Heithersay in 1973.1 Orthodontic extrusion is a conservative procedure that allows retention

of a tooth without extraction. Inability to keep the restorative margin at supragingival level leads to the ultimate failure of restoration. Orthodontic tooth movement can modify and improve the periodontal anatomy of the hard and soft tissue morphology as also periodontally damaged or fractured teeth.

Extrusion is a tooth movement that occurs in the direction of the normal eruptive process; forced orthodontic extrusion is movement of vertical translation (in a coronal direction) obtained through the application of light continuous forces.2,3

The indications and contraindications for orthodontic extrusion were discussed by Bach et al (2001).4 Indications for the treatment include - subgingival or infraosseous lesion of the tooth between the cemento-enamel junction and the coronal third of the root; restoration impinging on the biological width; reduction of angular bone defects and isolated periodontal pockets; to maintain the integrity of an alveolar ridge for implant placement, tooth extrusion is done prior to extraction to grow alveolar bone in the extraction socket for future implant placement; for treatment of trauma or impacted teeth (for e.g. canines).

The contraindications4 are - ankylosis, hypercementosis, vertical root fracture, root proximity, short roots, insufficient prosthetic space and exposure of the furcation. Extrusion is not recommended in case where it will not be possible to achieve a 1:1 crown root ratio after final restoration.

Extrusion is the easiest orthodontic movement to achieve because it closely resembles natural tooth eruption. Normally 0.2-0.3 Newton of force is required for the forced eruption of a single rooted

*Professor and Head**Senior Lecturer†Postgraduate StudentDept. of Orthodontics and Dentofacial Orthopedics Sree Balaji Dental College and Hospital, ChennaiAddress for correspondenceDr RV Murali Professor and Head Dept. of Orthodontics and Dentofacial Orthopedics Sree Balaji Dental College and Hospitals, Pallikaranai, Chennai - 600 100E-mail: [email protected]

abstract

Case report: The management of patients with traumatic injuries to their dentition is an integral part of general dental practice. The purpose of this paper is to discuss the immediate endodontic and orthodontic (lingual) management of traumatized anterior teeth with fracture at the subgingival level, which otherwise would have gone for extraction. History and clinical finding: A 24-year-old male reported with fractured left central incisor following road traffic accident. On clinical examination, it was observed that the upper left central incisor had a horizontal fracture at the cervical one-third level with the fracture line extending subgingivally on palatal side. The traumatized tooth was first treated endodontically, and then referred to our department for orthodontic extrusion before permanent crown placement. Treatment plan: Treatment plan was to extrude the fractured anterior tooth in order to keep the restorative margin supragingival. This was to be followed by a metal cast post and metal free ceramic crown to complete the restoration of tooth. Invisible approach (lingual orthodontics) was used as the patient was insistent upon the braces not being seen outside during the course of the treatment. Conclusion: Tooth extrusion techniques offers excellent treatment option for subgingival fractures. It is a well-documented clinical method for altering the relation between a nonrestorable tooth and its attachment apparatus, extruding sound tooth material from within the alveolar socket by light forces. The use of the lingual technique for forced eruption enhance acceptance of orthodontic treatment by adult patients.

Key words: Orthodontic, extrusion, subgingival fracture

Extrusion of Fractured Anterior Tooth - An Invisible ApproachRV Murali*, l Rajashekhar**, S Rajalingam†

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tooth.5 A 3-4 mm distance from the alveolar crest to the restorative margin has been recommended for optimal periodontal health.6

Traditional methods for orthodontic extrusion have been the use of labial appliances. This technique may be unacceptable to patients with serious esthetic concerns or needs. In such situations, lingual appliances may be an option for the patient.

Lingual orthodontics in the current status, was first introduced by Alexander et al7 and Fujita.8 Although this technique can be used to treat all kinds of malocclusion, it is preferred mostly by adult patients. This technique has changed the way of treating interdisciplinary cases with esthetic concerns, not only after treatment but even during the course of treatment.

Case Report

A 24-year-old male was referred to the Dept. of Orthodontics and Dentofacial Orthopedics, Sree Balaji Dental College and Hospital, Chennai, with a fractured upper left central incisor (21) subsequent to an injury. On clinical examination, it was observed that the upper right central incisor had a horizontal fracture at the cervical one-third level (Fig. 1 and 2) with the fracture line extending subgingivally on palatal side. There were no other injuries reported.

The traumatized tooth was first treated endodontically (Fig. 3), and then referred to our department for orthodontic extrusion before permanent crown placement. The patient was co-operative, and presented no contraindications for orthodontic treatment. As he was getting married, he preferred that the braces be put lingually and not labially. The lingual brackets (STb Brackets*) were positioned on the upper cast and a transfer tray made from glue gun** was fabricated (Fig. 4).

figure 1 and 2. Horizontal fracture of upper right central incisor with the fracture line extending subgingivally on palatal side.

figure 3. The traumatized tooth-treated endodontically.

figure 4. Transfer tray made from glue gun.

a composite veneer was added to the fractured incisor. However, the margin was kept 2 mm short to help in assessing the extrusion process (Fig. 7).

*Ormco Corporation, 1717 West Collins, Orange, CA 92867.**Bosch PKP 18E Glue Gun, Robert Bosch Gmg H, P.O. Box 106050, Stuttgart, Germany.

After complete oral prophylaxis, etching with 37% orthophosphoric acid done and the brackets were bonded on to the upper teeth (Fig. 5). A lingual button bonded on 21 and was tied with 0.012” NiTi lingual arch wire (Fig. 6). To avoid the lingual button and archwire being seen through the fractured incisor,

figure 5. Stb brackets bonded to the upper arch.


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figure 8. Postextrusion radiograph.

figure 9. Gingivectomy done to contour the gingival line.figure 6. Lingual button bonded on 21 and was tied with 0.012” NiTi lingual arch wire.

figure 7. Incisal margin of composite veneer margin kept 2 mm short to help in assessing the extrusion process.

The patient was recalled once weekly to check the extrusion. The necessary movement of the tooth (approximately 3 mm) to recover the biologic width had been attained in a period of two months. This was very evident on the radiograph (Fig. 8).

Once the required extrusion achieved the archwire was removed, and the lingual button was debonded. After the procedure of orthodontic extrusion the circumferential supracrestal fiberotomy around the exposed tooth was done to cut the stretched periodontal fibers to avoid reverse movement of the root intrusion to the earlier position.9-11 Following supracrestal fiberotomy procedure gingivectomy was

figure 10. Post and core on fractured (21).

done to contour the gingival line (Fig. 9). Upon debonding, a metal free ceramic crown was given in 21 after post and core (Fig. 10 and 11).

Discussion

The restoration of fractured incisor with a subgingival fracture line has been managed over the years with the comprehensive multidisciplinary approach, in various ways. The method of tooth extrusion, first described by Hiethersay,1 uses the simple physiologic process of normal tooth eruption and applies it clinically to increase the clinical length of the crown.

figure 11. Metel free ceramic cemented.


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Tooth extrusion has been achieved by different methods including labial fixed appliances, modified archwires, mini implants and recently lingual bracket systems.

Many adults now prefer the use of lingual brackets to labial appliances for esthetic reasons. In this case, the patient showed willingness for the treatment only after the option of lingual appliances was given. In this case report, a multidisciplinary approach of the fractured tooth using lingual orthodontics has been highlighted.

Conclusion

A multidisciplinary approach is necessary for the restoration of tooth fractured at subgingival level, because the margin of restoration should ideally be supragingival.

In this clinical report, a treatment modality for forced eruption therapy that minimizes esthetic impairment was described. The use of the lingual technique for forced eruption may enhance acceptance of orthodontic treatment by adult patients who wish to avoid unnecessary esthetic compromises while undergoing the treatment of fractured tooth.

