faculty of dental science issue-1.pdf · dr. hiral purani, dr. sagar patel, dr. ripal shah 66 10...

Faculty of Dental ScienceDharmsinh Desai University

NADIAD

JOURNAL OF DENTAL SCIENCES Volume - VIII Issue 1

I-N-D-E-XMessage 1Editorial 5-6

Conservative dentistry and Endodontics

1 Apexification : creating obstruction for constructionDr. Amee Patel, Dr. Dipti Choksi, Dr.Barkha Idnani

7

2Broken instrument retrieval from maxillary 2nd molar:a case reportDr. Rutu Doshi, Dr. Dipti Choksi, Dr. Barkha Idnani

14

3A holistic approach to aesthetic enhancement using direct compositerestoration- a case reportDr. Chandani Nayak, Dr. Dipti Choksi, Dr.Barkha Idnani

20

Oral and Maxillofacial Surgery

4

Pectoralis major myocutaneous flap formandibular reconstruction in oralsquamous cell carcinoma: a case reportDr. Shripal Jani, Dr. Hiren Patel,Dr.Haren Pandya, Dr. Hitesh Dewan,Dr. Bijal Bhavsar, Dr. Urvi Shah, Dr.Kartik Dholakia

25

5

Dental management of patients onantiplatelet andanticoagulant therapy: a reviewwith current perspectivesDr. Parth Parikh, Dr. Hiren Patel,Dr. Haren Pandya,Dr. Hitesh Dewan, Dr. Bijal Bhavsar,Dr. Urvi Shah,Dr.Kartik Dholakia

33

6

Dental management in patients withrenal disorders: a review with current conceptsDr. Enosh Steward, Dr. Hiren Patel,Dr.Haren Pandya, Dr. Hitesh Dewan,Dr. Bijal Bhavsar, Dr. Urvi Shah,Dr.Kartik Dholakia

42

JOURNAL OF DENTAL SCIENCES Volume - VIII Issue 1

Pedodonitcs

7Amelogenesisimperfecta: a case reportDr. Vrushang Soni, Dr. Viraj Talsania, Dr. Dharmik Patel,Dr. Jyoti Mathur

52

Periodontics & Oral Implantology

8

A survey of attitude about smoking, associated with periodontaldisease and dental implantsDr. Sagar Patel,Dr. Shalini Gupta, Dr. Vasumati Patel,Dr. Hiral Purani, Dr. Kinjal Gabani, Dr. Ripal Shah

57

9

Tooth brushing behaviours and dental abrasion amongthe population in Nadiad, Gujarat, India: a cross-sectional study.Dr. Kinjal Gabani, Dr. Vasumati Patel, Dr. Shalini Gupta,Dr. Hiral Purani, Dr. Sagar Patel, Dr. Ripal Shah

66

10 Periodontal health status of different socio-economicgroups :A cross sectional studyDr. Ripal Shah Dr. Vasumati Patel, Dr. Shalini Gupta,Dr. Hiral Purani, Dr. Kinjal Gabani, Dr. Sagar Patel

74

11Nanorobot- The next generation of dentistryDr. Taruna Sharma, Dr. Viraj Talsania,Dr. Shalini Gupta

81

Preventive and Public Health Dentistry12 Caries risk assessment: A new horizon in preventive approach

Dr. Heena Pandya, Ishani Thakkar, Dr. Jitendra Akhani89

Prosthodontics & Crown and Bridgework13 Implant retained overdenture with bar attachment:a case report

Dr. Khushali Patel, Dr. Somil Mathur, Dr. Rakesh Makwana ,Dr. Snehal Upadhyay, Dr. Vinit Shah

94

14 Full-mouth rehabilitation of partially edentulous patient withseverely worn dentition: a case reportDr. Pankti Naik, Dr. Somil Mathur, Dr. Rakesh Makwana ,Dr. Snehal Upadhyay, Dr. Vinit Shah

102

1Journal Of Dental Science Volume – VIII Issue - 1

Vice Chancellor's Message

Faculty of Dental Science is a shining feather in the hat of Dharmsinh Desai Universitysince last 13 years. I feel nothing less than immense pride at the functioning and stature that theFaculty of Dental Science has achieved. Be it staff or student satisfaction, infrastructure orresources the university has always supported development and will continue to do so in thefuture.

I congratulate the editorial committee for coming up with the new issue of the Journal of theFaculty of Dental Science. Wishing glorious new heights in the field of research and publication.My best wishes and blessings remain with the entire team of Faculty of Dental Science forcontinued progress.

Dr. H.M Desai,

Vice Chancellor,

Dharmsinh Desai University,

Nadiad





Dr. H.M Desai,

Vice Chancellor,


Nadiad





Dr. H.M Desai,

Vice Chancellor,


Nadiad


Trustee's Message

I have seen the development of the Faculty of Dental Science since over a decade, and I applaudtheir stellar performance. They have grown as an institute to reckon with and they have grown asa family. The levels of education and values have always seen an upward graph, and theuniversity looks upon them as an exemplary faculty. I am overjoyed to be a part of this team andpledge my support to the Faculty Dental Science at all times.

Mr. Ankur Desai

Trustee

Dharmsinh Desai University

Nadiad.


Coordinator's Message

Times change, and with it, so do the face of education, the need of education and the modicum of

conveying scientific matter. It is a matter of immense pride and pleasure for me, as the journal of

dental sciences has stayed thus, with constant up-gradations and contributions from staff and

students alike. The upkeep of the culture that encourages scientific writing and documentation is

what keeps the wheels of an institute well oiled and running. I congratulate the entire team of

JODS on yet another brilliant achievement.

Dr. Bimal.S. Jathal,

University Co-ordinator,


Nadiad


Dean's Message

We’re moving forward....join the momentum!

I am extremely happy while penning down this message for our very own Journal of DentalScience, which is an integral part of our institution. We live in a world of information andtechnology and obtaining information has never been easy. In science the books and journalshave been the original source of information and research. Through this journal issue we aim ateducating the readers by highlighting current concepts and treatment aspects in dentistry.Keeping in pace with the current scenario, this year we are going for the online publication of thejournal.

I congratulate the entire editorial committee for its painstaking efforts in bringing out the currentissue of the Journal of Dental Science. I am sure it will serve its purpose of dissemination ofknowledge for students and the faculty.

Dr. Hiren PatelDeanFaculty of Dental ScienceDharmsinh Desai UniversityNadiad.


From the Editor's Desk

“Never let it rest until better turns to best!”

Journal of Faculty of Dental Science, DDU, and Nadiad is afacet to which all of us are associated with. It is a huge responsibilityentrusted on me to be the editor of this prestigious journal. With theblessings of God, my parents and great help and support from myassociate editors Dr.Jigar Purani Dr.Heena Pandya and all themembers of the editorial board, we are today able to present thisissue of our journal.

A great deal of appreciation goes to the former editor Dr.Somil Mathur.During his tenure he and his team have worked with complete dedication bringing to the journal a strongvision and wealth of knowledge.

We at the editorial office filter the manuscripts not only for accuracy but also for balance.This takespatience and time to give true dimension and meaning to the content.Hence I request you all to bear withus.I have noticed that manuscripts get rejected due to plagiarism. We as authors need to check ourmanuscripts for plagiarism before submission so as to not face disappointment on this aspect.

Second thing I would request all the authors to strictly follow the journal guidelines.This will take lesstime for acceptance and publication.

Third aspect to be taken into consideration is the name of authors to be included in the article. I suggestyou all to follow authorship criteria given by ICMJE (www.icmje.org).

We at the journal office are committed to excellence to bring out the best from our authors.I am interestedin your view point and would like to keep an open line of communication with our readers. Please emailyour suggestions, criticisms and comments to [email protected].

“Together we can....”

Dr.Shalini Gupta

Editor

Journal of Dental SciencesDharmsinh Desai UniversityNadiad


Dharmsinh Desai UniversityFaculty of Dental Science

JOURNAL OF DENTAL SCIENCESEditorial Committee Members

Editor

Dr. Shalini Gupta

Professor, Department of Periodontia, FDS, DDU.

EDITORIAL COMMITTEE MEMBERS

Dr. Heena Pandya

Reader, Department of Preventive and CommunityDentistry, FDS, DDU.

Dr. Jigar M. PuraniReader, Department of Oral and MaxillofacialPathology, FDS, DDU.

REVIEWER COMMITTEE MEMBERS

Dr. Amit Mendiratta

Lecturer, Department of Orthodontics, FDS, DDU.

Dr. Hitesh Dewan

Professor, Department of Oral and MaxillofacialSurgery,FDS, DDU.

Dr. Jyoti Mathur

Professor & Head, Department of Pedodontics, FDS,DDU.

Dr. Kevin Parikh

Reader, Department of Oral Medicine, FDS, DDU.

Dr. Kunjal Mistry

Reader, Department of Conservative Dentistry andEndodontics, FDS, DDU.

Dr. Snehal Upadhyay

Lecturer, Department of Prosthodontics, FDS, DDU.

Dr. Vishal Sahayata

Lecturer, Department of Periodontics, FDS, DDU.

Technical Advisor

Dr. Kartik Dholakia

Lecturer, Department of Oral and MaxillofacialSurgery,FDS, DDU.

ADVISORS

Dr. Hiren Patel

Dean, Professor & Head, Department of Oral andMaxillofacial Surgery,FDS, DDU.

Dr. B. S. Jathal

Co-ordinator and Professor, Department ofPeriodontia, FDS, DDU.

ADVISORY BOARD

Dr. Amish Mehta

Professor & Head, Department of Orthodontics,FDS, DDU.

Dr. Bhupesh Patel

Professor & Head, Department of Oral andMaxillofacial Pathology, FDS, DDU.

Dr. Dipti Choksi

Professor & Head, Department of ConservativeDentistry and Endodontics

Dr. Preeti Shah

Professor & Head, Department of Oral Medicine,FDS, DDU.

Dr. Somil Mathur

Professor & Head, Department of Prosthodontics,FDS, DDU.

Dr. Vasumati PatelProfessor & Head, Department of Periodontics, FDS,DDU.

Journal Of Dental Science Volume – VIII Issue – 1 7

ABSTRACT :Open apices with necrotic pulp and periapical lesion present a special challenge in this regard asthey are arduous to treat via conventional endodontic therapy. Apexification using an apical plugof novel biomaterial like Mineral Trioxide Aggregate (MTA) has emerged as an alternative tolong-term intracanal use of calcium hydroxide. This case report attempts to discuss the treatmentprotocol and successful management for such a challenge- traumatized immature tooth withopen apex and radicular cyst.

Keywords: Open apex, immature necrotic permanent tooth, MTA, calcium hydroxide,apexification, radicular cyst

APEXIFICATION : CREATING OBSTRUCTION FOR CONSTRUCTION

*Dr. Amee Patel **Dr. Dipti Choksi ***Dr. Barkha Idnani

Introduction

The immature root with a necrotic pulp andlarge periapical lesion presents multiplechallenges to successful treatment.

i. The infected root canal space cannotbe disinfected with the standard rootcanal protocol with the aggressiveuse of endodontic files.

ii. Once the microbial phase of thetreatment is complete, filling the rootcanal is difficult because the openapex provides no barrier for stoppingthe root filling material beforeimpinging on the periodontal tissues.

*Post Graduate Student

**Professor and Head of Department

***Professor

Department of Conservative Dentistry and

Endodontics,

Faculty of Dental Science, Dharmsinh Desai

University, Nadiad.

iii. Even when the challenges describedearlier are overcome, the roots ofthese teeth are thin with a highersusceptibility to fracture.1

These problems are overcome by using adisinfection protocol that does not includeroot canal instrumentation, stimulating theformation of a hard tissue barrier orproviding an artificial apical barrier to allowfor optimal filling of the canal, andreinforcing the weakened root againstfracture during and after an apical stop isprovided.

Corresponding Author:Dr. Amee Patel ,3rd year Post Graduate Student,Department of Conservative Dentistry andEndodontics.Faculty Of Dental Sciences, DharmsinhDesai University,College Road, Nadiad 387001, Gujarat.(M) +91 9409669369Email:[email protected]

8Journal Of Dental Science Volume – VIII Issue – 1

Until recently, the traditional approach tothe treatment of non-vital teeth withincompletely developed roots has beenapexification by inducing the formation ofmineralized tissue in the apical portion ofincompletely formed apex.The barrierfacilitates the placement of an appropriateroot-filling whilst reducing the possibility ofthe sealant or root-filling extruding intoapical tissues.2, 3

Morse et al reported in their literaturereview three techniques to obturate animmature tooth, which involved the use of aroot-filling material without the induction ofthe apical closure4:

i. placement of a large gutta-perchafilling or customized gutta-perchacone with sealer at the apex;

ii. placement of gutta-percha withsealer or zinc-oxide/ eugenol short ofthe apex;

iii. periapical surgery.

These techniques did not gain popularitysince there was no physical apical barrier tofacilitate obturation. However Morse etal.4also reported two techniques, whichaimed to provide the formation of an apicalbarrier:

• placement of calcium hydroxide to inducea mineralized apical barrier;

• placement of a biocompatible materialsuch as dentinal chips against which a root-filling could be placed.

This case report evaluates the effect ofcalcium hydroxide with mineral trioxideaggregate (MTA) apexification in large

cystic area with a successful conservativenon‑surgically management of a ridiculercyst associated with permanent maxillaryright central and lateral incisor in a 24year old female patient.

Case report :

A 24 year old female patient reported tothe Department of Conservative Dentistryand Endodontics, Faculty of DentalSciences, with a complaint of persistentpain, mobility and swelling in upper frontteeth and palatal area which would occurevery 8-9 months for past 3 years andregress after pus discharge.

Illustration 1: Swelling in palatal area

Past history revealed trauma to maxillaryanterior teeth 10 years back and she didn’ttake any medical intervention during thesame.

Clinical examination revealed that themaxillar right central incisor (#11), rightLateral incisor (#12) teeth were foundto be non vital (necrotic) with grade IIMobility.


Illustration2: Preoperative photograph

An occlusal view of the palate revealedwell- defined radiolucency of considerablesize, involving anterior part of the palate inrelation to #11, #12, with a thin radiopaqueborder. The clinical and radiographic signswere suggestive of chronic periapical cyst inrelation to #11, #12.

Illustration 3: Preoperative radiograph

As the patient was very apprehensiveand not willing for surgical intervention,and non-surgical treatment was plannedfor the management of the pathologyand the informed consent was taken.

Cystic fluid was first aspirated with22 gauge needle from dependent part ofthe swelling on the palate which wasslightly pale straw colored and it wassent for microscopic examination inlaboratory which confirmed it asperiapical cyst.

Illustration 4: Aspirated cystic fluid

Treatment was carried out under localanesthesia. Access cavity was prepared underrubber dam isolation and working length wasdetermined using electronic apex locator andradiographs.

Illustration 5: Working length

determination

On the next visit, calcium hydroxide[Ca(OH)2] with iodoform paste (Metapex, Meta-biomed) was delivered up to the cystic lesionthrough the root canal of teeth (#11 #12). Accesscavity was sealed with interim dressing. Thepatient was kept on follow up.


Illustration 6: Ca(OH)2intracanalmedicament placed

Illustration 7: Six month follow up

The intracanal Ca(OH)2 dressing wasreplenished after every 2 monthsinterval up to 6 months. After 6 monthsof commencement of treatment,calcium hydroxide had induced abarrier against which MTA could becondensed. Calcium hydroxide wasremoved using 17 % EDTA(PrevestDenPro) and copious irrigationand this was verified radio graphically.

Illustration8: Removal of intracanalmedicament

MTA (Angelus) was mixed according tomanufacturer’s guidelines to a thick creamyconsistency. It was then placed 1 mm short ofthe working length using a carrier andcondensed with minimal pressure using thebroad end of appropriate sized pluggers. Dueto its hydrophilic nature, MTA adapts well tothe peri-apical tissues. This was repeateduntil approximately five mm of the materialwas deposited in the apical region which wasverified with a radiograph.

Illustration 9: Apical plug of MTA


A moist cotton wool pledget was thenplaced in the canal (#11) overnight.Thefollowing day, the cotton wool pledget wasremoved and remaining canal space wasobturated by injectable medium viscositythermoplasticized gutta percha(Ultrafil 3D,Coltene)and resin based sealer (AH plus,Dentsply). Access cavities were sealedwith nano-hybrid compositeresin.(Grandio, VOCO)

Illustration10: Obturation with

thermoplasticized gutta percha

Follow up after 1 month revealed asignificant reduction in the size of palatallesion and the palate became normal inappearance. After 3 months, palpableportion of palate become hardened andthe radiolucency of the lesion starteddisappearing but larger amount ofmedicament was still remaining withinthe lesion. However, at 6‑month followup the radiograph showed partialradiopacity with some medicamentapparent in the lesion. Nine monthfollow-up revealed asymptomatic andadequately functioning teeth withradiographic signs of healing.

Illustration 11: Follow up after 9 months

Illustration 12: Final Prosthesis


Discussion :

The above case report presents a triad oftrauma, open apex and periapical lesion.

A combined of approach of aspirationtechnique, calcium hydroxide, mineraltrioxide aggregate. was used to manage thecase.

A periapical lesion increases in size withan increase in the hydrostatic pressure due tofluid accumulation in the bony cavity. Thisincrease in hydrostatic pressure enhances theosteoclastic activity. The aspiration throughthe root canal technique aids in decreasingthe hydrostatic pressure in the periapicallesion.5

The response to trauma can be varied.Some pulps remain apparently normal withno adverse effects; whereas others becamenecrotic. Necrotic pulps provide a goodnutritional supply for pathogenic bacteria,which must be present for the development ofa periapical lesion. The treatment optionsavailable to manage large cysts range fromnonsurgical root canal treatment and/or apicalsurgery to extraction. In some instances,nonsurgical treatment may be ineffective ordifficult; those cases may be treated bysurgery. In the present study, radiographsrevealed that the involved teeth had largeperiradicular lesion with uniformly denseradiolucency and well-defined marginsaround the apices.

