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NEW CONCEPT OF DENTAL ARCH IN CHILDREN
 

NEW CONCEPT OF DENTAL ARCH IN CHILDREN

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    NEW CONCEPT OF DENTAL ARCH IN CHILDREN NEW CONCEPT OF DENTAL ARCH IN CHILDREN Document Transcript

    • EN TAL ASSO Journal of the Indian Dental Association D C IAINDIAN Tamil Nadu State Branch TI O N Journal Office : Vel Dental Home, No.10, Bharathi Street, Pondicherry - 605 001.Volume 5 Issue 16 Knowledge . Service . Love Jan. - Mar. 2013 www.jidat.in Advisors President DR. D. SENTHIL KUMAR Dr. S. Thillainayagam Honorary State Secretary DR. C. SIVAKUMAR Dr. C.R. Ramachandran Dr. Gunaseelan Rajan Honorary Treasurer DR. T.S. RANJITH Dr. George Paul President-Elect DR. S. THILLAINAYAGAM Dr. Sivapathasundaram Dr. S.M .Balaji Imm. Past President DR. K. RAJASIGAMANI Dr. N.R. Krishnaswamy Vice Presidents DR. A.P. MAHESWAR Editor in chief DR. RADHA KRISHNAN Dr. A. Thangavelu DR. V. BASKAR Associate Editors Hony. Jt. Secretary DR. M. SETHU ANANDAN Dr. Jayantha Padmanaban Dr. G. Ulaganathan Hon. Asst. Secretary DR. A.L. MEENAKSHISUNDARAM Assistant Editors Convenor C.D.E. DR. J. SELVAKUMAR Dr. J. Selvakumar Dr. V. Arun Prasad Rao Convenor C.D.H DR. S. THIRUNEELAKANDAN Dr. Thamarai Selvi Honorary Editor DR. ANNAMALAI THANGAVELU Dr. R. Madhan Convenor - Care & Concern DR. BALA. SIVA GOVINDAN Sectional Editors Dr. A. Tamizhchelvan Executive Committe Members Dr. G. Mohan Dr. Vijay Vaikunth Dr. Balamurugan .L Dr. Pradeep R. Dr. S. Rajasekar Dr. Benedict .V Dr. Prince Soyus Suresh Dr. R. Sasirekha Dr. Chendil Maran Dr. Rajarajan Immanuvel Dr. A.P. Maheswar Dr. Dhineksh Kumar .N Dr. Rajasekaran .K.G Dr. S. Murugesan Dr. Elango .K Dr. Ravi Shankar .DM Dr. Subramanium Dr. Karthik .K Dr. Samuel Pushparaj Reviewers Dr. Kanna Peruman .J Dr. Saravana Bharathi Dr. S. Ramaswamy Dr. Kalaiselvan .N Dr. Surendra Babu .J Dr. Vijayalakshimi Dr. Kandasamy Ramesh .M Dr. Sudhakar .G Dr. Madhavan Nirmal Dr. Kumar .K Dr. Sudhakaran .B Dr. Vidya Dr. Mohamhed Mustafa .S.T Dr. Sukumaran .D.K Dr. S. Karthikeyani Dr. Murugesan .S Dr. Syed Rafiq Dr. A.L. Meenakshisundaram Dr. Nagaraj .V Dr. Vasantha Raj .R Dr. T.R. Sudharson Dr. Nanda Kumar .G Dr. Vasudevan Dr. J. Johnson Raja Dr. C. Hari Prasath Dr. Prakash .R Dr. Yogananth. R Dr. V. Balakumar Dr. Y.A. Bindhu Central Council Members Dr. A. Arvind Kumar Dr. Senthil Kumar Dr. Aravind Kumar .A Dr. Murali Baskaran .K Dr. J. Kannaperuman Dr. Arun .R Dr. Rajasigamani Dr. M. Ramaswamy Dr. Baby Johm .J Dr. Rajmohan .A Dr. N. Dhineksh Kumar Dr. (Capt) Bellie . R Dr. Senthilkumar D. Dr. Jagdeep Raju Dr. Gokul Raj .T Dr. Surendaran .G.P Theme Editors Dr. George Thomas Dr. Sivakumar .C Dr. Srivatsa Kengasubbiah Dr. Iyyappan shankar .V Dr. Sudharson .T.R Dr. Yoganand Dr. Johnson Raja Dr. Sethumadhavan .U Editorial Manager Dr. Maheswar .A.P Dr. Umashanka .K.K Dr. K. Vasanthakumar Dr. Meenakshi Sundaram .A.L Dr. Vijayakumar .P Publisher Edited by Designed & Printed by IDA TN State Branch Prof . Dr. A. Thangavelu MDS,DNB. Kannan Offset, Pondicherry - 1.
    • Guidelines for AuthorsSubmit all manuscripts to : Prof. Dr. A. Thangavelu, MDS, DNB., Vel Dental Home, No.10, Bharathi Street, Pondicherry - 605 001. 1. A Covering letter with the following words signed by all the authors should be submitted "The submitted material has not been published earlier and it is not under consideration for publication elsewhere. The copyright of the paper if published will stand transferred to the Journal of Indian Dental Association. We will indemnify and keep indemnified The IDA Tamilnadu State Branch and the Editorial Committee and the Editor of the Journal of the Indian Dental Association Tamilnadu against all claims and expenses including legal costs in case of breach of copyright or other laws arising as a result of publication of our articles" 2. Submit the final version of manuscript in MS Word format in a CD or send it by mail to the Editor newjidat@gmail.com 3. Send a Scanned photograph of the author /s 4. Editiorial decisions - all manuscripts submitted are peer reviewed by at least one external peer reviewer. 5. Decisions of the Editorials committee will be final 6. The Editor has the right to alter and modify the articles as per needs and space restrictions Manuscripts, Length and number of references-guidelines Research Articles Case Reports Correspondence 1. Manuscript 1. Title pages 1. Title pages 1. Title pages Text Parts 2. Postal Address/ 2. Postal Address/ 2. Postal Address/ Labelsheet Labelsheet Labelsheet 3. Blind Title Page 3. Blind Title Page 3. Blind Title Page 4. Structured Abstract 4. Case Report/s 4. Letter i. Objectives 5. Comments 5. Acknowledgments i. Materials and Methods 6. Acknowledgments 6. References list i. Results 7. Legends for figures ii. Conclusions 8. References list 5. Introduction 6. Methods 7. Results 8. Discussion 9. Conclusions 10. Acknowledgments 11. Legends for figures 12. References 2. Tables and Total tables + figures = 5 no tables +2/3 figures no table figures 3. Manuscript length 2000 words maximum 6000 words maximum 600 words maximum 4. References Original 20 review 40 3 to 5 3 to 5
    • From the Presidents desk At the outset I take this opportunity to thank all my IDA members and well wishers for honouring me on takingover as the President of IDA-Tamilnadu for the year 2013. I wish everyone of you to have a very productive and fruitfulNew year 2013. A month has passed and I am happy to inform you that I have already touched the ground and visited a fewbranches. It was a pleasure to meet and interact with several office bearers and members of Marthandam and Madurai. I am happy to see the enthusiasm among several of our members and I hope this spirit continues to prevail allacross the state so that all of us together can make IDA truly a larger and stronger body. I strongly believe that as dentists we have a strong commitment to the community in which we live. The basic aim of IDA is to promote oral health and hygiene in the country and all the efforts of IDA are directedat attaining this cherished goal. At the same time enhancing the image of our members in the public and promoting their professionaladvancements and their family security are matters very close to IDA. Organising lectures and scientific symposia are means of keeping abreast with the changing world of dentalscience and we are working on it. We need your cooperation and support in taking dentistry to higher levels of excellence and without that IDAwould not be able to achieve the goals it has set for itself. Vazhga IDA. Dr. D. Senthil Kumar BDS President, IDA-Tamil nadu C.Doraiswami Nalayini Dental Clinic, 8,Azad Street,Udumalpet.642126. 9842225506, sendhana@gmail.com.
    • From the Secretarys deskDear Friends,Wish You All Very Happy Prosperous New Year.Dentist are specialty oriented professional, each and every specialty in dentistry are interrelated and the specialist havegreat relationship with each other The present day development in the Dental field especially the technological advancesin each specialty create a great challenge to update and to put it in our day to day practice for the benefits of our patients.There is a wide range of technological changes in Dental Science- today. In these situations the journal published byState Branch of IDA plays a major role in getting the update information to the clinic desk .I am sure the Tamilnadu Journal (JIDAT) is severing the purpose for more than a year and continues to do so. Each andevery member reading the journal should promote the journal and motivate the other members to subscribe for thejournal. Similarly another field were we should improve is “Service and creation of Awareness among the rural patient.We can improve this by improving our local branch CDH programs. CDE Credit Point is must to renew our councilregistration. I sincerely request all the members to attend all IDA activities, and get the maximum benefit from ourassociation . Do more CDH Activities. Best Wishes. Dr.C. Sivakumar Hon. Sec IDA TN
    • From the Editors deskKnowledge, Service, LoveNothing as Empowering as Knowledge,Nothing as Compassionate as Service, &Nothing as Gratifying as Love!!!Dear Pals Wishes for a happy and prosperous new year. Hope this New Year brings all the strength and prosperity to ourprofession. After a long contemplation about 21st Dec 2012 – “The End Of The World “ , in spite of all prophesies ,Mayans calendar, earth changing the axis, comets hitting the earth ,we now see the survival of the human continue toexist towards 2013 and further . Life is like that!...we pass through the difficulties we face , we cross all the hurdles we come across . Its sure thatnothing can stops us from living. The thing is how we live is the questions? We should think and take that path whichlead us to live with morality, ethic and humanity. Each and every individual should try to live for good. All of us shouldtake a task to improve our standards There are lots of things to ponder, to enjoy, to correct , to modify and to change Letthe new year give all that strength to all our members to take a resolution , take a chance ,join hands and fight for ourrights and to stabilize our profession “ Dentistry” . Each one of us have a great role in it , let us not blame each others for the flaws Everyone has a responsibility, ifeach one of us walk towards that good changes I am sure our profession will leap ahead and be an envy to our colleagues,job opportunities, irregularities in dental education, Unethical practices, service to the needy and developing a clearidentity among the health professional are the areas of concern. So Let us arise, join hands to solve our problems, Let us change for the CHANGE and create a history. Prof. Dr. A. Thangavelu, MDS, DNB., Editor-in-Chief, JIDAT
    • Journal of the Indian Dental Association - Tamil Nadu Vol. 5 Issue. 16 Jan. 2013 ContentsForce Systems in Orthodontics – An Overview of Traditional and Recent Concepts 01Dr. Santhana Krishanan, Dr. K.Rajasigamani, Dr. N. Kurunji kumaran, Dr. V. VenkataramanaCranial Bone Graft for Orbital Floor Reconstruction 04Dr.C. Hari Prasath MDS, MOMS RCPS, Prof. Vinod Narayanan, MDS; FRDRCS; MOMS RCPSComparison of Radicular and Intra Radicular Stud Attachments: Case Reports 10Dr. Bharanija Kalidasan Selvi, Dr. Eazhil Raj, Dr. Jaya KrishnaKumar S, Dr. Azhagarasan N.SAn Insight to Single Visit Endodontics 14Dr. A. Shafie Ahamed, Dr. Deepa Vinoth KumarCommon and Uncommon form of Oral Mucocele 18Dr. Sudhaa Mani MDS , Dr. Eswaramurthy BDSInterim and Esthetic Management of an Avulsed Tooth 22Dr. S. Leena Sankari M.D.SPeriodontal Disease and Respiratory Infection - A Link 25Dr. P.l. Ravishankar, Dr. S. RajsekharMilestones in Periodontics 27Dr. D. Ida Sibylla BDS, M.Sc., (Neuroscience)
    • Vol. 5 Issue. 16 Jan. 2013Patient-Friendly Approach to the Management of Periodontal Disease 33Dr. M. Vijayalakshmi, Dr. Gayathri. S, Dr. M. G. Krishna Baba, Dr. Sumathi. H. Rao, Dr. T. GeethaPathophysiology of Acute Necrotizing Ulcerative Gingivitis(Anug) / Vincents Infection - A Review 36Dr. K. Sasireka M.D.S, Dr. M. Devi M.D.SA New Concept of Dental Arch of Children in Normal Occlusion 39Abu-Hussein Muhamad DDS, MScD, MSc, DPD, FICD, Sarafianou Aspasia DDS, PhDMobile Dental Clinic – An Outreach Government Programme - An Overview 45Dr. Ramasubramanian .S, BDSNon Pharmacological Management of Dental Anxiety in Adults 48Dr. A.M.Devapriya MDS, Dr.D.Mythireyi MDS
    • FORCE SYSTEMS IN ORTHODONTICS –AN OVERVIEW OF TRADITIONAL AND RECENT CONCEPTSDr. Santhana Krishanan1, Dr. K.Rajasigamani2, Dr. N. Kurunji kumaran3, Dr. V. Venkataramana 41. Assistant professor, 2. Vice principal, 3. Reader, 4. Reader,Department of Orthodontics, Raja Muthiah Dental College and Hospital, Annamalai University, Chidambaram ABSTRACT: There is little doubt that the prevalence of patients with underlying medical conditions seeking orthodontic care has increased over the past two decades. In this literature we are discussing some major medical problems and precautions to be taken during orthodontic treatment.INTRODUCTION: physiological reaction to the forces applied by mechanical procedures. The physiological process ofMechanotransduction is the field which discusses the resorption by the osteoclastic cells is the basic activitymechanism of biotransformation of force into biological that allows the bone to change and tooth to move. Sincereaction. In orthodontics force is used to correct a given these osteoclastic cells are carried by the blood to the sitemalocclusion, the tooth responds to the applied force and of their activity and resultant bone resorption, the keymove towards the proposed final ideal position. A better factor in the efficiency movement of teeth seems to be theunderstanding of force systems on the basis of physics, blood supply carries cell and sustains their activity. Whenmechanics and biology is a mandatory for proper a generous blood supply can be maintained by applying aunderstanding of orthodontic mechanotherapy. light force, tooth movement is more efficient. When blood supply to the area, the osteoclastic activity of boneIn this context, the present overview emphasizes on the resorption is limited and the teeth do not move or theytraditional and recent concepts of force systems utilizedin orthodontics and their corresponding biological move slowly. Heavy forces that squeeze out the bloodresponse produced by teeth. cells can limit the physiologic response and markedly affect the rate of tooth movement.1. OPTIMUM ORTHODONTIC FORCE 3. STAGES IN TOOTH MOVEMENTThe magnitude of the optimum force will vary dependingon the way it is distributed in the periodontal ligament i.e. Figure 1, explains the stages of tooth movement after anit is different for different types of tooth movement. application of a moderate orthodontic load of 20 to 50g.Smith and Storey1 in their study on tooth movement in 8patients concluded that optimal lower canine movementoccurs with 150 to 250 grams of force. At higher forcelevels of 400 to 600 grams, the anchor unit of the secondpremolar and first molar moved more than the canine.Fortin2 recommends 147 gm as the optimum force forpremolar translation in dogs. Reitan3 advocates 250 gms stages of tooth movementfor retraction of human lower canines. Lee recommends150 gms to 260 gms as optimum canine retraction force. Tooth movement can be differentiated into three phases.Rickctts and associates prescribe 75 gms as optimumforce for canine retraction. 3.1 Initial Phase2. PHYSIOLOGY OF TOOTH MOVEMENT This is characterized by rapid tooth movement. It lasts for 4 a few days normally. The rapid onset of displacementRuel W. Bench et al in 1978 put forth the physiology of immediately after force application suggests that toothtooth movement. The orthodontic movement of teeth movement in the initial phase largely representsoccurs as a result of the biological response and the displacement of the tooth in the periodontal space. 01 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • 3.2 Lag Phase tooth movement produced. This center of rotation (which characterizes the type of tooth movement) is determinedTooth does not move or show a relatively low rate of by the M/F parameter for a given tooth.displacement compared to the initial phase. This lag intooth displacement is due to the hyalinization (non 6. WAYS OF INCREASING M/F RATIOvitalization) of the periodontal ligament in maximal stressareas. No tooth movement can occur until the area of non Poul Gjessing6 observed that M/F ratio could be raised byvitalization has been removed by cellular process. I) Increasing the vertical dimension gingival to the bracket 2) Increasing the horizontal dimension in the apical part3.3 Post Lag Phase of the loop 3) Decreasing the interbracket distance 4) Positioning of the loop close to the tooth to be retractedHere, there is sudden increase in rate of tooth movement. 5) Angulating the mesial and distal legs of the springAs the hyalinized zones disappear, force producing 6) Adding more wire gingival to the bracket.frontal resorption on the alveolar bone increases the rateof tooth movement. 7. FORCE DECAY4. DESIGN FACTORS IN ORTHODONTIC The force magnitude of springs or loops graduallyAPPLIANCES declines as the tooth moves. This decline is force decay. Only in theory, it is possible to make a perfect spring, oneIn order to achieve the desired tooth movements, the that would deliver the same force day after day, no matterproper force system is a critical requirement. Few terms how much of how little the tooth moved in response tomust be borne in mind before determining the design that force. With many orthodontic device the force mayfactors. even fall to zero.A force is a load applied to an object that will tend to Based on force decay, force duration is classified asmove it to a different position in space. (figure 2)The moment of a force is equal to the magnitude of theforce multiplied by the perpendicular distance from itsline of action to the centre of resistance.The only force system that can produce pure rotation(i.e. a moment with no net force) is a couple which is twoequal and opposite, non-collinear but parallel forces.The point around which rotation actually occurs when anobject is being moved is center of rotation.Center of resistance is that point at which a free object orbody can be perfectly balanced. At this point, resistanceto movement is concentrated for mathematical analysis.5. FACTORS DETERMINING CENTRE OF RESISTANCERoot lengths, Marginal bone level, characteristic ofperiodontal ligament are some factors5 that has to beconsidered while determining center of resistance. Inorder to produce movement other than uncontrolledtipping by applying a force system only at the bracket, asingle force alone is insufficient [movements such as Types of forcesbodily translation as required in space closure using Continuousedgewise and preadjusted edgewise appliances]. In these Interruptedcases, a rotational tendency (moment) must also be Intermittentapplied to the bracket. In order to attain a desirable tooth movement, anThe proportion of the rotational tendency (moment) to optimum and a constant force is required. This is possiblethe force applied at the bracket will determine the type of only with a proper load deflection rate.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 02
    • 8. LOAD DEFLECTION RATE Light, intermittent forces during closing spaces allows the resorbed cementum to heal and prevent furtherRefers to the amount of force produced for every unit of resorption8. Mc Fadden et al9 found no difference in theactivation of an orthodontic wire or spring. If the rate is extent of root resorption in patients treated with orlower, the force is more constant as the tooth moves. without extractions.8.1. Wire Cross Section CONCLUSIONThe load deflection rate in a round wire is directly Till date force is the only medicine available in the handdependent on the fourth, power of wire diameter. For by orthodontists to cure malocclusion. Various methodsexample, if the cross-sectional diameter of a spring is of force generations have been attempted using elastics,reduced from 0.016 inch to 0.014 inch (Only 0.002 coil springs, alloy materials, magnets, and screws.inch), the load deflection rate is nearly halved. The load Irrespective of the utilized methods the applied forcedeflection rate of a rectangular wire is directly dependent should be optional in Biological nature to overcome theon the third power of the diameter. The rate is dependent iatrogenic root resorption and non vitality of tooth duringon the orientation of the rectangular dimensions. or after orthodontic treatment. A sound knowledge for biological response for an8.2. Wire Length applied force is the key to success in orthodontic treatment.The wire length changes the load deflection rate inverselyas the third power. For example, if the length of the spring REFERENCESis tripled, the load-deflection rate is dramatically reduced 1. Story E and Smith R. Force in orthodontics and itsby one twenty seventh its initial rate. Therefore, small relation to tooth movement. Aust dent j. 1952:56;11-increase in the length of the wire dramatically reduces the 18load deflection rate. 2. Fortin JM: Translation of premolars in dogs by8.3. Wire Material controlling the moment to force ratio on the crown. American Journal of Orthodontics and DentofacialAltering the material affects the spring rate in direct Orthopedics; 1971; 59; 541- 551.proportion to its modulus of elasticity. Stainless steel 3. Reitan K: Some factors determining the evaluation ofalloys have replaced the lower strength gold alloys many forces in orthodontics. American Journal ofyears ago. In order to improve the characteristics of Orthodontics and Dentofacial Orthopedics;stainless steel arch wire, multistrand wires with greater 1957;43:1;32-45.flexibility (i.e.) reduced load deflection rates have beenintroduced. 4. Ruel W. Bench, Carl F. Gugino, James J. Hilgers - Bioprogressive therapy part - 6. Journal of ClinicalROOT RESORPTION Orthodontics 1978:12;2;123-139Reitan has shown that external root resorption is weakly 5. Kazuo Tanne, Koenig, Charles J. Burstone - Momentrelated to force magnitude and closely related to the type to force ratios and center of rotation. Americanof tooth movement, specifically intrusion and tipping. Journal of Orthodontics and DentofacialExternal root resorption (ERR) is initiated 14 to 20 days Orthopedics 1988; 94: 426 -431.after force onset and the process of ERR continues even 6. Poul Gjessing - Biomechanical design and clinicalduring retention periods of up to 1 year. It is a product of evaluation of new canine retraction spring. Americanaverage force and the time during which it acts. Journal of orthodontics and dentofacial orthopedics 1985;87:5;353-362.Dougherty made a clinical observation that in the cases,in which maximum anchorage preparation was 7. Reitan. K. Biomechanical principles and reaction: In:necessary and extreme tip back bends placed, there was a Graber TM. Swain BT. Orthodontics-currentgreater resorption of mandibular 1st molars especially the principles and techniques: St. Louis CV Mosby.distal roots. 8. Steadman Sr. Resume of the literature on root resorption. Angle Orthodontist 1942:12;1;28-38Root resorption is the same, irrespective of the treatmentmodality. Be it Begg or edgewise, it is accepted that 9. Mcfadden et al. a study of the relationship betweenextensive tooth displacement, torque movements and incisor intrusion and root shortening. Americanjiggling forces are responsible for resorption7. Journal of orthodontics and dentofacial Orthopedics 1989; 96:5;390-396 03 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 resorption8
    • CRANIAL BONE GRAFT FOR ORBITAL FLOOR RECONSTRUCTIONDr.C. Hari Prasath MDS, MOMS RCPS1, Prof. VinodNarayanan, MDS; FRDRCS; MOMS RCPS21. Senior Lecturer, Division of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Tamilnadu.2. Division of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospital, Saveetha University, Chennai. Purpose : The study was to evaluate use of cranial bone grafts in orbital floor reconstruction. Patients and Methods : 12 patients with unilateral orbital floor fracture underwent cranial bone graft for correction of enophthalmos, hypopthalmos and diplopia. The inclusion criteria were pure blowout fracture of the orbit or impure blowout fracture of the orbit. Preoperative and postoperative CT scans, Radiographs and measurements were recorded. Results : Reconstruction of the orbital floor was done in twelve patients. The period of follow-up and evaluation for the cranial bone graft was 1 week, 3 months and 6 months. These patients underwent CT scans at six months period for evaluation of graft position, uptake. The pre operative enophthalmos in twelve orbital floor fractures varied from 3-6 mm. In this series of twelve orbital floor fracture the post operative enophthalmos score was =2 mm. Five out of twelve patients in the series had preoperative diplopia and none had postoperative diplopia at the time of follow-up and improvement of the eye position and gaze was also found during the checkups. Conclusion : Cranial bone is an accessible autogenous tissue which should be considered when an autogenous graft is needed for orbital floor fracture reconstructions.INTRODUCTION: the deformity of the bony structures, and this predisposes to entrapment of the soft tissues by the bony fragments.Fractures in and around the orbit are common. Theimportant aspect of orbital injuries is their intimate Surgical correction mandates replacement of the bonyrelationship with the globe, periorbital soft tissue, and soft tissues into anatomic position and if necessary,eyelids, sinuses, brain and the lacrimal apparatus. correction of the deficit in volume 4,5,6Blowout fractures of the orbit most commonly involve thefloor and/or medial wall. The displacement of the walls Despite the general good results of orbital reconstruction,can have serious sequelae regarding function and there are cases in which the cosmetic outcomes may beappearance of the eye 1. It can cause a number of different than those noted immediately after surgery. It isproblems, including diplopia, ocular muscle entrapment, suspected that the implant/graft and soft tissue undergoesand enophthalmos. From the functional standpoint, resorption, which also affects the position and possiblydisplacement of a bony wall disturbs the position of the function of the globe. However it is agreed that thesoft tissues, causing problems of eye movement and reconstruction of the orbital walls is essential to maintaindiplopia. Additionally, direct damage to the soft tissue shape and function of the orbit 7,8,9 . Autogenous cranialcan lead to scar contracture, globe dystopia, and bone grafts have been the preferred material fordysmotility. If the globe is injured, there can be a loss of reconstruction of the orbital walls for many years10,11 . Thevision 2. purpose of the study was to evaluate use of cranial bone grafts in orbital floor reconstruction.Several theories have been proposed to explain the effectof trauma to the orbit. In the hydraulic theory 2, a hard MATERIALS AND METHODS:object strikes the soft tissues of the orbit and transferspressures from these tissues to one of the orbital walls. The study consists of twelve patients who had orbitalThe inner wall then opens like a trap door in to the floor fracture during the period April 2006 to Marchadjacent sinus, and the soft tissues are pushed through the 2007. The inclusion criteria were patient with puredefect. In another theory, called buckling theory3, a force blowout fracture of the orbit, impure blowout fracture ofto the orbital rim causes the orbital walls to buckle, the orbit. The exclusion criteria were orbital fracture withdeforming them and the soft tissues. The deformity of the neurological complications, associated skull basesoft tissues of the orbit recovers much more slowly than fracture, direct trauma to the orbit.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 04