References Heithersay GS. Combined endodontic-orthodontic treatment of transverse root fractures in the region of the alveolar crest. Oral Surg Oral Med Oral Pathol 1973;36(3):404-15.Ingber JS. Forced eruption: part II. A method of

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treating nonrestorable teeth - Periodontal and restorative considerations. J Periodontol 1976;47(4):203-16.Gianelly A, Goldman HM. Biologic Basis of Orthodontics. Lea and Febiger Philadelphia, PA 1971:154-7.Bach N, Baylard J, Voyer R. Orthodontic extrusion: periodontal considerations and applications. J Can Dent Assoc 2004;70(11):775-80.Biggerstaff RH, Sinks JH, Carazola JL. Orthodontic extrusion and biologic width realignment procedures: methods for reclaiming nonrestorable teeth. J Am Dent Assoc 1986;112(2):345-8.Postashnick SR, Rosenberg ES. Forced eruption: principles and restorative dentistry. J Prosthet Dent 1982;48(2):141-8.Alexander CM, Alexander RG, Gorman JC, Hilgers JJ, Kurz C, Scholz RP, et al. Lingual orthodontics. A status report. J Clin Orthod 1982;16(4):255-62.Fujita K. Multilingual-bracket and mushroom arch wire technique. A clinical report. Am J Orthod 1982;82(2):120-40.Brown GJ, Welburry RR. Root extrusion, a practical solution in complicated crown-root incisor fractures. Br Dent J 2000;189(9):477-8.Arhun N, Arman A, Ungor M, Erkut S: A conservative multidisciplinary approach for improved aesthetic results with traumatized anterior teeth. Br Dent J 2006;201(8):509-12.JI J, Luo XP, Lu W, Shi YJ, Wu L, Shu CJ. Esthetics restoration after rapid orthodontic extrusion of subgingivally fractured incisor: a case report. Hua Xi Kou Qiang Yi Xue Za Zhi 2007;25(2):206-7.

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Fibrous dysplasia is a nonspecific hamartomatous skeletal developmental anomaly, characterized by slow progressive replacement of a localized area

of bone by an abnormal proliferation of isomorphic fibrous tissue.1 It is a fairly common, well-recognized and locally circumscribed benign disorder that was originally described by Lichtenstein more than 60 years ago. Although virtually all bones can be affected, the cranial and facial bones are most frequently involved.2 It may affect one (monostotic) or multiple bones (polystotic) and may represent part of McCune- Albright syndrome (polyostotic fibrous dysplasia, café-au-lait spots and endocrinopathy).3 It accounts for 2.5 to 10% of all bone tumors.4

Recently, it has been found that it is caused by activating somatic mutation of the GNAS1 gene, resulting in substitution of cysteine or histidine with arginine in a position 201 in the G-protein alpha subunit (Gs-α) protein.3 The factors predisposing remain unknown, but it is probably a developmental mesodermal disorder which may be triggered by trauma

(Rees, 1976),5 disordered metabolism of calcium and phosphorus,2,6 hyperplasia of osteoblasts.2,7 The central area of the lesion is filled by fibrous tissue that may contain foci of calcified bone, hyaline, cartilage, cysts and giant cells (Hutter et al 1963).5 The radiological appearance is usually typical, but the importance of biopsy is emphasized by the erroneous diagnosis in 25 of 90 reviewed cases by Harris et al (1949).5

The clinical pattern of the disease also varies in distribution and appearance. Whether the disease is generalized or localized depends on: 1) The size of the cell mass at the point of the mutation during embryogenesis and 2) the site in the cell mass where the mutation occurs.4,8

Case Report

Case 1

A 16-year-old female came to our Dept. of Oral Medicine and Radiology with a slowly growing swelling in left side of face for past five years. Patient’s history dates back to five years when she fell from a cot and developed mild swelling and pain in left middle part of face.

Extraoral examination revealed, obvious facial asymmetry along left side of face with diffuse, hard, nontender swelling roughly measuring 5 cms diameter in size mediolaterally and superoinferiorly. Intraorally a single well-defined bony hard and

*Senior Lecturer**Postgraduate Student†Professor and HeadDept. of Oral Medicine and RadiologyMeenakshi Ammal Dental College, ChennaiAddress for correspondenceDr C Sumathy Senior Lecturer No. 171, Medavakkam Main Road, Surendra Nagar Adambakkam, Chennai - 600 088E-mail: [email protected]

abstract

Fibrous dysplasia is a developmental tumor like condition that is characterized by replacement of normal bone by an excessive proliferation of cellular fibrous connective tissue intermixed with irregular bony trabeculae. Fibrous dysplasia of the jaw are believed to be benign, self-limiting, nonencapsulated mainly occurring in young subjects. Although, jaw lesions of fibrous dysplasias are usually monostotic, they may occasionally be part of a polyostotic process. Enlargement of the lesions is slow and insidious and persists until cessation of growth, even though in some cases it may continue into adulthood. Monostotic fibrous dysplasia of the maxilla is the most common site of involvement in the facial bones and accounts for approximately 70% of those with facial involvement. Computed tomography (CT) imaging study of the disease is useful for evaluation and treatment planning. We report, two cases with a slow growing swelling in left side of face.

Key words: Fibrous dysplasia, monostotic, computed tomography imaging, maxilla

Fibrous Dysplasia of the Maxilla - Report of Two Cases with ReviewC Sumathy*, C Seethalakshmi**, K Saraswathy Gopal†

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figure 1 A and B. Extraoral and intraoral view showing diffuse swelling in the left maxillary region.

figure (2). Occlusal view showing diffuse radiopacity and expansion of buccal cortical plate in the left maxillary alveolar bone (A); Intraoral periapical radiograph showing ground glass appearance and loss of lamina dura in relation to the teeth (B); OPG showing mixed radiopaque and radiolucent lesion is the left posterior part of maxilla (C); PA view of the skull showing diffuse radiopacity in the left side of the maxilla (D).

nontender swelling evident in left buccal vestibule in relation to 24, 25, 26, 27 and roughly measures 6 cms anterioposteriorly and 4 cms superoinferiorly (Fig. 1 A and B). On radiographic examination, intraoral periapical view revealed dense radiopacity with ground glass appearance in relation to the teeth. Maxillary occlusal view revealed ground glass appearance of maxilla and expansion of left buccal cortical plate. Orthopantomogram-revealed dense opacification and obliteration of left maxillary sinus in relation to 24, 25, 26 and 27. Posteroanterior skull view also revealed dense radiopacity obliterating the maxillary sinus (Figs. 2 A-D). Computed tomography (CT) of maxilla and reformatted images revealed an expansile lesion in the left zygomatic maxillary junction with areas of ground glass attenuation and the lesion displaced the lateral wall of maxilla medially (Fig. 3). The biochemical marker, serum alkaline phosphatase was significantly

elevated, however, serum calcium and phosphorous levels were normal.

The histopathological report showed immature woven bone with the characteristic Chinese letter pattern interspersed within a rich fibrocellular connective tissue with feature suggestive of fibrous dysplasia (Fig. 4). The patient was recalled after the finish of growth spurt.

Case 2

A 25-year-old male came to our Dept. of Oral Medicine and Radiology with a swelling in right side of face for past three years. Patient’s history revealed that the swelling initially was small and gradually attained the present size. Patient had a previous history of similar swelling at the same site seven years back for which he was surgically-treated. The patient was informed that the swelling might recur and to report after the age of 25.

Extraoral examination revealed, obvious facial asymmetry along right side of face with diffuse, hard, nontender swelling roughly measuring 4 × 6 cm diameter in size mediolaterally and superoinferiorly,

A B

A B

C D

figure 3. CT showing diffuse thickening and expansion of the left maxillary bone with ground glass appearance.

figure 4. The H&E section of 40x view shows irregular bony trabeculae with cellular connections tissue.


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respectively. Intraorally, a single well-defined bony hard and nontender swelling was evident in right buccal vestibule in relation to 13 upto distal end of 17 which roughly measured 5 cms anteroposteriorly and 3 cms superoinferiorly (Fig. 1 A and B). On radiographic examination, maxillary occlusal view revealed ground glass appearance of maxilla and expansion of right buccal cortical plate (Fig. 2). CT of maxilla and reformatted images revealed diffuse thickening and expansion of the right maxillary bone with ground glass appearance and obliteration of the maxillary sinus suggestive of fibrous dysplasia of the right maxilla (Fig. 3. A and B).

figure 1 A and B. Extraoral and intraoral view showing diffuse swelling in the right maxillary region; Postoperative intraoral view showing sutures placed (C).

A B

C

figure 2. Occlusal view showing diffuse radiopacity and expansion of buccal cortical plate in the right maxillary alveolar bone.

Patient was advised maxillary re contouring and was surgically managed (Fig. 1 C). The histopathological report revealed irregular, curvilinear trabeculae supported in a fibrous connective tissue stroma suggestive of fibrous dysplasia of right maxilla (Fig. 4).

Discussion

Fibrous dysplasia is the replacement of normal bone with fibrous tissue causing painless expansile lesions that impair cosmetic and structural function of bone. They constitute 7% of all nonmalignant bone tumors and may be either monostotic or polyostotic.9-11 The monostotic form is more commonly found in the facial skeletal region. These fibrous lesions are generally non-neoplastic, but rare malignant transformation has been described.11-13 Most of these fibrous lesions are believed to be self-limiting after puberty or when the patients growth is complete11 as described in our first case. In 1937, Albright, Butler, Hampton and Smith14,15

figure 3. CT showing diffuse thickening and expansion of the right maxillary bone with ground glass appearance (A). 3D-reconstruction image of the skull showing the bony swelling in the right maxilla (B).

figure 4. H&E section of scanner view showing curvilinear pattern of irregular bony trabeculae, along with connective tissue stroma.