Calcium hydroxide has also beentraditionally used for apexification ofnonvital immature teeth. However, thismethod is time-consuming and the barrierformed is usually incomplete, revealing‘tunnel defects’ histologically which canallow microleakage.6 Furthermore, long-termexposure of root dentin to calcium hydroxidecan lead to a decrease in the fractureresistance of teeth. With the MTA apical plug

technique, a one-step obturation after shortcanal disinfection with calcium hydroxidecould be performed. MTA has beensuccessfully used for apexification ofnonvital immature teeth. It is moreadvantageous than calcium hydroxide withregard to its sealing ability and reducedtreatment time. Reports advocating singlesession placement of MTA as an apicalbarrier without inter appointment calciumhydroxide placement are scarce.7

MTA, when it comes in direct contactwith the tissues forms calcium hydroxide thatreleases calcium ions for cell attachment andproliferation. . Scaffolding is provided forhard tissue formation by MTA whichmodulates cytokine production, encouragesdifferentiation and migration of hard tissueproducing cells. Hydroxyapatite is formed onthe surface of the mineral trioxide aggregate,thus providing a biologic seal.8

Clinicians may restore the tooth aftersetting of MTA. Thus, the fracture resistanceof teeth with thin dentinal walls increases.MTA can also be used in teeth with pulpnecrosis and inflamed periapical lesionsbecause it may set in moist environments.9

Conclusion :

Endodontic therapy with repeatedintracanal dressing obviates the need forsurgery in most of the clinical scenarios.

Based on this case report results, thefollowing conclusions can be made:

MTA showed clinical andradiographic success as a materialused to create apical closure innecrotic immature permanent teeth.

MTA is a promising replacement forCa(OH)2 for the apexificationprocedure.


Endodontic therapy using a combination ofcalcium hydroxide dressing and MTAplacement was successful in healing largeradicular cyst thus highlighting endodonticbiologic rationale.

References :

1. Trope M. Treatment of the immaturetooth with a non-vital pulp and apicalperiodontitis. Dent Clin North Am2010;54(2):313–324.

2. Güneş B, Aydinbelge HA. Mineraltrioxide aggregate apical plug methodfor the treatment of nonvital immaturepermanent maxillary incisors: Three casereports. Journal of ConservativeDentistry : JCD.2012;15(1):73-76.

3. Vojinovic J, Cupic S, DolicMirjanic D,Sukara S, Obradovic M. Success rate ofthe endodontic treatment of youngpermanent teeth with calcium hydroxide.Contemp Mater. 2010 ;(2):164–167.

4. Morse DR, Larnie J, Yesilsoy C.Apexification: review of theLiterature.QuintessenceInternational.1990;21(7),589-596.

5. Fernandes M, de Ataide I. Nonsurgicalmanagement of a large periapical lesionassociated with an immature toothdisplaying external inflammatoryresorption. J Conserv Dent2015;18(4):349-353.

6. S.G. Damle, H. Bhattal, A.LoombaApexification of anterior teeth: acomparative evaluation of mineraltrioxide aggregate and calciumhydroxidepasteJ ClinPediatr Dent,2012;36(3)263-268

7. Gawthaman M, Vinodh S, Mathian VM,Vijayaraghavan R, Karunakaran R.Apexification with calcium hydroxideand mineral trioxide aggregate: Reportof two cases. Journal of Pharmacy &Bioallied Sciences. 2013;5(2):131-134.

8. Asgary S, Moosavi SH, Yadegari Z,Shahriari S. Cytotoxic effect of MTAand CEM cement in human gingivalfibroblast cells: scanning electronicmicroscope evaluation. N Y State Dent J2012;78(2):51–54.

9. Torabinejad M, Abu-Tahun I.Management of teeth with necrotic pulpsand open apices. Endod Top2012;23:105–130.


BROKEN INSTRUMENT RETRIEVAL FROM MAXILLARY 2ND

MOLAR- A CASE REPORT

*Dr. Rutu Doshi **Dr Dipti Choksi ***Dr. Barkha Idnani

Abstract :

One of the most common mishaps occurs during routine endodontic treatment is the fracture

of instrument inside the root canal. The separated instrument leads to metallic obstruction and

prevents thorough cleaning and shaping procedures. Factors should take into the consideration

are tooth type and canal curvature, instrument position and type before attempting instrument

retrieval. This case report illustrates instrument retrieval from 27 using small artery forceps and

re root canal treatment of same tooth.

Keywords: H file, instrument separation, instrument retrieval, stieglitz pliers, artery forceps

Introduction

Separation of endodontic instruments withinthe root canal is an unfortunate occurrencethat may hinder root canal procedure andaffect the outcome. This instrument isusually some type of file or reamer but caninclude gates-Glidden or peeso reamers,lentulo spiral paste fillers, thermomechanical gutta percha compactors, tips ofhand instruments such as explorers or guttapercha spreaders. The separated instrumentleads to metallic obstruction in the rootcanal and prevents thorough cleaning andshaping procedures.1The retrieval of

separated instruments is usually verydifficult and often ineffective. Differentmethods have been proposed for retrievingobjects separated into the root canal.In thepast, chemicals such as hydrochloric acid,sulfuric acid, and concentrated iodinepotassium iodide were used in an attempt todissolve the metal obstruction, which is nowirrelevant because of the metals used today,as well as the obvious safety issues.Recently, specialized devices and techniqueshave been introduced specifically to removeseparated instruments such as ultrasonicdevices, Instrument Retrieval System (IRS)and Masserann kit.

*Post Graduate Student

**Professor and Head of Department

***Professor

Department of Conservative Dentistry andEndodontics,Faculty of Dental Sciences,Dharmsinh Desai University, Nadiad.

Corresponding Author:Dr.Rutu DoshiDepartment of Conservative Dentistry andEndodontics, Faculty of Dental Sciences,Dharmsinh Desai University,College road, Nadiad-387001.Gujarat.(M)[email protected]


All these devices have shown limitations,such as excessive removal of root canaldentin, ledging, perforation, limitedapplication in narrow and curved roots, andextrusion of the separated portion throughthe apex.2

If broken instrument is located at theroot canal orifice level or just below it thatcan be grasped by various forceps. Use offorceps not only prevents the excessiveremoval of dentin, it also reduces chances ofroot fracture and furcal perforation byoverzealous use of ultrasonics. This paperreports a case of H file retrieval with smallcurved artery forceps from 27 and re rootcanal of the same tooth.Case reportA 35 year old female patient referred toDepartment of Conservative Dentistry andEndodontics with the chief complains ofcontinuous pain at upper left side of mouthfor 1 week. Pain was intermittent in nature,dull and that was not associated with anykind of swelling or sinus tract.Patientpresented with past dental history ofpreviously attempted root canaltreatment.Intra oral examination revealedfractured temporary restoration in relation to27 and tooth was tender to percussion.Radiographic examination revealed afractured instrument in the distobuccal canalof 27. It was engaged into remaining gutta-percha of the same canal. There wasincomplete biomechanical preparation aswell as nonobturated other two canals(mesiobuccal and palatal).Detailedradiographic examination revealed abouttype of the separated instrument. It wastortuous in shape, it was H file. Theperiodontal space widening with apicalradiolucency was present in 27.Based onclinical and radiographical examinationdiagnosis of asymptomatic apicalperiodontitis of 27 was made. Re root canaltreatment of 27 with broken instrument

retrieval from distobuccal canal of 27 wasplanned.

Illustration 1: Pre operative IOPA

of 27 showing separated

instrument in distobuccal canal

Illustration 2: Clinical photograph

showing orifice enlargement with

separated instrument in distobuccal

canal of 27.











canal of 27.











canal of 27.


Treatment plan :

On the first appointment, localanaesthesia (2% Lignocaine with adrenaline,Xicaine, ICPA, India) was administered.Fractured temporary restoration wasremoved and straight line access wasestablished. As seen in pre operativeIOPAR, H file was embedded in dentin aswell as in apical 5mm of gutta-percha.(Illustration 1)Following step by steptechnique was followed to remove it. Agroove was prepared along side of theinstrument with the hand K files (No.10)(Mani, Japan) to create a working space tofacilitate the entry with Gates Gliddendrills into distobuccal canal of 27. Orificeenlargement was done with no 2 and 3 GatesGlidden drills. (Dentsply Maillefer,Ballaigues, Switzerland) (Illustrati-on-2) Bythis enlargement, a space to place smallartery forceps was prepared. (Illustration-10)A firm grip was established with small andcurved artery forceps and gentle, coronallydirected pulling force was applied. Repeatedapplication of pulling as well as counterclock wise motion with firm grip of arteryforceps did disengagement of H file fromRoot dentin as well as from apical guttapercha & successful retrieval of H file fromthe distobuccal canal was done.(Illustarion-3)

Remaining Gutta percha was removed withthe help of Gutta percha solvent (RC Solve,Prime Dental) and H file from distobuccalcanal of 27.Negotiation of all 3 canal wasdone. (Mesiobuccal, Distobuccal, Palatal.)(Illustration-4)Working length wasmeasured of all 3 canal and was confirmedby IOPAR.(Illustation-5) Biomechanicalpreparation done with copious irrigationwith diluted 5% sodium hypochlorite(VishalDentocare).Master cone fit was checked andconfirmed by IOPAR, obturation done withAH plus sealer (Dentsply, Detrey,Gmbh,Germany). (Illustration 6, 7) Postendodontic restoration was done with hybridcomposite (Unicorn Denmart, Prime Dental,USA).

Illustration 3: retrieved H file fromDistobuccal canal of 27.

Illustration 4: All 3 canalnegotiation


Treatment plan :






Treatment plan :






Discussion :Decision on management of intracanalseparated instrument should consider thefollowing3-11:1. Root canal anatomy accommodatingfragment.2. Stage of root canal preparation at whichthe instrument separated.

3. Expertise of clinician.4. Armamentarium available.5. Potential complication of treatmentapproach adopted.6. Strategic importance of the toothinvolved.7. Presence or absence of periapicalpathosis.8. Design of separated instrument

Guidelines for management of brokeninstrument are:Referring the patient to a specialist is a firstoption if the following is true12:

Illustration 5: working lengthdetermination

Illustration 6: master coneconfirmation

Illustration 7: Obturation

Illustration 8: Post endodonticrestoration of 27


















1. The clinician is incompetent attechniques.2. Good armamentarium is not available.Two approaches are there for management

of intracanal separated instrument.1. Orthograde approach: This includes:a. Removal of instrument.b. Bypass of instrument.c. Cleaning and shaping at the level offractured instrument.2. Surgical approach:1. Orthograde approachAttempt of removing the fragment can beestablished as a first management optionwhen the following is true13, 14:1. The fragment is accessible (located in thecoronal third, middle coronal part of the rootcanal, or before the canal curvature).2. There is a low risk of furthercomplications.3. The tooth is strategically important.4. The instrument separated at an early stageof root canal cleaning and shaping.5. The clinician is well trained or hassufficient experience.Attempt at bypassing the fragment can beconsidered in the following circumstances15:1. As a second approach if removalattempt(s) fail.2. As a first approach if the fragmentseparated at an early stage of the cleaningand shaping and is inaccessible (located inthe apical canal third, middle apical part ofthe root canal, or beyond the canalcurvature).3. In a strategically important tooth, and theclinician has sufficient experience.

Leaving the fragment in situ, filling theroot canal to the fragment level andreviewing the case can be considered in thefollowing circumstances:1. As a last conservative approach whenattempts at removal and bypassing of thefragment are unsuccessful.

2. As a first approach if the clinician is notconfident or competent at other conservativeoptions.3. As a first approach if the instrumentseparated at a late stage during root canalcleaning and shaping in inaccessible part ofthe canal.2. Surgical approachIt can be considered in the followingsituations:1. As a last resort if other conservativeapproaches fail, post-treatment diseasedeveloped, and the tooth is strategicallyimportant.2. As a first approach when periapicalpathosis is present at the time of instrumentseparation, especially if the separationoccurred at an early stage of instrumentation

As in this case report we have used smallartery forceps for retrieval of intracanalseparated instrument. Other than that varioustypes of forceps are available like:7, 15

Haemostats,Stieglitz forceps,Modified Castroviejo needle holder,Perry plier.

Illustration 9: A Stieglitz plier


















A Stieglitz plier is specifically designed forretrieval of coronally located brokeninstrument. Smaller beak size eases its use(Illustration-9). So this various forceps aregood substitutes of ultrasonics for retrievalof coronally located broken instrument toprevent overzealous preparation of canal andits risks.

Conclusion :

There is no standardized procedure forsuccessful and guaranteed removal ofseparated instrument from root canal.Improved visualization combined with aconservative approach leads to favorableprognosis of tooth. Vast majority ofseparated instruments can be removed ifdone with care, time and rightarmamentarium, with proper knowledge ofroot anatomy and position of the fracturedsegment. The best antidote for a broken fileis prevention.

References :

1. Raju Chauhan. Anil Chandra. Retrieval of aseparated instrument from the root canalfollowed by non-surgical healing of a largeperiapical lesion in maxillary incisors - A casereport. Endodontology 2013; 25(2):68-3.

2. Al‑Zahrani and Al‑Nazhan. Retrieval ofseparated instruments. Saudi EndodonticJournal 2012; 2(1):41-5.

3. Madarati.Management of Intracanal SeparatedInstruments. J Endod 2013; 39(5): 569-583.

4. Ruddle CJ. Nonsurgical retreatment. J Endod2004; 30(12):827-45.

5. Nevares G, Cunha RS, Zuolo ML, Bueno CE.Success rates for removing or bypassingfractured instruments: a prospective clinicalstudy. J Endod 2012; 38(4):442-4.

6. Shrivastava S. Retrieval of separated intracanalinstrument: a review. International JournalDental Health Science 2014; 1(6):788-95

7. Yoshi tarauchi. Removal of separated files fromroot canal with a new file removing system. JEndod 2006; 32(8):789-96.

8. Souter and Messer. Complications Associatedwith Fractured File Removal Using anUltrasonic Technique. J Endod 2005; 31(6):450-2.

9. Gencoglu, Helvacioglu. Different techniques toremove fractured endodontic instruments.European Journal of Dentistry 2009; 3(2):90-5.

10. Hilsmann & Schinkel. Influence of severalfactors on success or failure of removal offractured instrument from the root canal. EndoDent Traumatol 1999; 15(6): 252-8.

11. Rambabu T. Management Of FracturedEndodontic Instruments In Root canal: Areview. Journal of Scientific Dentistry 2014;4(2):40-8.

12. Suter B, Lussi A, Sequeira P. Probability ofremoving fractured instruments from rootcanals. International Endodontic Journal 2005;38(2):112– 23.

13. Duigou C. Discuss the prevention andmanagement of procedural errors duringendodontic treatment. Aust Endod J. 2004;30(2):74-8.

14. Cheung GS. Instrument fracture: mechanisms,removal of fragments, and clinical outcomes.Endodontic Topics. 2007; 16(1):1-26.

15. SpiliP, ParashosP, MesserHH.The impact ofinstrument fracture on outcome of endodontictreatment. J Endod 2005; 31(12):845-50.

Illustration 10: small arteryforceps



Conclusion :


References :



















Conclusion :


References :


















A HOLISTIC APPROACH TO AESTHETIC ENHANCEMENT USINGDIRECT COMPOSITE RESTORATION- A CASE REPORT

*Dr. Chandni Nayak ** Dr Dipti Choksi ***Dr Dr. Barkha Idnani

Abstract:Aesthetic dentistry has evolved since the last many years with the advent of composite resin.The use of direct composite restoration to redesign and recontour anterior teeth has evolved andalso played a very important role in not only developing the patients functional requirements butalso helped majorly to build the overall confidence and well being of the patient.

Keywords: Aesthetics, composite resin, smile design ,recontouring.

Introduction

Anterior crown fractures are common formof injury that mainly affects children andadolescents. Uncomplicated crown fractureto the permanent teeth has an intense effectnot only on the patient’s appearance, butalso on function and speech.1,2

The predictable esthetic restoration ofbroken incisal edge of maxillary centralincisors is a demanding and techniquesensitive procedure. Its success is dependenton operator’s skills and knowledge and alsoon adhering to a systematic and problemsolving approach.1,2

*Post Graduate Student, Department ofConservative Dentistry and Endodontics.**Professor and Head of Department,Department of Conservative Dentistry andEndodontics***Professor, Department of Conservative

Dentistry and Endodontics.Faculty of Dental Science, Dharmsinh DesaiUniversity, Nadiad.

A logical method is used to build upmorphologically correct composite res-torations by careful selection of compositeshades, tints and opaquers. In accuratecombinations, an illusion of varyingtranslucencies and opacities become visibleover natural tooth structure.3

Fracture during and after an apical stop isprovided.