    • These patients had a previous history of blunt trauma or fracture site. Donor defect is packed with surgicalroad traffic accident to the facial skeleton or orbit. (oxidized cellulose). The harvested cranial graft isOpthalmological and neurological evaluation 12 was prepared and ends are smoothened. Osteotomy cuts areobtained for all the patients. Routine radiographs 13 and placed if needed to gain the shape of the floor. The cranialcomputer tomography scans taken to identify the site and graft is inserted in the defect site and globe position andsize of the fracture. Patients underwent orbital floor level is compared clinically with the opposite normalreconstruction with cranial bone graft for enophthalmos side.and impairment in the range of ocular movements. RESULTSPre operative and post operative enophthalmos weremeasured by corneal projection using a Hertel Reconstruction of the orbital floor was done in twelveExopthalometer. More than 2mm difference was needed patients. The time from initial injury to surgery variedto show clinically evident enophthalmos. The eye from one week to twelve weeks with a median of sixposition on one side could also be used as a control for weeks. The period of follow-up and evaluation for thethe other in the absence of orbital rim displacement. cranial bone graft was 1 week, 3 months and 6 months.Ocular motility was tested in the field of gaze for any The most common preoperative clinical findings in thismuscle entrapment. The purpose of the surgery was to series were limited ocular motility, paresthesia, diplopiareduce the enophthalmos to as close to zero as possible and enophthalmos. The indication for surgery in thewhen comparing the pre operative values. patients was orbital floor defect with herniation of orbitalReconstruction with cranial bone graft was done in tissue or orbital floor defects associated with othertwelve patients. In this series the cause of injury were midface fractures with significant enophthalmos.blunt trauma in 4 patients and road traffic accident in 8patients. The age ranged from 24 yrs to 39 yrs with a mean Out of twelve patients, one had developed post operativeof 30.25 years. infection in the surgical site after one month and ectropion of the lower eyelid was present. Plate removalThe post operative follow up was scheduled for One was done for that patient after six months since theweek, Three months and Six months after surgery and fixation was found to be loose on re-exploration. Scarpost operative CT scans and radiographs were taken to revision was done for the ectropion of the lower eye lid.evaluate the graft position, uptake. These post operative In these twelve patients graft was left in situ with outfollow ups were used for determining resolution of plating or other kind of fixation. In this series one patientenophthalmos and diplopia. had a breach of inner cortex of the calvarium with a duralOPERATIVE TECHNIQUE: tear and venous bleed. The adjacent temporalis muscle was taken, crushed, and used as a plug to close the defectLower mid lid- crease incision is placed on the skin or the and to stop bleeding. The patient was evaluated for signsdissection is carried through the existing wound. of neurologic changes which were found to beUnfortunately, there are limitation to dissect within the completely absent.orbit and are described as “Safe distances”5. Thesubcutaneous dissection is carried out in inferior These patients underwent computer tomography scans atdirection to the orbicularis muscle fibers and stopping six months period for evaluation of graft position, uptake.when the orbital septum is encountered. Once the They were also evaluated as to whether theseptum is encountered, the preseptal approach is then enophthalmos became clinically insignificant orcarried out inferiorly to the orbital rim. The periosteum is reduced. The pre operative enophthalmos in twelveincised just below it and subperiosteal dissection is orbital floor fractures varied from 3-6 mm. The postcarried out from orbital rim to the fracture site. operative enophthalmos was analyzed at three and six months, a time when swelling was believed to haveCranial bone graft is harvested by placing approximately subsided. The patients out come were recorded as either6cm skin incision on the mid portion of the parietal bone successful (a post score of =2 mm) or unsuccessful (a postand dissection is carried till the periosteum. Once the score of >2 mm). In this series of twelve orbital floorperiosteum is incised, bony marks are placed on the fracture the post operative enophthalmos score was =2cranial bone. Cuts are deepened and limited to the outer mm. Five out of twelve patients had preoperativedipole. The ends are beveled in 45° angulations and the diplopia and none had postoperative diplopia at the timechisel and mallet is used for harvesting of the graft. The of follow-up and improvement of the eye position andbony graft harvested is usually exceeding the size of the gaze was also found during the check ups. 05 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • GRAFT PRE OP PRE OP POST OP POST OP DISCUSSION NO ENAOPTAHM DIPLOPIA ENAOPTAHM DIPLOPIA 1 4 _ 0 _ The use of bone grafts has played an important role in oral 2 5 + 2 _ and maxillofacial surgery with relative disagreement _ _ among surgeons on the different grafting methods 3 3 0 _ _ existing. The important criteria’s to be considered when 4 4 1 _ _ evaluating grafting materials include biocompatibility, 5 4 0 availability, osteogenesis, ability to act as a matrix, and 6 5 + 2 _ mechanical stability14,15 7 6 + 2 _ 8 3 _ 0 _ The standard regenerative bone grafting material used is 9 4 _ 2 _ autogenous bone for its capability to support 10 3 _ 1 _ osteogenesis, osteoinductive and osteoconductive 11 5 + 2 _ properties. Three forms of free bone grafts include _ cortical, cancellous, and corticocancellous 16. Cortical 12 6 + 2 grafts are able to withstand early mechanical forces; < 2mm –Successful, > 2mm - unsuccessful however, they require more time to revascularize. Common donor sites for bone grafting are cranial vault, iliac crest, ribs, mandibular symphysis, and external oblique ridge 7,16. Particularly the calvarial bone is more permanent than bone from other donor sites 14. Variable rates of resorption are seen, if iliac bone is used. But an appropriate graft selection should be based upon the goals of reconstruction. Different materials are used for orbital floor fractures reconstructions are autogenous and allogenous grafts 2,7 (cranial bone, iliac, rib, symphysis, septal and auricular cartilage) or synthetic material (alloplastic materials- Preoperative CT titanium mesh). When alloplastic materials are used complications such as extrusion, foreign body reaction, infection, displacements are possible sequelae 7 . The ideal management of orbital floor fractures continues to be debated. Cranial bone grafts are widely used for numerous maxillofacial reconstructive surgical procedures. We sought to illustrate the usefulness of cranial bone grafts in orbital floor fracture reconstruction mainly because of the histomorphological similarities of the bone, curvature of the bone to the recipient site and it is particular integration with the facial bone structure. An ideal Intra operative graft Harvest material should closely replicate the tissue it replaces 16. Advantages with calvarial bone grafting are minimal postoperative pain, scar is hidden in the hair line, propensity to maintain original graft volume, local availability, low infection rate and less donor site morbidity 10,11. Disadvantages with calvarial bone grafting can be difficulty to run two surgical teams simultaneously, may not yield sufficient cancellous bone (<30cc), neurologic sequelae may arise with other potential complications10. Possible Complication rate were 5.6-7.6%. Reported complications are, hematoma/seroma, infection, dural tear with possible Postoperative CT CSF leakage, leptomeningeal cyst, laceration of superiorJIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 06
    • sagittal sinus. Voska P et al used cranial bone grafts for ocular examination is necessary; in particular, specialtreating posttraumatic defects, defects originated after attention is required to check vision and pupillarytumor removal and cranial anomalies in 95 patients. No response for optic neuropathy and to assess extraocularserious postoperative complications appeared in any of motility and forced ductions/generations for extraocularthe 95 patients. In 10% of the cases, when bone grafts muscle entrapment, ischemia, hemorrhage, or orbitalwere used like onlays, he reported resorption was up to compartment syndrome22. Following the findings, a20% of the volume. Author in conclusion added that rigid carefully planned surgical treatment of blow-out fracturesmethod of fixation of the graft will reduce the resorption is proposed in correlation with the clinical symptoms andrate 11. Smolka et al states that calvarial split bone grafts radiological evidence and proper history.shows low rate of bone resorption after extensive alveolarridge reconstruction 17. CT scans are the method for evaluation of orbital floor fractures 4. Axial and coronal CT scans is the standardStanislaw B.Bartkowski et al evaluates 90 patients with diagnostic imaging technique for assessing orbitalblow-out fracture of the orbit and states that in cases with trauma, and careful analysis of CT slices can contributea defect of the orbital floor fracture reconstruction, the toward improved planning of treatment 23,24,25,26.best material is autogenous bone graft18. V. Ilankovan et al Calculations of blow-out fractures of the orbital floor byin 1992 states that orbital reconstruction can be 3D-CT and 2D-CT method are accurate for assessing theperformed using with cranial bone graft in 222 patients area of fracture and the volume of herniated tissue 23.with 279 calvarial grafts. There were 13 (4.6%)complications, most occurring during harvesting full- In our clinical study, twelve patients with orbital floorthickness calvarial grafts. fracture were analyzed from 2006 to 2007 at the department of Oral and Maxillo-Facial Surgery. AgeThe main aim of surgical treatment is the anatomical ranged from 24 to 39 yrs. The reconstruction was madecorrection of the bony defect by restoring the anatomy by calvarial bone grafts taken only from the outer table ofand volume of the orbit to avoid any complications. the calvarium. The size of the graft was approximatelyOrbital floor morphology differs with age and gender. from 2cm to 2.5cm. In this study we analyze the pro andThe inclination of the orbital floor is steeper in children vs of calvarial bone grafting. Today alloplastic materialsthan in adults and in males than in females. Also the merit certain circumstances only when bone autogenouslowest point shifts lower and more posteriorly as patient graft is contraindicated or when the surgeon dont want toages 19 use it and is also cost effective. At the end of six monthsIn case of orbital blowout fractures the most commonly we found that the graft position, uptake was excellentfractured area is the orbital floor; where intrusion and with less resorption rate and no donor site morbidity.entrapment of the orbital content, and more specifically, Orbital surgery is not risk free. The decision to proceedof the inferior rectus and the inferior oblique muscles or with surgery must consider potential surgicaltheir facial attachments into the fracture lines and toward complications, which can include blindness, subsequentthe maxillary sinus . They account to approximately 11% infection of implanted material, orbital implantof fractures involving the orbit 20. The indications and migration, postoperative mydriasis, epiphora, andtiming for fracture repair are still controversial5,6. Lester M worsening diplopia 27,28.Cramer1 study shows that the earlier the surgery isperformed the easier it is to accomplish successful We are in the conclusion that on the basis of ouranatomic reductions and to ensure uniform excellent investigations early surgical treatment leads toresults. The “ideal” time to intervene after fracture satisfactory long-term results. As a result of favorableoccurrence cannot be precisely defined. Ultimately, the biological response in our study with no surgicaldecision to proceed with surgery should be based on the complications, cranial bone graft was considered to be apatient’s symptoms, clinical findings, and thorough promising autogenous material for orbital floor fractureinformed consent about the risks and benefits of surgical reconstructions with advantages of minimalintervention 8. postoperative pain, scar hidden in the hair line,Symptoms of orbital floor fractures include orbital pain, propensity to maintain original graft volume and lessenophthalmos, hypesthesia in the V2 distribution donor site morbidity. This, together with our favorable(infraorbital: cheek and teeth), and diplopia. Eyelid experience, encourages us to continue to use cranialecchymosis, subcutaneous emphysema, ptosis, epistaxis, bone graft in the future. Thus we conclude by saying thatlacrimal system injuries, and pupillary dilation may be cranial bone graft is an ideal autogenous material forassociated with orbital floor fractures 6,21. Thorough orbital floor fracture reconstruction. 07 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • REFERENCES: 13. Stephen H. Miller and William J. MorrisCurrent. Current concepts in the diagnosis and management1. Lester M. Cramer, Frank M. Tooze and Sidney of fractures of the orbital floor, The Am J Surg, 1972, Lerman. Blowout fractures of the orbit, Br J of Plast 123(5); 560-563. Surg, 1965, 18; 171-179. 14. Edward Ellis III, Elias Messo. Use of nonresorbable2. Dongmei He, Preston H. Blomquist and Edward alloplastic implants for internal orbital Ellis III. Association between Ocular Injuries and reconstruction, J Oral Maxillofac Surg, 2004, 62(3); Internal Orbital Fractures, J Oral Maxillofac Surg, 873-81. 2007, 65(4); 713-720. 15. Mario F. Muoz Guerra, Jesus sastre Terez et al.3. Shoab A. Siddique and Robert H. Mathog. Reconstruction of orbital fractures with dehydrated Comparison of parietal and iliac crest bone grafts for human duramater, J oral maxillofac surg, 2000, orbital reconstruction, J Oral Maxillofac Surg, 58(12): 1361-1366. 2002, 60(1); 44-50. 16. Risto Kontio. Treatment of orbital fractures: The case for reconstruction with autogenous bone, J Oral4. Oliver Ploder, Clemens Klug, Werner Backfrieder, Maxillofac Surg, 2004, 62(1); 863-68. Martin Voracek, Christian Czerny and Manfred Tschabitscher. 2D- and 3D-based measurements of 17. Smolka W, Eggensperger N , Carollo V, Ozdoba C, orbital floor fractures from CT scans, J Cranio- Lizuka T. Changes in the volume and dentistry of Maxillofac Surg, 2002, 30(2); 153-159 calvarial split bone grafts after alveolar ridge augmentation. Clin Oral Impl Res. 2006, 17; 149-5. B.T. Evans and A.A.C. Webb. Post-traumatic orbital 55. reconstruction: Anatomical landmarks and the concept of the deep orbit, Brit J Oral Maxillofac 18. Bartkowski SB, Krzystkowa KM: Blow-out fracture of Surg, 2007, 45(3); 183-189. the orbit. Diagnostic and therapeutic considerations, and results in 90 patients treated, J6. Hartstein ME, Roper-Hall G. Update on orbital floor Oral Maxillofac Surg, 1982, 10; 155-164. fractures: indications and timing for repair, Facial Plast Surg. 2000, 16(2); 95-106. 19. Tomohisa Nagasao, Makoto Hikosaka, Tadaaki Morotomi, Maki Nagasao, Kaoru Ogawa and Tatsuo7. Mordechai Kraus, Albert Gatot and Dan M. Fliss. Nakajima. Analysis of the orbital floor morphology, J Repair of traumatic inferior orbital wall defects with Cranio-Maxillofac Surg, 2007, 35(2); 112-119. nasoseptal cartilage, J Oral Maxillofac Surg, 2001, 59(12); 1397-1400. 20. Chen JM, Zingg M, Laedrach K, Raveh J. Early surgical intervention for orbital floor fractures, J Oral8. Lena Folkestad and Gösta Granström. A Maxillofac Surg, 1992, 52; 935-41. prospective study of orbital fracture sequelae after 21. Michael A. Burnstine, Clinical Recommendations change of surgical routines, J Oral Maxillofac Surg, for Repair of Isolated Orbital Floor Fractures An 2003, 61(9); 1038-1044. Evidence-based Analysis, Ophthalmol 2002, 109; 1207–1213.9. M. Marasco and F.S. De Ponte. Reconstruction of orbital floor fractures. A current surgical 22. K. de Man, R. Wijngaarde, J. Hes and P.T. de Jong. management, J Cranio-Maxillofac Surg, 2006, Influence of age on the management of blow-out 34(1);11. fractures of the orbital floor, Int J Oral Maxillofac Surg, 1991, 20(6); 330-336.10. V. Ilankovan and I.T. Jackson. Experince in the use of calvarial bone grafts in orbital reconstruction, Brit 23. Harris GJ, Garcia GH, Logani SC, MurphyML, Sheth J Oral Maxillofac Surg, 1992, 30(2); 92-96. BP, Seth AK: Orbital blow-out fractures: correlation of preoperative computed tomography and11. Koz~k J., Voska P. Long-term experiences with postoperative ocular motility. Trans Am calvarial bone grafts in cranio- maxillo-facial Ophthalmol Soc 1998 96: 329–347. surgery, J Cranio-Maxillofac Surg, 1996, 24(1); 65. 24. Edward Ellis and Yinghui Tan. Assessment of12. Thomas H. OHare. Blow-out fractures: A review, J internal orbital reconstructions for pure blowout Emerg Med, 1991, 9(4); 253-263. fractures: Cranial bone grafts versus titanium mesh, J Oral Maxillofac Surg, 2003, 61(4); 442-453.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 08
    • 25. Stewart MG, Patrinely JR, Appling WD: Late proptosis following orbital floor fracture repair. Arch Otolaryngol Head Neck Surg, 1995, 121:649.26. Sachs ME: Orbital floor fractures: The maxillary approach. Adv Ophthalmic Plast Reconstr Surg 6:387, 198727. Lena Fol kestad and Thomas Westin: Long-term sequelae after surgery for orbital floor fractures, Otolaryngol Head Neck Surg 1999;120:914-21.28. H. Popat and Liu D. Blindness after blow-out fracture repair. Ophthal Plast Reconstr Surg 2007;10:206–10. Corresponding author : Dr C. Hariprasath, Senior Lecturer, Division of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Tamil Nadu – 608002, INDIA hcprasath@yahoo.co.in + 91 9487474246 09 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • COMPARISON OF RADICULAR AND INTRA RADICULARSTUD ATTACHMENTS: CASE REPORTSDr. Bharaniraja Kalidasan Selvi1, Dr. Eazhil Raj2, Dr. Jaya KrishnaKumar S3, Dr. Azhagarasan N.S41. Senior lecturer, Department of Prosthodontics, SRM Dental College, Bharathi salai, Ramapuram, Chennai-89.2. Reader, Department of Prosthodontics, Chettinad Dental college and Research Institute, OMR, Padur, Chennai- 603103.3. Professor, Department of Prosthodontics, Ragas Dental College & Hospital, 2/102, East Coast Road, Uthandi, Chennai-119. .4. Professor & H.O.D, Department of Prosthodontics, Ragas Dental College & Hospital, 2/102, East Coast Road, Uthandi, Chennai-119. Key words: Tooth supported overdenture, stud attachments, radicular attachments, intra radicular attachments. ABSTRACT: Complete dentures present many problems that may be avoided by the retention of roots of selected key teeth. Retention of these roots makes possible to fabricate a denture that provides support, retention, stability and comfort, superior to that of a conventional complete denture. Alveolar bone is preserved, and the occlusal vertical dimension and centric relation are maintained. Facial and lip changes are minimized, while the ability to masticate is maximized. The patient experiences a sense of security and feels that he has his teeth and he looks his best. Despite recent developments in dental implantology, the conservative approach to root preservation is still valid. Placement of attachments in the abutments further increases retention of overdentures. Though many attachments such as stud and bar attachments are available, proper selection to meet patient’s needs is essential.Short running title: Clinical report on usage of stud retention of the denture, thereby helps in betterattachments. mastication9,10,11. The overdentures render maximum support and improve compromised esthetic appearanceARTICLE PROPER in patients with congenital anomalies such as cleft palate, ectodermal dysplasia, hypodontia, those with sequelae ofINTRODUCTION: maxillofacial trauma and tumor1. Other patients who may benefit from tooth-supported dentures are those withEdentulousness was once considered to be a normal part malrelated ridges, those facing the loss of teeth in oneof aging and the conventional way of treating edentulous dental arch while the other arch is dentulous, those withpatients was by means of complete dentures. However, unfavourable tongue positions, muscle attachments, orlimitations such as residual ridge resorption, loss of residual ridges and those who encounter difficulty withocclusal stability, undermined esthetic appearance & stability or retention of conventional complete denture2.decrease in neuromuscular skills in manipulating thedentures as age progresses has detracted the quality of life The tooth supported overdentures are of two types,of such patients1. Considerable clinical experience and conventional and with attachments1,12. The notion ofdocumented research have underscored the merits of underscoring the use of attachments shifts theretained natural teeth or substitution by dental implants to conventional overdenture design which providesserve as abutments under complete dentures and partial stability and retardation of RRR, to major emphasis ondenture2-6. In this regards overdentures have found prosthesis retention. Overdenture attachments areincreased application in prosthodontics. available for chair side procedure or requiring a laboratory casting. The attachments are of bar and studPeriodontally compromised teeth are often too weak to types1,12. Stud type attachments may be positioned oversupport a partial denture for long term. The larger crown the root/ implant (radicular) or in the root/ implantroot ratio created by periodontal disease results in forces abutment (intra radicular). In intra radicular stud typethat can gradually extract the remaining teeth. Reduction attachments, a prefabricated component is placed withinof the clinical crown creates a more favorable crown to the center of the teeth root and the male component isroot ratio to compensate for progressive bone loss, to incorporated in the impression surface of overdenture.increase the longevity of remaining natural teeth and The radicular attachment is incorporated on or into a postprovides adequate place for the overlying artificial and coping type casting. The crown root ratio is alsodenture tooth and denture base4,7,8. They also provide enhanced with the low profile of the stud typepsychological benefit to the patient, tactile attachments12.discrimination, better load transmission of the prosthesisto the underlying structures and improve stability &JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 10