A B


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reported a syndrome, McCune-Albright syndrome consisting of a triad with café-au-lait skin pigmentation, endocrine abnormalities (especially precocious puberty in females) and widespread skeletal alterations consistent with fibrous dysplasia. In 1938, the skeletal lesions were completely described by Lichtenstein14,16 and the term polyostotic fibrous dysplasia was proposed. It was later recognized that other endocrinopathies, including hyperthyroidism,17,18 growth hormone excess,18-20 renal phosphate wasting with or without rickets/osteomalacia18,21 and Cushing’s syndrome could be found in association with the triad.18,22-24 Craniofacial fibrous dysplasia typically presents at around 10 years of age and then progresses throughout adolescence.4,25 The disease was initially thought to become inactive after childhood but subsequent reports have proved this to be untrue. The clinical presentation depends on the site, duration, extent and nature of the lesion.4,26 Growth of the tumor occurs during a certain period, usually before maturation of the craniofacial skeleton, and then the tumor becomes clinically quiescent.2

These lesions tend to be firm painless swelling or deformity of the maxillofacial region. Those lesions of the midface and periorbital region may be initially seen with nasal obstruction, sinus symptoms, headache, dental problems and possible visual disturbance. Radiographic findings demonstrate the classic ground glass appearance with radiolucent lytic lesions and ill defined borders on standard X-ray films.11 Occasionally, the radiograph may reveal predominantly sclerotic lesions with or without accompanying lytic lesions. Its nonspecific radiological appearance makes it difficult to differentiate from other conditions such as ossifying fibroma and Paget’s disease.4,25,27 CT is a better radiological and superior diagnostic tool for assessing the extent of the tumor. Fibrous dysplasia has characteristic appearances on CT and consists of three varieties: Ground glass pattern (56%), homogenously dense pattern (23%) and cystic variety (21%).4,28

Serum alkaline phosphatase and urinary hydroxy-proline are biochemical markers used to monitor response in the nonsurgical treatment of the disease.4 The histological features composed of curvilinear trabeculae of woven bone surrounded by moderately cellular fibroblastic proliferation. The shapes of trabeculae mimic Chinese characters and the bone lacks osteoblastic rimming. The histological features

of fibrous dysplasia are site specific, in the cranial bones, they are pagetoid in nature, whereas in gnathic bones they are hypercellular, and in the axial/appendicular skeletons they have a Chinese character pattern.4,29

Luck (1950) said that ‘no effective treatment is known’ for fibrous dysplasia. The active phase of fibrous dysplasia usually starts in early childhood and gradually becomes quiescent and finally, with termination of skeletal growth, the process becomes inactive and then ceases to grow. The surgical intervention is generally directed at the cosmetic facial deformities and cranial nerve compression. Surgery is indicated at any age, if important function is threatened, deformity becomes substantial or complications develop. Medical treatment has a role in the management of craniofacial fibrous dysplasia. Some authors have reported the use of steroids, mainly in the treatment of visual symptoms from optic nerve compression.1 Medical management also includes bisphosphonates (pamidronate). This group of drugs inhibits osteoclastic activity, and serum alkaline phosphatase, a marker for bone turnover is consistently reduced They are generally safe and well-tolerated, although one reported side effect is atypical fever.4 The malignant or sarcomatous transformation of fibrous dysplasia is a rare complication, occurring in 0.4-4% of cases. The commonest types of sarcoma complicating fibrous dysplasia are osteosarcoma, fibrosarcoma and chondrosarcoma.1 With proper understanding, diagnosis and management, a good outcome can often be achieved. Periodic CT and local bone mineral density can be used to follow the progression of the disease and assess the need for any secondary surgical procedures.

ReferencesMubeen, Kiran Kumar KR. Craniofacial polyostotic fibrous dysplasia: report of a case with review of literature. JPFA 2009;23:92-6.Chen YR, Wong FH, Hsueh C, Lo JJ. Computed tomography characteristics of non-syndromic craniofacial fibrous dysplasia. Chang Gung Med J 2002;25:1-8.Pruksakorn P, Shuangshoti S, Siwanuwatn R, Lerdium S, Sunhornyohin S, Snaboon T. Craniofacial fibrous dysplasia. Inter Med 2010;49(3):249-50.Chen YR, Chang CN, Tan YC. Craniofacial fibrous dysplasia an update. Chang Gung Med J 2006; 29(6):543-9.

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Liakos GM, Walker CB, Carruth JA. Ocular complications in craniofacial fibrous dysplasia. Br J Opthalmol 1979;63(9):611-6.Murray RC, Kirkpatrick HJ, Forrai E. A case of Albright’s syndrome (osteitis fibrosa disseminata). Br J Surg 1946;34:48-57.Changus GW. Osteoblastic hyperplasia of bone: a histochemical appraisal of fibrous dysplasia of bone. Cancer 1957;10(6):1157-61.Cohen MM Jr, Howell RE. Etiology of fibrous dysplasia and McCune-Albright syndrome. Int J Oral Maxillofac Surg 1999;28:3666-71.Myer CM, Mortellite AJ, Yamik GA, et al. Malignant and benign tumors of the head and neck in children. In: Pediatric Facial Plastic and Reconstructive Surgery. Smith JD, Bumsted RM, (Eds.), Raven Press: New York, NY 1993:235-61.Waldron CA. Fibro-osseous lesions of the jaws. J Oral Maxillofac Surg 1993;51(8):828-35.Frodel JL, Funk G, Richardson M. Management of aggressive midface and orbital fibrous dysplasia. Arch Facial Plast Surg 2000;2(3):187-95.Beuerlein ME, Schuller DE, DeYoung BR. Maxillary malignant mesenchymoma and massive fibrous dysplasia. Arch Otolaryngol Head Nesck Surg 1997;123(1):106-9.Ruggieri P, Sim FH, Bond JR, Unni KK. Malignancies in fibrous dysplasia. Cancer 1994;73(5):1411-24.Pound E, Pickrell K, Hunger W, Barnes W. Fibrous dysplasia (ossifying fibroma) of the maxilla: analysis of 14 cases. An Surg 1965;161:406-10.Albright F, Butler A, Hampton A, Smith P. Syndrome characterised by osteitis fibrosa disseminata, areas of pigmentation and endocrine dysfunction with precocious puberty in females. New Engl J Med 1937;216:727.Leichtenstein L. Polyostotic fibrous dysplasia. Arch Surg 1938;36:874.Mastorakos G, Mitsiades NS, Doufas AG, Koutras DA. Hyperthyroidism in McCune-Albright syndrome with a review of thyroid abnormalities sixty years after the first report. Thyroid 1997;7(3):433-9.Dumitrescu CE, Collins MT. McCune-Albright syndrome. Orphanet J Rare Dis 2008;3:12.

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Sherman SI, Ladenson PW. Octreotide therapy of growth hormone excess in the McCune-Albright syndrome. J Endocrinol Invest 1992;15(3):185-90. Akintoye SO, Chebli C, Booher S, Feuillan P, et al. Characterization of gsp-mediated growth hormone excess in the context of McCune-Albright syndrome. J Clin Endocrinol Metab 2002;87:5104-12. Collins MT, Chebli C, Jones J, Kushner H, Consugar M, Rinaldo P, et al. Renal phosphate wasting in fibrous dysplasia of bone is part of a generalized renal tubular dysfunction similar to that seen in tumor-induced osteomalacia. J Bone Miner Res 2001;16(5):806-13. Danon M, Crawford JD. The McCune-Albright syndrome. Ergeb Inn Med Kinderheilkd 1987; 55:81-115. Diaz A, Danon M, Crawford J. McCune-Albright syndrome and disorders due to activating mutations of GNAS1. J Pediatr Endocrinol Metab 2007;20(8):853-80. Kirk JM, Brain CE, Carson DJ, Hyde JC, Grant DB. Cushing’s syndrome caused by nodular adrenal hyperplasia in children with McCune-Albright syndrome. J Pediatr 1999;134(6):789-92.Chen YR, Kao CC. Craniofacial tumors and fibrous dysplasia. In: Plastic Surgery: Indications, Operations, and Outcomes. Vol 2; Achauer BM, Eriksson E, Guyuron B, et al. (Eds.), Craniomaxillofacial, Cleft and Pediatr Surg Mosby: St Louis 2000:729-39.Leeds N, Seaman WB. Fibrous dysplasia of the skull and its differential diagnosis. A clinical and roentgenographic study of 46 cases. Radiology 1962;78:570-82.Wagner P, Heilmann P, Schulz A, Nawroth P, Kasperk Ch. Fibrous dysplasia: differential diagnosis from Paget’s disease. Dtsch Med Wochenschr 2002;127(3):2264-8.Brown EW, Megerian CA, McKenna MJ, Weber A. Fibrous dysplasia of the temporal bone: imaging findings. AJR Am J Roentgenol 1995;164(3):679-82.Riminucci M, Liu B, Corsi A, Shenker A, Spiegel AM, Robey PG, et al. The histopathology of fibrous dysplasia of bone in patients with activating mutations of the Gs alpha gene: site specific patterns and recurrent histological hallmarks. J Pathol 1999;187(2):249-58.