The dental composite has emerged as a topranked material over other direct restorativecounterparts. Their evolution since theirintroduction in dentistry has resulted inbetter bonding, optical and handlingproperties. Their performance has also beensupported by many longevity studies.4

Corresponding Author:Dr. Chandni NayakDepartment OfConservative Dentistry AndEndodontics,Faculty Of Dental Sciences,Dharmsinh DesaiUniversity, College Road,Nadiad 387001, Gujarat.(M)+91 [email protected]


For more than 40 years dentists worldwidehave been using directly placed resin-bonded composite to restore damagedanterior teeth. While such techniques areinvariably more conservative of tooth tissuethan indirect procedures, operativetechniques using direct composite can bechallenging and are considered techniquesensitive. Clinicians require both technicaland artistic skill to provide compositerestorations that restore function andaesthetics to blend seamlessly with theresidual dentition. 1,3

The great popularity of composite resinrestorations also results from theiracceptable longevity at relatively lowfinancial cost.4

This article provides an update on theaesthetic considerations involved in therestoration of anterior teeth with directlyplaced composite and outlines thecontemporary materials, equipment andtechniques that are available to optimizeevery clinical stage.

Case Report 1:

A 24 year old male patient reportedto the Department of Conservative Dentistryand Endodontics, Faculty of Dental Science,Nadiad, with the chief complaint offractured teeth associated with pain in theupper front region of jaw. Patient presentedhistory of trauma due to a road trafficaccident 6 days back.Intraoral examination revealed incisalfracture in relation to the upper left anteriortooth (Illustration no.1).There was no laceration on the lower andupper lip and the extraoral examination wasnot significant. The clinical examinationnoted: Ellis Class II fracture in 22

Pulp vitality test ( Electric Pulp test ) wasperformed in 21,11 showed normal responsebut were kept on follow up.The temporomandibular Joint showed noabnormalities or fracture.

Illustration no.1 Pre-Operative

Case Report 2:

A 18 year old female patient reportedto the Department of Conservative Dentistryand Endodontics, Faculty of Dental Science,Nadiad, with the chief complaint ofmalformed and fractured teeth associatedwith pain in the upper front region of jaw.Patient presented history of trauma due to afall 8 years back.Intraoral examination revealed incisalfracture in relation to the upper right centraland rotated lateral incisor. ( Illustration no2).Clinical examination noted :Ellis Class IIfracture in 21, 22 rotated ,there was no softtissue lacerations on upper and lower lipPulp vitality test ( Electric Pulp test ) wasperformed in 21,22 showed normal responsebut were kept on follow up. Thetemporomandibular Joint showed noabnormalities or fracture.





Case Report 1:




Case Report 2:






Case Report 1:




Case Report 2:




Radiographic examination with intraoralperiapical (IOPA) radiograph revealed:Horizontal fracture which extended inenamel, dentin but not involving the pulp.No discontinuity of Lamina dura was seenin apical one-third. Based on the clinicalfindings a holistic treatment plan was madefor both the cases using directcomposite restoration.

Treatment Plan: Case 1Patient was explained about the

minimal invasive treatment plan. The shadewas selected for composite build up , B2 /I.Putty Guide was used to achieve the palatalguidance (illustration no 3) and reproducethe natural form in relation to 21.A longhollow enamel bevel was given with adiamond point ( TR-13 Mani Inc)The Toothwas etched with 37% phosphoric acid(Dtech), then air dried with bonding agentand light cured.The initial build up was done with a opaqueresin shade (Unicorn Denmart Shade OP) onthe putty guide.( illustration no 4 )Once the palatal guide was build the the restwas restored with consequent increments ofcomposite( Unicorn Denmart B2 / I)The restoration was then finished andpolished with finishing and Polishing discsand strips (Shofu).( illustration no 5).

Illustration no.3 Putty Index

Illustration no.4 Palatal buildup

Illustration no.5 Post-operative



















treatment plan and the shade was selected .Putty Guide was used to achieve the palatalguidance and reproduce the natural form inrelation to 11.The enamel margin wasprepared with diamond points ( Mani Inc SO21) in relation to 12. The Tooth was etchedwith 37% phosphoric acid (Dtech), then airdried with bonding agent and light cured.The initial build up was done with a opaqueresin shade (Unicorn Denmart Shade OP)on the putty guide.Once the palatal guide was build the the restwas restored with consequent increments ofcomposite( Unicorn Denmart A1/2 / I)The restoration was then finished andpolished with finishing and Polishing discsand strips (Shofu). ( illustration no 6 )

Illustration no.6 Post-Operative

enabled by an intact pulpal circulation.4,5

Thus, the primary objective in themanagement of such cases is to limit thepulpal inflammation to a transient level andprevent bacterial ingress. This is bestachieved by an efficient dentin seal.6

The conventional choice of treatment forthese cases is a direct composite resinrestoration vs the lithium disilicate emax as

it is more cost effective and requiresminimal preparation of the tooth surface.3,5

The reference guide is created from theteeth (as reconstructed on a model), whichmakes it possible for the clinician toincrease the success rate.1,2

The advantage is that the restorativeprocedure can be carried out in two shortclinical sessions, with a drastic reduction inchair time; this factor is important to ensurethe child’s cooperation. The size, shape andinclination of the teeth are determined inadvance, which reduces the need foreventual adjustments.6

In addition, the use of a reference guidemakes it possible for two or more teeth to berestored simultaneously, in contrast with theconventional technique.7

Besides functioning as a matrix forreconstructing the anatomy of the teeth, thereference guide functions as a baffle plate tohold the restorative material, facilitating itsinsertion into the area to be reconstructed.8,9

Study by Sá FC et al on a Nine-year clinicalevaluation of composite resins in Class IIIrestorations concluded the efficacy anddurability of direct composite restoration 9.

Conclusion:The accurate diagnosis combined

with an esthetic design and well executedrestorative step aim to improve and restorethe natural appearance of teeth.10 Thereby,knowledge of dental morphology isessential, as well as aspects regardingoptical and dynamic properties of dentalstructures. 11,12

Composites have been widely used incosmetic procedures, due to diversity ofshades and effects that allow detailing thedental structures.13,14

The present case supports the plethora of




































reports of successful treatment of estheticenchancement of teeth with the use of directcomposite restoration. The technique offersa simple, quick and effective treatmentoption that is also acceptable for thepatients.

References:

1. Hansika Pahuja, Gaurav Kumar Mittal,Shashank Agarwal, Aviral Verma, HimaniTomar. Restoring esthetics in fracturedanterior teeth- template technique.International Journal of ContemporaryMedical Research 2016;3(5):1283-1284.

2. Sapna C. M, Renjith Kumar, Rakesh R.Rajan, Priya R. Uncomplicated crownfracture: A biological management option.International Journal of Applied DentalSciences 2014; 1(1): 15-17

3. Correia AMO, Vieira VM, Rocha DM andMendonça AAM. Aesthetic Restoration ofMaxillary Incisors with Composites: CaseReport. Austin J Dent. 2015;2(1): 1012.

4. Robert Strain Class IV Composite repairJournal of Cosmetic Dentistry.2014;30(1).

5. Nayak UA, Khandelwal V, NayakPA,Thakur JS .BMJ Case Rep Restoration offractured anterior permanent teeth usingreference guide technique. 2013. 9:299–303.

6. Fahl N Jr. A polychromatic compositelayering approach for solving a complexClass IV/direct veneer/diastemacombination: Part II. Pract Proced AesthetDent 2007; 19(1): 17–22.

7. Dipesh Parmar, Adrian CC Shortall and FJTrevor Burke . Direct Anterior Composites:A Practical Guide; Dent Update 2013;40,11

8. Chu FC, Siu AS, Newsome PR, Wei SH.Management of median diastema. General

Dentistry 2001;49:282–7.9. Fátima Cristina De Sá, Ticiane Cestari

Fagundes, Wagner Baseggio, EduardoBresciani, Terezinha Jesus Esteves Barata,Eduardo Batista Franco. Nine-year clinicalevaluation of composite resins in Class IIIrestorations. Braz Dent Sci 2015Oct/Dec;18(4)

10. Loguercio AD, Lorini E, Weiss RV, ToriAP, Picinatto CC, Ribeiro NR, et al. A 12-month clinical evaluation of compositeresins in class III restorations. J Adhes Dent.2007 Feb;9(1):57-64.

11. van de Sande FH, Opdam NJ, Rodolpho PA,Correa MB, Demarco FF, Cenci MS. Patientrisk factors’ influence on survival ofposterior composites. J Dent Res. 2013Jul;92(7 Suppl):78S-83S.

12. Lawrence HP, Thomson WM, BroadbentJM, Poulton R. Oral healthrelated quality oflife in a birth cohort of 32-year olds.Community Dent Oral Epidemiol. 2008Aug;36(4):305-16.

13. Hickel R, Roulet JF, Bayne S, Heintze SD,Mjor IA, Peters M,et al. Recommendationsfor conducting controlled clinical studies ofdental restorative materials. InternationalDental Journal 2007;57:300–2.

14. Demarco FF, Corrêa MB, Cenci MS,Moraes RR, Opdam NJ. Longevity ofposterior composite restorations: not only amatter of materials. Dent Mater. 2012Jan;28(1):87-101.

15. da Rosa Rodolpho PA, Donassollo TA,Cenci MS, Loguercio AD, Moraes RR,Bronkhorst EM, et al. 22-Year clinicalevaluation of the performance of twoposterior composites with different fillercharacteristics. Dent Mater. 2011Oct;27(10):955-63.


PECTORALIS MAJOR MYOCUTANEOUS FLAP FOR MANDIBULARRECONSTRUCTION IN ORAL SQUAMOUS CELL CARCINOMA: A

CASE REPORT

*Dr.Shripal R. Jani **Dr.Hiren Patel ***Dr.Haren Pandya***Dr. Hitesh Dewan ****Dr.Bijal Bhavsar ****Dr.Urvi Shah

*****Dr.Kartik Dholakia

AbstractThe pectoralis major myocutaneous (PMMC) flap can be used as either a pedicled or a free flap.The PMMC flap is still considered a workhorse flap for soft tissue reconstruction of the head andneck region. Although the increased use of free tissue transfers to reconstruct complex bony andsoft tissue defects has overshadowed the PMMC flap to an extent, it remains a very useful,versatile, and reliable reconstructive option for many head and neck defects of the mucosa orskin, or both.Moreover, the proximity to the head and neck region larger arc of rotation and richvascular supply are additional advantages of the PMMC flap. This article describes a case of oralsquamous cell carcinoma of left lower alveolus reconstructed with PMMC flapafterhemimandibulectomy and modified neck dissection.

Keywords: pectoralis major mayocutaneous flap, head and neck reconstruction,oral squamous cell carcinoma

Introduction

Carcinomas of the oral cavity formthe second most common cancer in India.Patients usually present with advanceddisease which requires extensive ablativesurgery.

* 3rd year Post Graduate student,** Dean and Head of the Department,*** Professor,**** Reader,***** LecturerDepartment of Oral & MaxillofacialSurgery,Faculty of Dental Science,Dharmsinh Desai University,Collage Road, Nadiad

Modern head and neck surgery ischaracterized by its emphasis on threeimportant objectives of reconstructive andrehabilitative procedures: esthetic, functionand coverage of vital structures. Restorationof normal oral function following suchextensive surgery-

Corresponding author:

Dr.Shripal R. Jani

8-b, LaxminarayanBunglows,

Near H.P Petrol pump,

Rajesh Tower Road, Vadodara

Email ID: [email protected]

Contact: +91 9428692949


depends on variety of factors which includereconstruction of complex osseous, dentaland soft tissue anatomy. To achieve optimalfunction and aesthetics is therefore achallenge to oral and maxillofacialsurgeon.1,2

The use of myocutaneous flaps hasbeen a huge step forward in head and neckoncological surgery, as it allows coveringextensive resection, which is necessary tocomply with the demands of radical removalof malignant tumours and at the same time,achieving acceptable morphological andfunctional restoration. The concept ofpectoralis major island flap was introducedby Brown in 1977. Stephen Ariyan in 1979used PMMC flap in head and neckreconstruction.3

The PMMCflap is a Type Vmusculocutaneous axial pattern flap whichoffers enormous advantages by being easilyaccessible, versatile, bulky, and wellvascularised and most importantly does notrequire micro-vascular expertise for flaptransfer.4 It allows for one stagereconstruction immediately after resectionand tends to achieve a harmonious balancewithin the aims of maxillofacialreconstructive surgery.5, 6

Case report :

A 53 years old male patientconsulted our department for pain in lowerleft back tooth region since 2 years and alsoexperienced reduced moth opening since 1year.

On examination, ulcero-proliferativegrowth was seen on the left buccal mucosaextending from lower left first premolar tosecond molar involving the gingivo-buccalsulcus. The lesion was approximately 4 to 5cm in size. (Illustration 1-2)

Illustration 1: Pre-operative facial profile

Illustration 2: Intraoral photograph

Orthopantomogram (OPG) suggestedawell-defined radiolucency with corticatedborders involving alveolus on left side ofmandible extending anteriorly up to thedistal surface of second molar andposteriorly up to the mesial surface of thesecond molar. (Illustration 3)





Case report :










Case report :







Illustration 3: Pre-operative OPG

Punch biopsy was taken and sent forhistopathological examination. Diagnosis ofsquamous cell carcinoma was established.Computed tomography (CT) scan revealedmucosal thickening with enhancement seenalong left buccal mucosa and bony erosionin left mandibular region with left side levelIB and II lymphnodes involvement.

All pre-operative investigations(blood reports, chest x-ray,Electrocardiogram) were done and patientwas operated under general anaesthesia.Apron incision was given with 15 numbersurgical blade on left side to raise the sub-platysmal flap superiorly till lower border ofthe mandible, mastoid tip posteriorly andmidline of neck anteriorly. (Illustration 4and 5) Modified neck dissection type II wascarried out and lymphnode levels IA, IB,IIA, IIB, III and IV were removed.(Illustration 6) Lip split incision was givenfor resection of primary tumour on left sideof the mandible.Hemimandibulec-tomy ofleft side was done by using physio-dispenserand oscillating saw. (Illustration 7)Specimens were sent for histologicalexamination and reconstruction was done byusing type V axial pattern single paddlePMMC flap.

Illustration 4: Apron incision given

Illustration 5: Sub-platysmal flap wasRaised














Illustration 6: Specimen of modifiedneck dissection II

Illustration 7: Specimen ofhemimandibulectomy

The position of the skin paddle onchest wall was adjusted so that it overlies themuscle entirely. Skin incision was takenalong the marking and extended laterally upto anterior axillary fold (Illustration 8 and9).

Illustration 8: Skin paddle design andincision

Illustration 9: Exposure of PMMC flap














Illustration 10: Elevation of PMMC flapwith peddicle

Monopolar cautery was used to raisethe pectoralis major muscle medially andinferiorly to the skin paddle and dissectedfrom the ribs and intercostal muscles andtunnel was created by subplatysmal plane ofdissection over the clavicle for the passageof the flap to the neck (Illustration 10 and11). Flap was transferred to the recipientside through the tunnel and secured with 3-0vicryl suture to cover the defect which wasapproximately 5 to 6 cm in size afterresection of the primary tumour (Illustration12). After chest and neck drains wereplaced, final closure was done by using 3-0vicryl suture and skin staples (Illustration13).

Illustration 11: Skin tunnel overclavicle

Illustration 12: PMMC flap placed onrecipient site












Illustration 13: Sutures taken

Follow up of the patient was done atregular time interval and at the end of 1 yearthe surgical area (recipient site) and chestarea (donor site) were healed without anyrecurrence of the lesion (Illustration 14 and15). Illustration 16 shows facial profile ofthe patient at follow up period.

Illustration 14: Post-operative photo ofrecipient site after 1 year

Illustration 15: Post-operative photo ofdonor site after 1 year

Illustration 16: Post-operative facialProfile

Discussion :

The PMMC flap, after first beingdescribed by Ariyan,has been widely used asa workhorse flap for head and neckreconstruction.7Even with the worldwide useof free flaps, these have remained themainstay reconstructive procedures in manycases for a variety of reasons. The mainadvantages were the ease of its technical







Discussion :








Discussion :



aspects, the proximity to the head and neckregion, and the possibility of obtaining alarge amount of well-vascularized tissue forreconstruction of wide defects afterresection of malignant tumours of the headand neck in a single-stage procedure. Otheradvantages include: (1) Muscle pedicle inthe neck effectively covers the exposedcarotid vessels after radical neck dissectionrecreating the sternomastoid prominence (2)Elevation of the flap does not require anyposition changes during surgery and (3)Effective combinations with other flaps canbe used for large defects.8, 9

The complication rate of the PMMCflap when used for reconstruction varies indifferent studies.10,11 Kroll et al havedescribed in their article that thecomplication rates after PMMC flapreconstruction in female patients are greaterbecause of the interposition of breast tissuebetween the muscle and the skin paddle.Preoperative planning, operative technique,and postoperative management playedimportant roles in reducing the complicationrate and yielding better outcomes.12

The reported disadvantages of thePMMC flap concern the thickness of themyocutaneous flap, the functional andcosmetic donor defects, excessive bulk inobese or muscular patients, difficulty using abipaddled flap in obese patients, and thepossibility of hiding the recurrence of themalignant tumor. Another disadvantage ofthe PMMC flap is its poor vascularity inobese patients and over the random distalend of the rectus abdominis muscle causingpartial dehiscence, fistulation, and infectionand resulting in a prolonged hospital stay.Troublesome hair growth in the oral cavityin men is another area of concern. 13,14

In female patients with PMMC flapreconstruction, it has been described that

vascularity is compromised because of theintervening mammary fat between themuscle and subcutaneous tissue; however,ultimately, it provided a better contourcompared with male patients in thepostoperative period because there wasabout 50% bulk reduction within 3 monthsof surgery after division of the motornerves.15

Conclusion :

Over the years, the PMMC flap hasstill retained its significance inreconstruction after head and neck cancersurgery. Despite the use of microvascularflaps, PMMC flap still remains an excellentreconstructive option in head and neckcancers.It can be used as a salvage flap inthe event of microvascular flap failure.Because of its simplicity, ease of technique,versatility, and reliability, reconstructionwith the PMMC flap appears to be safe andeffective.