    • CASE REPORTS:Case 1: A 74 year old female patient presented with thecomplaint of inability to retain partial denture in thelower arch. Her dental history revealed that the patienthad been completely edentulous in upper arch andpartially edentulous in lower arch for past five years andhad been wearing dentures. Clinical examinationrevealed ill fitting lower denture with the presence of Intaglio surface of the denture with33,35,41 and 43. Patient had been a known diabetic for resilient female element.past 10 years and has neuromuscular inco-ordination andunder medication the same. Radiographic investigationsrevealed generalized bone loss.Taking into consideration patient’s age, medical andpsychological status, overdentures with stud attachmentswere planned with 33 and 43 as abutments. The heightand width of the abutments were evaluatedradiographically and clinically and intra radicular studtype attachment was selected (zest standard, zest anchorsattachment system, CA). Sprue former attached to wax patterns with castable male component. Abutment teeth adequately prepared after elective endodontic procedure. Metal female element oriented over cemented male components. Metal female element luted in prepared root recess. Orientation of male component analog in reline impression. Resilient male element placed in position. Intaglio surface of denture with female components. 11 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • Endodontic procedures for the abutment teeth were bone, the health of the individual, and the amount ofcompleted and adequately prepared for overdenture trauma to which the structures are subjected4.procedures (fig 1). The complete denture was fabricated.The abutment was clinically reduced to the height of The concept of overdentures developed as a simple andabout 1mm above the gingival tissue level and a pilot economic alternative to prolong the retention andhole made in canal orifice with No 700 carbide bur of a function of the last few remaining teeth in a compromiseddepth of 7mm. The drill was aligned parallel to path of dentition. The biological maintenance of ainsertion of the denture. The pilot hole was enlarged neuromuscular mechanism, the temporomandibularusing No 6 round carbide bur to a depth of 4mm. The articulation and a better medium for support and stabilitydiamond sizing bur was used to create a full 360 degree for a denture can be accomplished better by retainedrecessed seat in the occlusal surface. The metal female natural teeth than by the mucoperiosteum4. The area thatelement was tried in the prepared root recesses for proper is most critical for maintaining teeth to retain alveolarfit and then cemented using glass ionomer cement (fig 2). bone is the anterior region of the mandible. PreservationThe resilient male element was attached to female of atleast two roots in the anterior mandible to avoid theelement (fig 3). The lower denture was tried in to check advanced resorption of the anterior edentulous mandiblefor clearance to accept resilient males. A small vent hole has been the primary application of the overdenture7.was made on the lingual surface of the denture. Self cureacrylic resin of thin consistency was placed in the denture Natural roots may prevent or retard residual alveolarrecess and also painted around the male elements. bone loss. The threshold of minimal perceived pressureDenture was seated in the patient’s mouth and was asked was significantly lower with overdentures supported byto occlude. Excess material was expressed through the tooth roots than by implants due to presence of receptorsvent hole and sufficient time was allowed for the resin in periodontal ligament10,14,15.material to set. The overdenture was removed, finishedand polished. (fig 4). Stud attachments are simple and versatile in connecting complete denture to remaining natural teeth / implants. ACase 2: A 63yr old patient presented with complaint of solid attachment as that used in case 2, allows noinability to eat and speak properly due to missing teeth. movement between the male and female elements. ThisHe gave history of partial edentulousm for past two years. feature transfers stress towards the roots / implants andClinical and radiographic examination revealed presence away from the ridge. The intra radicular resilient stud typeof 33 and 44 with adequate bone support. Various attachments allow movement in any plane and transferstreatment options were explained to patient and stress away from the root/ implants and towards theremovable prosthesis was considered. The inter ridge tissues. For this reason, resilient attachments are selecteddistance was found to be adequate for placement of much more frequently than solid attachments. Retentionradicular attachments. The adequate tooth preparation achieved is satisfactory and they promote better oralwas performed and denture construction was done till the hygiene. The intra radicular attachment requires lesstrial denture stage. Root preparation was done and the space than other attachments and doesn’t requirecastable male component was attached to the post additional precious metal casting. Any significantpattern and parallelism checked. After investing (fig 5), divergence between the roots or between roots and pathcasting, finishing and polishing, the post was cemented. of insertion of the denture results in rapid wear of maleThe metallic female was oriented over the male components and requires frequent replacement12.component (fig 6) and a reline impression was madeusing trial denture. The analog of male component was Disadvantages of overdenture include fracture of dentureoriented to the female component in the impression (fig base resin, fracture of teeth, need for changes of7) and denture was processed. The retention rings were prosthetic design followed by fabrication of newplaced in the female component incorporated in the final prosthesis. Prosthesis related adjustments include soredenture (fig 8). Denture was seated intraorally and spots, relining of overdenture, occlusal adjustments,evaluated. changes of tooth arrangement for esthetic reasons, excessive wear of teeth10.DISCUSSION: SUMMARY:Extraction of entire dentitions with complete denturereplacements was used to be promoted as an inexpensive Now a days numerous attachments are available suitableand permanent solution for oral health care in the past. for various clinical scenario. With proper case selection,The structure of maxillae and mandible was designed to treatment plan considering biological and prosthodontichold the natural teeth roots, but not to act as a supporting aspects and post insertion maintainence, overdenturesfactor for artificial dentures. So it is certain that resorption with attachments can be used with great success tooccurs if this structure is disturbed4,13. The rate of improve retention and esthetics.resorption depends on three factors; the character of theJIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 12
    • REFERENCES 14. Mericske-Stern R, Hofmann J, Wedig A, Geering AH. In vivo measurements of maximal occlusal force and1. Zarb GA, Bolender CL, Carlsson G,editors. minimal pressure threshold on overdentures Boucher’s prosthodontic treatment for edentulous supported by implants or natural roots: A patients. 11th ed. St Louis: Mosby-Year Book; 1997. comparative study, Part I. Int J Oral Maxillofac2. Morrow RM, Feldmann EE, Rudd KD, Trovillin Implants 1994; 9: 63-70. HM.Tooth-supported complete dentures:An 15. Crum J, Loiselle RJ. Oral perfection and approach to preventive prosthodontics J Prosthet proprioceptions. A review of the literature and its Dent. 1969;21(5):513-22. significance to Prosthodontics. J Prosthet Dent 1972;3. Lord JL, Teel S. The overdenture. Dent Clin North Am 28: 215-30. 1969;13:871-81.4. Miller PA,Complete dentures supported by natural Corresponding author : teeth J Prosthet Dent. 1958: 8(6):924-928. Dr.K.S.Bharaniraja, M.D.S. Senior lecturer, Department of Prosthodontics, SRM Dental College,5. Fenton AH, Hahn N. Tissue response to overdenture Bharathi salai, Ramapuram, Chennai-89. therapy. J Prosthet Dent 1978; 40: 492-8. Tamil Nadu, India. Email id: bharanija@gmail.com6. Toolson LB, Taylor TD. A 10- year report of a Mobile number: 919841228066, longitudinal recall of overdenture patients. J Prosthet Fax number: 044- 22492429. Dent 1989; 62:179-81.7. Fenton AH. The decade of overdenture: 1970-1980. J Prosthet Dent 1998;79(1):31-6.8. Crum RJ, Rooney GE. Alveolar bone loss in overdentures; a 5year study. J Prosthet Dent 1978; 40:610-3.9. Bassi F. Comparing overdenture therapies with teeth and implant abutments. Int J Prosthodont 2009; 22(5): 527-28.10. Hug S, Mantokondis D, Mericske-Stern R. Clinical evaluation of 3 overdenture concepts with tooth roots and implants: 2-year results. Int J Prosthodont 2006; 19(3): 236-243.11. Rissin L, House JE, Manly RS, Kapur KK.Clinical comparison of the masticatory performance and electromyographic activity of patients with complete dentures, overdentures, and natural teeth. J Prosthet Dent 1978; 39:508-11.12. Prieskel H. Overdentures may easy. Berlin: Quintessence; 1996.13. Atwood DA, Coy WA. Clinical, cephalometric, and densitometric study of reduction of residual ridges. J Prosthet Dent 1971; 26: 280-5. 13 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • AN INSIGHT TO SINGLE VISIT ENDODONTICSDr. A. Shafie Ahamed1, Dr. Deepa Vinoth Kumar21. Professor, Dept of Conservative Dentistry and Endodontics,Rajah Muthiah Dental College, Annamalai University, Chidambaram. Tamil nadu. Key words: Periapical lesions, calcium hydroxide, nonsurgical endodontic therapyINTRODUCTION: INDICATIONS FOR SVE : • Uncomplicated vital teeth.Single visit endodontics (SVE) is gaining popularity thesedays as compared to multiple visits. SVE implies • Physically compromised patients who have to make‘Conservative non-surgical treatment of an an effort to come to the dental clinic.endodontically involved tooth consisting of completebiomechanical preparation and obturation of the root • Medically compromised patients who requirecanal system in one visit’.The concept of single visit antibiotic prophylaxis and sometimes alteration inendodontics started at least 100 years old. In the recent the medication they take.years single visit endodontics has gained increased • Fractured anterior where esthetics is a concern.acceptance as the best treatment for many cases. Recentstudies have also shown that there is no difference in • Apprehensive but cooperative patientquality of treatment and incidence of post treatment • Patients who require sedation or operation room.complication or success rates between single visit andmultiple visit root canal treatment (Albashaireh and • Uncomplicated non vital teeth with sinus tract.Alnegrish, 1998;Weiger et al.,2000;Sathorn etal.,2005;Field et al.,2004). Many dentists nowadays CONTRA INDICATIONS FOR SVE :prefer single visit endodontic treatment because of many • Acute alveolar abscess cases with pus discharge.advantages. Perhaps, the most important advantage is theprevention of root canal contamination and bacterial re- • Patients who have acute apical periodontitis withgrowth that can occur when the treatment is prolonged severe pain on percussionover an extended period due to leakage of temporary seal(Trope et al., 1999; Soltanoff and Montclair, 1978; • Painful non vital tooth with no sinus tract.Pekruhn, 1981; Rudner and Oliet, 1981; Lin et al.,2007 ). • Asymptomatic teeth with apical lesion and no sinus tract.REASONS FOR NOT DOING SVE • Cases with procedural difficulties like calcified1) Fear of post-op pain. canals, curvatures, extra canals, etc....2) Fear of failure. • Patients with TMJ disorders and inability to open the3) Lack of time. mouth.4) Lack of clinical experience. • Teeth with limited access.5) Lack of equipment. • Non surgical retreatment cases.6) Fear of being “unconventional”. OLIET’S CRITERIA FOR CASE SELECTION7) Fear of patient not accepting SVE • Positive patient’s acceptance.8) Discomfort to the patient. • Sufficient available time to complete the procedureGUIDELINES FOR SVE properly.1. Accurate diagnosis • Absence of any acute symptoms requiring drainage via the canal and of persistent continuous flow of2. Proper case selection exudates or blood.3. Skilled operator • Absence of anatomical obstacles like calcification4. Working time not more than 60 minutes in the canals and procedural difficulties (ledge formation, blockage, perforation).JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 14
    • ADVANTAGES Studies evaluating healing of single visit and multiple visit• Intimate awareness of the canal anatomy root canal treatment immediately following instrumentation. Trope et al (1999) 64 Vs 74 %• No risk of losing important landmarks. Weiger et al (2000) 83 Vs 71 %• Canal is never cleaner than immediately after Peters and Wesselink (2002) 81 Vs 71 % proper instrumentation.• No risk of flare-up induced by leakage of temporary The success of endodontic treatment is directly seal. associated with infection control. The literature indicates that rotary, hand or hybrid instrumentation, even when• Teeth are ready for final restoration, diminishing the risk of a fracture necessitating extraction. performed correctly, is inadequate to clear all organic and inorganic debris from the root canal system. For this• Patient’s pre appointment anxiety and post- and other reasons, irrigating solutions play an important operative discomfort are limited to one episode. role making up for the shortcomings of instrumentation• Time is saved for the patient and for practitioner and complementing endodontic disinfection procedures since the treatment is completed in one visit. (Almeida et al., 2012; Bashetty and Hegde, 2010). Post instrumentation sampling showed reductions ofDISADVANTAGES cultivable microbiota. However bacteria still found in• Inability to dry the canals completely. 62% of teeth in one visit group and 64% in two visit group• Insufficient time to complete the procedure. (Kvist et al., 2004). Mechanical debridement with antibacterial irrigation (0.5% NaOCl) can render 40-60%• Possible stress of TMJ musculature or increased of treated teeth bacteria negative (Bystrom and Sundqvist, psychological stress on patients or clinicians because of longer appointment time or both. 1983, Sjogren et al.,1997). Intraradicular microbes surviving root canal treatment- entomed by obturation• Flare-ups cannot be easily treated by opening the and die as a result of inadequate nutrients. Kronfeld’s tooth for drainage. theory, bacterial count decreases –suitable environmentIS THE PROGNOSIS? for healing.Compromised by performing RCT in One appointment POST-OPERATIVE PAIN AND FLARE-UP IN SVE----NO There are numerous studies focusing on post operativeIn Humans, over whelming evidence shows the healing is pain and flare up in SVE and MVE. Most of the studiessame for both single or multiple visits regardless of pulp result showed that there is not much significant differencevitality (Trope et al., 1999; Weiger et al., 2000; Peters and in the post operative pain between SVE and MVE.Wesselink, 2002). Post operative pain Flare up • Pekruhn-1981,1986 • Eleazer and Eleazer-1998 • Almeida et al-2012 • Oginni and Udoye-2004 • Bashetty and Hegde -2010 • Trope-1991 • El Mubarak et al-2010 • Imura and Zuolo-1995 • Siqueira and Barnett-2004 • Walton and Fouad-1992 • Di Renzo et al-2002 • Albashaireh and Alnegrish -1998 • Fava-1995 • Oliet-1983 • Roane et al-1983 • Soltanoff and Montclair-1978 • Fox et al-1970 • Al-Jabreen and Tarik -2002 15 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • Morse defines “Flare-up” as either patient’s report of pain 2. Preparatory phase – contents of root canal removednot controlled with over the counter medication or as and canal prepared for filling materialincreased swelling. 3. Restorative phase – filling of the canal to obtain aWalton defines “Flare-up” within a few hours to a few hermetic seal at the cementodentinal junction anddays after a root canal treatment procedure, a patient has post endodontic restorationeither pain or swelling or combination of both. SVE is now within the reach of most practitioners, as newThe factors that can reduce the incidence of flare-up, pain technology provides better designs of instruments forand swelling are prophylactic antibiotics (Penicillin V or canal shaping and efficient cleaning protocols forerythromycin). Intentional over instrumentation of root meticulous canal cleaning and disinfection followed byinto the approximate center of the bony lesion reduces three dimensional filling of the canal.SVE is successfulthe prevalence of flare-ups from about 20% to 1.5% (non- when there is careful case selection and strict adherencevital) (Fox et al., 1970). to standard endodontic principles.Pain in endodontic procedures is related to the presence REFRERENCEor absence of inflammation. It is reasonable to assumethat if severe inflammation exists before treatment, there Albashaireh ZS, Alnegrish AS (1998). Postobturation painwould be a tendency to expect a distinct increase in the after single and multiple-visit endodontic therapy.postoperative pain after a single-visit procedure rather Aprospective study.J Dent 26(3):227-32.than if two or more visits were used. If single-visitprocedure is performed on teeth that have a potential for a Al-Jabreen, Tarik M (2002) Single visit endodontics:"flare-up," antibiotics are suggested beginning 48 hours Incidence of post-operative pain after instrumentationpreoperatively. This routine has greatly reduced the with three different techniques:An objective evaluationnumber of flare-ups (Soltanoff and Montclair.,1978). study. Saudi Dental Journal: 14(3);136-139SUCCESS RATE AND FAILURE OF SVE: Almeida G, Marques E, De Martin AS, da Silveira Bueno CE, Nowakowski A, Cunha RS (2012). Influence ofPrognostic studies have shown that there is no substantial Irrigating Solution on Postoperative Pain Followingdifference in the success rate of single and multiple Single-Visit Endodontic Treatment: Randomized Clinicalappointment cases ( Sathorn et al.,2005;Figini et Trial. J Can Dent Assoc78:c84al.,2008;Field et al.,2004). Necrotic teeth with apicalperiodontitis showed favorable periapical healing at 12 Bashetty K, Hegde J (2010). Comparison of 2%months, with no statistically significant differences chlorhexidine and 5.25% sodium hypochlorite irrigatingbetween groups (Penesis et al., 2008). Failure of 5.2% in solutions on postoperative pain: a randomized clinicalsingle visit cases. The incidence of failure was higher in trial. Indian J Dent Res 21:523-7teeth with periapical extension of pulpal disease whichhad no prior access opening (Pekruhn, 1986). Byström A, Sundqvist G (1983). Bacteriologic evaluation of the effect of 0.5 per cent sodium hypochlorite inHealing following endodontic therapy will usually occur endodontic therapy. Oral Surgery, Oral Medicine andfollowing an accurate diagnosis, proper case selection, Oral Pathology 55, 307–12.and the use of skilled techniques of treatment. Theseprocedures are based upon known biological principles DiRenzo A, Gresla T, Johnson BR, Rogers M, Tucker D,incorporated into the technique triad, specifically: BeGole EA( 2002). Postoperative pain after 1 and 2 visitbiomechanical preparation of the canal system, root canal therapy. Oral Surg Oral Med Oral Pathol Oraldebridement and disinfection, and complete obturation Radiol Endod 93(5):605-10of the prepared canals. Each of these objectives must beachieved in order to ensure a successful result. El Mubarak AH, Abu-bakr NH, Ibrahim YE(2010 ). Postoperative pain in multiple-visit and single-visit rootCONCLUSION canal treatment. J Endod 36:36-9.As far as the endodontic treatment aspect is concerned, Eleazer PD, Eleazer KR (1998). Flare-up rate in pulpallywhether it is SVE/MVE three basic phases has to be met to necrotic molars in one-visit versus two-visit endodonticobtain success. treatment. J Endod 24:614-6.1. Diagnostic phase – disease determination and design Fava LR (1995).Single visit root canal treatment: of treatment plan incidence of postoperative pain using three different instrumentation techniques. Int Endod J 28:103-7.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 16
    • Field JW, Gutmann JL, Solomon ES, Rakusin H( 2004). A Roane JB, Dryden JA, Grimes EW (1983). Incidence ofclinical radiographic retrospective assessment of the postoperative pain after single and multiple-visitsuccess rate of single-visit root canal treatment .Int Endod endodontic procedures. Oral Surg Oral Med Oral Pathol.J 37:70-82. 55(1):68-72.Figini L, Lodi G, Gorni F, Gagliani M(2008). Single versus Rudner WL, Oliet S (1981).Single-visit endodontics: amultiple visits for endodontic treatment of permanent concept and a clinical study. Compend Contin Educteeth: a Cochrane systematic review. J Endod. Dent. 2(2):63-8.34(9):1041-7. Sathorn C, Parashos P & Messer HH (2005) .EffectivenessFox J, Atkinson JS, Dinin AP, Greenfield E, Hechtman E, of single versus multiple-visit endodontic treatment ofReeman CA, Salkind M, Todaro CJ(1970). Incidence of teeth with apical periodontitis: a symptomatic review andpain following one-visit endodontic treatment. Oral Surg meta-analysis. IEJ 38: 347–355Oral Med Oral Pathol. (1):123-30. Sathorn C, Parashos P, Messer HH (2006). Single-visitGagliani M, Figini L, Lodi G, Gorni F (2008). Single more effective than multiple-visit root canal treatment?Versus Multiple Visits for Endodontic Treatment of Evidence-Based Dentistry 7, 13–14.Permanent Teeth: A Cochrane Systematic Review.Journal of Endodontics 34, 9: 1041-104. Siqueira JJ, Barnett F (2004). Interappointment pain: mechanisms, diagnosis, and treatment. Endod TopicsImura N, Zuolo ML(1995) Factors associated with 7:93-109.endodontic flareups: a prospective study. Int Endod J,28:261-5. Sjögren U, Figdor D , Persson S, Sundqvist G(1997). Influence of infection at the time of root filling on theJacob S (2006), Single Visit endodontic Famdent practical outcome of endodontic treatment of teeth with apicaldentistry handbook 6:1-6 periodontitis. International Endodontic Journal 30, 297–306Kvist T, Molander A, Dahlen G, Reit C ( 2004)Microbiological evaluation of one and two-visit Soltanoff W, Montclair NJ (1978) A Comparative Study ofendodontic treatment of teeth with apical periodontitis: a the Single-Visit and the Multiple-Visit Endodonticrandomized clinical trial. J Endod 30:572-6. Procedure. JOE 4:278-281Lin LM, Lin J, Rosenberg PA(2007). One-appointment Trope M (1991). Flare-up rate of single-visit endodontics.endodontic therapy:Biologic considerations J Am Dent Int Endod J 24(1):24-6.Assoc 138(11):1456-62 Trope M, Delano EO, Orstavik D (1999). EndodonticOginni AO, Udoye CI(2004) Endodontic flare-ups: treatment of teeth with apical periodontitis: single vs.Comparison of incidence between single and multiple multivisit treatment.J Endod 25:345-50.visit procedures in patients attending a Nigerian teachinghospital BMC Oral Health, 4:1-6 Walton R, Fouad A (1992) Endodontic interappointment flare-ups: a prospective study of incidence and relatedOliet S (1983) Single-visit Endodontics: A Clinical factors. J Endod, 18:172-7.Study.JOE 4:147-152 Weiger R, Rosendahl R, Lost C(2000) Influence ofPekruhn RB (1986). The incidence of failure following calcium hydroxide intracanal dressings on the prognosissingle-visit endodontic therapy.J Endod 12(2):68-72. of teeth with endodontically induced periapical lesions. Int Endod J 33:219-26.Pekruhn RB (1981). Single-visit endodontic therapy: apreliminary clinical study. J Am Dent Assoc.103 :875-7. Corresponding author :Penesis VA,Fitzgerald PI, Fayad MI, Wenckus CS, BeGole Dr. Deepa Vinoth kumar,EA, Johnson BR(2008) Outcome of One-visit and Two- Senior lecturer, Dept of Conservativevisit Endodontic Treatment of Necrotic Teeth with Apical Dentistry and Endodontics,Periodontitis: A Randomized Controlled Trial with One- Rajah Muthiah Dental College,year Evaluation JOE 34 :251-257 Annamalai University,Peters LB, Wesselink PR(2002) Periapical healing of Chidambaram. Tamil nadu.endodontically treated teeth in one and two visits deepavino@sify.comobturated in the presence or absence of detectablemicroorganisms.Int Endod J 35:660-7. 17 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • COMMON AND UNCOMMON FORM OF ORAL MUCOCELEDr. Sudhaa Mani MDS1 , Dr.Eswaramurthy BDS21. Department of Oral Medicine & Radiology, Reader, Vivekanandha Dental college for women, Tiruchengodu.2. Kannan Dental Clinic, 658,Sathy Main Road, Masjid Building, Kavindapadi, Bhavani tk, Erode dt Keywords: Mucocele, mucocele treatment, Minor salivary Glands ABSTRACT: Mucocele is a common lesion of the oral mucosa that results from an alteration of minor salivary glands due to a mucous accumulation. Mucocele involves mucin accumulation causing limited swelling. Two histological types exist – extravasation and retention. Mucoceles can appear at any site of the oral mucosa where minor salivary glands are present. Diagnosis is principally clinical; therefore, the anamnesis should be carried out correctly, looking for previous trauma. The most common location of the extravasation mucocele is the lower lip, while retention mucoceles can be found at any other site. Mucoceles can affect the general population,but most commonly young patients (20-30years old). Clinically they consist of a soft, bluish and transparent cystic swelling which normally resolves spontaneously. Treatment frequently involves surgical removal. Nevertheless micromarsupialization, cryosurgery, steroid injections and CO2 laser are also described. We felt it would be interesting to present two different clinical characteristics of mucoceles,as it is common lesion. It would be clinically significant for their treatment and evolution in order to aid decision-making in daily clinical practice.INTRODUCTION vesiculobullous disease, but the lesions persist for extended time.5Mucocele is a clinical term that applies to mucousextravasation phenomenon(MEP) and mucus retention Histopathology reveals that extravasation mucocelescyst(MRC).Each has a distinctive pathogenesis and undergo three evolutionary phases. In the first phase,microscopy, they are considered separately. mucous spills diffusely from the excretory duct into connective tissues where some leucocytes andMUCUS EXTRAVASATION PHENOMENON histiocytes are found. Granulomas appear during the resorption phase due to histocytes, macrophages andEtiology of MEP is traumatic severance of a salivary glandexcretory duct, resulting in mucus escape, or giant multinucleated cells associated with a foreign bodyextravasation , into surrounding connective tissue. reaction. In the final phase connective tissue cells form a pseudocapsule without epithelium around the mucosa.6,7Clinical feature shows that lower lip is the most commonsite, but buccal mucosa, anterior ventral surface of the MUCUS RETENTION CYST (MRC)tongue, floor of the mouth and retromolar region areoften affected. Lesions are uncommonly found in other Etiology of MRC is due to obstruction of salivary flowintraoral regions where salivary glands are located, because of a sialolith, periductal scar, or impingingprobably because of a lower susceptibility to trauma. tumour.It presents as relatively painless smooth surfaced massranging in size from few millimeters to 2 cm in diameter. Clinical feature shows that MRC is less common thanIt has a bluish color when mucin is superficially located. MEP.It usually appears in an older age group and is mostAdolescents and children are more commonly affected commonly seen in the upper lip, palate, cheek, and floorthan adults.1_4 of the mouth. Lesions present as asymptomatic swellings, usually without antecedent trauma. They vary in sizeSuperficial mucocele is a variant of extravasation type. It from 3 to 10 mm and on palpation swelling is mobile andis believed to arise as a result of increased pressure in theouter most part of the excretory duct. These lesions are non tender. The overlying mucosa is intact and of normalasymptomatic and numerous, occurring most commonly color. Mucin in floor of mouth lesions may penetratein the retromolar area, soft palate and posterior buccal musculature and escape into the soft tissues of the neck,mucosa. Their clinical appearance suggests a causing a ‘plunging ranula’.8JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 18