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Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae. It is essentially a disease of peripheral nerves but also involving

the skin and mucous membrane.1

Lepra bacilli are spread by:Droplet infectionSkin-to-skin contactPlacenta and breast milk

Exit and entry is oronasal mucosa: This was first described by Armauer Hansen in 1874, leprosy was the first human disease to be associated with a bacterium.2 It is seen in tropical and subtropical countries. There is no human infectious disease in which the clinical picture is so varied as that of leprosy. Clinical leprosy can vary from the presence of an insignificant area of hypopigmented skin lesion that heals spontaneously to widespread damage to peripheral nerves, eyes, bones, muscles and other tissues. These varied manifestations are due to the result of varying host responses to M. leprae.3 Leprosy is chronic in nature and the patient progressively develops deformities of extremities and face. The facial structures are affected and this unesthetic

*Professor, Dept. of Oral PathologyRajah Muthiah Dental College and Hospital, Annamalai UniversityChidambaram**Reader, Dept. of PeriodonticsPriyadarshini Dental College, Chennai†Professor and Head, Dept. of Oral PathologyMadha Dental College, ChennaiAddress for correspondenceDr TS Thirugnanasambandan Amma Dental Clinic71, GPM Street, Ambapuram, Gudiyatham, Tamil Nadu

abstract

Leprosy is a chronic granulomatous disease involving the skin, mucous membrane and affecting peripheral nerves. One hundred seventy-two patients suffering from leprosy were examined for facial changes, tooth loss, alveolar bone loss, facial paralysis and other relevant findings. The study comprised the three types of leprosy namely tuberculoid, borderline and lepromatous.

Key words: Tuberculoid leprosy, borderline leprosy, lepromatous leprosy, oral and facial changes in leprosy

Clinical and Pathological Evaluation of Oral Changes in LeprosytS thirugnanasambandan*, S latha**, M Sathish Kumar†

appearance is responsible for society dislike towards the patient. The society has created among themselves a fear and apprehension towards this disease. It is also noted that in dental profession many of the dental surgeons fail to attend these patients because of the fear of getting infected from these patients.

Deniellsen and Boeck4 1847 published in Norway a land mark atlas in which they clearly delineated the features of leprosy.

Armauer Hansen5 1874 reported microscopic observations of the organism M. leprae. Hence, it was named after him as Hansen’s disease.

Case Study

One hundred seventy-two patients suffering from leprosy were diagnosed clinically and histopathologic examination was done. Among the total number of 172 patients, 121 were males and 51 were females. This study recorded 70.35% of males and 29.65% of females suffering from the disease.

The total numbers of patients were divided into five groups according to the duration of disease.

Disease duration Percentage (%) and no. of patients

0-5 years 6.9% (12)

5-10 years 56.39% (72)

10-15 years 25% (13)

15-20 years 10.47% (18)

20-25 years 1.16%

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Result

The oral manifestations were recorded as follows:Among patients suffering for the past 0-5 years (6.97%) 4.65% were males and 2.33% were females. Five to 10 years of duration (56.39%) 41.86% were males and 14.53% were females. In 10-15 years of duration (25%) 18.60% were males and 6.39% were females. In 15-20 years of duration (10.47%) 4.06% were males and 6.39% were females. In 20-25 years of duration 1.16% were males. Oral manifestations were most severe in those patients with prolonged illness and it was more in males than in females. It was found that proportion of oral manifestations increased in severity

with duration of the disease. The different types of leprosy were studied and recorded as follows; 54.06% were lepromatous, 25.58% were borderline and 20.34% were tuberculoid.

Among the patients suffering from 5 to 10 years of duration 41.6% were tuberculoid type, 25.10% were borderline type and 33.33% were lepromatous type. Among the patients suffering from 10 to 15 years of duration 13.40% (males 7.2%, females 6.15%) were tuberculoid type, 26.8% (males 16.49%, females 10.30%) were borderline type, 59.7% (males 31.90%, females 27.8%) were lepromatous type.

Among the patients suffering from 15 to 20 years of duration 29.9% (males 11.6%, females 9.3%) were tuberculoid type, 11.6% (males 6.90%, females 4.6%) were borderline type and 67.4% (males 39.33%, females 27.90%) were lepromatous type of leprosy. Twenty to 25 years of duration 1.16% were lepromatous type.

With reference to the study of different facial changes the present study had established that among the patients with 0-5 years duration of leprosy 8.33% had saddle nose, 16.6% ear changes, 8.33% anesthetic patches. The predominant change with 0-5 years duration was ear change.

figure 4. Ulcerating of soft palate and uvula changes.

figure 1. Ear change. figure 2. Saddle nose.

figure 3. Maxillary alveolar bone loss and maxillary anterior loss.


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figure 5. Anesthetic patches and loss of eyebrows and eyelashes.

Among the patients with 5-10 years duration 17.50% had saddle nose 14.45% loss of eyebrows and eye lashes, 26.8% ear changes, 1.03% anesthetic patches

and 2.06% facial nodules. In this ear changes were predominantly occurring. Among the patients suffering from 10 to 15 years duration of disease, 55.81% had saddle nose deformity, 18.60% loss of eyebrows and eyelashes, 44.18% ear changes. Among the patients suffering from 15 to 20 years duration of disease, 55.55% had saddle nose, 66.66% loss of eyebrows and eyelashes, 61.11% ear changes, 11.11% facial paralysis.

Among the patients suffering from 20 to 25 years duration of disease all the patients had ear change, saddle nose, loss of eyebrows and eyelashes and 50% had facial paralysis.

As far as the oral manifestations of leprosy were concerned in the present study, it was recorded that among 172 patients of leprosy the major changes in order of reference were:

19.18% Maxillary alveolar bone loss16.86% Attrition of teeth16.27% Periodontal problem10.46% Loss of maxillary anterior teeth6.39% Pigmentations on the mucosa5.15% Angular chelitis5.15% Ulceration of the palate3.48% Patches on the tongue3.48% Changes in the uvula and soft palate

Discussion

In the present study, 172 patients were studied and it was found that males were more affected than females. This difference could be attributed to:

Males by their activity were more exposed to infection in the environmentDifficulty in examining womenBiological-lower susceptibility of females.

Various changes take place in leprosy progressively and according to duration the orofacial manifestations develop more. Hence, it is necessary to institute proper treatment as early as possible to prevent the genesis of advanced disease.

Oral manifestations of leprosy was found to be 2.33% in 0-5 years of disease, 14.53% in 5-10 years of duration, 6.39% in 10-15 years duration, 6.39% in

figure 6. Patches on tongue and pigmentation on the mucosa.


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figure 8. Lepromatous leprosy figure 10. Tuberculoid leprosy

figure 7. Mycobacterium leprae figure 9. Border line leprosy

15-20 years of duration. Oral changes develop in 0-5 years duration group also though incidence was more as the duration of the disease advanced. Oral manifestations are not static changes and they progressively increase as the duration of the disease progresses.

Irwin Lighterman6 1962, briefed the oral changes; in tuberculoid type sensory disturbances and motor paralysis occur in nerves supplying oral cavity. Hyperesthesia, paresthesia and anesthesia may occur. Complete or partial loss of sensation may occur in face, lips, hard palate, tongue, cheeks, gingiva. In lepromatous leprosy the oral changes occur more slowly, nodules were common in hard and soft palate, dorsum of tongue, lips, pharyngeal wall, tonsils.

Serra7 reported tongue lesions in 13 of 75 cases mostly arising at tip or base of the tongue. In advanced cases entire dorsum was deeply infiltrated giving a cobblestone appearance. In the present study, lepromatous leprosy was more common in long duration cases and tuberculoid type was more common in short duration cases. Among the facial changes saddle nose deformity was the most common in all types of Hansen’s disease.