References :

1. Miloro M. Peterson's principles of oral andmaxillofacial surgery, 2nded. Vol 2. LondonB C Decker 2004.

2. McGregor IA. Cancer of Face andMouth.London Churchill Livingstone 1986.

3. Fonseca RJ, Oral and Maxillofacial.Reconstructive and Implant Surgery Volume7, Saunders 2000

4. Jatin shahHead and Neck Oncology; 2nd

edition; 564-5655. Carlson ER. Pectoralis major myocutaneous

flap. Oral Maxillofacial SurgClin N Am2003,151565-575.

6. Magee WP, McCraw JB, Horton CE,Mclnnis WD. Pectoralis PaddleMyocutaneous Flaps: The Worldwrse OfHead And Neck Recontruction..TheAmerican Journal of Surgery 1980,1402507-513.

7. Liu R, Gullane P, Brown D, Irish J:Pectoralis major myocutaneouspedicled flapin head and neck reconstruction:retrospective review of indications andresults in 244 consecutive cases at theToronto General Hospital. J Otolaryngol30:34, 2001

8. Biller HF, Baek SM, LawsonW, et al:Pectoralis major myocutaneous island flapin head and neck surgery: Analysis ofcomplications in 42 cases. ArchOtolaryngol107:23, 1981

9. Schuller DE: Pectoralismyocutaneous flap inhead and neck cancer reconstruction. ArchOtolaryngol 109:185, 1983

10. McLean JN, Carlson GW, Losken A: Thepectoralis major myocutaneous flaprevisited: a reliable technique for head andneck reconstruction. Ann PlastSurg 64:570,2010

11. Kruse AL, Luebbers HT, Obwegeser JA,Bredell M, Gr€atz KW: Evaluation of thepectoralis major flap for reconstructive headand neck surgery. Head Neck Oncol 3:12,2011

12. Kroll SS, Goepfert H, Jones M,Guillamondegui O, Schusterman M:Analysis of complications in 168 pectoralismajor myocutaneous flaps used for head andneck reconstruction. Ann PlastSurg 25:93,1990

13. Zbar RIS, Funk GF, McCulloch TM, et al:Pectoralis major myofascial flap: A valuabletool in contemporary head and neckreconstruction. Head NeckOncol 19:412,1997

14. Bansal R, Patel TS, Bhullar C, et al:Metastases to the donor site of the pectoralismajor myocutaneous flap followingreconstructive surgery: A rare complication.PlastReconstrSurg 114:1965, 2004

15. Kruse AL, Luebbers HT, Obwegeser JA,Bredell M, Gr€atzKW:Evaluation of thepectoralis major flap for reconstructive headand neck surgery. Head Neck Oncol3:12,2011


DENTAL MANAGEMENT OF PATIENTS ON ANTIPLATELET ANDANTICOAGULANT THERAPY: A REVIEW WITH CURRENT

PERSPECTIVES

*Dr.ParthParikh ** Dr.Hiren Patel ***Dr.Haren Pandya***Dr.Hitesh Dewan ****Dr.Bijal Bhavsar ****Dr.Urvi Shah

*****Dr.Kartik Dholakia

AbstractThere are a variety of discordant approaches for the management of patients on

anticoagulant therapy undergoing dental or surgical procedures. As with all anticoagulants,bleeding, either spontaneous or provoked, is the most common complication so managementprotocols for the eventuality of bleeding is of utmost importance. Direct oral anticoagulants offerclinical advantages over warfarin, such as minimal drug interactions and fixed dosing without theneed for routine monitoring of coagulation status. A thorough medical and dental history iscritical to the identification of patients who may be on some type of hemostasis-alteringmedication. The dentist must be familiar with the types of diseases and conditions thatnecessitate the alteration of coagulation mechanisms and the different laboratory tests that areused to assess the coagulation status in these patients.

Key words: anticoagulants, hemostasis, minor surgery

Introduction

Hemostasis is a defense mechanismwhich preserves vascular integrity andavoids blood losses,while ensuring optimumfluidity throughout the circulatory system.Anticoagulant drugs inhibit the enzymevitamin K reductase, which mediatesconversion of vitamin K epoxide to its activeform.

* 3rd year Post Graduate student** Dean and Head of Department*** Professor**** Reader***** LecturerDepartment of Oral and MaxillofacialSurgery,Faculty of Dental Science,Dharmsinh Desai University,College Road, Nadiad.

As a result, the formation ofcoagulation factors dependent upon this activeform is inhibited, and the coagulation processis blocked. So with this hemostatic alterationbleeding becomes difficult to control. As aresult, some authors recommend suspending,reducing or replacing. Anticoagulationmedication prior to invasive dental treatments,while others advise against such measures,due to the possibility of an increased risk of

thromboembolic events.1

Corresponding author:Dr. Parth Parikh301, KirtankarmAppartment,Near digamber Jain Temple, DharmnagarPart 2,Sabarmati,Ahmedabad. Postal Code : 380005.Email id: [email protected] number:+919824600331, 8160479843


There are various anticoagulants inuse like warfarin, heparin and low molecularweight heparin. In addition to these there arevarious direct oral anticoagulants likedabigatran, argatroban, bivalirudin,desirudin and lepirudin. There are variousindications of using anticoagulants like indeep vein thrombosis, pulmonary embolism,myocardial infarction and in valvulardiseases. In addition the DOACs (direct oralanticoagulants) are becoming morefrequently prescribed and their use hassignificant implications for the managementof patients requiring anticoagulant therapybecause there is the elimination of the needfor monitoring, even if the patient is toundergo surgery. Secondly, these drugs areadministered orally at a fixed daily dose,making patient compliance more

straightforward.2,3

The coagulation teststhat are commonly used in practice tomonitor bleeding risk and anticoagulanttherapy are prothrombin time (PT), activatedpartial thromboplastin time (aPTT), andthrombin time (TT). The INR measures theratio of the patient’s PT to a normal samplethat is designed to standardize thedifferences among laboratories. It is alsoused to monitor warfarin therapy and the

extrinsic coagulation pathway.4

Guidelines state that INR of patientsshould be measured within 72 hour before

oral surgery or ideally within 24 hour.5

The present article offers an updateon the different types of antiplatelet drugsand anticoagulants currently available in themarket, with an evaluation of the risks andbenefits of suspending such drugs prior toinvasive dental treatment. In addition, areview is made of the current managementprotocols used in these patients.

Overview of antiplatelet drugsThere are various antiplatelet

medications that are used to aidanticoagulation for example, aspirin. Aspirinis one of the most commonly encounteredmedications in a patient’s drug history. Theactive ingredient is acetylsalicylic acid. It isused in the treatment of a myriad of conditionsand functions as an analgesic, anti-inflammatory, antipyretic, and antiplateletmedication. It belongs to the group ofmedications known as nonsteroidal anti-inflammatory drugs. It irreversibly inhibitsplatelet action, at lower dose it inhibits TXA2and at higher dose it inhibits TXA2 and PGI2.The PT, aPTT, and platelet count are usuallynormal in patients on aspirin therapy but thebleeding time may be prolonged. Clopidogrelirreversibly inhibits the adenosine diphosphatereceptors on platelets and thus inhibitsaggregation and clot formation. It is analternative drug for persons who requireanticoagulation who are unable to tolerate

aspirin therapy.4

Management of patients on salicylic acidtherapy

In general, salicylic acid intake is achallenge that surgeons can readily overcome.For uncomplicated forceps extraction of 1 to 3teeth, there is usually no need to interfere withaspirin treatment. In patients receiving up to100 mg salicylic acid daily, bleeding duringoral surgical procedures is controllable withsuturing and direct packaging with gauze,resorbable gelatin sponge, oxidized celluloseor microfibrillar collagen. If oozing still isseen, tranexamic acid locally will help. Inpatients receiving higher doses of salicylate,if there is concern, the current value ofbleeding time should be established. If it ishigher than 20 minutes, surgery should bepostponed. However, if emergency surgicaltreatment is needed, in consultation with thetreating physician, desmopressin acetatemay be given. If the patient is on SA and onother anticoagulation medications or with


some bleeding tendency, such ashemophilia, or uremia, medical adviceshould be sought to discontinue the use ofaspirin intake 7 days before oral surgery

procedures.6However currently Zhao et al

and Lu S Y et al studied that there is no needof stopping antiplatelet drugs if properhemostatic protocols are followed.

Overview of anticoagulants

Illustration 1Coagulation Cascade

Coagulation of blood comprises theformation of fibrin by a series of interactionsamong various protein factors and othersubstances present in plasma.7

Medications that interrupt the hemostasiscan be grouped into 2 primary categories:anticoagulants that interrupt the coagulationcascade and antiplatelet factors.

Warfarin is an oral anticoagulant thatwas discovered in Wisconsin more than 80years ago. It works by inhibiting vitamin K–dependant coagulation factors and its effectis dose dependant. The anticoagulationefficacy is measured by the PT and INR. Atarget INR range of 2.0 to 4.0 is used for

most patients. It is metabolized in the liverand excreted via the kidneys. Variousmedications can potentiate or decrease theeffect of the drug. Drugs that are highlyprotein bound will displace warfarin andincrease its blood concentration, leading toan increase in INR.

Heparin was discovered in 1916 andis usually derived from porcine mucosa. Itacts indirectly by activating plasmaantithrombin III and it inactivates thrombin.The heparin-AT III complex then binds toclotting factors of intrinsic pathway. It ismainly administered via IV infusion orintermittent SC injection. Theanticoagulation effects of this drug aremonitored via measuring the aPTT, whichshould be 1.5 to 2.0 times the normal.Platelets should also be reviewed because ofthe risk of the rare side effects of heparin-induced thrombocytopenia (HIT) andheparin-induced thrombocytopenia andthrombosis (HITT). These usually occurwithin the first 10 days of starting heparintherapy but can occur up to many weeksafter it has been discontinued.Depolymerization of heparin produces lowmolecular-weight heparin (LMWH).LMWH requires less monitoring thanheparin because it has differentanticoagulant profile; selectively inhibitfactor Xa with little effect on IIa. As a resultit has smaller effect on aPTT and wholeblood clotting time. LMWH is also used forin-hospital patient care for therapeutic orprophylactic treatment of conditions such asdeep vein thrombosis. LMWH is availablefor SC or IV use only. Warfarin is known tohave its clinical and practical limitations soultra-low molecular-weight heparins arecurrently being developed; for example,semuloparin and bemiparin.4


Management of patients on warfarin andother oral coumarin anticoagulationtherapy

Traditionally, patients on oralanticoagulant therapy were placed into 1 ofthe following 3 categories, which dictated theappropriate anticoagulation therapy: 1, low-risk procedures required no change inanticoagulation medication; 2, moderate-riskprocedures indicated withdrawal ofcoumarin 2 days before the procedure andverification of INR the day of the procedureand 3, for high-risk dental procedures, aheparin protocol was stronglyrecommended. The management of patientson anticoagulant therapy should certainlytake into consideration the type of thesurgical procedure, the INR value.6 Thereare some guidelines for using warfarin andheparin therapy they are given in table 1 andtable 2.11

Dental perspectivesAnticoagulants present management

problems in oral surgery mainly because ofprolonged intraoperative and postoperativebleeding. They are used according to theirrecommended doses (Table 3).The following general points should beconsidered in patients for oral surgery onanticoagulant therapy:1. Dental preventive care is especiallyimportant to minimize the need for surgicalintervention.2. Systemic conditions that may aggravatethe bleeding tendency can be present. TheseConditions include a wide range ofdisorders, including coagulopathies,thrombocytopenias and vascular disorders,such as Ehlers-Danlos syndrome, liverdisease, renal disease, malignant disease,and HIV infection.3. Drugs that cause increased bleedingtendency should be avoided.4. Any surgical intervention can causeproblems; thus, the possibility of alternatives

to surgery eg, some local analgesicinjections can cause serious problems.5. Other interventions to avoid, if possible,include regional local analgesic injectionsshould always be considered. The patientsshould be warned in advance of the procedureof the increased risk of intraoperative andpostoperative bleeding andintraoral/extraoral bruising. If the bleedingtendency is great, dental extractions, othersurgical procedures spaces of neck andobstruct airway; intraligamentary or intra-papillary injections are far safer.9,10

Operative carePatients on oral anticoagulants are

especially at risk from haemorrhage under-some circumstances (Table 4).

Whenever possible, potentiallyproblematic surgical procedures are bestcarried out in the morning, allowing more timefor hemostasis before nightfall. Surgeryshould be performed with 2% lidocaine with1:80,000 or 1:100,000 epinephrine unless thepatient is an active cocaine abuser or a cardiacpatient, in which case epinephrine should beavoided. Surgery should be carried out withminimal trauma to both bone and soft tissues.Local measures are important to protect thesoft tissues and operation area and minimizethe risk of postoperative bleeding. In the caseof difficult extractions, when mucoperiostealflaps must be raised, the lingual tissues in thelower molar regions should preferably be leftundisturbed because trauma may open upplanes into which hemorrhage can track andendanger the airway. The buccal approach tolower third molar removal is therefore safer.Minimal bone should be removed and theteeth should be sectioned for removal wherepossible. Meticulous curettage of theextraction site is essential to avoid excessivebleeding because when postoperativebleeding occurs, the cause is not necessarilythe prolonged INR but may be localinfection. In the case of multiple extractions,postoperative bleeding does not occur in all


extraction sites; rather, it usually occurs inonly 1 site, often alocation associated withsevere periodontitis. Bleeding should beassessed intraoperatively, and if there isconcern, one should place in the extractionsite an absorbable hemostatic agent such as:oxidized regenerated cellulose; resorbablegelatin sponge; collagen; cyanoacrylate; orfibrin glues, which consist mainly offibrinogen and thrombin and provide rapidhemostasis and tissue sealing and adhesion.Suturing is desirable to stabilize gingivalflaps. Resorbable sutures are preferredbecause they retain less plaque. Nonresorbablesutures should be removed at 4 to 7 days.Gauze pressure containing trenexemic acidshould be applied for 10 minutes that can alsohelp to achieve hemostasis.10, 11

Postoperative careCareful mouth cleaning after surgery

is essential. Many patients can be managedafter surgery with antifibrinolytic agentsgiven topically as a mouthwash during thefirst 7 to 10 days. If the patient continues tobleed, desmopressin acetate may help. Thissynthetic analogue of vasopressin inducesthe release of factor VIIIC, vonWillebrand’s factor, and tissue plasminogenactivator from storage sites in endothelium.It is given as an intranasal spray.1.5-mgdesmopression per mL with each 0.1-mLpump spray delivering a 100-to 150-

microgram dose.12,13

ConclusionThe surgical management of patients

on oral anticoagulant therapy remains achallenging area for dentists. Specifically,that patients must first be assessed by theirprimary physician and dentist to determinetheir thromboembolic risk. Then their surgicalneeds should be evaluated and stratified.Patients who are at moderate to high risk ofthromboembolism and patients who requiremoderate to high levels of surgicalintervention should be referred to an oral and

maxillofacial surgeon. The basis of prudentmanagement for these patients, however,remains rooted on the 5 planks listed earlier:(1) status of their medical condition, (2)proper laboratory assessment of theircoagulation profile before surgery, (3)accurate categorization of theirthromboembolic profile, (4) appropriatesurgical risk stratification and effective localcontrol, and (5) close extended postoperativemonitoring. However, patients with aprolonged APTT or PT value have a higherrisk of bleeding, therefore, adequate localhemostasis and careful follow up arerequired.

Bibliography

1. Ana M L, Begonya C L andCarmen G E. Dental managementof patients receiving anticoagulantand/or antiplatelet treatment. JClinExp Dent. 2014 Apr; 6(2):e155–e161.

2. Richard L. S, Sarah A. S.Emergent Bleeding in PatientsReceiving Direct OralAnticoagulants. Air Med J

2016May-Jun; 35(3):148-55.

3. Janoly B, Loiseau K, Luaute J,Sancho P. Oral anticoagulanttreatment – Evaluating theknowledge of patients admittedinphysical medicine andrehabilitation units. Ann PhysRehabilMed. 54 (2011) 172–180.

4. Ladi D, Mitchell A, Oral surgeryfor patients on anticoagulanttherapy: Current thoughts onpatient management. Dent Clin NAm 56 (2012) 25–41.


5. Altaf H S, Soban Q K, Faleh A,NaseerQ,Ishfaq A B, MohammedZ K.Knowledge of medical anddental practitioners towards dentalmanagement of patients onanticoagulant and/or anti-platelettherapy.The Saudi journal for dental

research.July(2015);6:2;91-97.

6. S. Johnston: An evidence summaryofthe management of patientstaking direct oral anticoagulantsundergoing dental surgery. Int. J.Oral Maxillofac.Surg. 2016; 45:618–630.

7. R.S. SatoskarTextbook ofpharmacology and

pharmacotherapeutics.20th

edition

8. Benjamin A Steinberg,Jonathan PPiccini anticoagulation in atrialfibrillationBMJ 2014;348:g2116

9. Crispianscully, Roderick ACawson.Medical problems in

dentistry. 4th

edition.

10. Mark N. L, Gary R, Seth L.Hemorrhagic Complications ofanticoagulant treatment CHEST 2001;119:108S±121S

11. Crispian Scully, Andy Wolff . Oralsurgery in patients on anticoagulanttherapy Oral Surg Oral Med OralPathol Oral Radiol Endod2002;94:57-64

12. Holbrook A, Schulman S.Antithrombotic therapy and preventionthrombosis. 9th edition. CHEST 2012Feb;141(2):e152S-e184S

13. Yoshinari M, Chizuko Y, Yuko I.Tooth extraction in patients takingnonvitamin K antagonist oralanticoagulation. Journal of dentalscience (2016) 11, 59-64.