    • Histopathology reveals that cyst like cavity is formed mucoceles, marsupialization would avoid damage tolined by normal but compressed ductal epithelial cells. vital structures. 10 Clinically there is no differencecyst lumen contains inspissated mucin or a calcified between both types of mucocele, and are thereforesialolith. The connective tissue around the lesion is treated in the same manner. Nevertheless when anminimally inflamed, although the associated gland shows obstruction of retention mucoceles is detected treatmentobstructive change. involves the removing the top of the cyst and introducing a lacrimal catheter into the duct to dilate it .A non-surgicalDIAGNOSIS option that may be effective for a small or newly identified mucocele is to rinse the mouth thoroughly withDiagnosis is principally clinical; therefore, the anamnesis salt water (one tablespoon of salt per cup) four to six timesshould be carried out correctly, looking for previous a day for a few days. This may draw out the fluid trappedtrauma. The appearance of mucoceles is pathognomonic underneath the skin without further damaging theand the following data are crucial: lesion location, history surrounding tissue.of trauma, rapid appearance, variations in size, bluishcolour and the consistency . CASE REPORT 1:DIFFERENTIAL DIAGNOSIS A 60 year old female reported to the dental clinic with the chief complaint of swelling in the upper lip for the past 5Palpation can be helpful for a correct differential years.(FIG 1) History reveals swelling initially smaller indiagnosis. Lipomas and tumors of minor salivary glands size and gradually increases in its size. It was painless andpresent no fluctuation while cysts, mucoceles, abscess completely asymptomatic. she reveals that application ofand hemangiomas do. Mucoceles are mobile lesions with salt over swelling and by compressing it, there wassoft and elastic consistency depending on how much expulsion of fluid which results in decrease in size oftissue is present over the lesion .Despite this fluctuation, a swelling. After few days there was again increase in sizedrained mucocele would not fluctuate and a chronic of swelling.mucocele with a developed fibrosis would have lessfluctuation. A simple technique known as fine needle On examination , swelling situated over inner aspect ofaspiration biopsy (FNAB) is very helpful, especially when midline of upper lip. It measures about 2cm in size.differential diagnosis of angiomatous lesions is involved. Surface appears smooth and normal in colour. OnAbundant mucosa without epithelial components is palpation it is nontender. Consistency varies fromfound within mucoceles as well as many inflammatory fluctuant to firmness in few areas . It is freely mobile.cells, especially histiocytes. A histopathologic study iscrucial to confirm the diagnosis and to ensure that Hard tissue examination reveals there was fracturedglandular tissue is completely removed. Two types of 11&21.mucoceles exist: retention mucoceles and extravasationmucoceles. In the case of retention mucoceles a cyst Provisionally diagnosed as mucocele based on history ofcavity can be found, this is generally well defined with an painless swelling, repeated collapse and refilling of fluid.epithelial wall covered with a row of cuboidal or flat cells Furthermore on fine needle aspiration cystic fluid wasproduced from the excretory duct of the salivary glands. aspirated (FIG 2). Treatment includes aspiration whichCompared to extravasation mucoceles, retention results in shrinkage of swelling. Later vertical incision wasmucoceles show no inflammatory reaction and are true done and the fibrosed tissue completely excised alongcysts with an epithelial covering Extravasation mucoceles with glandular structures.are pseudocysts without defined walls. The extravasatedmucous is surrounded by a layer of inflammatory cells Histopathological examination of excised tissue showsand then by a reactive granulation tissue made up of extravasation of free mucin with an inflammatoryfibroblasts caused by an immune reaction. Eventhough response that is followed by connective tissue repair.there is no epithelial covering around the mucosa, this is Neutrophils and macrophages are seen and granulationwell encapsulated by the granulation tissue.9,10 tissue forms around the mucin pool. Based on these investigations final diagnosis of mucus extravasationTREATMENT phenomenon was made. Patient was recalled after a week in which complete healing of the lesion observedSome mucoceles spontaneously resolve on their own (FIG 3)after a short time. Others are chronic and require surgicalremoval. Recurrence may occur, and thus the adjacent CASE REPORT 2 :salivary gland is excised as a preventive measure. Smallmucoceles can be removed completely with the marginal A 40 year old female complains of swelling over left innerglandular tissue before suture. In the case of larger side of cheek mucosa for past 6 months. History reveals it was painless swelling with gradual increase in size. On 19 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • examination ,swelling located over left buccal mucosa. Itmeasures about 1x1 cm. Surface appears as smooth,translucent, pale coloured mocosa with mildpigmentation (FIG 5). Palpation reveals nontender andconsistency as soft and fluctuant. Provisionally diagnosedas mucocele .Under local anaesthesia complete surgical excision andsuturing was done (FIG6). The removed mucous plug(FIG7) was subjected to histopathological examination. Fig 5 Excised Mucous PlugMicroscopic examination reveals the extravasatedmucous is surrounded by a layer of inflammatory cellsand then by a reactive granulation tissue made up offibroblasts. Final diagnosis of mucous extravasation cystwas given. Fig 6 – Post Operative Fig 1 Swelling in Upper Lip Fig 2 Shrinkage of Swelling on Aspiration Fig 7 Showing Extravasation of free mucin with an inflammatory response that is followed by connective tissue repair. DISCUSSION Clinical significance of discussing this common lesion is to emphasize the unique clinical presentation of first case report. Commonly the presentation of MEPs site of occurrence is lower lip lateral to midline with age Fig 3 Follow Up After a Week predilection of younger group. While in this case report 1 location is midline of upper lip and the occurrence of lesion also in older age which is quite uncommon. Further consistency also varies from fluctuant to firm. It signifies that in longer duration mucocele, there would be fibrosis which results in firmness. Hence we Dental surgeons should consider all the above features in ruling out the differential diagnosis of swelling in upper lip. Case report 2 shows common Fig 4 Swelling Over Left Buccal Mucosa presentation of mucocele.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 20
    • REFERENCES1. Baurmash HD. Mucoceles and ranulas. J Oral Maxillofac Surg. 2003;61:369-78.2. Huang IY, Chen CM, Kao YH, Worthington P. Treatment of mucocele of the lower lip with carbon dioxide laser. J Oral Maxillofac Surg. 2007;65:855- 8.3. Anastassov GE, Haiavy J, Solodnik P, et al. Submandibular gland mucocele: diagnosis and management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89(2):159-63.4. Azuma M, Tamatani T, Fukui K, et al. Proteolytic enzymes in salivary extravasation mucoceles. J Oral Pathol Med 1995;24(7): 299-302.5. Baurmash H:The etiology of superficial oral mucoceles. J Oral Maxillofac Surg 2002;60:237-38.6. Samer, Terezhatmy & Moore: Mucocele: Quintesscence International: 2004;35(9)766-67.7. Jinbu Y, Kusama M, Itoh H, et al. Mucocele of the glands of Blandin-Nuhn: clinical and histopathologic analysis of 26 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95(4): 467-70.8. Sugerman PB, Savage NW, Young WG. Mucocele of the anterior salivary glands: Report of 8 cases. Oral Surg Oral Med Oral Patho Oral Radiol Endod 2000;90: 478-82.9. Vander Goten A, Hermans R, Smet Mh, Baert AL. Submandibular gland Mucocele of the extravasation type. Pediatr Radiol 1995;25:366-68.10. Luiz AC, Hiraki KR, Lemos CA Jr, Hirota SK, Migliari DA. Treatment of painful and recurrent oral mucoceles with a high-potency topical a corticosteroid: a case report. J Oral Maxillofac Surg. 2008;66:1737-9 Corresponding author : Dr. Sudhaa Mani MDS, 658, Sathy Main Road, Masjid Building, Kavindapadi, Bhavani tk, Erode dt-638455 Mobile No:99427 41216 E-Mail:drsudhaamanimds@gmail.com 21 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • INTERIM AND ESTHETIC MANAGEMENT OF AN AVULSED TOOTHDr. S. Leena Sankari M.D.SAssociate professor, Shree Balaji dental college and hospital, Oral pathology. ABSTRACT: A spectrum of treatment modalities are available for the replacement of missing tooth, the options expands from replacement with conventional removable prosthesis to titanium based implant prosthesis. When the loss of anterior tooth occurs in younger age group then choosing the right treatment modality, with minimal or no adjacent tooth preparation, immediate restoration of esthetics and cost effective management to a patient is quite challenging to any dental practitioner. Aim of this paper is to describe the treatment performed in a 12 year old boy for whom the clinical crown of his avulsed right maxillary central incisor was used as a pontic and this procedure was advocated over other replacement procedures.INTRODUCTION: CASE REPORT:Trauma, advanced periodontal disease, repeated failure A 12 year old boy reported to our dental office with aof endodontic treatment, root resorption may inevitably chief complaint of avulsed maxillary right central incisor.result in loss of a tooth[1,2]. 1- 16% of trauma results in Patient had been traumatized by a fall from bicycle beforecomplete loss of a tooth or tooth avulsion. Maxillary a month and had fractured his leg apart from this avulsioncentral incisors are the most vulnerable teeth to be injury. He went to a general physician for emergencyavulsed during trauma. Tooth avulsion may occur at any management of the fractures wherein they hadage group but the most common age for permanent immobilized the patient for a month. He also had deepdentition is 8-12 years[3]. A wide range of treatment lacerations in his lower lip during the accident for whichmodalities are available for the management of an the general physician had placed sutures and had doneavulsed tooth each having its own merits and demerits. the emergency management.The best option has to be chosen according to the age ofthe patient, socio-economic status, condition of the Patient had brought his avulsed tooth when he reportedadjacent teeth and systemic illness [1] . to our dental office but the tooth was contaminated and was under dry storage for a month since the time ofFirst and foremost option to be considered when an avulsion [Figure 1] On clinical examination, the adjacentanterior tooth is avulsed is replantation of the same, anterior teeth 21 and 12 showed positive response toprovided the tooth was preserved accordingly, since long vitality testing and the soft tissue around the socket wasstorage time would result in inflammatory root resorption almost closed and healed [Figure 2]. The occlusion wasor ankylosis[4]. Conventional removable prosthesis onprime esthetic zone is not preferred for a young patient as normal and no signs of parafunctional habits werethe selection of right colour, size and shape of an acrylic observed. Since patient was so concerned andtooth and provision of retention clasp is aesthetically less apprehensive due to anterior tooth loss, he neededconvincing[1,4]. Fixed partial denture needs adjacent tooth immediate replacement of the anterior tooth.preparation which is not advisable for young age patients A decision was taken against replantation in this casedue to higher chances of pulpal exposure[5]. Implantsupported prosthesis is not economically feasible for all since the extra oral dry storage time was almost a monththe patients and systemic disorder may contradict the and the soft tissue around the socket had nearly healed.procedure[5]. Fixed partial denture was not indicated considering the age of the patient as adjacent tooth preparation would beComposite resin bonded bridge reinforced with wire, required which might probably damage the pulp tissue.using a natural tooth as a pontic is an immediate, cost Implant was also not indicated considering the age andeffective simple technique to be considered. Using the poor socio economic status of the patient. In view of allnatural tooth itself as a pontic is esthetically well accepted the above factors it was decided to use the clinical crownby the patient as it has its own advantages of providing the of the avulsed tooth as a natural tooth pontic and splint itright size, shape, colour and psychological benefit to the to the adjacent teeth using composite.patient [6].JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 22
    • CLINICAL PROCEDURE: 13. Finishing and polishing procedures were carried out using composite finishing discs (Soflex discs, 3M).1. A pre-operative irreversible hydrocolloid impression [Figure 7].(Vignette, Dentsply India) was made for the upper archand cast was poured using dental stone [Figure 3]. 14. Oral hygiene instructions were given to the patient.2. The crown was separated from the root of the avulsed 15. First recall appointment was made a week later.tooth using diamond disc. The patient was highly motivated by the esthetic result [Figure 8].3. After sectioning, the newly created apical opening ofthe pulp canal was cleaned and sealed using flowablecomposite resin. (Tetric N flow, Ivoclar, Vivadent,Leichtenstein).4. A modified ridge lap shape was given to the cervicalarea to facilitate cleaning and provide an emergenceprofile.5. Position of the natural tooth pontic was tried andverified on the cast [Figure 4]. Avulsed tooth 11 Pre treatment view6. For added mechanical retention, grooves were placedon the lingual aspect of the pontic.7. A 30 gauge ligature wire was twisted and bonded to thenatural tooth pontic using flowable composite resin(Tetric N flow, Ivoclar, Vivadent, Leichtenstein) andappropriate length of the wire necessary to be bonded tothe adjacent abutment teeth was cut [Figure 5and 6].8. The natural tooth pontic was then tried in the patient’s Pre treatment model Trial fit of the pontic in themouth and necessary occlusal adjustments were made. model after root resection9. The enamel surfaces of the abutment teeth (21 and 12)were scaled and polished with pumice and thoroughlyrinsed and dried. No mechanical retention was preparedon the abutment teeth.10. The lingual enamel surface of the abutment teeth wasetched with 37% ortho phosphoric acid gel for 20seconds, rinsed and dried. Natural tooth pontic with Natural tooth pontic with twisted wire bonded to it twisted wire bonded to11. After application of the bonding agent (3M Adper – labial view it-palatal viewsingle bond) and curing, a thin layer of light curedcomposite was applied to all etched surfaces and theligature wire was slightly embedded in that layer andcured. Finally a second layer of composite was added tothe lingual side of the ligature wire and light cured.12. Excess composite resin was removed and occlusalinterferences were again checked during protrusive andlateral excursions. Post treatment view 23 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • DISCUSSION: prosthesis. A fixed bridge or an implant could be designed later on. This paper thus highlights an esthetic,Loss of permanent anterior tooth compromises speech fixed and interim solution to an avulsed tooth in childrenand esthetics, impairs personality, affects mastication and where replantation and other mode of treatment areencourages tongue thrusting.[4] Boys show a higher considered undesirable.prevalence of avulsion injuries as compared to girls in theratio of 3:1, probably because of more outdoor sports REFERENCE:related trauma. [7] The immediate treatment for avulsion isreplantation and stabilization in its anatomically correct 1. Parolia A, Shenoy KM, Thomas MS, Mohan M. Use oflocation to optimize healing of the periodontal ligament a natural tooth crown as a pontic following cervicaland neuro-vascular supply while maintaining esthetic root fracture: a case report. Aust endod J 2010;and functional integrity. At times replantation is 36:35-38.contraindicated due to the childs dental development 2. Reddy R, Reddy S. Natural tooth as a pontic, a longstage (risk of ankylosis where considerable alveolar term provisional fixed partial denture using a fibregrowth has to take place), compromised medical reinforced composites over an integrated implants:condition and compromised integrity of the avulsed tooth case report. Andhra Pradesh State dental journalor supporting tissues.[8] 2010;3(3):98-100.Replantation upto 60 minutes of extra oral dry times, of 3. Lee JY, Vann WF, Sigurdsson A. Management ofavulsed immature teeth has been reported where only avulsed permanent incisors: A decision analysis15% showed evidence of periodontal healing.[7] But with based on changing concepts. American academy ofextra oral dry times of more than 1 hour it is unwise to pediatric dentistry 2001; 23(3): 357-360.replant the tooth because of an increased incidence ofreplacement resorption. The immediate treatment that 4. Ulusoy AT, Cehreli ZC. Provisional use of a naturalcan be provided to the patient or trauma related tooth tooth crown following failure of replantation: a caseavulsion is in the form of a space maintainer. Failure to report. Dental traumatology 2008; 24:96-99.do so can lead to drifting of the adjacent teeth, midlinedeviation and space loss apart from over eruption of 5. Kermanshah H, Motevasselian F. Immediate toothantagonistic teeth. Mastication, speech and esthetics replacement using fibre-reinforced composite andalso get compromised. [7] natural tooth pontic. Operative dentistry 2010; 35(2); 238-245.The space loss following dental avulsion can be bridgedby a removable partial denture, but it may be bulky and 6. Reddy MN, Mehta DS. Natural tooth pontic foruncomfortable for the patient, and may impede healing. [9] periodontally compromised anterior teeth. AndhraThey also have the disadvantage of being more Pradesh State dental journal 2010; 3(3):125-127.dependent on patient compliance and can get lost or 7. Sharma U,Garg AK ,Gauba K.An interim fixedbroken. [7] More permanent solutions in the form of fixed prosthesis using natural tooth crown aspartial dentures or cast partial dentures are available pontic.Contemporary Clinical Dentistrywhich are not cost effective and also are not ideal as the 2010;1(2):130-132.abutment teeth available are not best suited to receivethese prosthesis.[6] A composite resin bonded bridge 8. Guidelines for the management of traumatic dentalreinforced with wire, using a natural tooth pontic is a cost injuries II:Avulsion of permanent teeth. Dentaleffective, simple and easy technique providing the best traumatology .2007; 23(2):66-71.esthetically acceptable immediate result. Using thenatural tooth itself as a pontic has varied advantages of 9. Kretzschmar JL. The natural tooth pontic: a temporarybeing in the right size, shape and most importantly of the solution for a difficult esthetic situation. J am Dentsame colour. The psychological benefit on the patient of Assoc 2001; 132: 1552-1553.using own tooth as a pontic is of great value andadvantage. [6] Corresponding author : Dr.S.Leena Sankari M.D.SCONCLUSION: Associate professor Shree Balaji dental college and hospitalIn our case considering all the above factors it was Oral pathologydecided to use the patient’s natural tooth as pontic and Tamilnadu, India.retention was obtained by bonding it to the adjacent tooth Email: drleena.sankari@gmail.com,using a ligature wire which will serve as an interimJIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 24
    • PERIODONTAL DISEASE AND RESPIRATORY INFECTION- A LINKDr. P.l. Ravishankar1, Dr. S. Rajsekhar21. Professor & HOD, Dept of Periodontics, Sri Sai Dental College & Research Institute, Srikakulam (AP)2. Professor, Dept of Periodontics, Rajah Muthaih Dental College & Hospital, Chidambaram. Keywords: Periodontal disease,COPD,oral systemic relation. ABSTRACT: When putatative periodontal bacteria from the mouth and throat are inhaled into the lower respiratory tract, they can cause infection or make existing conditions - such as chronic obstructive pulmonary disease, emphysema etc. Literature suggests PD sufferers have elevated levels of bacteria, including gram-negative enteric species and Psuedomonas aeruginosa. In fact, scientists estimate the prevalence of certain microorganisms - staphylococci, Enterobacteriaceae, and yeasts - in dental plaque at upwards of 77 percent. Some are particularly difficult to eradicate, remaining in patients with PD following antibiotic treatment. Any bacterial presence, in turn, places individuals at higher risk for developing disorders like pneumonia. This life-threatening infection affects patients of all ages, but particularly the elderly and immunocompromised individuals. This article provides the biologic basis for the connection between periodontal disease and respiratory disease.INTRODUCTION: in patients with periodontitis. 30 to 40 % of aspiration pneumonia, predominantly necrotizing pneumonia orPeriodontitis is considered to be the most frequent oral lung abscesses, has anaerobes in etiology, the mostdisease. Microorganisms and products of their frequent organisms being Proteus gingivalis (PG),metabolism are responsible for its development, and for Bacteroides oralis, Eikenella corrodens, Fusobacteriumthe destruction of the supportive apparatus of the tooth. nucleatum, Actinobacillus actinomycetemcomitans,From the large number of the bacteria dwelling in the Peptostreptococcus and Clostridium. It is possible thatbiofilm on the tooth surface, Porphyromonas and even Streptococcus viridans plays a role in thePrevotella (previously black pigmented Bacteroides development and/or progression of pneumonia.species), Bacteroides forsythus and Actinobacillusactinomycetemcomitans have been emphasized because Bacterial respiratory infections are thought to be acquiredof their pathogenic influence on the periodontal tissue(1). through aspiration (inhaling) of fine droplets from theThe microorganisms of the dental plaque, and their mouth and throat into the lungs. These droplets containmetabolic product may - especially in advanced cases of germs that can breed and multiply within the lungs tothe disease - enter the blood stream during mastication or cause damage. Recent research suggests that bacteriatherapeutical procedures. The consequences may occur found in the throat, as well as bacteria found in thein the most distant organs, which is the case in the mouth, can be drawn into the lower respiratory tract. Thisdevelopment of sub acute endocarditis, some respiratory can cause infections or worsen existing lung conditions.diseases (pneumonia, emphysema, and chronic People with respiratory diseases, such as chronicobstructive pulmonary disease), coronary heart disease, obstructive pulmonary disease, typically suffer fromatherosclerosis and ischemic stroke, and diabetic reduced protective systems, making it difficult toglycemic control changes. eliminate bacteria from the lungs.EFFECT ON RESPIRATORY DISEASE: Scientists have found that bacteria that grow in the oral cavity can be aspirated into the lung to cause respiratoryBacteria that reproduce in the mouth can also be carried diseases such as pneumonia, especially in people withinto the airways in the throat and lungs, increasing the periodontal disease. This discovery leads researchers torisks for respiratory diseases and worsening chronic lung believe that these respiratory bacteria can travel from theconditions, such as emphysema. oral cavity into the lungs to cause infection.As early as 1968 Potter et al. described the presence ofdental diseases in subjects with pulmonary diseases. Oral Chronic obstructive pulmonary diseases (COPD) causebacteria can enter the lower respiratory tract by aspiration persistent obstruction of the airways. The main cause ofand cause pneumonia. Severe infections of the lungs can this disease is thought to be long-term smoking.develop after aspiration of salivary secretion, especially Chemicals from smoke or air pollution irritate the airways to cause obstruction. Further damage to the tissue and 25 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • working function of the lungs can be prevented, but CONCLUSION:already damaged tissue cannot be restored - untreated orundetected COPD can result in irreversible damage. Poor oral hygiene leads to an increase in the mass andScientists believe that through the aspiration process, complexity of dental bacterial plaque. Periodontitis canbacteria can cause frequent bouts of infection in patients result and may complicate subsequent efforts to improvewith COPD. Studies are now in progress to learn to what oral hygiene. In susceptible patients such as those whoextent oral hygiene and periodontal disease may be are debilitated, hospitalized, or residing in long-term careassociated with more frequents bouts of respiratory facilities, this increased bacterial burden may increasedisease in COPD patients. the risk of pneumonia and may also play a role in exacerbation or progression of COPD. Improving oralBiologically credible Mechanisms: hygiene and treating the periodontal disease could decrease oropharyngeal colonization by pathogenicSeveral biologically plausible mechanisms have been put bacteria and thereby reduce the significant costs,forth to explain how periodontitis can lead to respiratory morbidity, and mortality associated with seriousdisease. Salivary enzyme activity is increased in respiratory infections in vulnerable patients. Dentists areperiodontitis and can promote the adhesion of more often able to contribute to the improvement andpathogenic bacteria to the oral surfaces, thereby altering maintenance of general health of their patients. New,oropharyngeal colonization patterns8,26. In addition, oral evidence-based, advances in periodontology, and inbacteria involved in periodontitis can stimulate oral general medical specialties, clearly show a relationshiptissues and periodontium to release cytokines, which are between oral and systemic diseases.proteins involved in cellular interactions and immuneresponses. These cytokines can promote adhesion of REFRENCES:respiratory pathogens to mucosal surfaces, therebyleading to oropharyngeal colonization. 1. Mojon P. Oral health and respiratory infection. J Can Dent Assoc. 2002;68:340-345.Periodontitis may also affect pathogen adhesion torespiratory epithelium. In vitro studies indicate that the 2.. Russell SL, Boylan RJ, Kaslick RS, et al. Respiratorypresence of Streptococcus gordonii, a key bacteria in pathogen colonization of the dental plaque ofdental plaque formation, enhances the ability of institutionalized elders. Spec Care Dentist.pathogens such as H. influenza to adhere to respiratory 1999;19:128-134epithelial cells. In response to bacterial adhesion,respiratory epithelial cells may release cytokines and 3. Scannapieco FA. Role of oral bacteria in respiratoryattract neutrophils, which in turn release proteolytic infection. J Periodontol. 1999;70:793-802.enzymes that damage the epithelium and increase itssusceptibility to infection. In addition, cytokines released 4. www.perio.orgfrom inflamed periodontal tissues may enter therespiratory tract in aspirated saliva, triggering the samesequence of events, including neutrophil recruitment,epithelial damage, and infection(2). Corresponding author :There are a number of other possible mechanisms in the Dr. S. Rajsekharinfluence of bacteria on the pathogenesis of respiratory Professor, Dept Of Periodontics,diseases: Rajah Muthaih Dental College&hospital, Chidambaram.• Aspiration of oral pathogens (PG or AA, for example).• Alteration of the mucous surface by salivary enzymes in periodontitis, leading to an increase in adhesion and colonization of respiratory pathogens.• Periodontal disease-associated enzymes may destroy salivary pellicles on pathogenic bacteria.• Alteration of respiratory epithelium by cytokines from periodontal disease facilitating the infection of the epithelium with respiratory pathogens(3,4).JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 26