This could be due to the early pathogenesis of the disease in the superior part of nasal mucosa in nasal cavity. Nasal cartilages are affected causing destruction and producing saddle nose deformity in the face. The ear changes occurred in patients who had duration for more than 0-5 years contradictory to certain previous studies where ear changes occur only in early stages. The reason for the ear changes was due to infiltration of lepra bacilli in helices and lobes of ear producing degeneration and formation of granulation tissue which was responsible for ear lobe enlargement and a certain amount of cartilage of the ear was also affected. Facial nodules appear as the disease progresses and advances in duration.

In this study, the other facial changes recorded were loss of eye brows and eyelashes and anesthetic patches. The anesthetic patches remained as it was without increase in size and area. This may be because lepra bacilli were confined to a particular nerve and did not spread to other nerves. Three cases were suffering from unilateral facial paralysis in the total number of cases studied. The infection spreads below as the disease progresses and causes destruction of anterior nasal spine and maxillary anterior alveolar bone. As the anterior alveolar bone


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of maxilla is resorbed, the incisor teeth are lost. This finding was seen in some of the cases studied.

In the present study, majority of patients had attrition and periodontal problem. The reason for attrition was not known and had not been reported in the earlier literature. Most probably it may be due to the wear and tear caused due to the use of coarse abrasives for cleaning the teeth or due to aging.8 These changes of nasal septal destruction, anterior nasal spine, maxillary alveolar bone loss and nasal infection were very characteristic changes in leprosy according to Scollard.5

The observation of erythematous patches on tongue were thought to be anesthetic patches on the mucosa. But on carrying sensitivity test there was no loss of sensation in the patch area. And so no mucosal anesthetic patches were recorded in this study. Study revealed six cases in which soft palate and uvula were affected with severe thickening. This morphological alteration cannot occur directly so some kind of granulomatous change such as ulceration would have taken place before leaving a fibrotic scar. Speech defects were reported in such cases in literature by Lightenmen6 et al 1962.

Oral and facial changes do occur in all types of leprosy. When compared with the previous studies, the orofacial manifestations were less both qualitatively and quantitatively when compared to previous studies and this may be because a large number of patients in the study were either under treatment or treated and the number of untreated patients were very less. The recorded findings of lepra bacilli in saliva also suggest that the oral cavity is an infected area in Hansen’s patients and confirmed with studies of Stephen Hubscher9 et al 1979.

Clinical handling of oral cavity both in diagnosis and treatment can be done without any fear and apprehension because few numbers of inflammation and ulcerations do occur in oral cavity. But even if lesions do exist in the oral cavity a proper aseptic and

antiseptic care can be taken to give dental treatment to these patients.

Conclusion

It is the responsibility of the dental professional to check patients for orofacial manifestations. If they do present they should be treated properly by consulting the leprologist and the progress of the disease can now be controlled with multiple drug therapies. The present observations indicate that orofacial manifestations of Hansen’s disease are not severe enough to infect doctors and attending dental surgeons. Even if there are active lesions dental treatment can be given with protection without ostracizing the agonized patients as service is of prime importance to dental surgeons.

ReferencesRobbins: General Pathology Text Book. Pg: 122-4.Lawrence A, Sehachner M. Textbook of Pediatric Dermatology. 2nd edition, Vol. I Pg: 1236-42.Job CK. Pathology of leprous osteomyelitis. Int J Lepr 1963;31(1):26-33.Danielsen K. Maxillary and Dental changes in young leprosy patients in Thailand. Indian J Lepr 1973;41(6):645-6.Scollard DM. Oropharyngeal leprosy in art, history and medicine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87(4):463-70.Lighterman I, Watanabe Y, Hidaka T. Leprosy of the oral cavity and adnexa. Oral Surg Oral Med Oral Pathol 1962;15:1178-94. Nah SH, Marks SC, Subramaniam K. Relationship between the loss of maxillary anterior alveolar bone and the duration of untreated lepromatous leprosy in Malaysia. Lepr Rev 1985;56(1):51-5.Academic Proceedings of Dr Mgr Medical University Tamil Nadu Madras Volume V. Workshop on Early Detection of Leprosy.Hubscher S, Girdhar BK, Desikan KV. Discharges of Mycobacterium leprae from the mouth in lepromatous leprosy patients. Lep Rev 1979;50(1):45-50.

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The hard tissue repository of the pulp space presents many complex configurations, which makes the designing of instruments and

instrumentation techniques most difficult. Adequate knowledge of the space anatomy, armamentarium and methodology are essential for the successful outcome of the treatment. Root canal therapy depends on various clinical procedures and skills yet, the factor of substance is essentially satisfactory and shaping for a positive outcome.

To achieve this objective, the quests for newer instruments and instrumentation techniques have been continuously evolving over the years. Reamers are the original intracanal instruments used since the 19th century for root canal instrumentation. With the advent of file system, in which the principle of design were altered to make the instrument more efficient. Initially, these instruments were fabricated from carbon steel, which is replaced by stainless steel owing to its high of corrosion and brittleness.1

Nickel-titanium alloys are 2-3 times more flexible and have superior resistance to fracture when compared to stainless steel. This property allowed them to negotiate curved canals with less lateral stresses and

transportation.2,3 The cutting efficiency of nickel- titanium is found to be impaired when compared to stainless steel instruments and they fracture without any warning due to phase transformation. This led to a withdrawn attitude towards nickel-titanium with many users.4,5

As a solution to the problems encountered in canal preparation, a new instrument system called the EZ-fill safe-sided has been recently developed bearing in mind the positive features of both stainless steel and nickel-titanium.

The purpose of this study is to compare the cutting efficiency, alterations in surface characteristics and hardness of conventional instruments versus the new flat-sided designed instruments (EZ-Fill safe-sided) for canal preparation.


Grouping of the Selected Sample

The resin blocks were divided into three groups of six blocks each as Group A, B and C. The dimensions of the resin block are; the length of the block - 30 mm, the width and the height being 10 mm. The canal had an initial apical diameter of 0.08 mm, the length of the canal measured 19 mm from the external surface of the block and the canal curvature was estimated as 30° (Schneider’s method). Two separate sets of EZ-fill instruments were obtained for Group A and Group B. Color coding was done on the bottom of each resin block for better identification. Group A - pink, Group B - blue, Group C - green. Instrumentation in all the groups was performed by using step- back method.

*Reader, HKE Society, S Nijalingappa Institute of Dental Sciences Gulbarga, Karnataka**Reader†Professor‡Professor and HeadDept. of Conservative Dentistry and EndodonticsSree Balaji Dental College and Hospital, ChennaiAddress for correspondenceDr VG SukumaranProfessor and HeadDept. of Conservative Dentistry and EndodonticsSree Balaji Dental College and Hospital, Chennai - 600 100

abstract

Endodontic therapy has made deep inroads into every sophisticated dental practice today. Adequate knowledge of the space anatomy, armamentarium and methodology are essential for successful treatment. The aim of this study is to compare the cutting efficiency, surface change and hardness of EZ-fill safe sider with K-file.

Key words: EZ-fill, K-file, safe sider

Cutting Efficiency, Surface Change and Hardness: EZ-fill Safe Sider Instruments vs K Files Abilash*, R Mensudar**, Vivekandhan†, Subbiya†, VG Sukumaran‡

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Group A: Samples instrumented with EZ-fill safe-sided instrument system - both stainless steel and Ni-Ti as recommended by the manufacturer.

Group B: Samples instrumented with EZ-fill safe-sided instrument system-only stainless steel instruments were used.

Group C: Sample instrumented with conventional K-files - stainless steel.

Before instrumentation, the resin blocks in all the groups were weighed using an electronic weighing device (Mettler Toledo). The purpose of preweighing was to quantitatively evaluate the weight loss before and after instrumentation in Group A, Group B and Group C.

Specific Observation of Instruments before Instrumentation

The instruments (no. 20 and no. 25) were observed under stereomicroscope at 40x magnification to detect any surface defects caused by the manufacturing process.

Before instrumentation, the instruments in all the three groups (no. 20 and no. 25) were evaluated for their hardness, which was performed using Vickers microhardness tester (Reichert MD 4000E Ultra Microhardness Tester) and the readings were recorded.

Canal Preparation in Group A

Using a watch winding motion, a no. 8 stainless steel instrument was negotiated to the apex, keeping the canal wet with physiological saline. Working length (18.5 mm) was determined visually by inserting a no. 8 stainless steel instrument until it was visible at the apex and then subtracting 0.5 mm from that measurement.