Table 1. Guidelines for warfarin therapy after surgery11

Day 1: Obtain baseline INR.

Start warfarin with 10-mg dose on night of surgery. Use lower doses (2 to 5 mg) if patient iselderly, chronically malnourished, has liver disease, or is on medication that can potentiatewarfarin. Alternatively, can use patient’s known usual maintenance dose.

Day 2: Check INR (reflects first dose only).

If INR _ 1.5, give same dose.

If INR _ 1.5, give lower dose.

Day 3: Check INR (reflects first 2 doses).

If INR _ 1.5, it suggests that a higher than average maintenance dose (_5 mg) will benecessary.

If INR is 1.5 to 2.0, it suggests that average maintenance dose (approximately 5 mg) will benecessary.

If INR _ 2.0, it suggests that lower than average maintenance dose (_5 mg) will be necessary.


Table 2. Guidelines for monitoring Heparin Therapy11

1. Check APTT 6 hours after initial bolus and 6 hours after any dose change. Adjustheparin infusion until APTT is therapeutic (46 to 70 seconds).

2. When 2 consecutive APTTs are therapeutic, order APTT every 24 hours only (andadjust drip as needed).

3. Dosages of heparin when calculated by weight are rounded off to nearest 100 U/h.

4. Order complete blood cell and platelet count every 3 days during heparin therapy.

5. Stop heparin 4 hours before surgery. After surgery, restart heparin immediately withsame rate used before surgery when APTT was therapeutic.

Table 3. Recommended Doses of Anticoagulant/Antithrombotic Therapies

Notes: aPTT = activated partial thromboplastin time; INR = International Normalized Ratio; IV =intravenous; SC = subcutaneous 8

DrugDoseform

Recommended dose

Aspirin

Oral

75 to325 mg daily

Clopidogrel oral75 mg daily with aspirinwhen warfarin therapy isunsuitable

Heparin IV

70 units/kg bolus then 15units/kg/hour infusion;Adjust dose based on APTTand hospitall’snomogram

Warfarin IV or oral

Individualize the dose; adjustdose based on INRTarget INR = 2.5, 2.0 to 3.0.(with mechanicalvalve, target INR > 2.5)


Table 4: Scottish dental clinical effectiveness guidelines6

Dental Procedures that Low risk of postoperative Higher risk of

are unlikely to cause bleeding complications postoperative bleeding

bleeding complications

(1)Local anaesthesia by (1)Simple extractions (1–3, (1)Complex extractions,

infiltration, intraligamentary with restricted wound size) adjacent extractions that will

or mental nerve block cause a large wound, or

more than three extractions

(2)Local anaesthesia by (2)Incision and drainage of at once

inferior dental block or other intraoral swellings

regional nerve blocks (2)Flap raising procedures:

(3)Basic periodontal (3)Detailed six-point full a)Elective surgical

examination (BPE) periodontal examination extractions

(4)Supragingival removal of (4)Root surface b)Periodontal surgery

plaque,calculus, and stain instrumentation (RSI)

c)Preprosthetic surgery

(5)Direct or indirect (5)Direct or indirect

restorations with restorations with subgingival d)Peri-radicular surgery

supragingival margins margins

e)Crown lengthening

(6)Endodontics (orthograde)

f)Dental implant surgery

(7)Impressions and other

prosthetic procedures (3)Gingival recontouring

(8)Fitting and adjustment of (4)Biopsies

orthodontic appliances


DENTAL MANAGEMENT IN PATIENTS WITH RENAL DISORDERS: AREVIEW WITH CURRENT CONCEPTS

*Dr. Enosh Steward **Dr. Hiren Patel ***Dr. Haren Pandya

***Dr. Hitesh Dewan ****Dr. Bijal Bhavsar ****Dr. Urvi Shah

*****Dr. Kartik Dholakia

AbstractEvery dental professional is confronted regularly with patients suffering from single or

multiple systemic disorders which necessitate modification in routine dental therapy. Renaldisease, whether acute or chronic, constitute a large volume of patients who are suffering fromunderlying, untreated hypertension or diabetes ultimately leading to renal failure. Patients ondialysis or undergoing renal transplant therapy demand utmost care during dental treatment. Thisarticle aims at reviewing current perspectives in dental management of these patients.

Keywords: renal disease, renal transplant, dental treatment

Introduction

With innovations in field ofmedicine and technology, the oral healthcare professionals have to apply aholistic approach for the management ofpatients with complex medical problems.Among the various systemic disorders, amajor cause of morbidity and mortalityworldwide is posed by renal diseases,

* 3rd year Post Graduate student,** Dean and Head of Department,*** Professor**** Reader***** Lecturer

Department of Oral and MaxillofacialSurgery,Faculty of Dental Science,Dharmsinh Desai University,College road, Nadiad.

as kidneys are the vital organs formaintaining a stable internal environment.1

Multiple complex functions like excretion ofmetabolic waste, regulation of electrolyteconcentration and blood volume, regulationof erythrocyte production in bone marrowand calcium homeostasis are performed bykidneys. Kidney diseases can be classifiedinto developmental or inherited diseases andwith respect to further course of illness, theycan be sub-classified into chronic and acuterenal diseases.

Corresponding author:Dr. Enosh Steward,

5B, Vaibhav Society,

Near Muslim Hostel,

Vallabh Vidyanagar.

Email id: [email protected]

Ph: +91 81600 86668, +91 98259 40564


Like any other systemic conditions,renal diseases can cause oralmanifestations.2The prevalence of orallesions is affected by the accompanyingsystemic disease. For example, non-diabeticuremic patients may not show as much oforal manifestations like diabetic uremicpatients.3Experiments have shown thatpyelonephritis can be caused by a bacterialinfection which is inoculated in the kidneyfrom any chronic dental infection.Experimental evidence support a connectionbetween renal calculus and oral infection.4Inpre-transplantation stage (PRTS), impairedrenal function can lead to differenthematologic and metabolic disorders whichinvolve oral cavity and jaw bones that caninterfere with food intake and lead toincreased catabolism and deterioration of thecondition.5Periodontal disease, narrowing ofthe pulp chamber, enamel abnormalities,premature tooth loss and xerostomia areseen greatly among dialysis patients whichmay be related to a variety of factors likerelative state of immune-suppression,medications, renal osteodystrophy and boneloss, and restriction of oral fluid intake.6

Malnutrition can be of a significant problemfor dialysis patients and this condition canbe exacerbated by ill-fitting dentalprosthesis, local infections and carious ormissing teeth. Maintaining oral hygiene getsincreasingly important when a patient is acandidate for renal transplantation, whereinimmunosuppressive protocols may furtherpredispose to oral and most likelydisseminated infection.7Familiarity with thenature of the disease in question andpossible complications that may develop inthese patients is indispensable prior to anydental treatment, particularly of invasivenature as it is the case in surgicalinterventions.8The description of commonrenal disorders and their dental managementis highlighted subsequently in the article.

Chronic kidney diseaseChronic Kidney Disease (CKD) is

defined as structural or functionalabnormalities of the kidney, with or withoutdecreased GFR, manifested by pathologicalabnormalities or markers of kidney damage,including abnormalities in the compositionof the blood or urine or abnormalities inimaging tests. (GFR <60ml/min/1.73m2forthree months or more, with or withoutkidney damage).9 Thus kidney function isimpaired followed by high loss of fluidsfrom the body due to increased excretion ofurine. The immune system of the patients isgrossly weakened and consequently, there isgreater tendency to infection. Candidiasis,intra-oral ulcers, xerostomia and paleness ofsoft tissues is common. With CKD, thefollowing have to be kept in mind

Absorption of medications administered peros is reduced due to reduced absorptioncapacity of gastrointestinal tract.

Anaemia results due to reducederythropoietin production. Fresh bloodtransfusion should be avoided because everytransplantation is the introduction of newantigens in the body and it can react byproducing antibodies against it.10

Bleeding tendency increases due to plateletdysfunction and so APTT and INR have tobe monitored carefully.10

In patients with severe renal disease,changes occur in the periodontium like lossof lamina dura and trabecular pattern of jawbones.7

Acidosis in patients with CKD may reducethe effectiveness of local anaesthetics.11

Secondary hyperparathyroidism is verycommon which is a result of phosphateretention and it influence on hyperproduction of parathyroid hormone leadingto increased loss of calcium in the bones.12

General Anesthetics is to be avoided inCKD patients whose potassium level is over5.5 mmol/L or else there is an increased riskof arrhythmia.9


Progressive loss of kidney function,ultimately results in clinical syndromewhich is denoted as uremia. The systemicsigns of renal failure and uremia such ashematologic changes, bone metabolismchanges and alterations in immune statuscan be significant to the dental practitioner(Table 1).13Among individuals with chronickidney disease, the stage is defined by thelevel of GFR, with higher stagesrepresenting lower GFR levels. Based onGFR, classification of CKD can be done asgiven in table 2.14

Renal failure is a debilitating diseasecarrying high mortality as well as morbidity.It needs long term treatment likecontinuation of life-long renal replacementtherapy in the form dialysis or the renaltransplantation.15

Acute renal failureAcute renal failure is caused by three

factors i.e. pre-renal, renal and post renalfactors.16 Acute tubular necrosis,hypovolemia, intestinal nephritis and urinarytract obstruction can cause acute renalfailure. Tubular dysfunction and depressionin the glomerular filtration rate (GFR)occurs which rises the serum creatinine andblood urea nitrogen (BUN) levels. Themajor metabolic defect is an inability tohandle hydrogen ions and secrete potassiumions and thus if left untreated, these patientsbecome acidotic and hyperkalemic whichcan lead to cardiac irritability andarrhythmias if the patient is challenged bysurgery. If the condition is prolonged orpermanent, it may be necessary to place ashunt in the patient’s arm for repeatedhemodialysis.17

Patients on dialysisDialysis is used if serum creatinine is

between 600-800 micromol/L and they areof two types namely: i) Haemodialysis ii)Peritoneal dialysis.8

In course of dialysis, patient is givenparenteral heparin to prevent coagulation ofblood which is retained for 4-6 hours afteradministration. This is important for thetiming of dental intervention i.e. extractionshould be done a day after dialysis when theanticoagulant’s effect is minimum while thedialysis effect is maximal. Dialysis patientsare more susceptible to bleeding andinfection. Drugs like streptomycin,kanamycin, vancomycin and tetracyclineshould be avoided as their excretion isthrough kidneys.18

Renal transplant patientsTransplantation is recommended for

patients with End Stage Renal Disease(ESRD) who are medically suitable since asuccessful transplant offers enhanced qualityand duration of life and is more effectivemedically and economically thatdialysis.16However, unlike patientsundergoing dialysis, those receiving kidneytransplants receive immunosuppressivetherapy to prevent T-cell allo-immunerejection response.19These patients areextremely sensitive to infection. Theimmunosuppressant therapy may involvemany side effects like hypertension, diabetesand increased bleeding that in turn maylargely affect the oral surgical intervention.Because of potential adrenal crisis risk, it isnecessary to alter steroid therapy.20


Nephrotic syndrome

Nephrotic syndrome is a clinicaldisease comprising of stages likeproteinuria, hypoproteinemia andhyperlipidemia. Diabetes, Systemic LupusErythematosus (SLE) and amyloidosis aremost common causes of nephrotic syndromewhile among the primary kidney diseases,the most important are the diseasesinvolving immune deficiency i.e.glomerulonephritis.8 It is characterized byalterations of perms-electivity at theglomerular capillary wall, resulting inprotein loss through the urine. In nephroticsyndrome, proteinuria exceeds 1000mg/m2/d or spot urinary protein to creatinineratio exceeding 2mg/mg.21 Treatment aimsin reducing proteinuria, control infectionsand prevent thromboembolism.16 Forpatients who are undergoing invasive dentalprocedures and are on corticosteroids,corticosteroid cover should be administeredto minimize the risk of adrenal crisis.21

Alterations of cellular immunity andmalnutrition occur to a protein restricted dietlead to immuno-deficiency in nephroticsyndrome patient. It can also cause Epstein’ssyndrome which is an idiopathic nephriticsyndrome with typical changes in themucous of new borns in the form of salty,pseudo-diphteric layers stretching over softpalate in the shape of butterfly. Patients withnephrotic syndrome are prone to infectionand thus prophylactic antibiotics becomeimportant before endodontic therapy,extractions and other invasive procedures.Thus, dental intervention should not beundertaken unless in urgent cases and anephrologist should be consulted.8

Dental considerations

Halitosis and metallic taste are caused byincreased concentration of urea in saliva andits transformation intoammonium.22Xerostomia is due torestriction of fluid intake, side effect ofantihypertensive drugs, salivary glandalteration and oral breathing secondary tolung perfusion problems. Pale mucosa is dueto anaemia.22Uremic stomatitis is attributedto painful lesions often occurring on theventral surface of the tongue and on anteriormucosal surfaces. They are resistant totreatment as far as urea levels remain highand heal spontaneously when the renaldisorder has resolved.23Gingival bleedingresulting from platelet dysfunction andeffects of anticoagulants. Gingivalhyperplasia secondary to drug treatment(cyclosporine/nifedipine) which is one of themost widely documented oral manifestationsin patients. The condition is aggravated bypoor oral hygiene.24Severe erosions on thelingual surfaces of the teeth are due tofrequent regurgitation and vomiting inducedby uremia and medication and nauseaassociated to dialysis.2There may be delaysand alterations in eruption of teeth.2Pulpobliteration can be possible due toalterations in calcium and phosphorousmetabolism.25Changes in maxillary boneoccurs secondary to renal osteodystrophywhich causes demineralization of bone withloss of trabecular pattern and cortical boneloss, giant cell radio transparencies ormetastatic calcifications of soft tissues. Theyare at increased risk of fracture during dentaltreatment like extraction.2Diminishedprevalence of caries has been observed andattributed to the protective effect on the partof urea, which inhibits bacterial growth andneutralizes bacterial plaque acids.7Tartarformation is due to increased levels of ureain saliva and altered calcium and


phosphorous metabolism.26Candidiasis ismost common both in transplant patients andin patients undergoing dialysis.Cytomegalovirus infection is frequent in thefirst months after transplantation andprolonged immune suppression can increasepatient vulnerability to human herpes virus-8.24Mucosal lesions like Oral HairyLeukoplakia (OHL) can occur due to druginduced immune suppression.24

Malignization due to increased susceptibilityto epithelial dysplasia and carcinoma of thelip attributable to the treatment followingrenal transplantation has been postulated.Increased risk of malignization in CRFprobably reflects the effects of iatrogenicimmune suppression, which increasesmucosal susceptibility to virus-relatedtumors like kaposi’s sarcoma or non-Hodgkin lymphoma.24

Dental management

Consultation with the nephrologistprovides information on the state of thedisease, the type of treatment, the besttiming of dental management, or the medicalcomplications that may arise. Anymodification of the usual medication usedby the patients or of other aspects of theirtreatment must first be consulted with thenephrologist.25

Prior to any invasive dental treatment, acomplete blood count is to be obtained withcoagulation tests in view of possiblehaematological alterations. It is essential toeliminate any infection in the oral cavity assoon as possible, with the consideration ofantibiotic prophylaxis when bleeding and/ora risk of septicaemia is expected like inextractions, periodontal treatments,endodontics and periapical surgery, theplacement of orthodontic braces, tartrectomywhen bleeding is expected, implant surgery,and the re-implantation of avulsedteeth.27Blood pressure is to be monitoredbefore and during treatment, with the

administration of sedation to lessen anxiety.The metabolism and elimination of certaindrugs are altered in situations of renalfailure. In such cases dose adjustment ormodification of the dosing frequency isneeded (Table 3). The prescription ofaminoglycoside antibiotics and tetracyclinesis to be avoided, because of theirnephrotoxicity. Penicillins, clindamycin andcephalosporins can be administered at theusual doses, and are the antibiotics of choice– though the dosing interval should beprolonged. As regards analgesics,paracetamol is the non-narcotic analgesic ofchoice in application to episodic pain.Aspirin possesses antiplatelet activity, andas such should be avoided in uremicpatients. As regards the rest of nonsteroidalanti-inflammatory drugs (indomethacin,ibuprofen, naproxen and sodium diclofenac),dose reduction or even avoidance isindicated in the more advanced stages ofrenal failure, since they inhibitprostaglandins and generate a hypertensiveeffect. Benzodiazepines can be prescribedwithout the need of dose adjustments,though excessive sedation may occur. Thenarcotic analgesics (codeine, morphine andfentanyl) are metabolized by the liver, andso usually do not require dose adjustment.Close cooperation between medical anddental professionals is desirable in order toimprove the oral and general health of thepatient, based on the creation of a dentalcare program in the context of amultidisciplinary approach to the disease.2

For dialysis patients :

Patients on peritoneal dialysis require nospecial measures as regards dental treatment,beyond those already commented above.Due to the already mentioned reasons,dialyzed patients are at an increased risk ofbleeding. It is advisable to provide dentaltreatment on non-dialysis days, to ensure the


absence of circulating heparin, which has ahalf-life of about four to six hours.7 In anycase, prior to invasive procedures, it isimportant to request a complete blood countand coagulation tests, and to ensure thatlocal hemostatic measures are available:mechanical compression, sutures, topicalthrombin, microfibrilar collagen andoxidized regenerated cellulose.2APTT andINR should be checked prior to the surgicalintervention. Desmopressin has beenproposed for the control of severe bleedingin patients with renal failure, and conjugatedestrogens can be used to achieve longer termhaemostasis.28 Tranexamic acid in the formof a rinse or administered via the oral routeat a dose of 10-15 mg/kg body weight a daydistributed in 2-3 doses, may also proveuseful.29Short acting barbiturates should beused like pentobarbital as it is metabolizedin liver.18Although there is somecontroversy in the literature regarding theneed for antibiotic coverage to preventbacterial-endocarditis in dialyzed patients,endocarditis is effectively a potentialcomplication in such patients. Therecommended antibiotic regimen is 2 g ofamoxicillin via the oral route one hourbefore the dental procedure. In the case ofpatients with allergy to penicillin,clindamycin is the drug of choice (600 mgvia the oral route, one hour before theintervention).2Dialyzed patients aresubjected to numerous transfusions andblood exchanges, and this implies anincreased risk of infection in the form ofHIV, HBV, HCV and tuberculosis. Periodicmonitoring is required, with the adoption ofmeasures to avoid both personal contagionon the part of the dental professional andcross-contamination in the dentalclinic.2Hemodialysis can affect the serumconcentrations of different drugs used byCRF patients, when such substances areadministered before the dialysis session.