    • MILESTONES IN PERIODONTICSDr. D. Ida Sibylla BDS, M.Sc., (Neuroscience)11. Tutor, Department of Periodontics, Sathyabama University, Dental College & Hospital, Chennai - 600119.INTRODUCTION 4. The Modern Era 5. The Nineteenth centuryPeriodontal diseases are considered to be as old as thehistory of mankind1. The earliest evidence of periodontal 6. The Twentieth centurydisease is dated back to the ancient Egyptian and MiddleEastern world, where there are skeletal and written The Prehistoric Era and the Early Middle Eastern &records 2 . However, methodical or therapeutic Egyptian Civilizationsapproaches did not exist until the middle ages andmodern treatment with a scientific base and sophisticated Evidence of chronic periodontal disease and chronicinstrumentation did not develop until the 18th century1. abscess has been found in the extensive paleolithicBefore the 1950s diseases pertaining to the teeth were material available. Babylonian and Assyrian medicinetreated by root debridement and extraction of the affected comes from the clay tablets of the great library ofteeth. Prior to the 1970s the symptoms of periodontal Ashurbanipal (king of Assyria) which includes a numberdiseases were treated with the goal of radical elimination of remedies for periodontal disease. One such remedyof the periodontal pocket. The procedures done were was that if a man’s teeth were loose and itchy, a mixture ofgingivectomy, flap procedures and osseous surgery. The myrrh, asafoetida and opopanax as well as pine-control of subgingival infection by means of scaling and turpentine shall be rubbed on his teeth until blood comesroot planning with or without antibiotics was followed in forth and he would recover2.the 1980s. At present it is expected that the clinicians willbe met with new possibilities as a paradigm shift is Ancient Egyptians are known for the first artistic drawingsinevitable for periodontal practice in the new that emphasize the importance of beauty and hygiene. Inmillennium. This strongly suggests that by the end of the addition to the practice of bathing in oils, the Egyptiansfirst quarter of the twenty-first century, local delivery of used many products to freshen their breath. They chewedantimicrobials, growth and differentiation factors, and sodium carbonate or rinsed their mouth with honey androot biomodification agents will have a major impact on water to which goose fat, frankincense, cumin, and ocherthe practice of periodontics13. The history of implant had been added4.dentistry spans not only decades, but millennia. Theancient cultures of the world in Egypt, Honduras, China, The medical treatises of ancient Egypt were recorded onand Turkey, among others substituted missing dentition papyrus and they were mostly based on magic andwith shells, stones, ivory, and other human or animal religion2. The papyrus on the primary surgical treatise wasteeth15. The establishment of metal replacements for teeth the Edwin Smith Papyrus. A prescription to strengthen theis a relatively recent development. Researchers also periodontally diseased teeth was one part each ofsuggest that lasers could be applied for dental treatments powdered flint stones, green lead and honey rubbed onincluding periodontal, restorative and surgical the teeth. Hesy-Re, an Egyptian scribe, was often calledtreatments 1 6 . Another fascinating technique of the first dentist. In ancient India during the Brahmanperiodontal microsurgery is an evolution of surgical period of Indian medicine Susruta Samhita and Charakaprocedures to permit reduced trauma17. The application Samhita described gum disease and its treatment. Susrutaof plastic surgical principles to periodontal tissues described how the gums of the teeth swell, becomecomprises the field of periodontal plastic surgery. It has putrefied, slimy and emit a fetid smell5. He has alsoprogressed to become an inevitable part of periodontal devoted a section to proper tooth brushing and the use ofpractice. mouthwashes to cleanse the tongue. Charaka’s work was devoted to oral hygiene and the management of oralHISTORY OF PERIODONTOLOGY diseases but it was considered less interesting as it was a mixture of magic and religion.The time periods of the evolution of periodontics are21. The prehistoric era and early Civilizations In China medicine became more sophisticated. They also used various mixtures of herbs and minerals such as2. Classical and medieval ages powder of dried up mouse bone and urine of a child2.3. The Middle Ages 27 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • They also used chopsticks as toothpicks. A system of THE RENAISSANCEdental decoration with jadeite inlays evolved in Mayancivilization which was purely cosmetic and not Dentistry made little progress in the 17th century.restorative.20 [Image 1]. Although these led to prevention Surgeons and barbers who practiced dentistry wereof caries sometimes many harmful side effects like considered inferior and self taught.2 A series of Papalperiapical abscesses developed. During the middle edicts prohibited monks from performing any type ofeastern and Mediterranean civilizations they followed surgery, bloodletting or tooth extraction. Barbers oftenthe rabbinical laws founded on tradition which was assisted monks in their surgical ministry because theycalled as the Talmud. According to the Talmud, when a visited monasteries to shave the heads of monks and theman looses his teeth his nutrition is diminished, and that tools of the barber trade were sharp knives and razors thatuntil 40 years solid food is necessary but after 40 years were useful for surgery. After the edicts, barbers assumedliquid food is sufficient due to early loss of teeth and the monks’ surgical duties such as bloodletting, lancinginefficient mastication. abscesses, extracting teeth, etc.The Phoenicians excelled in working with gold. Theybound loose periodontally involved teeth with gold.2 Paracelsus developed an interesting and unusual theory[Image 2] of disease, the doctrine of calculus. Antony van Leeuwenhoek, a tradesman in Holland who learned toCLASSICAL AND MEDIEVAL AGES grind glasses around 1668 made simple microscopes and observed with them. In 1683 he wrote to the royal societyAristotle investigated oral disease and talked about the about his observations on the plaque he found betweencauses of periodontal disease and discussed the nature of his own teeth, describing that it is a little white matter,occlusion and the shape of teeth. In Rome Celsus offered thick as a batter. He coined the term dental plaque2.treatment for a number of periodontal conditions. He also described Oral microbial flora and conductedOribasius has a number of sections on toothache and antiplaque experiments using strong vinegar in his owngingival inflammation. Haly Abbas recommendsmethods for cleaning the mouth in Arabian medicine. mouth and in vitro on bacteria in a dish. Antony vanAvicennas used extensive materia medica for periodontal Leeuwenhoek and Marcello Malphigi are considereddiseases. Albucasis understood that calculus deposits on important in the development of sciences that laterthe teeth were the major etiologic factors of became fundamental to Periodontology2.periodontitis2. He described in detail the technique ofscaling the calculus deposits from the teeth with a set of THE EIGHTEENTH CENTURYinstruments he developed. [Image 3] Dentistry in general and periodontics in particular,THE MIDDLE AGES especially because of Pierre Fauchard went through a period of great progress in this century. According toDuring the Early Middle Ages in Europe medicine, Pierre Fauchard [Image 4] the severe mouth diseases thatsurgery, and dentistry were generally practiced by sailors suffered, particularly scurvy, has induced him tomonks, the most educated people of the period. The specialize in the treatment of the diseases of the mouth6.Arabic treatises derived their information from Greek Fauchard was one who had belief in the local etiology ofmedical treatises but added many refinements, periodontitis as opposed to the contemporary theory of aparticularly in surgical specialities. The Guy de Chauliacoffers extensive medicaments for the treatment of various systemic causation. He introduced five instrumentsdiseases of the teeth, gingiva and oral mucosa2. calling them the rabbit chisel, parrot’s bill, graver withPomegranate juice was considered an excellent three facets, hook like a Z, and a knife2. John Hunterastringent mouthwash. Tartar was removed by scalers, portrays the displacement of teeth as a consequence ofsince rinses and tooth powders would not have any effect the loss of adjacent or opposing teeth. He describedupon it. 2 pocket formation and bone loss. He also differentiated scurvy from other gum diseases.THE MODERN ERA THE NINETEENTH CENTURYThe first dental book was published in German in 1530.2Paracelsus developed an engrossing hypothesis of In the second half of the 19th century the discovery ofdisease and claimed pathologic calcification occurs in a anesthesia, germ theory of disease and the discovery of x-variety of organs due to a metabolic disturbance. rays had a particular impact on periodontics5. HenceEustachius offered modern treatment for periodontal periodontal surgical techniques became more complexdisease which includes scaling and curettage of and sophisticated, not only for solving disease problemsgranulation tissue to allow reattachment of the gingival but also for esthetics and function.and periodontal tissues.2JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 28
    • PERIODONTAL MICROBIOLOGY Hunter reported in the British Medical Journal on the topic "Oral Sepsis as a Cause of Disease" blaming poorIn the 1880s the germ theory of disease, proven by dental health and conservative dentistry as the cause ofPasteur and Koch, suggested that periodontal disease was the plethora of systemic diseases. The report was basedalso caused by germs. Over time, specific bacterial types, on the focal infection theory3. A focal infection is asuch as Porphyromonas gingivalis, were discovered and localized or generalized infection caused byshown to be important in the cause of periodontal dissemination of microorganisms or toxic products from adisease. At the same time, inflammatory mediators, such focus of infection3. The present evidence for theas prostaglandins and interleukins, and enzymes, such as relationship of oral microorganisms and systemicmatrix metalloproteinases, were discovered and found to disease, particularly that of the coronary arteries, is verybe important participants in the destruction of limited due not only to a dearth of prospective studies andperiodontal tissues7. a complete lack of interventional studies but also to very significant methodological difficulties associated with theAdolf Witzel in 1881 presented clinical manifestations of clinical studies that have been performed.3 Also, theperiodontal disease (infectious alveolitis), describing occurrence of metastatic infections from the mouth togingival recession, pocket formation, calculus deposits distant bodily sites is rare. Hunter and other advocates ofand suppuration. He differentiated bone loss caused by the theory were unable to elucidate possible interactivesenile atrophy of the alveoli and described treatment for mechanism between oral and systemic health.alveolar pyorrhea. Between 1871 - 1907 Miller publishedhis classic book “The microorganisms of the human Calculus was considered as the consequence and not amouth” and described the features of periodontal disease, cause for pocket formation.considering the role of predisposing factors, irritationalfactors and bacteria in the etiology of pyorrhea alveolaris. Spirochetes, Fusiform Bacilli & Streptococcus viridians were considered in the search for an etiologic agent forCLINICAL PERIODONTOLOGY periodontal disease. Morris Karolyi 1901 and Paul R Stillman described traumatic occlusion. Many paradigmsLeonard Koecker in1821 described inflammatory concerning the epidemiology, pathogenesis, andchanges in gingiva following the presence of calculus, systemic impact of periodontal diseases have beenwhich lead to mobility and exfoliation of teeth. The local modified. For example, bacterial biofilms are essential tofactors include inordinate use of mercury, irregularities in induce periodontitis but their mere presence is nottooth position and neglect of cleanliness. Levi Spear sufficient to initiate disease9. It is also now recognizedParmly (1790-1859) was the father of oral hygiene and that the host response to these biofilms causes most of thethe inventor of the dental floss2. Dental floss is defined as destruction of the periodontal tissues.a waxen silken thread which is to be passed through theinterstices of the teeth between their necks and the arches Due to the improvement of facilities in the dental officesof the gum, to dislodge the irritating matter which no during the 20th century gingival changes were detectedbrush could remove. John M Riggs is considered as the much easily and the significance was analysed. Thefirst Periodontist in history[Image 5]. He described periodontal probe, and its use was described byperiodontal disease occurring in 4 stages which was F.V.Simonton in 1925. Simonton insists that the only waycalled Riggs disease2. to determine the existence and extent of pyorrhea is the measurement of the pockets either instrumentally,1st : margin of gingiva roentgenographically or both. Periodontal probe2nd : alveolar border, pockets filled with pus. (Periodontometer) was developed by Hanford & Patten. The first use of radiograph for Periodontal diagnosis was3rd : thicker portions of alveolar bone by William Herberst robins in December 1896. Atlas4th : involved all portions of the alveolar bone and the documented patterns of bone loss & correlated them togingiva clinical findings2. The phase of nonsurgical therapy was developed duringWilliam J Younger in 1897 designed scaling instruments 1900 – 1950. The champion of non-surgical therapy iswhich have been the basis for modern instruments. Isador Hirschfeld. Some of the instruments used were Riggs’ set of scalers, William J Younger’s delicate bladesTHE TWENTIETH CENTURY and David Smith’s files.Throughout the 20th century, an understanding of the Plaque control techniques were brought forth in therole of causative bacteria and the susceptible host in the twentieth century. The brushing techniques wereinitiation and progression of periodontal disease has explained by Alfred Fones in 1934, Paul R Stillman inemerged from the efforts of scientists and clinicians 1932, William J Charters in 1935 and Charles C Bass inworldwide8. In 1900, the English physician William 19402. 29 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • Periodontal surgery (1900 to 1950): Robert Neumannproposed a surgical flap in 1912. He took radiographs,performed frenotomies, presurgical scaling, provisionalsplinting, and demonstrated toothbrushing withhorizontal strokes. In 1917, Leonard Widman performedsurgery to gain access to the root. Olin Kirkland in 1932,performed modified flap operation with Kirklandgingivectomy knives. Henry Goldman in 1942,published a book on periodontology. He performedgingivoplasty by reshaping the gingiva for purpose of Courtesy: Fermin A. Carranza. Carranza’s clinicalattaining a most desirable form and not for pocket periodontology 9th edition, 2002eradication. A. W Harlan 1906, performed root coverageof isolated recessions. Fermin Carranza proposedindications for osseous removal.Hans R Muhlemann described methods to measure toothmobility, Sulcus bleeding index and introduced thedentifrice. Per-Ingvar Branemark conducted vitalmicroscopy studies of bone marrow in rabbit fistula anddemonstrated integration of the titanium chamber andpresence of osseointegration after placement of implants.Dahl in 1940 created the subperiosteal implant, astructure that rested on and not in, the jaw. Theseimplants developed complications including infectionand bone resorption. Leonard Linkow developed theblade fixture for areas of deficient bone. With time, the Image 4 – Pierre Fauchardblade design fell out of favor as its complication rateprecluded its use. In its place came the root form implant, Courtesy: Fermin A. Carranza. Carranza’s clinicalwhich is the current standard shape.15 periodontology 9th edition, 2002 Image 1– A system of dental decoration with jadeite inlays in Mayan civilization Image 5 – John riggs Courtesy: Concepts of Esthetic Dentistry – Pathways of the Dentist Courtesy: Fermin A. Carranza. Carranza’s clinical periodontology 9th edition, 2002 Courtesy: www.periocraze.com Image 6 – Periodontal microsurgery equipment Image 3 – Instruments developed by Abulcasis for scaling the calculus deposits from the teeth Courtesy: Dennis A. Shanelac, Periodontal Microsurgery J Esthet Restor Dent 15: 2003.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 30
    • DISCUSSION AND CONCLUSION Milestones in Periodontics have evolved from the prehistoric era till date. Evidence of Periodontal disease was found in the prehistoric era and the remedies for the same were put forth.2 The ingredients for freshening the breath4 were formulated many years back. We have been able to appreciate the binding of loose periodontal teeth during the same era.5 Another milestone of development occurred in the middle ages, modern era and the renaissance where medicaments were developed for the treatment of teeth, gingival, and oral mucosa. Books were also published. Image 7 - Subgingival scaling done with laser Er : YAG The discovery of microorganisms is discussed and periodontics progressed to a great extent in theCourtesy: Dae Hyun Lee, Application of laser in periodontics: eighteenth century.5 A new approach in periodontal treatment, October 2007, volume 12, No.10. Instruments were developed for scaling and curettage which have been discussed. The dawn of the nineteenth century witnessed the discovery of x-rays, anaesthesia and the development of the germ theory of disease by Pasteur and Koch.RECENT ADVANCES IN PERIODONTICS: The twentieth century saw the major milestones inThe future of Periodontology can be renamed as the periodontics such as the focal infection theory discussedspeciality of Periodontal medicine and surgery. Plastic in detail, the development of many instruments surgicalsurgery is a clinical discipline in which surgical techniques by Robert Neumann and the principle oftechniques are employed to reconstruct or repair bodily implants, thereby giving an upliftment to the field ofstructures. These may be missing, defective, or damaged periodontics.2through injury or disease. Microsurgery offers newpossibilities to improve periodontal care in a variety of Further, advanced and recently introduced techniquesways. Periodontal plastic microsurgery [Image 6] that have been discussed include lasers16 and periodontalinvolves correcting gingival recession, restoring the microsurgery17 which focus on esthetics and function thatedentulous ridge, establishing an esthetic smile line, and is more acceptable to the patient. As we look back at thean excellent wound healing after surgical procedures. Its milestones of development in periodontics we feel webenefits include improved cosmetics, rapid healing, have come a long way and the urge to discover manyminimal discomfort, and enhanced patient acceptance.17 such treatment modalities.The use of lasers for treatment has become a common A view of the evolution of periodontics has shown aphenomenon in the medical field. The first laser device gradual progress from a small beginning to a verywas made by Maiman in 1960, based on theories derived advanced stage. But there are many more goals to beby Einstein in the early 1900s16. Lasers have the advantage achieved which is possible only by having a completeof reduced bleeding intraoperatively and less pain knowledge about the history and evolution ofpostoperatively. Several hard tissue lasers with similar periodontology. The usefulness of the implant trendswavelengths are used for cavity preparation and caries discussed above is yet to be determined. With time, someremoval18 eg Er : YAG, Er : YSGG. The hard tissue of these innovations may become conventions; othersprocedures done with lasers in periodontics are scaling of will end up as historical sidenotes. Lasers and periodontalroot surfaces, calculus removal, osteoplasty and microsurgery17 are considered the current trends inostectomy [Image 7]. The soft tissue procedures periodontal therapy which is widely accepted by theperformed in periodontics are soft tissue ablation, sub patient. Nevertheless there is a great need to develop angingival curettage, photoactivated dye disinfection of evidence based approach to the use of lasers for theperiodontal pocket and deepithelialization to assist treatment of periodontal diseases, as there is insufficientregeneration and the lasers used are Erbium: Yttrium- evidence to suggest that any specific wavelength of laseraluminium-garnet, Holmium: Yttrium-aluminium- is superior to the traditional modalities of therapy19.garnet19. Advances in the fields of molecular biology, human genetics and stem cell biology have set the stage for 31 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • significant discoveries that will pave the way for the 17. Dennis A. Shanelac, Periodontal Microsurgery Jdevelopment of procedures needed for the predictable Esthet Restor Dent 15:XXX–XXX, 2003.regeneration of periodontal tissues10. 18. L J Walsh, The current status of laser applications in dentistry, Australian dental Journal 2003; 48: (3):BIBLIOGRAPHY 146-155.1. Yilmaz et al, the evolution of clinical periodontal 19. Charles M. Cobb Lasers in periodontics: A review of therapy, J Marmara university, 1994 sept 2(1): 414 – the literature. Journal of periodontology; vol.77, 23 No.42. The history of periodontology downloaded from 20. Courtesy : Pathways of the Dentist – Concepts of www.periocraze.com. esthetic dentistry3. Thomas j. pallasch, DDS, MS and Michael J wahl DDS, the focal infection theory: appraisal and reappraisal, 2000 journal of the California dental association.4. The evolution of mouthwash Corresponding author : Dr. D. Ida Sibylla BDS, M.Sc., (Neuroscience)15. Saxen l proc Historical background of Tutor, Department of Periodontics, Sathyabama University, periodontology finn dent soc, 1986:82(3): 152-62. Dental College & Hospital, Chennai - 600119.6. Muroff F the rationale of periodontal therapy Mcgill e-mail : ida2sibylla@gmail.com Dent Rev 1969 Jan – feb:31(2):28-30. Cell : 99402668537. Williams RC, understanding and managing periodontal diseases: a notable past, a promising future, J periodontology 2008 Aug: 79(8 suppl): 1552-9.8. Williams RC: a century of progress in understanding periodontal disease, compend contin educ Dec 2002 (5 suppl): 3 – 10.9. Greenstein G and Lamster, Changing periodontal paradigms therapeutic implications. Int J periodontics and restorative dentistry 2000 Aug 20(4): 336 – 5710. Armitage GC and Robertson PB, the biology, prevention, diagnosis and treatment of periodontal diseases: scientific advances in the united states. Journal of American dental association 2009 sept 140, suppl1: 36s-43s.11. Tonetti MS, advances in periodontology. Prim dental care 2000 oct: 7(4):149-52.12. Anjus chiedozic, ehow contributor, the history of periodontics.13. Vandersall DC, Periodontics in the new millennium. Dent clin North America 1998 July: 42(3) : 543-6014. Fermin A. Carranza. Carranza’s clinical periodontology 9th edition, 200215. Michael Sonick, Implant Dentistry: Evolution and Current Trends, Inside dentistry, October 2006, volume 2, issue 616. Dae-hyun Lee Application of laser in periodontics: A new approach in periodontal treatment, October 2007, volume 12, No.10.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 32