The time taken for canal instrumentation, starting with no. 8 instrument till the completion of the procedure was recorded using a stopwatch. The time recorded was only for the instrument’s function in the canal excluding the time taken for irrigation, cleaning of the instrument and instrument change. The number of strokes used per instrument was also recorded.

One stroke is one cutting cycle i.e., insertion of the instrument, perform watch winding motion and

withdrawal of the instrument from the canal. This sequence was followed till no. 20 instrument snugly fitted at the working length.

Stereomicroscopic evaluation was performed for no. 20 instrument at 40x magnification after 50, 100, 150, 200, 250 and 300 strokes to detect the changes that occur on the surface of the instrument. After this, coronal enlargement was performed using Gates Glidden burs in a step-back manner. All these procedures were performed under copious irrigation.

The no. 25 safe-sided instrument was instrumented 1 mm short of the working length and this instrument was also observed under the stereomicroscope after 50, 100, 150, 200, 250 and 300 strokes to observe any changes in the surface characteristics of the instrument. The canal was prepared till no. 40 size instrument using a step-back technique. Stainless steel no. 20 size instrument was used as a patency file for recapitulation.

Following this, Ni-Ti 30/0.04 tapered EZ-fill safe sided instrument was placed in the canal and before it was negotiated to the working length, the point from where the instrument binded initially in the canal to the working length was recorded. This instrument was further worked to the working length. A similar procedure was repeated for Ni-Ti 25/0.08 taper EZ-fill safe-sided instrument. These two instruments were also observed under stereomicroscope at 40x magnification to detect any changes in the instrument morphologically.

Canal Preparation in Group B

The same procedure was performed as in Group A with the EZ-fill safe-sided instruments and the time taken for canal instrumentation was recorded.

Canal Preparation in Group C

The same procedure was performed using the conventional K files and the time taken for canal preparation was recorded and tabulated.

Evaluation of Hardness after Instrumentation

The instruments (Stainless steel no. 20 and 25 in all groups) were evaluated for hardness with a Vickers microhardness tester under a load of 200 gs for 10 seconds. The instrument was mounted on the porcelain slab with a modeling wax. The purpose of


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using modeling wax was to hold the instrument firmly on the slab to avoid movement when the indenter of the microhardness tester was placed on the instrument. The instrument was observed under the optical microscope at 160x magnification to obtain a clear flat image, which was then subjected to indentation. After the application of load, a diamond-shaped indentation was observed on the instrument surface.

Results

Mean and standard deviation are estimated for each study groups. Mean values were compared by student’s independent ‘t’ test and one way ANOVA.

Multiple range tests by Turkey-HSD procedure is employed to identify the significant groups, if p value in one way ANOVA is significant. In the present study, p < 0.05 is considered as the level of significance.

Mean value of weight difference in Group A (0.01 ± 0.0001 g) is significantly higher than the mean weight difference in Group B (0.005 ± 0.001 g) and Group C (0.006 ± 0.001 g) (p < 0.05). However, there is no significant difference in weights between Group B and Group C (p > 0.05) (Table 1).

The mean difference of hardness of no. 20 instrument in Group C (150.9 ± 46.0) is higher than Group A (71.1 ± 36.7) and Group B (84.4 ± 18.4) (Table 2). There is no statistical significant difference (p = 0.08), which could be due to the less number of readings taken for the sample. But there is a significant change seen in the mean value of Group C, which is twice that of Group A and B.

The mean difference of no. 25 instrument in Group C is higher (127.0 ± 32.7) when compared to Group A

(33.1 ± 14.6) and Group B (65.2 ± 12.2), which shows a statistical significant difference (p - 0.01)

Discussion

Physical and mechanical characteristics of endodontic instruments are the most vital factors, which determine their cutting efficiency and effective serviceability. One such attempt has been made by essential dental systems involving Musikant et al, in developing an instrument system with a different geometry after several years of research called the EZ-fill safe-sided system, which they claim to have superior properties over the conventional instruments.6

Resin blocks are used to overcome the impossibility of accurately determining the original canal shape before preparation in natural roots. Moreover, if the original canal shape is not known, the effects of instrumentation are also unknown. The advantages of using resin simulated canals is that the curvatures and the shape

table 1. Mean, Standard Deviation and Test of Significance of Mean Values for Weight of Resin Blocks before and after Instrumentation between Different Study GroupsVariable Groups Mean ± SD (grams) P value Significant groups at 5%

levelWeight of blocks before instrumentation

A B C

3.43 ± 0.01 3.42 ± 0.01 3.43 ± 0.01

0.18 (NS) --

Weight of blocks after instrumentation

A B C

3.42 ± 0.01 3.41 ± 0.02 3.42 ± 0.01

0.45 (NS) --

Difference in weight of blocks before and after instrumentation

A B C

0.01 ± 20.001 0.005 ± 0.001 0.006 + 0.001

<0.0001 (Sig) A vs B, C

table 2. Comparison of Mean Differences of Hardness of Instruments before and after Instrumentation between Different Study GroupsInstrument Group Mean ± SD HV P valueNo. 20 A

C71.1 ± 36.7

150.9 ± 146.00.08 (NS)

No. 20 B C

84.4 ± 18.4 150.9 ± 46.0

0.08 (NS)

No. 25 A C

33.1 ±14.6 127.0 ± 32.7

0.01 (Sig)

No. 25 B C

65.2 ± 12.2 127.0 ± 32.7

0.01 (Sig)


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of the canal, dimensions and hardness are known, the instrumentation canal so be directly visualized, which helps in better standardization.7,8

In Group A, the Ni-Ti 0.08 taper instrument got separated despite the use of watch winding motion as recommended. This separation could be attributed to the failure to recognize that the rate of taper of instrument exceeded the rate of taper of the canal that prevented apical file movement. When an instrument binds on its more shank side cutting blades, the clinician loses apical control. Attempting to work straighter files in curved canals first invites block then predisposes to formation of a ledge that is seen with stainless steel instruments.9, 10 This could be the reason for the greater taper instruments whether hand or rotary are manufactured with nickel-titanium.

Musikant et al described that the EZ-fill safe-sided incorporates a ‘D’ shape cross-section by making the circular configuration flat on one side. It also increases instrumentation efficiency because the vertical blades created by the flat sweeps the debris from the flutes to the relieved area. The flat reduces the amount of the instrument cutting surface in contact with the canal, which results in a slightly less efficient instrument but easier to use in the canal as it is not fully engaged in the canal circumferentially. It also provides the dentin debris generated during canal instrumentation to get accumulated in the space between the flat and the canal wall. Therefore, the debris doesn’t wedge between the instrument and canal wall. Because less of the instrument is cutting at any one time, less stress is placed on the instruments. By lowering the stresses, the chance of instrument breakage is reduced and consequently the instruments last longer. Further, the flat is not cut deeply into the core of the metal of the instrument, so it increases the flexibility without compromising the strength.

It was observed in this study during instrumentation with the safe siders, there was a sufficient volume of irrigant present in the canal between the flat portion of the instrument and the canal wall making the instrumentation more efficient.11 The resin shavings were seen suspended in the irrigant lowering the rate of smear layer formation which was not so in the conventional preparation. The wet environment was persistent right through the preparation and the presence of irrigant also reduced the wear and tear

of the instrument. The claims made by Musikant et al were well-observed and appreciated during canal preparation in our study.

The conventional preparation using K files (Group C) was found to be more time consuming when compared to Group B and required greater force causing more hand fatigue as compared to the EZ-fill safe-sided instruments. This was due to the greater binding and less flexibility of these instruments. The apical packing of debris was found to be more and required frequent recapitulation.12

The instruments in all the groups were examined under a stereomicroscope at 40x magnification before and after instrumentation and for every 50th stroke till 300 strokes. The observations revealed that the stainless steel K files showed more deformations, especially rolling over of the cutting edges, which appeared after 50 strokes, which was not seen in the EZ-fill safe-sided counterparts. The rollover of the blades is more in K file #20 that was due to the greater binding as it was used before coronal flaring. After 100 strokes, more rolling over was seen in K files when compared to EZ-fill safe-sided instruments. The rolling over was exaggerated in K files after 150 strokes whereas initial changes on the cutting blades of the EZ-fill safe-sided instruments was observed. Significant rollover occurred after 300 strokes for EZ-fill safe- sided where as loss of metal, dented and grooved cutting edges was seen on the surface of K files.

From these findings, it is evident that the safe-sided had a pronounced efficiency, durability when compared to the conventional K files. However, clinical trials would be more substantiative.