Supplementary dosing after dialysistherefore may be needed.28

For transplant patients:

It is important to conduct dentalevaluation prior to renal transplantation, inorder to eliminate the existing infectiousfoci. Teeth offering an uncertain prognosisare to be removed.7The potential for oralinfections after transplantation is very high,since these patients receive immuno-suppressive therapy. Prophylactic antibiotictreatment is therefore indicated beforeinvasive dental procedures are carried out.Prolonged corticosteroid therapy may makeit necessary to administer a supplementarydose in situations of stress, such as whenvisiting the dentist, in order to avoid anadrenal crisis. The most recent guidesrecommend a dose of 25 mg ofhydrocortisone via the intravenous route,before the intervention.24Regimen mostoften include Calcineurin Inhibitor (CNI),corticosteroids, anti-proliferatives and co-stimulation blockers. Azothioprine is thecommonly used to prevent organ rejection.Initially high doses of the drug are reducedto 50 to 150 mg/day after two or threemonths. In the first 6 months aftertransplantation, patients should avoid anyelective dental treatment.

Conclusion :

A thorough check of the oral cavityin patients of renal failure is invaluable todiagnosis at an early stage of multi-systemdisease. Patients with renal diseases areextremely delicate group of patients.Therefore, these patients should be routinelyevaluated for oral lesions and treatedaccordingly. The dental management ofpatients with renal disease is complicated bysystemic consequences of renal failureparticularly anaemia, bleeding tendency,


cardiovascular or endocrine diseases, butwith the use of proper treatment protocols,the dental management in these patients canbe effective and safe. Dental treatment insuch patients implies close cooperationbetween the dentist and the nephrologist.

References :

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4. Donald Griffith. Infection-induced renalcalculi. Kidney international 1982; 21:422-30.

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8. Sulejmanagic H, Sulejmanagic N, Prohic S,Secic S, Miseljic S. Dental treatment ofpatients with kidney diseases-review.Bosnian journal of basic medical sciences2005; 5(1):52-56.

9. Shilpa et al. Oral manifestations of chronickidney disease- an overview. Internationaljournal of Comtemporary medical research2016; 3(4):1149-52.

10. Krishnan M. Preopeartive care of patientswith kidney disease. American family ofphysicians 2002; 66(8):1471-6.

11. Sladen RN. Anesthetic considerations forpatient with renal failure. Anesthesiol. Clin.North America 2000; 18(4):863-82.

12. Kho HS, Lee SW, Chung SC, Kim YK.Oral manifestations and salivary flow rate,ph and buffer capacity in patients with endstage renal disease undergoing dialysis. OralSurg Oral Med Oral pathol Oral Radiol.Endod 1999; 88(3):316:319.

13. Davidson SS. Diseases of kidney andurinary system. In: Haslett C, Chilvers ER,Hunter JAA, Boon NA. Davidsons:Principles and practice of medicine 18th ed.UK: Church Hill Livingstone 1999.

14. Floege J, Johnson R J, Feehally J.Comprehensive Clinical Nephrology 4th edElsevier Inc; 2010.

15. Sunil MK, Kumar R, Sawhney H, Gaur B,Rastogi T. Spectrum of OrofacialManifestations in Renal Diseases. J OrofacRes 2012; 2:216-220.

16. Crispian Scully. Scully’s medical problemsin dentistry. 7th edition, Edinburgh.Churchill Livingstone, 2014

17. Daniel Laskin. Oral and Maxillofacialsurgery. Volume one, St. Louis. Mosby,2004.

18. James Hooley, William Petersen. Dentalmanagement of patients on hemodialysis.O.S. O.M. O.P. 1969; 28(5):660-65.

19. Schuller PD, Freedman HL, Lewis DW.Periodontal status of renal transplantpatients receiving immune-suppressivetherapy. J Periodontol 1973; 44(3):167-70

20. Naylor GD, Fredericks MR. Pharmacologicconsiderations in the dental management ofthe patient with disorders of the renalsystem. Dent Clin North Am 1996; 40(3):665-683

21. Bagga A, Mantan M. Nephrotic syndrome inchildren. Indian J. Med. Res. 2005; 122:13–28.


22. De la Rosa García E, Mondragón Padilla A,Aranda Romo S, BustamanteRamírez MA.Oral mucosa symptoms, signs and lesions, inendstage renal disease and non-end stagerenal disease diabetic patients. MedOralPatol Oral Cir Bucal. 2006;11(6):E467-73.

23. Antoniades DZ, Markopoulos AK,Andreadis D, Balaskas I,Patrikalou E,Grekas D. Ulcerative uremic stomatitisassociated withuntreated chronic renalfailure: report of a case and review oftheliterature. Oral Surg Oral Med OralPathol Oral Radiol Endod.2006;101(5):608-13.

24. Proctor R, Kumar N, Stein A, Moles D,Porter S. Oral and dentalaspects of chronicrenal failure. J Dent Res. 2005;84(3):199-208.

25. Davidovich E, Davidovits M, Eidelman E,Schwarz Z, Bimstein E.Pathophysiology,therapy, and oralimplications of renal failure in childrenandadolescents: an update. Pediatr Dent.2005;27(2):98-106.

26. Bots CP, Poorterman JH, Brand HS,Kalsbeek H, Van AmerongenBM, VeermanEC, et al. The oral health status of dentatepatientswith chronic renal failureundergoing dialysis therapy. Oral Dis.2006;12(2):176-80.

27. Werner CW, Saad TF. Prophylacticantibiotic therapy prior to dentaltreatmentfor patients with end-stage renal disease.Spec Care Dentist. 1999;19(3):106-11.

28. Kerr AR. Update on renal disease for thedental practitioner. Oral Surg Oral MedOral Pathol Oral Radiol Endod. 2001;92(1):9-16

29. Mannucci PM. Treatment of vonWillebrand’s Disease. N Engl J Med.2004;351(7):683-94.

Tables

Table 1. Signs and symptoms of renal

failure and uremia

Signs Symptoms

Peripheral edema ‘Restless’ legs

Rise in blood

pressure

Leg cramps

Pericardial effusion Ankle edema

Confusion, coma,

lethargy

Loss of libido

Renal osteodystrophy Feeling cold

Pallor due to anemia Pruritus

Bruising due to

platelet dysfunction

Insomnia


Table 2. Classification of CKD based on GFR

CKD

stage

Definition

1 Normal or Increased GFR, some evidence of kidney damage reflected bymicroalbuminuria, proteinuria and hematuria as well as radiologic or histologicchanges

2 Mild decrease in GFR (60-89ml/min per 1.73m2) with some evidence of kidneydamage reflected by microalbuminuria, proteinuria and hematuria as well asradiologic or histologic changes

3

3A

3B

GFR 30-59 ml/min per 1.73m2



4 GFR 15-29 ml/min per 1.73m2

5 GFR <15 ml/min per 1.73m2 when renal replacement therapy in the form of dialysis

or transplantation has been considered to sustain life


Table 3. Alteration in the dosage of medicines according to creatinine clearance

PharmaceuticalSubstance

Adjustment based on Creatinine Clearance (ml/min)

>50 10-50 <10

Antimicrobials

Amoxicillin Usual dosage every 8

hours

Usual dosage every 8 or

12 hours

Usual dosage every 12-

18 hours

Erythromycin Regular dosage and rate Regular dosage and rate Reduced dosage to 50-

75%

Clindamycin Regular dosage and rate Regular dosage and rate Regular dosage and rate

Metronidazole Regular dosage and rate Regular dosage and rate Reduced dosage to 50%

Aciclovir Usual dosage every 8

hours

Usual dosage every 12-

24 hours

Usual dosage every 48

hours

Ketoconazole Regular dosage and rate Regular dosage and rate Regular dosage and rate

Analgesics

Aspirin Regular dosage and rate Adjustment of the rate of

Administration

Avoid

Paracetamol Regular dosage and rate Regular dosage and rate Adjustment of the rate of

Administration

Ibuprofen Regular dosage and rate Regular dosage and rate Avoid

Diclofenac Regular dosage and rate Regular dosage and rate Avoid

Naproxen Regular dosage and rate Regular dosage and rate Avoid

Local anaesthetics

Lidocaine Regular dosage and rate Regular dosage and rate Regular dosage and rate

Mepivacaine Regular dosage and rate Regular dosage and rate Regular dosage and rate

OTHERS

Prednisone Regular dosage and rate Regular dosage and rate Regular dosage and rate


AMELOGENESIS IMPERFECTA: A CASE REPORT

*Dr. Vrushang Soni *Dr.Viraj Talsania*Dr. Dharmik Patel **Dr. Jyoti Mathur

AbstractStructural defects of teeth are the inherited or acquired conditions which affect the normal

structure of teeth like enamel, dentin, pulp, or cementum. Due to such defect, patient’s normalfunction of teeth is hampered. So it is necessary to identify the type of defect by properinvestigation techniques and establish the treatment plan to restore the function of teeth. In thiscase report, clinical and radiographic investigation procedures of a patient with the structuraldefect is described.Key words : structural defect, discoloration of teeth, thinning of enamel, roughened surface,chipping of enamel

Introduction

Genetic causes have been identified forboth isolated teeth malformations and for thedental anomalies seen in patients withcraniofacial developmental defects.1

Mutation in several genes like ENAM,AMELK, DSPP, DMP-1, IBSP, SPP1, etc.have been associated with orofacial anddental defects.2 Developmental anomalies oftooth is mostly divided on the basis of: (1)Number of teeth (2) shape of teeth (3) sizeof teeth (4) structure of teeth. Genetic toothanomalies are many a times associated withsyndromes or transferred by hereditarytraits.

*Interns

**Head Of The Department

Department of Pediatric and Preventive

Dentistry,

Faculty of Dental Science

Dharmsinh Desai University, Nadiad-

387001, Gujarat, India.

Sporadic occurrence of genetic anomalies ispresumed to be caused by dominant orrecessive multifactorial inheritance, by newmutation or by stochastic occurrences. Thisarticle refers to laboratory investigations andhistological differences in structural defectof tooth.

Case report

A 12 years old male patient reported toDepartment of Pediatric and PreventiveDentistry, Faculty of Dental Science, DDU,Nadiad with the chief complain ofdiscoloration and wearing of all teeth(Illustration 1 to Illustration 5)

Corresponding Author:

Vrushang Soni,

16, Meghdoot society, Bh. Aryakanya

Vidhlaya, Karelibaug,

Vadodara. Postal Code- 390018.

Email ID: [email protected]

Contact Number: +91 9426156920


Illustration 1: Initial intraoral viewshowing the teeth with amelogenesis

imperfect

Illustration 2: View of lingual surface ofleft mandibular posterior teeth

Illustration 3: View of lingual surface ofright mandibular posterior teeth

Illustration 4: View of occlusal surface ofleft maxillary posterior teeth

Illustration 5: View of occlusal surface ofright maxillary posterior teeth

The parents also expressed concern thatthere was delay in eruption of permanentteeth and change in colour of same duringthe time of eruption. Patient’s past medicalhistory was non-contributory. There was nohistory of any unusual bone brittleness orunexplained hearing loss in the family orany other systemic illness or drug usage inpresent or past. Abnormality was notdetected on general physical examination. Itis necessary to perform the investigations forthe diagnosis of the disease so that a propertreatment plan can be implemented. Numberof teeth present were


16 55 54 53 12 11 21 22 63 64 65 26

46 85 84 83 42 41 31 32 73 74 75 36

His first paternal cousins have similarcondition of teeth. The thickness of enamelwas decreasing from posterior teeth toanterior teeth. The teeth were yellowishbrown in color and carious lesions wereabsent. It was seen that enamel was notpresent on all surface of deciduous teeth.Patient also had poor oral hygiene withmoderate to severe dental plaqueaccumulation along with debris and calculuswhich caused roughening of teeth surface.Gingival tissues around most of permanentand primary teeth showed mildinflammation. The thickness of enamel wasreduced with localized chipping of enamelsurface in anterior teeth region.Radiographic features were evaluated by anorthopantomograph (Illustration 6). It showsthat following teeth are present in oralcavity.

17 16 15 55 14 54 13 53 12 11 21 22 63 23 64 24 65 25 26 27

47 46 45 85 44 84 43 83 42 41 31 32 73 33 74 34 75 35 36 37

Uneven thickness of enamel is seen inclinical and radiographic finding offollowing teeth:

16 55 54 53 12 11 21 22 63 64 65 26

46 85 84 83 42 41 31 32 73 74 75 36

Enamel thickness is adequate in eruptingpermanent teeth:

17 2747 37

Roots showed normal length and form. Pulpchambers were regular in size.

Illustration 6: Orthopantomograph(OPG)of patient

Pulp obliteration is not seen in any presentteeth. Radiodensity of enamel is more thanthe radiodensity of dentin. Cementum,alveolar bone and periodontal ligamentspace appear normal. Cervical constriction isnot seen in any teeth. Enamel is of variablethickness in the specimen tooth. Enamel isabsent on the incisal surface whereas on theproximal surface the thickness is reduced(Illustration 7).

Illustration 7: Radiovisiography(RVG) ofmandibular anterior teeth


Discussion:

Amelogenesis Imperfecta is adevelopmental, often inherited disorderaffecting dental enamel. It may beassociated with systemic features andcomprises of diverse phenotypic entities.3

On intraoral examination in patient affectedwith amelogenesis imperfect by Begum N4

showed generalized yellowish discoloration.The thickness of enamel was reduced withlocalized chipping of enamel in anteriorteeth region. Radiographic examinationrevealed a generalized loss of enamelthickness. Similar clinical and radiographicfeatures can be seen in our case. Seow5

studied 32 patients from 17 families withseveral types of amelogenesis imperfectwhich showed that 3 families had yellowishteeth. The enamel tended to chip awayeasily, exposing large areas of dentin. Alsopatients were disposed to poor gingivalhealth because of enhanced plaque retentionand calculus formation which resulted inrough enamel surface. These findingssupported the clinical findings seen in ourcase. Study by Mehta DN6 showed thatenamel was softer in consistency withchipping of enamel on probing. Panoramicradiograph showed presence of thin layer ofenamel with radiodensity of enamel morethan dentin which supports our study.Yamaguti PM7 examined 12 familymembers which revealed that there werealteration in shape and colour of teeth andareas with fractured enamel. Theseobservations were also found in clinicalexamination of our patient. Due to suchstructure of enamel, there were failures incomposite veneering due to lack of goodenamel bonding. Full coverage restorationscan be the another treatment option in futurewhen all permanent teeth have erupted fullyin the oral cavity.

Conclusion:

The diagnosis we have done are fromclinical and radiographic features ofamelogenesis imperfecta whichdifferentiates it from other structural defects.So, from clinical and radiographicinvestigations, we are able to know theextent of disease and number of teethaffected. So we can plan a better treatmentfrom the investigations. Also the progressionof disease can be stopped and restoring thepatient’s normal function and improving theesthetics.The treatment objectives were to improve

the esthetics, prevent further loss of toothstructure and improve his periodontal health.As the part of the treatment plan, thetreatment plan was explained to the childand his parents. The initial treatment wasscaling and patient was instructed methodsto maintain proper oral hygiene which wasfollowed by composite veneering underideal conditions and extraction of overretained deciduous teeth. The restorationimproved the esthetic appearance of hissmile.

Acknowledgements:

We would like to thank Research andDevelopment department of DharamsinhDesai University for helping us with themicroscope techniques for examining thehistological section. We would also like tothank Department of Prosthodontics: crownand bridge for taking RVG of patient.


References:

1. Ophir DK, Snehlata O,Ann H, MariaH, Miroslav P, Renata P.Developmental disorders of thedentition: An update. Am J MedGenet. 2013;4:318-332.

2. Bailleul-Forestier I, Molla M,Verloes A, Berdal A. The geneticbasis of inherited anomalies of teeth.Part 1: clinical and molecular aspectsof non-syndromic dental disorders.Eur J Med Genet. 2008;51:273-91.

3. Paine ML, Whitw SN, Luo W, FongH, Sarikaya M, Snead ML.Regulated expression dictatesenamel structure and tooth function(review). Matrix Biol. 2001;20:273-92.