    • PATIENT-FRIENDLY APPROACH TO THE MANAGEMENTOF PERIODONTAL DISEASEDr. M. Vijayalakshmi, Dr. Gayathri. S1, Dr. M. G. Krishna Baba2, Dr. Sumathi. H. Rao3, Dr. T. Geetha41. Senior lecturer 2. Professor & Head of Department 3. Reader 4. LecturerDepartment Of Periodontology, Sathyabama University Dental College And Hospital, Chennai Keywords: Desmoglein, auto-antibodies, corticosteroid. ABSTRACT: Pemphigus vulgaris (PV) is a chronic autoimmune intraepithelial blistering disease. PV almost always affects the mouth and it can be the initial site of presentation in about 40% to 50% of cases, before skin and other mucosal sites (esophagus, pharynx, larynx, nasal and genital) become involved. The blister break to form large denuded areas of skin which can prove fatal if extensive areas are involved. Early recognition of this lesion may prevent delayed diagnosis and inappropriate treatment of a potentially fatal chronic dermatological condition.INTRODUCTION: patient. The patient should know what he is suffering from and why; what treatment he has to undergo, what heThe basic complaints by patients in day to day dental can expect during and after treatment, the prognosis,practice are bleeding gums bad breath, gaps between number of sittings and cost. This is essential so that patientteeth, loose tooth, and tooth or root sensitivity. Most understands the nature and cause of the disease and alsopatients are apprehensive about visiting a dentist either clears any misgivings, will relax and be co-operativedue to some previous bad experience or transferred fear during the treatment.from others. The most common misconceptionsassociated with periodontal treatment and which are A correlation between the patient’s systemic health andnaively believed and cited by patients as the reason for dental health and further its significance is much harpednot availing treatment and spread to others are :- in literature. Physiological conditions such as pregnancy which alter the gingival health1,the importance ofA. Teeth become weak and irregular after dental scaling periodontal care in patients with systemic conditions or cleaning such as diabetes2, heart problems pose a challenge to theB. The teeth become mobile and sensitive with regular overall dental treatment. An insight to periodontal cleaning medicine and its importance has to be highlighted inC. Teeth develop gaps due to cleaning relevant cases.D. Dental treatment or intervention causes tooth loss After diagnosis the patient must be told what he /she is suffering from and what is the cause for the disease, howThese results from lack of knowledge about the disease, the problem usually started and how it had progressed.importance of oral hygiene, treatment and complications What is Biofilm/Plaque needs to be explained withif any. Thorough examination, which marks the main examples so that he/she can understand what he mustforte of proper diagnosis along with treatment planning, look for and eliminate while brushing. An explanationpatient education and regular patient follow up forms the about the formation of biofilm, its prevention and itsfour pillars of successful management of the periodontal removal after formed will also aid in education.disease. INFORMATION TO PATIENTPatient education and motivation and thereby the patientcompliance are critical for successful periodontal Post-operative sequelae such as possibility of bleeding,management. The Practitioner’s role in achieving the developing of gaps between teeth and sensitivity andabove is crucial. loosening of teeth and whether the changes are temporary or permanent must be informed andDIAGNOSIS: explained. Information about the post-operative care and maintenance must be given and insisted upon.Patients should be thoroughly examined after taking adetailed history. Routine dental education as to nature EDUCATION OF MASSES: The following topics have toand progression of the diagnosed periodontal disease explained:-along with treatment planning must be given to the 33 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • WHAT IS PERIODONTAL DISEASE? TREATMENT PLANNING:This question must be answered and explained in simple A thorough case sheet listing the dental status of theterms. The role of oral hygiene, local and systemic factors patient on day one and the possible treatment suggestionsexplained in simple terms. have to be clearly recorded. The patient is made to understand the various treatment modalities and furtherBIOFILM: accept the current trends of treatment.Biofilms have been defined as matrix embeddedmicrobial populations, adherent to each other and or to Proper case reviews are done from time to time to checksurfaces or interfaces. Biofilms colonize a diverse set of and reassess the prognosis. The recall of the patient ismoist surfaces including the oral cavity, bottom of boats done periodically and photographs and radiographs areand the inside of pipes and drainage as well as rocks in assessed. Patient education pre-operative, andstreams. The role of constant moistness and stagnation reinforcing the same during, and post the procedure aidscan be explained with simple examples like the slime in increasing the belief of the patient towards periodontallayer found on the walls of a glass of water that has been disease prognosis.left idle for a few days3. Some patients do not turn up due to relief from their mainPeriodontal disease is a biofilm mediated disease and for complaint. Hence constant patient motivation andexample Porphyromonasgingivalis is an anaerobic encouragement of the patient for complete treatmentbacterium that resides within the biofilm community in should be stressed for better final outcome of the case. Athe gingival crevice and is regarded as a major causative regular maintenance program of 6-month recalls helpsagent in the initiation and progression of severe forms of the patient understand the importance of the dentalthis disease4. treatment and improves the survival rate of the teeth.DENTAL PLAQUE: Patient education includes audiovisual aids, pamphlets, instruction sheets, model demonstrations of the brushing,Dental plaque which is the biofilm attached to tooth flossing and interdental brushing techniques reiterate thesurface as a result of persistent moistness. It is composed fact the communication in all forms makes dentalmainly of bacteria embedded in a matrix of extracellular education simplified for the patient. Post treatmentbacterial polymers and salivary or gingival exudate complaints should be handled with care answering everyproducts. It is well documented that accumulation of question of the patient and if handled properly thesebacterial plaque at the gingival margin results in the patients come for regular recall and turn out to be branddevelopment of gingivitis and the gingivitis can be ambassadors of the treatment.reversed with the implementation of oral hygienemeasures5, 6. Some patients with severe loss of attachment INFORMATION ABOUT PROGNOSIS TOmay have minimal levels of bacterial plaque on the PATIENT:affected teeth, indicating that the quantity of plaque is notof major importance in the disease process. Thus the WHAT ARE THE BENEFITS OF TREATMENT?importance of the composition or quality of theWHAT ARE THE COMMON SIGNS AND SYMPTOMS Immediately after scaling and root planing there is aOF PERIODOTNAL DISEASE? dramatic reduction in microorganisms. Reevaluation of the periodontal case should be carried out at about 4The patient has to be told that he/she may have weeks after completion of the scaling and root planingperiodontal disease if they have - procedures. This permits time for both epithelial and connective tissue healing and allows the patient time to! Bleeding gums when brushing practice and perfect oral hygiene skills to achieve! Red, swollen puffy looking or tender gums maximum improvement. Gingival inflammation is usually substantially reduced or eliminated within 3 to 4! Abscess on the gums weeks after removal of calculus and local irritants.! Pus secreting between the teeth and gums Healing consists of the formation of a long junctional! Shaky teeth epithelium rather than new connective tissue attachment! Teeth appearing to drift apart from its original to the tooth surfaces. The attachment epithelium position reappears in 1 to 2 weeks. Gradual reduction in inflammatory cell population, crevicular fluid flow, and! Receding gum line repair of connective tissue result in decreased clinical! Persistent bad breath signs of inflammation with less redness and swelling7.! Vague discomfort or dull ache of gums and teethJIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 34
    • WHAT WILL HAPPEN IF PAITENT DOES NOT six months8, 9, 10. The dentist determines the frequency ofCONTINUE THE TREATMENT? the visits, which depends on the severity of the disease, the overall oral health, and the risk factors involved. MostIf gingivitis is not treated it can progress to periodontitis. people with a history of periodontal disease start with aThe gums start to pull away from the teeth and are filled three-month supportive periodontal treatment schedule.with plaque and become infected. As the plaque spreadsand grows beneath the gum line the body immune system After reviewing changes in the medical and dentalfights the bacteria. Bacterial toxins and body enzymes history, an oral examination will be performed to checkfighting the infection actually starts to break down the for hidden problems which include an oral cancerbone and connective tissue that hold teeth in place. If left screening and a thorough periodontal examination.untreated the underlying bone and connective tissue Radiographs may be taken to check for cavities andattachment is destroyed. The teeth may eventually changes in bone levels. Oral hygiene is evaluated,become loose and may need removal. Periodontitis can reviewed and reinforced. Scientific research has provenrange from mild to moderate to even severe forms. Supportive Periodontal Treatment will avoid the recurrence and progression of periodontal disease11.The prognosis for patients with gingival and periodontaldisease is critically dependent on the patient’s attitude; In short, to conclude, the patient needs to be heard, talkedthese mainly are, the desire to retain the natural teeth and to, be told, made to understand and willingly submit forwillingness and ability to maintain good oral hygiene. treatment and maintenance program.Without these, treatment cannot succeed. Patients shouldbe clearly informed of the important role they must play REFERENCES:for treatment to succeed. If patients are unwilling or 1. LoeH:Periodontal changes in pregnancy,Junable to perform adequate plaque control and to report Periodontol 36:209,1965.for the timely periodic maintenance checkups andtreatments that the dentists deems necessary, they can 2. HirschfeldI :Periodontal symptoms associated withrefuse to accept the patient for treatment or extract teeth diabetes,J Periodontal 5:37, 1934.that have a hopeless or poor prognosis and performscaling and root planning on the remaining teeth. 3. Jill S. Nield Gehrig: Foundations of periodontics for the dental hygienist.The dentist should make it clear to the patient that if theperiodontal condition is treatable; the best results are 4. Haffajee A.D. & SocranskyS.S (1994) Microbialobtained by prompt treatment and patient cooperation. If etiological agents of destructive periodontal diseases,the condition is not treatable or the patient is not willing Periodontol 2000 5:78, 1994.for any aspect of the plan, the teeth should be just aspromptly extracted. 5. MariottiA: Dental plaque-induced gingival disease, Ann Periodontol 4:7, 1999.SUPPORTIVE PERIODONTAL TREATMENT: 6. LoeH,TheladeE, Jensen SB: Experimental gingivitis inThis term expresses the essential need for therapeutic man JPeriodontol 36:177, 1965.measure to support the patient’s own efforts to control theperiodontal infections and to avoid re-infection. Like 7. Cobb CM: Non-Surgical pocket therapy –cardiovascular disease and diabetes, periodontal disease mechanical, Ann Periodontol 1:443, 1996is a chronic ailment that has to be closely monitored on an 8. Lindhe J, Nyman S. Long-term maintenance ofon-going basis. After completion of the active phase of patients treated for advanced periodontal disease, Jperiodontal treatment, a personalized program of ClinPeriodontol1984;11:504-514.supportive periodontal treatment will help the patientmaintain periodontal health. 9. Haffajee AD, Socransky SS, Smith C, Dibart S. Relation of baseline microbial parameters to futureDaily brushing and flossing will keep the formation of periodontal attachment loss. Jcalculus to a minimum but would not prevent it ClinPeriodontol1991;18: 744-750.completely. Thorough or meticulous plaque control,periodontal maintenance procedures are designed to 10. Lindhe J, Nyman S. The effect of plaque control andminimize the recurrence and progression of periodontal surgical pocket elimination on the establishment anddisease in patients who have been previously treated for maintenance of periodontal health. A longitudinalperiodontal problems. study of periodontal therapy in cases of advanced disease J ClinPeriodontol1975;2:67-79.Periodontal maintenance is an evaluation geared towardsidentifying factors that may interfere with oral health. 11. Cohen RE, Position paper: Periodontal maintenance.These visits may be scheduled every few weeks or every J Periodontol 2003;74:1395-1401. 35 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • PATHOPHYSIOLOGY OF ACUTE NECROTIZING ULCERATIVEGINGIVITIS (ANUG) / VINCENTS INFECTION - A REVIEWDr. K. Sasireka M.D.S1, Dr. M. Devi M.D.S21. Professor-Dept of Periodontics, 2. Reader-Dept of Oral Pathology, Adhiparasakthi Dental College and Hospital. Keywords: Necrotizing ulcerative gingivitis, acute lesions, and oral mucous membrane. ABSTRACT: Necrotizing ulcerative gingivitis is one of the relatively common acute lesions involving the oral mucous membrane. It is generally involved in the younger age group. It is destructive and ulcerative lesions of the oral mucous membrane that may be in severe cases extend into the alveolar mucosa and perforate the skin of the cheek.INTRODUCTION • The surface of the gingival craters is covered by a gray, pseudomembranous slough demarcated from theAcute necrotizing ulcerative gingivitis (ANUG) is an remainder of the gingival mucosa by a pronouncedinflammatory destructive disease of gingiva that presents linear erythema.characteristic signs and symptoms. It was recognized byXenophon who mentioned that Greek soldiers were • In some cases the lesions are denuded of the surfaceaffected with sore mouth and foul smelling breath, hi pseudomembrane, exposing the gingival margins1778 John Hunter described the clinical findings of which is red,shiny and hemorrhagic.ANUG. hi 1886 Hersch a German pathologist discussedsome of the features associated with the disease such as • The characteristic lesion progressively destroys theenlarged lymph nodes, fever, malaise and increased gingival and underlying periodontal disease.salivation. In 1890 Plaut and Vincent described the • Spontaneous gingival bleeding or pronounceddisease and attributed its origin to fusiform bacilli and bleeding on the slightest stimulation are the additionalspirochetes. It was commonly known as Vincents characteristics clinical signs.infection during the first half of the 20th century, but itscurrent designation is acute necrotisizing ulcerative • Other signs include foteid odour and increasedgingivitis. salivation.CLINICAL FEATURES: • ANUG can occur in otherwise disease free mouths or can be super imposed on chronic gingivitis orANUG is characterized by sudden onset, sometimes periodontal pocket.following an episode of debilitating disease or acuterespiratory tract infections. A change in living habits, ORAL SYMPTOMSprotracted work without rest and physiological stress are • The lesions are extremely sensitive to touch andfrequent features of patients history patients complain of a constant radiating gnawingCLASSIFICATION type of pain that is intensified by spicy or hot foods and chewing.• Necrotizing ulcerative gingivitis most often occurs as an acute disease. • There is metallic foul taste and patient is conscious of an excessive amount of pasty saliva.• Its relatively mild and more persistent form is referred to as sub acute disease EXTRA ORAL AND SYSTEMIC SIGNS AND SYMPTOMS • Patients are usually ambulatory.• Recurrent disease is marked by periods of remission and exacerbation • Local lymphadenopathy and a slight elevation in temperature are common features of the mild andORAL SIGNS moderate stage of the disease.• Characteristic lesions of ANUG are punched out, • In severe cases there are marked systemic crater like depressions at the crest interdental papillae, complications such as high fever, increased pulse rate, subsequently extending to the marginal gingival. leucocytosis and loss of appetite and general lassitude.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 36
    • • Systemic reactions are more severe in children DIAGNOSIS OF ANUG insomnia, constipation, gatrointestinal disorders, headache and mental depression accompany the Diagnosis is based on clinical findings - A bacterial smear condition. may be used to corroborate the clinical diagnosis. Microscopic examination of the biopsy specimen is notCLINICAL COURSE sufficiently specific to be diagnostic.The clinical course is indefinite if untreated ANUG may DIFFERENTIAL DIAGNOSIS OF ANUGresult in progressive destruction of the periodontium anddenudation of the roots. • Acute herpetic gingivostomatitis • Desquamative gingivitisHISTOPATHOLOGY • Periodontal pocketMicroscopically the lesion appears as a non specific acute • Streptococcal gingivostomatitisnecrotizing inflammation at the gingival margininvolving both the stratified squamous epithelium and • Apthous stomatitisunderlying connective tissue. The surface epithelium isdestroyed and replaced by a pseudomembraneous mesh • Gonococcal gingivostomatitiswork of fibrin, necrotic epithelial cells • Syphilitic lesionpolymorphonuclear neutrophils (PMNs) andmicroorganisms. MANAGEMENT OF ANUGBacteria associated with ANUG: Listgarten et al studied Treatment of ANUG consists of management of the acutethe lesions of ANUG under electron microscope and inflammation of the gingiva, alleviation of generalizeddescribed four zones. toxic symptoms like fever, malaise and management of systemic predisposing factors.ZONE 1: Bacterial zone - The most superficial zoneconsists of different bacteria including a few spirochetes First visit - The clinician should record the detailedof small, medium and large types. history of the patient such as socioeconomic status, type of employment, mental stress, dietary habits, recentZONE2: Neutrophil rich zone - This zone contains illness and information regarding the onset and durationnumerous leucocytes, mainly neutrophils and bacteria of the acute gingival condition. Oral cavity is examinedincluding many spirochetes between the leucocytes. thoroughly. Clinical appearance of the ulcer, oral hygiene status and the periodontal status are evaluated.ZONES3: Necrotic zone - The zone consists of Sub mandibular and sub mental lymph node areas shoulddisintegrated cells, fibrillar material, remnants of collagen be palpated. Body temperature of the patient should alsofibers and numerous intermediate as well as the large be checked. Patient is advised to confine tooth brushingspirochetes to remove surface debris with dentifrice to maintain good oral hygiene.ZONE4: Spirochetal infiltration - This zone consists ofwell preserved tissue infiltrated with intermediate and Second visit -1-2 days later supra gingival scaling must belarge spirochetes done. Patients condition is improved. Patient is asked to follow the same instructions.PREDISPOSING FACTORS OF ANUG• Preexisting periodontal disease Third visit - 1-2 days later sub gingival scaling and root• Smoking planning is completed. Plaque control instructions were reinforced. Hydrogen peroxide rinses were discontinued• Nutritional deficiency but chlorhexidine rinses were maintained for 2 weeks.• Psychosomatic factors Subsequent visit - The affected area were checked. OralPREVALENCE OF ANUG hygiene instructions were reinforced. Patient is treated for generalized chronic gingivitis and marginal gingivitis.Epidemiological studies have shown rather low Patient is placed on maintenance program and recalledprevalence of ANUG prior to 1914 in USA and EUROPE on monthly basis for further check up. The patient wasbut during World War I and II, there were many episodes explained the need for intensive approximal cleaning toof ANUG among the allied troops. avoid recurrence of ANUG. 37 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • CONCLUSIONNecrotizing ulcerative gingivitis usually runs an acutecourse, is rapidly destructive and debilitating and couldhave various stages of the same disease (horning andcohen 1995). The treatment of the necrotizingperiodontal diseases is divided into 2 phases such asacute and maintenance phase. The aim of the acute phasetreatment is to eliminate disease activity. Themaintenance phase treatment aims the eliminating allgingival defects and creating optimal conditions forfuture plaque control. The elimination of predisposingfactors is most important to prevent recurrence.REFERENCES1. GLICKMANS CARANZA -Textbook of clinical periodontology 10* edition2. COHEN - Textbook of Periodontology3. LINDHE - Textbook of clinical Periodontology4. B.R.R VARMA, R.P NAYAK - Textbook of clinical Peridontology 2nd edition5. Folayan MO. The epidemiology, etiology, and pathophysiology of ANUG. The journal of contemporary dental practice (2004) Volume: 5, Issue: 3, Pages: 28-41 Corresponding author : Dr. K. Sasireka M.D.S Professor-Dept of Periodontics Adhiparasakthi Dental College and HospitalJIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 38