Hardness tests were performed for instruments before and after instrumentation and the values were recorded. The reason for evaluating the hardness was to show that there was an increase in hardness after instrumentation which is attributed to changes that occur due to cold working. The surface hardness, strength and the proportional limit are increased whereas the ductility and resistance to corrosion are decreased. Further cold working eventually leads the instrument to separate. The variables obtained show that the conventional stainless steel K files were work hardened more indicating greater stress strain levels than the instrument that underwent during


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instrumentation when compared to EZ-fill safe-sided instruments. Even though, the EZ-fill safe-sided is also a stainless steel instrument, the design, number of flutes and the core made the difference.

Acknowledgement

The Author wishes to acknowledge, his sincere efforts of Dr John Paul 1st year Postgraduate Student, Dept. of Conservative Dentistry and Endodontics for his sincere effort in preparing this manuscript.

Conclusion

Under the conditions of this study, EZ-fill safe-sided instruments proved:

More efficient than the conventional K filesAids in better removal of debrisCauses less fatigue to the operatorShows less cold working and therefore less chances of instrument separationMaintained a smooth reproducible glide path.

ReferencesSamyn JA, Nicholls JI, Steiner JC. Comparison of stainless steel and nickel-titanium instruments in molar root canal preparation. J Endod 1996;22(4):177-81.Esposito PT, Cunningham CJ. A comparison of canal preparation with nickel-titanium and stainless steel instrument. J Endod 1995;21(4):173-6.Walia HM, Brantley WA, Gerstein H. An initial investigation of the bending and torsional properties of Nitinol root canal files. J Endod 1988:14(7):346-51.

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Coleman CL, Svec TA, Reiger MR, Suchina JA, Wang MM, Glickman GM. Analysis of nickel-titanium versus stainless steel instrumentation by means of direct imaging. J Endod 1996;22(11):603-7.

Kuhn WG, Carnes DL Jr, Clement DJ, Walker-WA 3rd. Effect of tip design of nickel-titanium and stainless steel files on root canal preparation. J Endod 1997;23(12):735-8.

Deutsch AS. New EZ-Fill safe-sided Endodontic Instruments. Available at: www.endomail.com/articles/asd06 safesiders.html.

Chan AW, Cheung GS. A comparison of stainless steel and nickel-titanium K-files in curved root canals. Int Endod J 1996;29(6):370-5.

Coleman CL, Svec TA. Analysis of Ni-Ti versus stainless steel instrumentation in resin simulated canals. J Endod 1997;23(4):232-5.

Felt RA, Moser JB, Heuer MA. Flute design of endodontic instruments: its influence on cutting efficiency. J Endod 1982;8(6):253-9.

Grossman LI. Guidelines for the prevention of fracture of root canal instruments. Oral Surg Oral Med Oral Pathol 1969;28(5):746-52.

Grossman LI, Oliet S. Preparation of the root canal: equipment and technique for cleaning, shaping, and irrigation. In: Endodontic practice. Varghese Publishing House; Bombay 1988;11:179-228.

Schäfer E, Lau R. Comparison of cutting efficiency and instrumentation of curved canals with nickel-titanium and stainless steel instruments. J Endod 1999;25(6):427-30.

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Improving oral health in the rural children is still a dream come true in a developing country like India. Sadly what is termed the ‘inverse care law’

is all too prevalent in dentistry-‘deprived communities that suffer the most and so have the most need, receive the fewest resources’.1 For adults, the impact of social class on oral health status has been documented through several oral epidemiological studies especially with respect to dental caries and periodontal diseases.2 The disadvantaged social groups have a higher portion of teeth or tooth surfaces with unmet need for treatment when compared to the advantaged population. This pattern is the same with the child population also, where the proportion of children aged 12 and 15 with any known dental decay was higher among low

social class.3 This holds very much true in a country like India where majority of the Indian population (70-72%) live in the rural areas, of which more than 40% are children (as per census of 1991).4 These children tend to be more vulnerable to dental diseases due to social, economic and demographic factors like lack of awareness, lack of transportation, limited access to professional dental care, lack of perceived need for dental care.5

Aims and ObjectivesTo evaluate the awareness and knowledge among rural children on dental health problems, their oral hygiene practices and pattern of practices of dental treatment.To assess their oral hygiene status and to find out the proportion of children affected with caries.

Methodology

The study was a cross-sectional survey. Convenient sampling was done. On the day of screening all children aged 5-10 years (n = 81), who attended a Government school in a village of Kanchipuram district were included in the study. These children come to this school from various villages situated all around the school thus representing a fairly good geographical

*Assistant Professor (Epidemiologist) **Professor and HeadDept. of Community MedicineMeenakshi Medical College and Research Institute, Kanchipuram Tamil NaduAddress for correspondenceDr VC Punitha Assistant Professor (Epidemiologist) Dept. of Community MedicineMeenakshi Medical College and Research InstituteEnathur, Kanchipuram - 631 552, Tamil NaduE-mail: [email protected]

abstract

This study aimed to evaluate the knowledge, attitude and practices of rural children towards oral health and dental care as well as to assess the oral hygiene status among them. Children (n = 81) between the age group of 5 and 10, who attended the Government school in a village on the day of screening were recruited into the study. The subjects completed an interview schedule that aimed to evaluate young children’s, knowledge and attitude. Oral hygiene status was measured using the oral hygiene index. Results: Forty-one (50.61%) children were aware about caries as one of the common problem associated with mouth and teeth and only one child was aware about gum disease. Though 58% children were aware that sweets and chocolates cause dental caries, they were not aware of the other major factors that cause dental problems and how it can be prevented. The participants’ oral hygiene habits were found to be irregular, and children consulted the dentist only when there was pain (58.97%). Parents (48.14%) played an important role as a source of information to the children, than teachers (25.92%). The oral hygiene status was found to be fair (OHIs - 1.42) among these children and the proportion of children who had caries was 76.54%. Conclusion: The results of this study indicate that children’s, knowledge on dental health is poor. Children’s, parents and teachers attitudes toward oral health and dental care need to be improved. Oral health educational packages for rural school children, their parents and school teachers are recommended.

Key words: Oral hygiene, knowledge and attitude, rural children

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Oral Hygiene Status, Knowledge, Attitude and Practices of Oral Health among Rural Children of Kanchipuram DistrictVC Punitha*, P Sivaprakasam**


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area of study. A written consent was obtained from the school authorities before the commencement of the study. The knowledge and attitude of the children was assessed by using a pretested interview schedule. The children were then subjected to dental screening in an ordinary chair in broad daylight facing away from sunlight to detect clinically evident caries lesion and oral hygiene status. Oral examination was carried out using mouth mirror and explorer. Oral hygiene status was measured using the OHIs (Green and Vermillion index).6

Results of the Survey

A total of 81 children with a mean age of 8.5 years were screened. Of these 45 were males (55.55%) and 36 were females (44.44%).

Oral Hygiene Practices

Various questions were asked regarding the oral hygiene practices, such as how teeth are cleaned, what material is used to clean the teeth, etc. The results indicated that only 51 (62.96%) children are using brush while the rest 30 (37.03%) are using fingers to clean their teeth. It was seen that 75 (92.59%) children are brushing only once a day and only six (7.40%) twice-daily. Forty-five (55.55%) children are using tooth paste and 30 (37.03%) are using tooth powder to clean their teeth. The rest use datum with any abrasive materials like chalk powder, sand and charcoal. Of the 51 (62.96%) who used the brush, 26 (50.98%) children change their brush only when it gets worn out, 10 (19.60%) change every six months and four (7.84%) change between 3-6 months. Eleven (21.56%) children were not aware of how often to change their tooth brush. Thirty-one (38.27%) answered that they never rinse their mouth after eating while 26 (32.09%) children rinse sometimes and 24 (29.62%) rinse always (Table 1).