4. Begum N, Bhandarkar GP, Kini R,Naik V, Rashmi K, D Souza LC.Amelogenesis Imperfecta: A Seriesof Case Report. Int J Adv Health Sci.2015;2(1):17-21

5. Seow, W.Kim. Clinical diagnosisand management strategies ofamelogenesis imperfect variants.Pediatric dentistry. 1993;15:384-93

6. Mehta DN, Shah J, Thakkar B.Amelogenesis imperfect: Four casereports. J Nat Sc Biol Med.2013;4:462-5

7. Yamaguti PM, Acevado AC, dePaula LM. Rehabilitation of anadolescent with AutosomalDominant Amelogenesis Imperfecta:Case Report. Operative dentistry.2006;31(2):266-72


A SURVEY OF ATTITUDE ABOUT SMOKING, ASSOCIATED WITHPERIODONTAL DISEASE AND DENTAL IMPLANTS

*Dr. Sagar Patel **Dr. Vasumati Patel ***Dr. Shalini Gupta****Dr. Sumit Satwara *Dr. Kinjal Gabani *Dr. Ripal Shah

AbstractObjectivesThe purpose of the study was to investigate the attitude of patients towards smoking and theirknowledge of smoking as a risk factor for periodontal disease and dental implants.MethodsIn this cross sectional study, 158 subjects were provided a questionnaire survey about smokingstatus for the recognition of smoking as a risk factor for periodontal disease and dental implantsusing the Kano Test for Social Nicotine Dependence(KTSND).ResultsSmoking was recognized as a risk factor for periodontal disease by 150 patients(95%) and as arisk factor for dental implants by 92 patients (58%). The KTSND scores of the patients withknowledge of smoking as a risk factor and for dental implants was significantly lower than thoseof the patients without knowledge of smoking as a risk factor for periodontal disease and fordental implants, respectively.ConclusionIn order to increase the recognition of smoking as a risk factor for periodontal disease and dentalimplants and patient education must be improved.

Key words: Dental Implant, periodontal disease, smoking, smoking cessation, Kano test ForSocial Nicotine Dependence (KANO).

Introduction

Smoking is a risk factor for variousdiseases, including periodontal disease.1,2

*3rd year Post-graduate student

** Professor & Head

***Professor

**** Tutor

Department of Periodontics and OralImplantology,

Faculty of Dental Science, Dharmsinh DesaiUniversity, Nadiad

The oral tissue is most directly affected bysmoking; carbon monoxide, a component ofsmoke, initially impedes blood flow andthereafter impedes immune function.


Dr. Sagar Patel (MDS Part 3 PG Student)

14-Taksh Bungalows, Gorwa-Refinery road,

Gorwa, Vadodara.

Email:[email protected]

(M): +91 9601397734


Smoking affects dental implants aswell as the natural teeth. Strietzel et al.identified smoking as a risk factor for thesurvival rate of dental implants duringhealing.3

The Kano Test for Social NicotineDependence “KTSND”, is composed of 10questions that reflect 3 factors: the smoker’sattempt to undervalue the harm caused bysmoking, to overvalue the favourable effectsof smoking, and to justify smoking as anacceptable cultural and social behavior.4

Higher KTSND score reflect an increasedperception that the act of smoking isacceptable and justifiable, indicating agreater social dependence on nicotine.Smokers as well as non-smokers can answerthe questions in the KTSND. It is in theorder corresponding to current smokers,former smokers, and nonsmokers.4-9 Thescores change according to various factors,such as smoking experience, occupation,and circumstance.4-9

The purpose of the current survey isto investigate the attitude of patients towardssmoking and their knowledge of smoking asa risk factor for periodontal disease anddental implants

.Materials and Methods :

Total 158 patients who visited theDepartment of Periodontics, Faculty ofDental Science, Dharmsinh DesaiUniversity, Nadiad from December 2015 toJanuary 2016 were included in the studybetween age group of 15 to 70 years.

The survey methods includedadministering questionnaires to patients inEnglish as well as Gujarati (whicheverlanguage patient was comfortable with) andcollecting and analyzing the data. Thesurvey forms included details like patients’sex, age, smoking experience, knowledge ofsmoking as a risk factor for periodontaldisease and dental implants and the

questionnaire of Kano Test for SocialNicotine Dependence. The KTSND consistsof 10 questions with a choice of 4 responseswith scoring:

Score Criteria3 Definitely Yes2 Probably Yes1 Probably No

0Definitely No

Only Question 1 is scored in reverseorder, where “Definitely Yes” is scored 0,“Probably Yes” as 1, “Probably No” as 2and “Definitely No” as 3. The individualscores for each question are added to give atotal KTSND score that ranges from 0 to 30,with higher scores indicating a greater socialdependence on nicotine. The desiredKTSND score is ≤ 9.10, 11 In this study thesmoking rates between men and women, theKTSND scores were compared.

Results :

1. Patient characteristics (Table 1)The questionnaire was distributed to

a total of 158 patients. The mean age was31.6 years. The highest proportion ofsubjects was aged 30-39, followed by thoseaged 20-29, 40-49, 10-19, 50-59 and 60-69.

Overall, 11 (7%) subjects werecurrent smokers and 14 (9%) were formersmokers. Among men, 11 (15%) subjectswere current smokers and 14 (19%) wereformer smokers. Among women, all subjectswere non-smokers. The highest proportionof current smokers was aged 20-29, thenfollowed by 40-49 and 30-39.


2. KTSND scores (Table 2)The mean KTSND scores of the

current smokers, former smokers, and non-smokers were 14.36+6.29, 4.6+2.16 and0.02+0.2 respectively. The KTSND score of

the current smokers was higher than those ofthe former smokers and non-smokers. TheKTSND score of the former smokers washigher than that of the non-smokers.

Table 1 : Patient Characteristics

Regarding the knowledge of smoking as arisk factor for dental implants, out of all of

the respondents, 92 patientsreplied“Definitely Yes”. Out of these, 2

Male Female Total

Subject 75 83 158

Mean age 29.4+9.82 33.6+8.09 31.6+9.13

Smoker 11 0 11

Former smoker 14 0 14

Non smoker 50 83 133

AGE GROUP

10-19 12 1 13

20-29 30 22 52

30-39 21 42 63

40-49 9 16 25

50-59 1 2 3

60-69 1 1 2

SMOKERS’ AGEGROUP

10-19 0 0 0

20-29 6 0 6

30-39 2 0 2

40-49 3 0 3

50-59 0 0 0

60-69 0 0 0


patients were current smokers 1 was formersmokerand 89 were non-smokers.

The mean KTSND score of the subjectsanswering “Definitely Yes” regarding

knowledge of smoking as a risk factor forperiodontal disease was 11.6 + 2.87, that of“Probably Yes” was 11.1+7.51, that of“Probably No” and “Definitely No” was 0.

Table 2 : The KANO test for social nicotine dependence

Smokers

(Mean +SD)

Formersmokers

(Mean +SD)

Non smoker

(Mean +SD)

Q 1: Smoking itself is a disease 0.45+ 0.68 0.14+ 0.53 0

Q 2: Smoking is a part of culture 0 0 0

Q 3: Tobacco is one of life’s pleasures 2.18+1.67 0.92+0.47 0

Q 4: Smokers’ lifestyles may be respected 0.90+0.70 0.21+0.42 0

Q 5: Smoking sometimes enriches people’slives

1.45+0.93 0.14+0.36 0

Q 6: Tobacco has positive physical or mentaleffects

1.45+1.03 0.5+0.51 0

Q 7: Tobacco has effects to relieve stress 2.54+0.93 1.35+0.63 0.01+0.122

Q 8: Tobacco enhances the function ofsmokers’ brains 2.45+0.93 1.07+0.61 0.007+0.08

Q 9: Doctors exaggerate the ill effects ofsmoking

1.09+0.83 0.07+0.26 0.007+0.08

Q 10: People can smoke at places whereashtrays are available

1.81+1.25 0.21+0.57 0

Total KTSND Score 14.36+6.29 4.6+2.16 0.02+0.2

Moreover, the mean KTSND score ofsubjects answering “Definitely Yes”regarding knowledge of

smoking as a risk factor for dental implantswas 1.6+1.04, that of “Probably Yes” was12.6+4.40, that of “Probably No” was8.5+8.01, and that of “Definitely No” was 0.


4. Relationship between the KTSND scoresand the knowledge of smoking as a riskfactor for periodontal disease and dentalimplants (Table 5)

Smoking was not regarded as a riskfactor for either periodontal disease or dentalimplants by 8 patients because they did notanswer “Definitely Yes” to either question;these subjects are hereinafter referred to asthe “NN” group. The KTSND score of thesesubjects was 13.8+7.5. Smoking wasregarded as a risk factor for both periodontaldisease and dental implants by 92 patientsbecause they answered “Definitely Yes” forboth questions; these subjects are hereinafterreferred to as the “YY” group. The KTSND

score of these subjects was 0.17+1.04.Further, 58 patients thought that smoking isa risk factor for periodontal disease becausethey answered “Definitely Yes” forquestions regarding periodontal disease;these subjects are hereinafter referred to asthe “YN” group. The KTSND score forthese subjects was 1.72+3.8. Finally, nopatient thought that smoking is a risk factorfor dental implants only. The KTSND scoresof the “NN” group were higher than those ofthe “YY” and “YN” groups.

Table 3: Smoking as a risk factor for periodontal disease

Definitely yes Probably yes Probably no Definitely no

Smoker 5 6 0 0

Former smoker 13 1 0 0

Non smoker 132 1 0 0

Total 150 8 0 0

KTSND 11.6 + 2.87 11.1 + 7.51 0 0


Table 4: Smoking as a risk factor for dental implants

Definitely yes Probably yes Probably no Definitely no

Smoker2 4 5 0

Former smoker1 13 0 0

Non smoker89 43 1 0

Total92 60 6 0

KTSND1.6 + 1.04 12.6 + 4.40 8.5 + 8.01 0

Table 5: Relationship between the KTSND scores and knowledge of smoking as a risk factor

for periodontal disease and dental implants

Subjects KTSND Score

(Mean +SD)

Patients who think smoking is not a risk factor foreither periodontal disease or dental implants (NN)

8 13.8+7.5

Patients who think smoking is a risk factor for bothperiodontal disease and dental implants (YY)

92 0.17+1.04

Patients who think smoking is a risk factor forperiodontal disease only (YN)

58 1.72+3.8

Patients who think smoking is a risk factor fordental implants only (NY)

0 -

Discussion :

Tobacco smoking is among thelargest preventable causes of prematuredeaths globally.12 In 2010, an estimated 120million Indian adults were smoker, making


India is second to China in numberof smokers.13,14 The Indian governmentimplemented the Cigarettes and OtherTobacco Products Act (COTPA) in 2003and ratified the WHO’s FrameworkConvention on Tobacco Control in 2004, aswell as the Cable Television Networks(Amendment) Act 2000 prohibiting tobaccoadvertising in all state-controlled electronicmedia and publications, including cabletelevision.15-17 Further, the Government hasalso included tobacco control in thepriorities of the ongoing National RuralHealth Mission.18 Despite theseprogrammes, the major challenge to successis effective implementation of the provisionsof COTPA, especially in enforcement ofbans on smoking in public places (which areknown to raise cessation rates).12,16 Mostimportantly, the trends in smoking reflectthe lack of substantial increases in tobaccoexcise taxes, which have not kept up withthe increased affordability of cigarettes andbidis.19 Substantial increases in the numberof male smokers aged 15–69 years, risingover one-third since 1998 to nearly 108million in 2015.20 The increase is mostly dueto population growth offsetting the modestdeclines in prevalence over this time period,similar to the pattern observed in othercountries.20

Smoking is a risk factor for variousdiseases. Smoking was reported as a riskfactor for periodontal disease by Haber et al.and Genco et al., for the loss of periodontaltissue by Haffajee al., and for dentalimplants by Strietzel et al. and Liddelow etal.1,2,3,21,22 In order to maintain oral health,all patients must have proper informationand the rate of smoking should be 0%. Inthis study, 94.9% of patients had knowledgeof smoking as a risk factor for periodontaldisease, whereas 58.2% of patients hadknowledge of smoking as a risk factor fordental implants (Table 3). Lung et al.reported that only 6% of their respondents

were specifically aware of the link betweensmoking and periodontal disease.23

Awareness of smoking as an increased riskfor dental implants was very low comparedto that of regarding periodontal disease.. Inthis study, scores of 15.8, 6.5 and 0.4 wereobtained in current smokers, ex-smokers,and non-smokers, respectively. Yoshii et al.reported that KTSND scores of 18.0 ± 5.0,12.2 ± 4.9, and 12.2 ± 5.3 were obtained incurrent smokers, ex-smokers, and non-smokers, respectively.8

The patients’ mean age in this studywas 31.6, and the patients in this age groupwould have received sufficient educationregarding smoking cessation as youths.Therefore, the KTSND scores in this studywere relatively low. In this study, theKTSND scores of the subjects whoanswered “Definitely Yes” regardingknowledge of the association betweensmoking and periodontal disease (11.6) anddental implants (1.6) were lower comparedto those of the other subjects (Table 3).Further, when viewed individually, theKTSND score of the NN group was higherthan those of the other subjects (Table 5).Therefore, patient education regardingdental therapy potentially decreased theKTSND scores of these subjects. Inaddition, the boundary value betweennormal and high KTSND scores was set as10, based on the results of a surveyadministered to the attendees of a tobaccocontrol meeting who were not sociallydependent on nicotine.10

The KTSND questionnaire iscomprised of 10 questions related to 3factors: justifying smoking as an acceptablecultural and social behavior, overvaluing thefavorable effects of smoking, andundervaluing the harm caused by smoking.4

Questions 2, 3, 4, and 5 are related to thejustification of smoking as an acceptablecultural and social behavior, while questions6, 7, and 8 are related to overvaluing the


favorable effects of smoking. Questions 1, 9,and 10 are related to undervaluing the harmof smoking. In this study, the KTSNDscores of current smokers for Q 3, 5, 6, 7, 8,9 and 10 were higher than were those ofnon-smokers. Moreover, the KTSND scoresof current smokers for question other thannumber 2 were higher than those of ex-

smokers (Table 2). Therefore, this studysuggests that current smokers tend to bothglamorize smoking and underestimate theharm it causes.

The doctor and the patient mustremind themselves of the fact that smokingis a risk factor for various diseases.Regarding periodontal disease, currentsmokers have dark gum color, less bloodflow, stained teeth, and bad breath.Although patients can directly evaluate theiroral health themselves, they cannot evaluatetheir lungs. It is important for currentsmokers to realize the result of smokingcessation every day.

Conclusion :

In this study, 94.9% of patientsrecognized smoking as a risk factor forperiodontal disease, whereas 58.2%recognized smoking as a risk factor fordental implants. The KTSND score of thepatients who recognized smoking as a riskfactor for both periodontal disease anddental implants was significantly lowercompared to those of the other subjects.However, none of the KTSND scores in thisstudy reached the desired KTSND score. Inorder to increase the recognition of smokingas a risk factor for periodontal disease anddental implants patient education must beimproved.

References :

1. Haber J, Kent RL: Cigarette smoking in aperiodontal practice. J Periodontol 1992; 63:100-106.

2. Genco RJ, Borgnakke WS: Risk factors forperiodontal disease. Periodontol 2000 2013;62: 59- 94.

3. Strietzel FP, Reichart PA, Kale A: Smokinginterferes with the prognosis of dentalimplant treatment: a systematic review andmeta-analysis. J Clin Periodontol 2007; 34:523-544.

4. Yoshii C, Kano M, Isomura T: Aninnovative questionnaire examiningpsychological nicotine dependence, "TheKano Test for Social NicotineDependence(KTSND)". J UOEH 2006; 28:45- 55.

5. Kurioka N, Inagaki K, Yoshii C:Investigation of the perception of femalestudents towards tobacco smoking with TheKano Test for Social Nicotine Dependence(KTSND) in 2006 [in Japanese]. Jpn J TobControl 2007; 2: 62-67.

6. Inagaki K, Hayashi J, Ting CC: Dentalundergraduates’ smoking status and socialnicotine dependence in Japan and Taiwan -comparison between two dental schools [inJapanese]. Jpn J Tob Control 2008; 3: 81-85.

7. Inagaki K, Mukai M, Bessho M: Smokingstatus and social nicotine dependence amongworkers and teachers in the Kusumotocampus of Aichi-Gakuin University [inJapanese]. Aichi Gakuin J Dent Sci. 2009;47: 281-292.

8. Yoshii C, Kano M, Inagaki K: The KanoTest for Social Nicotine Dependence(KTSND) in samples from three hospitalemployees in Fukuoka prefecture [inJapanese]. Jpn J Tob Control 2007; 2: 6-9.

9. Yoshii C, Inoue N, Yatera K: An evaluationof social nicotine dependence of participantsat the annual meeting of the Japan lungcancer society using the Kano Test for


Social Nicotine Dependence [in Japanese].Haigan 2010; 50: 272-279.

10. Yoshii C, Kurioka N, Kano M: The KanoTest for Social Nicotine Dependence(KTSND) in samples from the attendants ofMiyako Tobacco Control Meeting [inJapanese]. Jpn J Tob Control. 2008; 3: 26-30.

11. Amagai K, Nakamura Y, Yoshii C: Smokingstatus and the Kano Test for Social NicotineDependence (KTSND) in employees of aregional cancer center in Japan. Jpn J TobControl 2011; 6:71-84.

12. Jha P, Peto R. Global effects of smoking, ofquitting, and of taxing tobacco. N Engl JMed 2014;370:60–8.

13. Shafey O, Eriksen M, Ross H. The TobaccoAtlas. 3rd edition Atlanta, USA: AmericanCancer Society, 2009.

14. Global Adult Tobacco Survey: India Report.Mumbai, India: International Institute forPopulation Sciences (IIPS), Ministry ofHealth and Family Welfare GoI, 2010.http://mohfw.nic.in/WriteReadData/l892s/1455618937GATS%20India.pdf

15. The Cigarettes and Other Tobacco Products(Prohibition of Advertisement andregulation of Trade and Commerce,Production, Supply and Distribution) Act;An Act enacted by the Parliament ofRepublic of India by notification in theOfficial Gazette. (Act 32 of 2003). In: IndiaPo, ed. New Delhi, 2003.

http://www.who.int/fctc/reporting/Annexthreeindia.pdf

16. Roemer R, Taylor A, Lariviere J. Origins ofthe WHO Framework Convention onTobacco Control. American Journal ofPublic Health. 2005;95(6):936-938.