    • A NEW CONCEPT OF DENTAL ARCH OF CHILDRENIN NORMAL OCCLUSIONAbu-Hussein Muhamad1 DDS,MScD,MSc,DPD,FICD, Sarafianou Aspasia2 DDS,PhD1, 2. University Of Athens, Greece Keywords: dental arch,occlusion ABSTRACT: The development of human dentition from adolescence to adulthood has been the subject of extensive study by numerous dentists, orthodontists and other experts in the past. While prevention and cure of dental diseases, surgical reconstitution to address teeth anomalies and research studies on teeth and development of the dental arch during the growing up years has been the main concerns across the past decades, in recent years, substantial effort has been evident in the field of mathematical analysis of the dental arch curve, particularly of children from varied age groups and diverse ethnic and national origins. The proper care and development of the primary dentition into permanent dentition is of major importance and the dental arch curvature, whose study has been related intimately by a growing number of dentists and orthodontists to the prospective achievement of ideal occlusion and normal permanent dentition, has eluded a proper definition of form and shape. Many eminent authors have put forth mathematical models to describe the teeth arch curve in humans. Some have imagined it as a parabola, ellipse or conic while others have viewed the same as a cubic spline. Still others have viewed the beta function as best describing the actual shape of the dental arch curve. Both finite mathematical functions as also polynomials ranging from 2nd order to 6th order have been cited as appropriate definitions of the arch in various studies by eminent authors. Each such model had advantages and disadvantages, but none could exactly define the shape of the human dental arch curvature and factor in its features like shape, spacing and symmetry/asymmetry. Recent advances in imaging techniques and computer-aided simulation have added to the attempts to determine dental arch form in children in normal occlusion. This paper presents key mathematical models & compares them through some secondary research study.INTRODUCTION mathematical model for the dental arch in humans, the earliest description of the arch was via terms like elliptic,Primary dentition in children needs to be as close as parabolic, etc and, also, in terms of measurement, thepossible to the ideal in order that during future adulthood, arch circumference, width and depth were some of thethe children may exhibit normal dental features like previous methods for measuring the dental arch curve.normal mastication and appearance, space and occlusion Various experts have defined the dental arch curvaturefor proper and healthy functioning of permanent through use of biometry by measurement of angles, lineardentition. Physical appearance does directly impact on distances & ratios (Brader, 1972; Ferrario et al., 1997,the self-esteem and inter-personal behaviour of the 1999, 2001; Harris, 1997; Braun et al., 1998; Burris andhuman individual, while dental health challenges like Harris, 2000; Noroozi et al., 2001). Such analysis,malocclusions, dental caries, gum disease and tooth loss however, has some limitations in describing a three-do require preventive and curative interventions right dimensional (3D) structure like the dental arch (Poggio etfrom childhood so that permanent dentition may be al., 2000). Whereas, there are numerous mathematicalnormal in later years. Prabhakaran, S., et al, (2006) models and geometrical forms that have been put forth bymaintain that the various parts of the dental arch during various experts, no two models appear to be clearlychildhood, viz., canine, incisor and molar play a vital role defined by means of a single parameter (Noroozi, H., etin shaping space and occlusion characteristics during al, 2001).permanent dentition and also stress the importance of thearch dimensions in properly aligning teeth, stabilizing the DEFINING THE DENTAL ARCHform, alleviating arch crowding, and providing for anormal overbite and over jet, stable occlusion and a Models for describing the dental arch curvature includebalanced facial profile. Both research aims and clinical conic sections (Biggerstaff, 1972; Sampson, 1981),diagnosis and treatment have long required the study of parabolas (Jones & Richmond, 1989), cubic spline curvesdental arch forms, shape, size and other parameters like (BeGole, E.A., 1980), catenary curves (Battagel, J.M.,over jet and overbite, as also the spacing in deciduous 1996), and polynomials of second to eight degree (Pepe,dentition. In fact, arch size has been seen to be more S.H., 1975), mixed models and the beta function (Braun,important than even teeth size (Facal-Garcia et al., 2001). et al, 1998). The definitions differ as because ofWhile various efforts have been made to formulate a differences in objectives, dissimilarity of samples studied 39 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • and diverse methodologies adopted and uniform results NORMAL OCCLUSION AND ITS CHARACTERISTICSin defining and arriving at a generalized model factoringin all symmetries and asymmetries of curvature elude Normal occlusion was first clearly defined by Angleexperts even today. Some model may be suitable in one (1899) which was the occlusion when upper and lowercase while others may be more so in another situation. In molars were in relationship such that the mesiobuccalthis respect, conic sections which are 2nd order curves, cusp of upper molar occluded in buccal cavity of lowercan only be applied to specific shapes like hyperbolas, molar and teeth were all arranged in a smoothly curvingeclipse, etc and their efficiency as ideal fit to any shape of line. Houston et al, (1992) defined normal occlusion asthe dental arch is thus limited (AlHarbi, S, et al, 2006). an occlusion within accepted definition of the ideal andThe beta function, although superior, considers only the which caused no functional or aesthetic problems. Andrews (1972) had previously also mentioned of sixparameters of molar width and arch depth and does not distinct characteristics observed consistently infactor in other dental landmarks. Nor does it consider orthodontic patients having normal occlusion, viz.,asymmetrical forms. In contrast, the 4th order polynomial molar relationship, correct crown angulation &functions are better effective in defining the dental arch inclination, absence of undesirable teeth rotations,than either cubic spline or the beta function (AlHarbi, et tightness of proximal points, and flat occlusal plane (theal, 2006). AlHadi and others (2006) also maintain that curve of Spee having no more than a slight arch andimportant considerations in defining the human dental deepest curve being 1.5 mm). To this, Roth (1981) addedarch through mathematical modelling like symmetry or some more characteristics as being features of normalasymmetry, objective, landmarks used and required level occlusion, viz., coincidence of centric occlusion andof accuracy do influence the actual choice of model relationship, exclusion of posterior teeth duringmade. protrusion, inclusion of canine teeth solely during lateral excursions of the mandible and prevalence of evenOCCLUSION AND ITS TYPES bilateral contacts in buccal segments during centric excursion of teeth. Oltramari, PVP et al (2007) maintainOcclusion is the manner in which the lower and upper that success of orthodontic treatments can be achievedteeth intercuspate between each other in all mandibular when all static & functional objectives of occlusion existpositions or movements. Ash & Ramfjord (1982) state that and achieving stable centric relation with all teeth init is a result of neuromuscular control of the components Maxim intercuspal position is the main criteria for aof the mastication systems viz., teeth, maxilla & functional occlusionmandibular, periodontal structures, temporomandibularjoints and their related muscles and ligaments. Ross MATHEMATICAL MODELS FOR MEASURING THE(1970) also differentiated between physiological and DENTAL ARCH CURVEpathological occlusion, in which the various componentsfunction smoothly and without any pain, and also remain Whether for detecting future orthodontic problems, or for ensuring normal occlusion, a study of the dental archin good health. Furthermore, occlusion is a phenomenon characteristics becomes essential. Additionally, intra-that has been generally classified by experts into three arch spacing also needs to be studied so as to help thetypes, namely, normal occlusion, ideal occlusion and dentist forecast and prevent ectopic or premature teethmalocclusion. eruption. While studies in the past on dentition in children and young adults have shown significantIDEAL OCCLUSION variations among diverse populations (Prabhakaran et al, 2006), dentists are continuously seized of the need toIdeal occlusion is a hypothetical state, an ideal situation. generalize their research findings and arrive at a uniformMcDonald & Ireland (1998) defined ideal occlusions as a mathematical model for defining the human dental archcondition when maxilla and mandible have their skeletal and assessing the generalizations, if any, in the dentalbases of correct size relative to one another, and the teeth shape, size, spacing and other characteristics.are in correct relationship in the three spatial planes at Prabhakaran et al (2006) also maintain that suchrest. Houston et al (1992) has also given various other mathematical modelling and analysis during primaryconcepts relating to ideal occlusion in permanent dentition is very important in assessing the archdentition and these concern ideal mesiodistal & dimensions and spacing as also for helping ensure abuccolingual inclinations, correct approximal proper alignment in permanent dentition during therelationships of teeth, exact overlapping of upper and crucial period which follows the complete eruption oflower arch both laterally and anteriorly, existence of primary dentition in children. They are also of the viewmandible in position of centric relation, and also that proper prediction of arch variations and state ofpresence of correct functional relationship during occlusion during this period can be crucial formandibular excursions. establishing ideal desired esthetic and functional occlusion in later years.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 40
    • While all dentists and orthodontists seem to be more or (1975). In Pepe’s view, there could be supposed to exist,less unanimous in perceiving as important the at least in theory, a unique polynomial equation havingmathematical analysis of the dental arch in children in degree (n + 1) or less (n was number of data points) thatnormal occlusion, no two experts seem agreeable in would ensure exact data fit of points on the dental archdefining the dental arch by means of a single generalized curve. An example would be the polynomial equationmodel. A single model eludes the foremost dental based on Le-Granges interpolation formula viz.,practitioners owing to the differences in samples studied Y = nΣ i](x-xi)/xi-xi), where xi, yi were data points. i=1Vi∏ [i≠with regard to their origins, size, features, ages, etc. Thuswhile one author may have studied and derived his In 1989, Jones & Richmond used the parabolic curve toresults from studying some Brazilian children under some explain the form of the dental arch quite effectively. Theirpreviously defined test conditions, another author may effort did contribute to both pre and post treatmenthave studied Afro-American children of another age benefits based on research on the dental arch. However,group, sample size or geographical origins. Also, within Battagel (1996) used the catenary curves as a fit for thethe same set of samples studied, there are also marked arch curvature and published the findings in the popularvariations in dental arch shapes, sizes and spacing as British Journal of Orthodontics, proving that the Britishfound out by leading experts in the field. Shapes are also researchers were not far behind their Americanunpredictable as to the symmetry or asymmetry and this is counterparts. Then, Harris (1997) made a longitudinalanother obstacle to the theoretical generalization that study on the arch form while the next year (1998), Brauncould evolve a single uniform mathematical model. and others put forth their famous beta function model forHowever, some notable studies in the past decades do defining the dental arch. Braun expressed the betastand out and may be singled out as the most relevant and function by means of a mathematical equation thus :significant developments in the field till date.The earliest models were necessarily qualitative, ratherthan quantitative. Dentists talked of ellipse, parabola,conic section, etc when describing the human dentalarch. Earlier authors like Hayashi (1962) and Lu (1966) In the Braun equation, W was molar width in mm anddid attempt to explain mathematically the human dental denoted the measured distance between right and leftarch in terms of polynomial equations of different orders. 2nd molar distobuccal cusp points and D the depth of theHowever, their theory could not explain asymmetrical arch. A notable thing was that the beta function was afeatures or predict fully all forms of the arch. Later on, symmetrical function and did not explain observedauthors like Pepe (1975), Biggerstaff (1972), Jones & variations in form and shape in actual human samplesRichmond (1989), Hayashi (1976), BeGole (1980) made studied by others. Although it was observed by Pepetheir valuable contributions to the literature in the dental (1975) that 4th order polynomials were actually a betterfield through their pioneering studies on teeth of various fit than the splines, in later analyses in the 1990s, itsample populations of children in general, and a appeared that these were even better than the betamathematical analysis of the dental arch in particular. (AlHarbi et al, 2006). In the latter part of the 1990s,While authors like Pepe and Biggerstaff relied on Ferrario et al (1999) expressed the dental curve as a 3-Dsymmetrical features of dental curvature, BeGole was a structure. These experts conducted some diverse studiespioneer in the field in that he utilized the asymmetrical on the dental arch in getting to know the 3-D inclinationscubic splines to describe the dental arch. His model of the dental axes, assessing arch curves of bothassumed that the arch could not be symmetrical and he adolescents and adults and statistically analysing thetried to evolve a mathematical best fit for defining and Monson’s sphere in healthy human permanent dentition.assessing the arch curve by using the cubic splines. Other key authors like Burris et al (2000), who studied theBeGole developed a FORTRAN program on the maxillary arch sizes and shapes in American whites andcomputer that he used for interpolating different cubic blacks, Poggio et al (2000) who pointed out thesplines for each subject studied and essentially tried to deficiencies in using biometrical methods in describingsubstantiate a radical view of many experts that the arch the dental arch curvature, and Noroozi et al (2001) whocurve defied geometrical definition and such perfect showed that the beta function was solely insufficient togeometrical shapes like the parabola or ellipse could not describe an expanded square dental arch form, perhaps,satisfactorily define the same. He was of the view that the constitute some of the most relevant mathematicalcubic spline appropriately represented the general analyses of recent years.maxillary arch form of persons in normal occlusion. Hiswork directly contrasted efforts by Biggerstaff (1972) who Most recently, one of the most relevant analyses seems todefined the dental arch form through a set of quadratic have been carried out by AlHarbi ad others (2006) whoequations and Pepe who used polynomial equations of essentially studied the dental arch curvature ofdegree less than eight to fit on the dental arch curve individuals in normal occlusion. They studied 40 sets of 41 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • plaster dental casts - both upper and lower - of male and used a parabola of the form x2 = -2py for describing thefemale subjects from ages 18 to 25 years. Although their shape of the dental arch while others like Pepe (1975)samples were from adults, they considered four most have stressed on the catenary curve form defined by therelevant functions, namely, the beta function, the equation y = (ex + e-x)/2. Biggerstaff (1973) has alsopolynomial functions, the natural cubic splines, and the mentioned of the equation (x2/b2) + (y2/a2) = 1 thatHermite cubic splines. They found that, whereas the defines an ellipse. BeGole (1980) then developed apolynomials of 4th order best fit the dental arch computer program in FORTRAN which was used toexhibiting symmetrical form, the Hermite cubic splines interpolate a cubic spline for individual subjects whobest described those dental arch curves which were were studied to effectively find out the perfectirregular in shape, and particularly useful in tracking mathematical model to define the dental arch. Thetreatment variations. They formed the opinion at the end method due to BeGole essentially utilized the cubicof their study of subjects – all sourced, incidentally, from equations and the splines used in analysis were eithernationals of Saudi Arabia – that the 4th order polynomials symmetrical or asymmetrical. Another method, finitecould be effectively used to define a smooth dental arch element analysis used in comparing dental-arch formscurve which could further be applied into fabricating was affected by homology function and the drawbacks ofcustom arch wires or a fixed orthodontic apparatus, element design. Another, multivariate principalwhich could substantially aid in dental arch component analyses, as performed by Buschang et alreconstruction or even in enhancement of esthetic beauty (1994) so as to determine size and shape factors fromin patients. numerous linear measurements could not satisfactorily explain major variations in dental arch forms and theCOMPARISON OF DIFFERENT MODELS FOR method failed to provide for a larger generalization inANALYSING THE DENTAL ARCH explaining the arch forms.The dental arch has emerged as an important part of ANALYSING DENTAL ARCH CURVE IN CHILDREN INmodern dentistry for a variety reasons. The need for an NORMAL OCCLUSIONearly detection and prevention of malocclusion is oneimportant reason whereby dentists hope to ensure a Various studies have been conducted by different expertsnormal and ideal permanent dentition. Dentists also for defining human dental arch curves by a mathematicalincreasingly wish to facilitate normal facial appearance in model and whose curvature has assumed importance,case of teeth and space abnormalities in children and particularly in prediction, correction and alignment ofadults. What constitutes the ideal occlusion, ideal intra- dental arch in children in normal occlusion. The study ofarch and adjacent space and correct arch curvature is a children in primary dentition have led to some notablematter of comparison among leading dentists and advances in dental care and treatment of various dentalorthodontists. diseases and conditions, although, an exact mathematical model for the dental arch curve is yet to be arrived at.Previous studies done in analyzing dental arch shape Some characteristic features that have emerged duringhave used conventional anatomical points on incisal the course of various studies over time indicate that noedges and on molar cusp tips so as to classify forms of the single arch form could be found to relate to all types ofdental arch through various mathematical forms like samples studied since the basic objectives, origin andellipse, parabola, cubical spline, etc, as has been heredity of the children under study, the drawbacks of thementioned in the foregoing paragraphs. Other geometric various mathematical tools, etc, do inhibit a satisfactoryshapes used to describe and measure the dental arch and perfect fit of any one model in describing the dentalinclude the catenary curves. Hayashi (1962) used arch form to any degree of correction. However, it hasmathematical equations of the form: y = axn + eα (x-β ) and been evident through the years of continuous study byapplied them to anatomic landmarks on buccal cusps and dentists and clinical orthodontists that children exhibitincisal edges of numerous dental casts. However, the certain common features during their childhood, whenmethod was complex and required estimation of the their dentition is yet to develop into permanent dentalparameters like α Also, Hayashi did not consider ,β , etc. form. For example, a common feature is the eruption ofthe asymmetrical curvature of the arch. In contrast, Lu primary dentition in children that generally follows a(1966) introduced the concept of fourth degree fixed pattern. The time of eruption of various teeth likepolynomial for defining the dental arch curve. Later, incisors, molars, canines, etc follow this definite patternBiggerstaff (1973) introduced a generalized quadratic over the growing up years of the child. The differences ofequation for studying the close fit of shapes like the teeth forms, shape, size, arch spacing and curvature, etc,parabola, hyperbola and ellipse for describing the form of that characterize a given sample under study forthe dental arch. However, sixth degree polynomials mathematical analysis, also essentially vary with theensured a better curve fit as mentioned in studies by Pepe, nationality and ethnic origin of a child. In oneSH (1975). Many authors like Biggerstaff (1972) have longitudinal study by Henrikson et al (2001) that studiedJIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 42
    • 30 children of Scandinavian origin with normal Battagel J.M., 1996, “Individualized catenary curves:occlusion, it was found that when children pass from their relationship to arch form and perimeter”, Britishadolescence into adulthood, a significant lack of stability Journal of Orthodontics, 23:21–28.in arch form was discernible. In another study, expertshave also indicated that dental arches in some children BeGole E. A., 1980, “Application of the cubic splinewere symmetrical, while in others this was not so, function in the description of dental arch form”, J Dentindicating that symmetrical form of a dental arch was not Res., 59:1549–1556.a prerequisite for normal occlusion. All these studies Biggerstaff, R.H., 1972, “Three variations in dental archbased on mathematical analysis of one kind or another form estimated by a quadratic equation”, Journal ofhave thrown up more data rather than been correlated to Dental Research, 51: 1509deliver a generalized theory that can satisfactorilyassociate a single mathematical model for all dental arch Brader A C, 1972, “Dental arch form related to intra-oralforms in children with normal occlusion. force: PR = C”, American Journal of Orthodontics, 61: 541–561CONCLUSION Braun S, Hnat W P, Fender D E, and Legan H L, 1998,Factors that determine satisfactory diagnosis in “The form of the dental arch”, Angle Orthodontist, 68:orthodontic treatment include teeth spacing and size, the 29–36dental arch form and size. Commonly used plaster modelanalysis is cumbersome, whereas many scanning tools, Burris B G, and Harris F H, 2000, “Maxillary arch size andlike laser, destructive and computer tomography scans, shape in American blacks and whites”, Anglestructured light, magnetic resonance imaging, and Orthodontist, 70: 297–302ultrasound techniques, do exist now for accurate 3-Dreconstruction of the human anatomy. The plaster Buschang PH, Stroud J, and Alexander RG, 1994,orthodontic methods can verily be replaced successfully “Differences in dental arch morphology among adultby 3-D models using computer images for arriving at females with untreated Class I and Class II malocclusion”,better accurate results of study. The teeth measurement European Journal of Orthodontics, 16: 47-52using computer imaging are accurate, efficient and easy Facal-Garcia M, de Nova-Garcia J, and Suarez-to do and would prove to be very useful in measuring Quintanilla D., 2001, “The diastemas in deciduoustooth and dental arch sizes and also the phenomenon of dentition: the relationship to the tooth size and the dentaldental crowding. Mathematical analysis, though now arches dimensions”. J Clinical Paediatric Dentistry, 2001,quite old, can be applied satisfactorily in various issues 26:65-9.relating to dentistry and the advances in computerimaging, digitalization and computer analysis through Ferrario V F, Sforza C, and Miani Jr A, 1997, “Statisticalstate-of-the-art software programs, do herald a new age in evaluation of Monson’s sphere in healthy permanentmathematical modelling of the human dental arch which dentitions in man”, Archives of Oral Biology, 42:could yet bring in substantial advancement in the field of 365–369Orthodontics and Pedodontics. This could in turn usherin an ideal dental care and treatment environment so Ferrario V F, Sforza C, Colombo A, Ciusa V, and Serrao G,necessary for countering lack of dental awareness and 2001, “3- dimensional inclination of the dental axes inprevalence of dental diseases and inconsistencies in healthy permanent dentitions – a cross-sectional study inchildren across the world. normal population”, Angle Orthodontist, 71: 257–264BIBLIOGRAPHY Ferrario V F, Sforza C, Poggio C E, Serrao G, and Colombo A, 1999, Three dimensional dental archAlHarbi, S., Alkofide, E.A. and AlMadi, A., 2006, curvature in human adolescents and adults”, American“Mathematical analysis of dental arch curvature in Journal of Orthodontics and Dento-facial Orthopaedics,normal occlusion”, The Angle Orthodontist: Vol. 78, No. 115: 401–4052, pp. 281–287 Harris E F, 1997, “A longitudinal study of arch size andAndrews LF, 1972, "The six keys to normal occlusion", form in untreated Adults”, American Journal ofAmerican Journal of Orthodontics & Dento-facial Orthodontics and Dento-facial Orthopaedics, 111:Orthopaedics, 62(3): 296-309 419–427Angle E.H., 1899, “Classification of malocclusion”, Hayashi, T., 1962, “A Mathematical Analysis of the CurveDental Cosmos, 4: 248-264 of the Dental Arch”, Bull, Tokyo Medical Dental University, 3: 175-218Ash M.M., and Ramfjord S.P.1982, Occlusion, 3rd edn,Philadelphia: W.B. Saunders Co 43 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • Hendrikson, J., Persson, M., and Thilander, B., 2001, Poggio C E, Mancini E, and Salvato A, 2000, “Valutazione“Long term stability of dental arch in normal occlusion degli effetti sulla forma d’arcata della terapia fi ssa e dellafrom 13 to 31 years of age”, European Journal of recidiva mediante la thin plate spline analysis”,Orthodontics, Pub 23: 51-61 Ortognatodonzia Italiana, 9: 345–350Houston WJB, Stephens CD and Tulley WJ, 1992, A Prabhakaran S, Sriram CH, Muthu MS, Rao CR, andTextbook of Orthodontics, Great Britain: Wright, Sivakumar N., 2006, “Dental arch dimensions in primarypp.1-13. dentition of children aged three to five years in Chennai and Hyderabad”, Indian Journal of Dental Research,Jones, M.L. and Richmond, S., 1989, “An assessment of Chennai, India, Retrieved from the Worldthe fit of a parabolic curve to pre- and post-treatmentdental arches”, British Journal of Orthodontics, 16: 85-93 Wide Web Feb 24, 2009: http://www.ijdr.in/text.asp?2006/17/4/185/29866Lu, K.H., 1966, “An Orthogonal Analysis of the Form,Symmetry and Asymmetry of the Dental Arch”, Ross I.F., 1970, Occlusion: A concept for the clinician, St.Oral Biology, 11: 1057-1069 Louis: Mosby Company.McDonald, F and Ireland A J, 1998, Diagnosis of the Roth RH, 1981, “Functional occlusion for theOrthodontic Patient, New York: Oxford University Press orthodontist”, Journal of Clinical Orthodontics, 15: 32-51Noroozi H, Hosseinzadeh Nik T, and Saeeda R, 2001, Sampson, P. D., 1981, “Dental arch shape: a statistical“The dental arch form revisited”, Angle Orthodontist, 71: analysis using conic sections”, American Journal of386–389 Orthodontics, 79:535–548.Oltramari PVP, Conti AC de Castro F, Navarro R de Lima,de Almeida MR, de Almeida-Pedrin RR, and Ferreira FPC,2007, “Importance of Occlusion Aspects in the Corresponding author :Completion of Orthodontic Treatment”, Brazilian Dental Abu-Hussein Muhamad, DDS,MScD.MSc,DPD,FICDJournal, 18 (1), ISSN 0103-6440 123 Argus Street 10441 AthensPepe, S.H., 1975, “Polynomial and catenary curve fits to Greecehuman dental arches”, J Dent Res. 54: 1124–1132. abuhusseinmuhamad@gmail.comJIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 44