Pattern of Practices for Dental treatments

Thirty-nine (48.14%) of the children reported that they had suffered from some form of dental problem in the last one year and four (4.93%) children were not aware as to whether they had experienced any dental problems.Of the 39 children who had a dental problem, only 23 (58.97%) consulted the dentist and pain was the main factor for these children to consult the dentist. Among the rest 16 children, no pain (8 children), parents did not take them to a dentist (5 children)

table 1. Oral Hygiene Practices among the Study Population

frequency Percentage (%)How do you generally clean your teethBrush 51 62.96Finger 30 37.03Brushing intervalsOnce 75 92.59Twice 6 7.40After every meal 0 0Materials used to clean teethTooth paste 45 55.5Tooth powder 30 37.03Others 6 7.40frequency of change of brush (n = 51)When it wears out 26 50.98Every 6 months 10 19.60Between 3-6 months 4 7.84Don’t know 11 21.56Mouth rinsing after eatingNever 31 38.27Sometimes 26 32.09Always 24 29.62

table 2. Pattern of Practices for Dental Treatment among the Study Population

frequency Percentage (%)teeth problems faced in the past 1-year (n = 81)Yes 39 48.14No 38 46.91Don’t know 4 4.93If yes did you consult the dentist (n = 39)Yes 23 58.97No 16 41.02Reasons for not consulting dentist (n = 16)No pain 8 50Parents did not take 5 31.25Treatment center far 3 18.75

and the treatment center located faraway (3 children) were the reasons given for not resorting to any treatment (Table 2).

Awareness and Knowledge of Dental Health Problems

On questioning about the common problems associated with mouth and teeth, it was seen that 41


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table 3. Knowledge and Awareness of Dental Health Problems (n = 81) among the Study Population

frequency Percentage (%)Common problemsassociated with mouth and teethTooth decay 41 50.61Gum disease 1 1.23Bad smell 4 4.93Crooked teeth 1 1.23Mouth ulcers 0 0Stained teeth 3 3.70Pain 4 4.93Don’t know 27 33.33Major factors that cause dental problemsEating sweets and chocolates

47 58.02

Not brushing regularly 13 16.04Not rinsing 0 0Consuming tobacco products 0 0Germs 2 2.46Don’t know 19 23.45How can you prevent dental problems?Avoiding sweets and chocolates

37 45.67

Regular brushing of teeth 12 14.81Visiting dentist 1 1.23Not consuming tobacco products

0 0

Gargling after taking food 3 3.70Don’t know 28 34.56Where did you get this information from?Parents 39 48.14Teachers 21 25.92Books 2 2.46TV 5 6.17Radio 0 0News paper 1 1.23

(50.61%) children were aware about tooth decay. Only one child (1.23%) was aware about gum disease. The other problems like, pain (4.93%), bad smell (4.93%), stained teeth (3.70%) and crooked teeth (1.23%) was less known by the children. The number of children who were unaware of the common problems associated with mouth and teeth were 27 (33.33%).

Children’s opinion on the major factors that cause dental problems revealed that, 47 (58.02%) were aware that eating sweets and chocolates can cause dental problems. Thirteen (16.04%) told that not brushing regularly can be one factor and, two (2.46%) said germs can cause dental problems. None of the children were aware that tobacco products can cause oral problems. Nineteen (23.45%) children were not aware of the major factors that cause dental problems.

With regard to the prevention of dental problems, 37 (45.67%) children informed that avoiding sweets and chocolates will prevent dental problems, only one student knew about the importance of visiting a dentist regularly. Twelve (14.81%) children were aware that by regular brushing of teeth, dental problems can be prevented. Twenty-eight (38.26%) children were unaware on how they can prevent dental problems (Table 3).

Source of Information

Parents (48.14%) were an important source of information to the children, followed by teachers (25.92%), and then by TV, books and news paper (9.86%).

Assessment of Oral Hygiene Status and Dental Caries

Oral hygiene status was measured using the OHIs. The oral hygiene status was found to be fair (OHIs - 1.42) among these children. The debris index was more (DI = 1.02) when compared to the calculus index (CI = 0.40). The proportion of children who had clinically evident caries was 76.54% (61 children out of 81 children).

Discussion

In the present study, 62.96% children were using tooth brush and 37% of children were using fingers to clean their teeth. The percentage of children using tooth brush was less when compared to the study

done by WHO, in a rural population in Uttaranchal state where 83% of the children used brushes.5 This can be because the children of this present study come from a very low socioeconomic background and affordability plays an important role. Some children resorted to the use of charcoal, sand or chalk powder as a medium to clean their teeth. This holds true with the study done by Mahesh Kumar et al7 in Chennai, where in their study population also children resorted to the use of charcoal as a medium to brush their teeth.


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Further, it was found that only 7% of the children brush twice-daily. This finding is very much less when compared to the study by Harikiran et al,8 where it was 38.5% and WHO study where it was 49%.5 The study revealed that children (51%) change their tooth brush only when it gets worn out and children’s practice on rinsing their mouth after every meal needs to be improved.

Children who were experiencing some form of dental problem in the last one year visited the dentist/or were taken to the dentist by their parents only when symptoms of pain was there and this showed that pain is the main factor for these children to visit the dentist. Study by Al-Omiri et al9 has also proved in their study that pain is the main driving factor for children to visit the dentist.

Only 67% of the children were aware of the common problems associated with mouth and teeth. The children were more aware about caries than periodontal conditions. This finding is similar to the study done by Al-Omiri et al. Though 58% children were aware that sweets and chocolates cause dental caries they were not aware of the other major factors that cause dental problems. None of the children had idea regarding that; chewing tobacco can cause dental problems. Awareness on tobacco and its consequences need to be stressed to children; 38.26% of children were unaware on how they can prevent dental problems. Overall, the level of oral health knowledge among the surveyed children was low.

The study revealed that more than media or teachers, parents played an important role to create awareness on dental health among children. This was in contrast to the study done by Harikiran et al where the participants received most information from television.

The oral hygiene status was found to be fair (OHIs -1.42) in these children. The debris index was more (DI = 1.02) when compared to the calculus index (CI = 0.40). This finding is similar to the study done by Sogi et al.10 The proportion of children who had caries in this group was 76.54%.

Limitations of the study: Owing to lack of personnel and budget, this study was done in this rural area by resorting into convenient sampling method.

Conclusion

Evidence had showed that strong knowledge of oral health demonstrates better oral care practice.

The change to healthy attitude and practice can be occurred by giving adequate information, motivation and practice of the measures to the subjects (Smyth et al, 2007).11 Results of this study prove that oral hygiene habits, oral health awareness and knowledge level among rural schoolchildren is poor and needs to be improved. Parents and teachers need to be informed, motivated about dental care so that their attitudes change. Based upon these findings, the establishment of a school-based oral health education program in rural school children, including parents and teachers is recommended.

ReferencesHart JT. The inverse care law. Lancet 1971; 1:405-12.

Beal (1989). In: Textbook of Community Oral Health. Pine CM, (Ed.), Wright Publications 1997:26.

Brien O. Children’s Dental Health in the United Kingdom 1993. OPCS; London 1994.

Census of India 2001. Report of the technical group on the population projections constituted by the National Commission on Population. May 2006.

Oral Health Status in rural child population: Promotional & Interventional Strategies. A GOI-WHO Collaborative Programme 2006-07. www.whoindia.org/en/.../Section 30_1453.htm -

Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.

Mahesh Kumar P, Joseph T, Varma RB, Jayanthi M. Oral health status of 5 years and 12 years school going children in Chennai city - An epidemiological study. J Indian Soc Pedod Prev Dent 2005;23(1):17-22.

Harikiran AG, Pallavi SK, Hariprakash S, Ashutosh, Nagesh KS. Oral health-related KAP among 11 - to 12-year-old school children in a Government-aided Missionary School of Bangalore city. Indian J Dent Res [serial online] 2008;19(3):236-42.

Al-Omiri MK, Al-Wahadni AM, Saeed KN. Oral health attitudes, knowledge, and behavior among school children in North Jordan. J Dent Educ 2006;70(2):179-87.

Sogi G, Bhaskar DJ. Dental caries and oral hygiene status of 13 to 14 year old school children of Davangere. J Indian Soc Pedod Prev Dent 2001;19(3):113-7.

Smyth E, Caamano F, Fernández-Riveiro P. Oralhealth knowledge, attitudes and practice in 12-year-old schoolchildren. Med Oral Patol Oral Cir Bucal 2007;12(8):E614-20.

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oriGinal research

Information for Authors

Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96:766-767). The Journal strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so.

The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklists should accompany each manuscript.

Covering Letter: The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper. Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors. Articles must be accompanied by a declaration by all authors stating that the article has not been published in any Journal/Book. Authors should mention complete designation and departments, etc., on the manuscript.

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Material and Methods: Theses should be described in sufficient details to permit evaluation and duplication of the work by others. Ethical guidelines followed by the investigations should be described.

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__________________________________________________________

Dr KMK Masthan

Professor and Head Department of Oral Pathology and Microbiology

Sree Balaji Dental College and Hospital Velachery Main Road, Narayanapuram, Pallikaranai

Chennai - 600 100, E-mail: [email protected], [email protected]

For Editorial Correspondence

Indian Journal of

Multidisciplinary Dentistry

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