    • MOBILE DENTAL CLINIC – AN OUTREACH GOVERNMENTPROGRAMME - AN OVERVIEWDr. Ramasubramanian .S, BDS1Madras Dental College and Formerly Assistant Dental Surgeon, CMC Hospital, Vellore,Now Chief Dental Surgeon, Mobile Dental Unit, Health Services, Government of Puducherry. ABSTRACT: The Mobile Dental Unit programme of Government of Puducherry Health Services is entirely funded by Government of Puducherry and has eight staff; so as to reach rural Primary Health Centres and Schools for Dental awareness Programmes and treatment camps inside the dental chair fitted van. The complete functioning is this community programme discussed.HISTORY: autoclave, ultrasonic scaler and cleaner RC instruments, reduction hand piece amalgamator. In addition the staffThis unit was started about 35 years ago along with nurse maintains an oxygen cylinder, emergency drugstudent health programme with a fully equipped van tray, ambu bag with mask, oral airway, foot operatedunder Directorate of Health & Family Welfare Services, suction apparatus and BP apparatus.Government of Puducherry, since then with enormouschanges the programme is still functioning. ACTIVITIES:HUMAN RESOURCES: The Mobile Dental Team visits both Rural Primary Health Centres and Government Schools. Dental Surgeon - 1 Public Health Nurse - 1 1. PRIMARY HEALTH CENTRES: Staff Nurse - 1 Dental Hygienist - 1 The Rural Primary Health Centres are informed well in Lower Division Clerk - 1 advance by post called Advance Tour Programme so as to Driver - 1 reach at least 2-4 weeks in advance then this date is Sanitary Assistant - 1 prominently displayed, sometimes certain Sub-Centres (Part Time) are also visited for Dental Screening Purposes. Peon - 1 The van with all staff along with autoclaved instrumentsVEHICLE: goes to the Primary Health Centre almost daily. In Primary Health Centres, usually simple extractions,The Mobile Dental unit Van is a six wheeler Swaraj scaling, fillings with glass Ionomer, miracle mix are done,mazda Van, which has a long clinic cabin fitted with ISO inside the van. Sometimes ,if x-rays are available anterior9001-2000 CERTIFIED DENTAL chair and accessories root canal treatment is also done. Local Anesthesia usedwith diesel as fuel. The present van was purchased in in the van is injection 2% Lignocaine with Adrenaline1996. Electricity is drawn by a lengthy wire into van 1:200000, Plain LA & Injection 0.5% Bupivacaine, whichfrom the power source of school or Primary Health helps the patients to have a painless period of about 5 to 6Centre. Vehicle is fuelled and maintained by hours. Chlorhexidine and desensitising dentifrice areGovernment Automobile Workshop, the clinic cabin is given for the needy patients. Mechanical tooth brush isfumigated with formalin once a week. given for a small number of differently abled students and patients.EQUIPMENTS Third molars and medically compromised are usuallyAn ISO 9001:2000 certified dental chair with referred to nearest teaching dental Hospital, JIPMER etc.,compressor, airotor, micromotor, LED Light Cure, filling After PHC’s visit the van returns to base-office formaterials like IXGP glass ionomer, IRM, ZnOE usual GP, autoclaving instruments refilling, gloves, LA, drugs etc.,silver amalgam/ Electrically operated Programmable and get ready for the next day visit. 45 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • 2. RURAL GOVERNMENT SCHOOL DENTAL HEALTHPROGRAMME:The School authorities are approachedduring April – May and appropriate permission soughtusually for Rural Government High/ Higher SecondarySchools. Then the programme starts by second week ofJune or so. The Advance tour Programme reaches theschool well in advance.The Public health Nurse, staffnurse and dental hygienist as a team help the dentalsurgeon to do the following,a) IEC The mobile dental van parked inside the ruralOn the day of the visit to school the banners are displayed primary health centre.for students on various topics like Dental & Oral Health,Dental Caries progression, Oral Cancer and ill effects oftobacco. The Hygienist demonstrates the ideal brushingtechnique with the help of dental models.b) RestorationMeanwhile the van is parked in a shady place wireplugged in school mains. Then some students preferablygirls from (BPL) below poverty line families, are selectedfrom IX th to XIIth , who have initial caries (class I) . Theninside the dental van, cavity is prepared with airotor andrestored with glass ionomer / miracle mix or even silver View of ISO 9001:2000 certified dental chair andamalgam, sometimes anterior LC fillings are also done. accessories fitted inside the vanc) APF GEL Topical FluorideStudents from VI th To VIII th of rural high and highersecondary schools are called for topical fluorideapplication with gel. The APF gel(acidulated phosphatefluoride) is applied directly over the teeth by studentsthemselves for 3 to 4 minutes. The applicator trays areexpensive hence used for differently abled students. APFGel i.e., 1.23 % w/w fluoride ion from 2.72% Sodiumfluoride manufactured by Pascal international Inc.,WA98004 USA 48 L is used. The work of Public health nurseis appreciated. The dental team at work as the schoolThe students who require extractions are selected and headmaster has a glimpse.asked to come to the nearest Primary Health Centre withparent for treatment on a later date.FINANCIAL OUTLAY:This year the fund was about one lakh rupees for fuel andvehicle repair and rupee 2 lakhs for consumables, underNon-plan head of account.MANAGEMENT:The office is situated on the First Floor of an UrbanPrimary Health Centre. The consumables are purchasedby placing orders after usual 3-4 quotation. The clerk The dental hygienist demonstrates the idealhelps in purchase of materials and settling the bills on brushing technique with a large dental model, also seen are banners on dental caries,time. brushing and oral cancer.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 46
    • ACKNOWLEDGEMENT: The programme bestows its gratitude to the former Director Dr. DilipKumar Baliga M.B.B.S.,M S., for his visionary zeal, encouragement and supporting in general and specially for topical fluoride application for school students as rural preventive oral health programme. Thanks to Mr. J.Jayapragash Stenographer in preparation of this manuscript A differently abled woman using a mechanical tooth brush provided by this unit. Corresponding author : Dr. S. Ramasubramanian Chife Dental Surgeon, Mobile Dental Unit, Office of the Programme Officer, National Programme for Control of Blindness, 1st Floor, Primary Health Centre, Murungapakkam, Puducherry – 605 004. Ph : 0413-2356803 Mobile : 09443293001 A Student receiving treatment inside the van.CONCLUSION:The Mobile Dental Programme has been a success asboth a preventive and treatment programme, sincetreatment like extraction; Scaling and filling are done attheir door step.In future the fuel of the vehicle can be CNG, fitted withGPRS, and computer, to have on line real timeconsultation etc., plan to rope in house surgeons andcommunity PG’s from nearby dental colleges.Suggestions welcome Director, DHFW Services, Saram,Puducherry – 605 013. Phone 0413—2249350. FAX0413-2249351 47 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • NON PHARMACOLOGICAL MANAGEMENT OFDENTAL ANXIETY IN ADULTSDr.A.M.Devapriya MDS1, Dr.D.Mythireyi MDS21,2. SRM Dental College , Department of Public Health Dentistry, Ramapuram, Chennai-600 089.INTRODUCTION: AETIOLOGY OF DENTAL ANXIETY:Dental anxiety is a very common problem encountered a. Direct conditioning : originates due to traumaticalmost everyday by the dental practitioner. In spite of the encounters in the dental officeadvances in the field of dentistry, and increased oral b. Vicarious learning, through role models, such ashealth awareness, dental treatment is frequently family, peers and societyassociated with pain and creates fear, anxiety, and c. Psychodynamic and personality aspects i.e., specificapprehension in the minds of people. Successful traits that when present, increase the patient’smanagement of these patients need clear understanding proneness for apprehension in the dental setting.of their reason for fear and anxiety and can prove to be achallenging experience for the dental team. d. Fear of pain: pain is a source of anxiety, anxiety is a factor which increases pain and increased painEPIDEMIOLOGY: incites further anxiety. e. Blood injury fearsDental anxiety has been ranked 5th among commonlyfeared objects or situations1. It has been estimated that 6 - f. Defined dental treatment factors: Specific dental15% of worlds adult population suffers from high dental treatment factors can arouse anxiety like injection and drill.anxiety and phobia2. Dental anxiety varies with age3,4,gender3,4,culture5 and from person to person. Women g. Other factors like fear of criticism by the dentist,have been reported to have higher level of dental anxiety dentist attitude, dental environment etcthan men3,4. Older people tend to have less dental anxiety Weiner and Sheehan (1990)7 suggested that dentalthan younger individuals3 while studies6 have shown that anxiety could be classified into two groups, with respectit remains unchanged with age. to the source of their anxiety asTERMINOLOGY: 1. Exogenous - conditioning via traumatic dental experiences or vicarious learning! Anxiety: is a general non specific feeling, an 2. Endogenous - vulnerability to anxiety disorders, as unpleasant emotional state, signaling the body to evidenced by general anxiety states, multiple severe prepare for something unpleasant to happen. Dental fears, and disorders of mood Consequences of dental anxiety is a state of apprehension that something anxiety for patient and dentist: dreadful is going to happen in relation to dental 1) Patients avoid dental treatment or postpone treatment or certain aspects of dental treatment . treatment until painful symptoms surfaces.! Fear: is a response to immediate threat. It is a short 2) Patients are uncooperative, frequently interrupt lived phenomenon, disappearing when the external during dental treatment, take longer time to treat8, threat passes. miss appointment9, generally do not follow recommendations, have frequent gagging ,! Phobia: form of fear which is Irrational and out of experience problems in achieving adequate local proportion to the demands of the situation, is beyond anaesthesia, voluntary control, cannot be explained or reasoned, 3) Stressful effect on the dentist10 and the dental team in persists for an extended period of time and is not age the form of frustration and a sense of inadequacy. specific. Dental phobia is abnormal fear or dread of 4) Failure to recognize dental fear and anxiety can affect visiting the dentist for preventive care or therapy and pain threshold of patient. This may lead to increased unwarranted anxiety over dental procedures. stress and stress related emergencies including hyperventilation and vasodepressor syncope.JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 48
    • IDENTIFYING DENTALLY ANXIOUS PATIENTS11: NON PHARMACOLOGICAL MANAGEMENT:Moderately anxious patients: A. BEHAVIOUR MANAGEMENT:Patients hide their anxiety. Prior dental experience American Academy of Pediatric Dentistry (AAPD) hasindicates history of emergency care only and multiple recently changed the terminology from “behaviourcancelled appointments. Patient appears to sit at the management” to “behavioral guidance” to betteredge of chair , eyes roaming around room, taking in describe a continuum of individualized interactioneverything, unnaturally stiff posture, arms and legs involving the dentist and patient, directed towardtensed. “White knuckle syndrome” patient clutches the communication and education, “which ultimately buildsarm rest of dental chair so tightly that their knuckles trust and allays fear and anxiety.”17become ischemic, Sweating of palm and foreheadnoticed with expressions like it’s hot in here, and when BEHAVIOUR MANAGEMENT TECHNIQUES ARE ASquestioned these patients answer quickly. FOLLOWSSEVERELY ANXIOUS PATIENTS: 1) Minimizing provoking stimulus: BehaviourThese patients do not attempt to hide their fear and management starts from the time the patient enters theanxiety from the dentist. They usually avoid dental care dental clinic, any provoking stimulus should be avoidedand present with severe pain, they would have tried all ,this should be taken care of by well mannered staff,home remedy and over the counter prescriptions and friendly and caring attitude of the dentist.when none of these worked they visit the dentist.Although these patients want to get treated, their extreme 2) Positive distractions : distracting by television,fear of dentistry makes them unable to tolerate dental walkman phones ( fig 1), audiovisual aidsprocedure. These patients have raised blood pressure,heart rate, have excessive sweating and dilated pupils 3) Tell, show, do technique: There is an element of fear in all unknown situations, so informing verbally andMEASUREMENT OF DENTAL ANXIETY: demonstrating practically before performing the procedure is called as tell, show, do technique, but thisUse of dental anxiety questionnaires like technique is not effective in phobic or neurotic patients.! Corahs dental anxiety scale12, 4) Simple relaxation techniques: Active relaxation! Modified Corah dental anxiety scale13, techniques by asking the patient to count backward from! Dental fear survey (Ronald kleinknecht)14, 1000 in steps of seven while concentrating on regular breathing, passive relaxation by playing soft music.! Speilberger state trait anxiety inventory15,! Visual analogue scale, 5) Modeling technique: The person observes someone else receiving dental treatment through a visual! Short dental anxiety scale16 presentation like films, slides, pictures or in person. When the anxiety producing situation is portrayed, thePATIENT MANAGEMENT: model shows no anxiety. Modeling leads a person to imitate the same response as the model18.Management can be:1) Non pharmacological management 6) Latrosedation : Relief of anxiety through the doctors behaviour. It involves use of euphemistic language • Behaviour management ,concern towards the patient, greeting the patient, • Acupuncture analgesia spending few moment before starting the treatment, • TENS caring for the patient. Effective iatrosedation,minimizes the depth of pharmacosedation (use of drugs to control2) Pharmacological management- anxiety) required to reach a desired level of relaxation • Anxiolytics ,also maximizes the effectiveness of pharmacosedative technique used. • Sedatives • Hypnotics 7) Contingent escape : Contingent escape offers • Anti histamines, momentary cessation in treatment conditional upon periods of acceptable target behavior. Escape, in this • Conscious sedation and technique, is used as positive reinforcement and is • General anaesthesia usually nothing more than a rest period from the 49 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • procedure. The rest period is earned (contingent) upon analgesia, substitution for premedication in generalcompletion of a desired behavior (acceptable tolerance anaesthesia, control of reflex and autonomic processesor participation in the procedure for a specific period of like gagging, nausea, salivary flow, bleeding ,valuable intime)18. eliminating fear of injections, claustrophobic feeling during nitrous oxide inhalation .8) Voice control: Voice control describes alterations ofvocal volume, pace, and intonation to gain patient’s 13) Guided imagery: Guided-imagery therapy is aattention and influence. psychotherapeutic method employing a patients own internal imagery to uncover and resolve emotional9) Biofeedback techniques : Biofeedback is a type of conflicts . Guided imagery requires the therapist to takedistraction technique that trains people to consciously an active role in guiding the patient through ancontrol certain bodily processes that normally happen exploration of fantasies, dreams, meditations, and otherinvoluntarily, such as heart rate, blood pressure, muscle creations of the imagination. It offers a number of benefitstension, and skin temperature.. The most commonly used over traditional psychotherapeutic approaches,and isforms of biofeedback therapy for controlling dental now finding widespread scientific and publicanxiety are Electromyography (EMG), which measures acceptance, and it is being used to teachmuscle tension, Thermal biofeedback, which measures psychophysiological relaxation, alleviate anxiety25 andskin temperature , electrodermograph (EDG) measures depression. This invaluable mind-body intervention canskin electrical activity and Neurofeedback or be applied with patients at all levels of ability/disability.electroencephalography (EEG) measures brain waveactivity. Respiratory rate biofeedback19 and voluntary B. ACUPUNCTURE ANALGESIA: Acupuncture needleheart biofeedback20 techniques have also been helpful in has been shown to affect 3 areas of the central nervousthe amelioration of dental anxiety system:10) Conditioning techniques: systematic desensitization i. spinal cord centre where enkephalins and– gradually acclimatizing the patient to very minor endorphins block incoming pain impulsesstimuli and teaching them to relax whilst they are beingapplied. Once relaxation is achieved the stimulus can be ii. the midbrain where endorphins activate the raphegradually increased usually over a considerable period of descending system to inhibit spinal cord paintime until the even most feared situation is manageable. transmission by monoamide neurotransmittersIn clinical situation it is applied by first introducingmirror, then probe , hand scalers, maxillary infiltration etc iii. the hypothalamus pituitary axis which releases beta endorphins into the CSF to cause analgesia11) Cognitive behavioural therapy (CBT): Cognitivetechniques can be used to help people gain conscious Endorphins released by acupuncture needle ( fig -3 ) willcontrol over their mental stress-inducing processes, it is a produce opoid like sedation, more of anxiolysis ,takes 20-form of psychotherapy that emphasizes the important 30 min to produce, and lasts for approximately 8-12 hrs,role of thinking in how we feel and what we do. eliminates only pain sensation, can be used inCognitive Behaviour Therapy was developed from combination with local anesthesia to reduce dosecognitive theory21. It works to modify biased and requirement .dysfunctional cognitive processing. Patients areencouraged to test out and experience new ways of C. TRANSCUTANEOUS ELECTRICAL NERVEthinking and behaviour. CBT has been shown to reduce STIMULATION: TENS (fig -4) activates large diameterdental anxiety22. non-noxious afferents which close the pain gate at spinal segments related to the pain. TENS effects may be due to12) Hypnosis : It is defined as “altered condition or state release of endogenous opioids23 which generate theirof consciousness characterized by a markedly increased analgesic action at peripheral, spinal and supraspinalreceptivity to suggestions, the capacity for modification sites. However, other neurochemicals have beenof perceptions and memory, and the potential for implicated in TENS analgesia including GABAsystematic control of variety of usually involuntary acetylcholine, 5-HT , noradrenaline and adenosine.physiological functions ”BARBER 1996 . Another less often used technique, is acupuncture-like TENS (AL-TENS). This activates small diameter afferentsIt can be incorporated in practice for treatment of dental which has been shown to close the pain gate using extra-anxiety ( fig 2) and phobias, pain management in TMJ segmental mechanisms24 . TENS can also be used as adisorders, facial neuralgias, comfort during prolonged counter-irritant, termed intense TENS, using high-treatment. modification of noxious dental habits, reduce intensity and high-frequency currents.the need for anaesthesia or analgesia, postoperativeJIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 50
    • training programs can help to fill this lacunae. Since a large proportion of patients can be treated by Behaviour modification alone, dental practitioners should recognize and apply these psychological methods for managing anxious patients in everyday practice. REFERENCES 1. Agras S, Sylvester D, Oliveau D (1969): The epidemiology of common fears and phobia. Fig 1 : Positive distraction using Walkman phones Comprehensive Psychiatry 10:151-156. 2. Eli I. Oral psychophysiology: stress pain and behaviour in dental care. Boca Raton, FL:CRC Press, 1992. 3. Milgrom P, Fiset L, Melnick S, Weinstein P (1988). The prevalence and practice management consequences of dental fear in a major US city. JAm Dent Assoc 116:641-647. Fig 2 : behavior modification therapy through hypnosis 4. Hakeberg M, Berggren U, Carlsson SG (1992). Prevalence of dental anxiety in an adult population in a major urban area in Sweden. Community Dent Oral Epidemiol 20:97-101. 5. Ekanayake L,Dharmawardena D:Dental anxiety in patients seeking care at the university dental hospitalin srilanka Community Dental Health 2003;20;112-116 6. Locker D, Liddell A (1995). Stability of Dental Anxiety Scale scores: a longitudinal study of older Fig 3: Acupuncture analgesia adults. Community Dent Oral Epidemiol 23:259-261. 7. Weiner, AA, Sheehan DV. Etiology of dental anxiety: psychological trauma or CNS chemical imbalance? Gen Dent 1990;38(1):39-43. 8. Filewich, R.J., E. Jackson, and H. Shore. “The Effects of Dental Fear on the Efficiency of Routine Dental Procedures.” J. Dent. Res. 60 (SpecialIssue A): Abstract No. 895, p. Fig 4: TENS Device 533, 1981.CONCLUSION: 9. Kleinknecht, R.A., R.K. Klepac, and L.D.Alexander. “Origins and Characteristics of Fear of Dentistry.”Dental anxiety is a multidimensional complex JADA 86:842-48, April 1973.phenomenon, which is influenced by personalitycharacteristics, fear of pain, past traumatic dental 10. Katz, C. “Reducing Interpersonal Stress in Dentalexperiences in childhood, and by dentally anxious family Practice.” Dent. Clin. North Ainer. 22 (3):347-59,members or peers. Handling anxious patients in dental July 1978.clinics becomes bothersome. This may be due to the fact 11. Stanley F malamed.Sedation: A guide to patientthat practitioners are not adequately trained to handle management:fourth edition,Mosby publicationsuch situations. Emphasizing behavioural managementtechnique in dental curriculum and undergoing adequate 51 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
    • 12. Norman L. Corah;Development of a Dental Anxiety 24. Wayne W. Herma; Joseph l. Konzelman Jr.; Robert Scale J DENT RES 1969 48: 596 W. Comer, Using transcutaneous electrical nerve stimulation to prevent postoperative pain JADA, Vol.13. Humphris G M, Morrison, T Lindsay S J E. The 133, May 2002 modified dental anxiety scale-validation and United Kingdom norms. 25. Lyndsay C. Bare, Lauren Dundes:Strategies for Combating Dental Anxiety Journal of Dental Comm Dent Health 1995; 12: 143–150. Education November 1, 2004 vol. 68: 1172-117714. Spielberger, C. D. 2010. State-Trait Anxiety Inventory. Corsini Encyclopedia of Psychology15. Kleinknecht RA, Thorndike RM, McGlynn FD,Harkavy J Factor analysis of the dental fear survey with cross-validation. Journal of the American Dental Association 108(1):59-6116. Aartman, I. H. A. (1998), Reliability and validity of the short version of the Dental Anxiety Inventory. Community Dentistry and Oral Epidemiology, 26: 350–354.17. American Academy of Pediatric Dentistry Clinical Affairs Committee-Behavior Management Subcommittee. American Academy of Pediatric Dentistry Council on Clinical Affairs-Committee on Behavior Affairs. Guideline on behavior guidance for the pediatric patient. Ped Dent 2005-2006;27(7 Reference Manual):92-100.18. Do C. Applying social learning theory to children with dental anxiety. J Contemp Dent Pract 2004;5:126-35.20.19. Morarend QA, Spector ML, Dawson DV, Clark SH, Holmes DC.The use of a respiratory rate biofeedback device to reduce dental anxiety: an exploratory investigation Appl Psychophysiol Biofeedback. 2011 Jun;36(2):63-70.20. C. Oliver and R. Hirschman:Voluntary Heart Rate Control and Perceived Affect J DENT RES 1982 :61: 821. Are Techniques Used in Cognitive Behaviour Therapy Applicable to Behaviour Change Interventions Based on the Theory of Planned Behaviour? Journal of Health Psychology Vol 10(1) 7–1822. Eric J. Getka, Carol R. Glass .Behavioral and cognitive-behavioral approaches to the reduction of dental anxiety Behavior Therapy, Volume 23, Issue 3, Summer 1992, Pages 433-44823. Tashani O, Johnson MI .Transcutaneous Electrical Nerve Stimulation (TENS) :A Possible Aid for Pain Relief in Developing Countries? Libyan J Med. 2009; 4(2): 62–65JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 52
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