17. The Cable Television Networks(Amendment) Act In: India Go, ed., 2000.http://www.wipo.int/edocs/lexdocs/laws/en/in/in033en.pdf

18. Kaur J, Jain DC. Tobacco control policies inIndia: implementation and challenges.Indian J Public Health 2011;55:220–7.

19. Jha P, Guindon GE, Joseph RA: A rationaltaxation system of bidis and cigarettes toreduce smoking deaths in India. Econ PolitWkly 2011;42:44–51.

20. Ng M, Freeman MK, Fleming TD: Smokingprevalence and cigarette consumption in 187countries, 1980–2012. JAMA 2014;311:183–92.

21. Haffajee AD, Socransky SS: Relationship ofcigarette smoking toattachmentlevelprofiles.J Clin Periodontol. 2001; 28: 283-295.

22. Liddelow G, Klineberg I: Patient-related riskfactors for implant therapy. A critique ofpertinent literature. Aust Dent J. 2011; 56:417-426.

23. Lung ZH, Kelleher MG, Porter RW: Poorpatient awareness of the relationshipbetween smoking and periodontal diseases.Br Dent J. 2005; 199: 731-737.


TOOTH BRUSHING BEHAVIOURS AND DENTAL ABRASION AMONGTHE POPULATION IN NADIAD, GUJARAT, INDIA:

A CROSS-SECTIONAL STUDY

*Dr. Kinjal Gabani **Dr. Vasumati Patel ***Dr. Shalini Gupta**** Dr. Hiral Purani * Dr. Sagar Patel *Dr. Ripal Shah

Abstract:Aim:To determine correlation between tooth brushing pattern and dental abrasions amongpopulation in Nadiad city,Gujarat. To suggest appropriate remedial measures to preventself‑inflicted injury.Material and Method:The study was carried out on 165 patients aged 20 years and above whovisited the Department of Periodontology and Oral Implantology, Faculty of Dental ScienceDharmsinh Desai Univarsity,Nadiad. Assessment form comprises a questionnaire andinformation on brushing pattern.Results:The study revealed a statistically significant relationship between abrasive lesions andage groups as well as technique of tooth brushing. Statistically significant difference was foundbetween abrasions and tooth brushing frequency, while no significant relation was found with thegender and type of toothbrush used.Conclusion:The prevalence of tooth brushing abrasions increases with age and is more affectedby technique of tooth brushing. Increased tooth brushing frequency and changing of toothbrushresult in an increase in the number of tooth abrasions. Therefore, dental professionals shouldmake evidence‑based recommendations to their patients and general masses.Key Words: Abrasion, Toothbrushing Pattern, Brushing frequency.

Introduction

Tooth wear is a common problem,but most often left untreated. The presenceof tooth wear might become more noticeableNowadays and in future. This occurrencecould be due to increased dental awarenessand people becoming more interested in

* 3rd year post graduate student**Professor and Head

***Professor****ReaderDepartment of Periodontology and OralImplantology, Faculty of Dental Science,Dharmsinh Desai University,Nadiad.

keeping their dentition healthy for a longertime which could be exposed to wear.1

Non‑carious cervical lesions (NCCLs) havebeen attributed to toothbrush abrasion,(commonly termed dental erosion), andabfraction. Dental abrasion is the mostprevalent form of NCCL.2

Corresponding Author:Dr. Kinjal Gabani (Post-graduate Part-3)79/80 MIG Shastrinagar,Near Sardar Circle,Bhavnagar 364002.Email: [email protected]. No.: +91 9512110178


An understanding of the multifactorialnature of tooth wear and its risk factors isimportant in the patient’s diagnosticprotocol and management strategy.3

Cervical tooth wear or tooth abrasion isdefined as the pathological wearing of dentaltissues or dental restorations by friction withforeign substances independent ofocclusion..4Abrasion can be caused due tovarious foreign objects, most common is dueto toothbrush mainly because of faulty toothbrushing technique. Cervical abrasion mayvary in its clinical presentation amongindividuals, and may cause painfulsensations linked to dentinal hypersensitivityand impair an individual’s oral hygieneperformance during tooth brushing.5,6

Tooth brushing is the most common meansof oral prophylaxis at an individual level andin the light of its potential benefits to oralhealth, the adverse effects or damage causedby tooth brushing can be rated as rathersmall.7Loss of hard tissue at the cervicalarea of teeth has been observed.8

Abrasion is defined as the pathologicalwearing away of dental hard tissue bymechanical forces..9 Although the clinicalappearance of these lesions varies, theyfrequently appear to be wedge‑shapeddefects having a bright surface, normalhardness and color, and a sharp border.10,11

Specific cause of these lesions is unknown.12

It has been suggested that they may becaused by a hard toothbrush, excessivebrushing pressure,13,14and abrasivetoothpaste. Wirdatul RD et al.,15 Bergstromand Lavstedt16 have revealed the role oftooth brushing techniques in thedevelopment of abrasive lesions. Although itis likely that small scratches on the toothsurface produced by the act of brushing canbe repaired by the precipitation of mineralsby the process of remineralisation, the

mechanical means used to ensure adequateoral hygiene in preventive dentistry has beenreported to be a probable main factor in thedevelopment of abrasion.17

Wear due to abrasion has been reportedmainly due to the brushing pressure appliedand stiffness of the bristles.18 As toothbrushing has been more common in modernera, it can be expected that not only will oralhygiene status ameliorate at a populationlevel but also the damage caused by toothbrushing will become more evident inoccurrence and severity.16 Literature doesnot reveal much data on the studies relatedto the association between tooth brushingand prevalence of abrasive lesions.18 Presentstudy has been conducted to determinewhether there is a correlation between dentalabrasions and the frequency and techniqueof tooth brushing, as well as to determinethe prevalence of abrasion age wiseandgender wise.

Materials and methods :

A cross-sectional study wasconducted from September 2015 toDecember 2015 among 165 adults (male 72,female 93) aged 20-65 years who attendedthe Department of Periodintics and OralImplantology, Faculty of Dental ScienceDharmsinh Desai University, NadiadGujarat. Patient included were: those usingmanual toothbrush for cleaning teeth,excluding those patients who were nothaving cervical carious lesions. Theexclusion criteria were: Teeth that hadclass‑V restoration done on the buccalsurface were not included in the study,Patients not willing to participate in thestudy, those using powered toothbrushes orchewing twigs as means of cleaning teeth,and those having generalized cervicalcarious lesions. A questionnaire wascompleted and abrasion on the buccal


surface of teeth was recorded using mirror,probe, and standard dental chair light usingtype III examination method. Patients wereexamined intra-orally by a single dentist,who is highly experienced andknowledgeable in the diagnosis of toothwear. The lesions, which were clearlyidentifiable at cement– enamel junction ofteeth and which were discolored,non‑carious, “C” or “V” shaped, andflat‑floored were all taken as wedge‑shapeddefects. They were recorded for eachpatient. The subjects with abrasive lesionswere classified according to age, gender,frequency of tooth brushing, tooth brushingtechnique, duration of changing worn outtoothbrush, and the type of toothbrush used.

Brushing frequency:The brushing frequency was

recorded as per the individual’s ownstatement: No brushing, once a day, twice aday, or thrice a day.

Tooth brushing technique:Tooth brushing technique was judged on thebasis of individual’s own demonstration oftheir brushing habits. The following modesof action concerning tooth brushingtechnique were recognized: (a)Horizontaltechnique with strokes parallel to the row ofteeth and perpendicular to the long axis ofteeth; (b) Vertical technique, parallel to thelong axis of teeth; (c)Roll technique, i.e. acoronally directed rolling movement fromthe gingiva over the tooth surface, and(d)Complex technique, i.e. a combination ofhorizontal and vertical strokes.Differentiation of the techniques used intomore distinct classifications, i.e. Bass,Charters, was not possible.

Changing toothbrush:Changing toothbrush due to wearing oftoothbrush bristles was classified as after 1

month, 2 months, or 3 months, or after 6months.

Stiffness of the bristle :

Stiffness of the bristles: Most of thesubjects were aware what kind of toothbrushthey used: Soft, medium, or hard, accordingto the manufacturer. Those who were indoubt were instructed to estimate thestiffness of their own brushes from referencebrushes: One soft, one medium, and onehard.

Statistical methods :

The data was analyzed using thesoftware “P” values ≤ 0.05 and ≤ 0.01 wereconsidered as statistically significant andhighly significant, respectively.

Results :

In order to determine the relationshipof abrasive lesions and age, subjects weredivided into five groups: 20‑24, 25‑34,35‑44, 45‑54, and 55-65. Gender wisedistribution of the abrasive lesion was alsonoted. The study shows that correlationbetween the age groups according to theoccurrence of abrasive lesions wasstatistically highly significant. (chart 1)

Table 1: Gender wise distribution

Abrasionpresent

Abrasionabsent

Total

Male 47 25 72

Female 40 53 93


Chart 1: Distribution of subjects withtoothbrush abrasion according to Age

groups.

The prevalence of abrasive lesions increasedwith advancing age. It was lowest in theyoungest age group 20‑24 years and highestin the oldest age group, i.e. 55 years andolder [Table 2]. It was highest among thesubjects who brushed their teeth once a day;59 (64.8%) has buccal abrasion. Statisticallythis relationship was highly significant[Table 2].

Table 2 : Toothbrush abrasion accordingto frequency of tooth brushing

FREQUENCY ABRASIONPRESENT

ABRASIONABSENT

TOTALNO

n % n %

Oncedaily

59 64.8 32 35.2 91

Twicedaily

35 63.6 20 36.4 55

Thricedaily

10 52.6 9 47.4 19

Abrasive lesions were most often seen inthose who brushed their teeth horizontally(56.6%), followed by those who brushed

vertically (50%) and abrasions were presentamongst those subjects who followed acombination of all the methods (45.4%), andthen by those who used the roll technique(33.3%). The relationship betweenfrequency of abrasion and tooth brushingtechnique was statistically significant [Table3].Presence of abrasions was highest amongthose who were changing their brushes after6 months or more (54.5%). This associationwas statistically highly significant [Table 4].

Table 3: Tooth brushing Technique andabrasion

Technique AbrasionPresent

AbrasionPresent

Total

n % n%

Horizontal43 56.6 33 43.4 76

Vertical 8 50 8 50 16

Roll6 33.3 12 66.7 18

Complex25 45.4 30 54.6 55

Table 4:Abrasion and duration ofchanging toothbrush.

Durationofchanging

ABRASIONPRESENT

ABRASIONABSENT

TOTALNO

n % n %

Every 1month

3 37.5 5 62.5 8

Every 2month

18 36 32 64 50

Every 3month

24 46.2 28 53.8 52

Every 6month

30 54.5 25 45.5 55

Type of toothbrush used according to thestiffness of the bristles, i.e. soft, medium,hard, also showed an association with theprevalence of abrasive lesions. It was

713

27

18

25 24

158

20-24 25-34 35-44 45-54

Abrasion & Agerelation

abrasion present abrasion absent



groups.




ABRASIONABSENT

TOTALNO

n % n %

Oncedaily

59 64.8 32 35.2 91

Twicedaily

35 63.6 20 36.4 55

Thricedaily

10 52.6 9 47.4 19





AbrasionPresent

Total

n % n%

Horizontal43 56.6 33 43.4 76

Vertical 8 50 8 50 16

Roll6 33.3 12 66.7 18

Complex25 45.4 30 54.6 55


Durationofchanging

ABRASIONPRESENT

ABRASIONABSENT

TOTALNO

n % n %

Every 1month

3 37.5 5 62.5 8

Every 2month

18 36 32 64 50

Every 3month

24 46.2 28 53.8 52

Every 6month

30 54.5 25 45.5 55


23

8 5

45-54 55 ABOVE

Abrasion & Agerelation

abrasion absent



groups.




ABRASIONABSENT

TOTALNO

n % n %

Oncedaily

59 64.8 32 35.2 91

Twicedaily

35 63.6 20 36.4 55

Thricedaily

10 52.6 9 47.4 19





AbrasionPresent

Total

n % n%

Horizontal43 56.6 33 43.4 76

Vertical 8 50 8 50 16

Roll6 33.3 12 66.7 18

Complex25 45.4 30 54.6 55


Durationofchanging

ABRASIONPRESENT

ABRASIONABSENT

TOTALNO

n % n %

Every 1month

3 37.5 5 62.5 8

Every 2month

18 36 32 64 50

Every 3month

24 46.2 28 53.8 52

Every 6month

30 54.5 25 45.5 55



highest among those who used hard brush(60%) than those subjects who used softbrush (46.7%) [chart 2]. However,association between these two variables wassignificant.

Chart 2: Abrasion and type of toothbrushused.

Discussion :

The etiology of cervical abrasion ismultifactorial and is a combination ofseveral types of wear factors, such as age,diet, gingival recession, periodontal health,dentifrice, speed, and pressure used duringbrushing, which are interrelated. It is clearthat tooth brushing plays an important role.The present results confirm an associationbetween improper tooth brushing, method oftooth brushing, wearing of bristle, cleanteeth, and abrasion, in general, clinical wearof tooth.23 However, many things remainunknown regarding the causes of abrasion.Therefore, the etiology of the wedge‑shapedlesion is highly complicated, as there arewide variations in the clinical characteristicsof these lesions. Some lesions are narrowlynotched at the cement‑enamel junction andsome extend broadly into the root region.The etiology of cervical abrasion ismultifactorial and interrelated. It has become

clear that tooth brushing plays an importantrole. The present results confirm at thepopulation level, previous findings fromlaboratory testing and clinical observationthat a relationship exists between toothbrushing and cervical abrasion.21 As a resultof advancement in preventive andrestorative dentistry, number of olderpatients who have managed to preserve theirteeth is on the increase, which leads todifferent problems, the most important ofwhich is the development of cervical lesionsin the elderly.18

Saerah et al.,19and Attin et al.8,20 havefocused on the examination of the toothbrushing techniques and abrasive qualitiesof toothpastes as well as types oftoothbrushes.

Bergstrom and Lavstedt. 16 revealed in theirstudy that in the development of abrasivelesions, frequency and technique of brushingand also the materials used for toothbrushing are affected for the abrasion ofteeth. In the present study, all the studysubjects who brushed their teeth also usedtoothpaste. Considering the fact that theabrasive lesions have presumably beenformed over a long time, during this timemany different toothpastes and toothbrushesmust have been used. Present study onlydeals with the distribution of abrasivelesions according to tooth brushingtechniques, tooth brushing frequency,duration of change of toothbrush, and typeof toothbrush used according to the stiffnessof bristles. Literature review has shownmany studies21‑23 which revealed thatcervical tooth wear lesions increase withadvancing age. Present study also revealedthat the frequency of tooth brushingabrasions increased with age and thedifference among age groups wasstatistically highly significant.

0

20

40

60

80

Soft Medium Hard

Type of toothbrush andAbrasion

ABRASION ABRASION ABRASION ABRASION


Radentz et al.,24 and Ozgoz et al.,25 reportedthat frequency of cervical abrasions washigher among males than females and thisdifference was statistically significant.Similar results were obtained in the presentstudy. However, different results wereobtained in the studies where the distributionof abrasions among gender was notsignificant. Despite the contradictory views,more abrasive lesions among males werefound in the studies conducted by Ashley10

and Hawkins et al.26 suggests that men exerthigher pressure on teeth while brushing thanfemales and the duration of brushing islonger for men.

Brushing technique has also shownstatistically significant results with theformation of wedge‑shaped defects. It hasbeen shown that depending on the toothbrushing technique, forces of differentseverity and shapes would occur in thecervical region of teeth. These differences inthe techniques have become influential inthe investigation of relations between themand the prevalence of cervical tooth lesions.Present study has reveled higher prevalenceof cervical abrasion in those subjects whobrushed their teeth horizontally, although thedifference was statistically significant. Astudy conducted by Ullman A et al.,22 hasshown similar results, whereas the studyconducted by Litonjua et al.6 showedcontrasting results.

Duration of changing the toothbrush has alsoshown to be directly effective on theoccurrence of abrasions. Those subjects whoadmitted of changing their brush due tofraying of bristles after 6 month havesignificantly more number of lesions thanthose who change it after 3 months or more.Similar results have been obtained in a studyconducted in Turkey.22

The stiffness of bristles available as soft,medium, and hard also added to the presenceof lesions. Those subjects who used hardtoothbrushes showed more cervical lesionsthan those using soft toothbrushes. But herethe force used may have an additive effect.Yadav et al.,28 Borcic et al.,29 and Masato etal.,30 have also reported similar results intheir studies.

Conclusion :

Present study gives ample evidencethat there exists a relationship between toothabrasions and brushing frequency,technique, stiffness of bristles, and durationof changing toothbrush. Individual orientedfactors, especially brushing technique anddaily frequency of brushing, seem to be ofprime importance for the occurrence andseverity of abrasion and seem to exert agreater influence than morematerial‑oriented tooth brushing factorssuch as brush materials. It is a prudentsuggestion that an emphasis may be givenon the correct method, frequency, andchoice of the brush, while giving oralhygiene maintenance instructions to thegeneral public. People may be furnishedwith appropriate prophylactic measures thatare effective for oral cleanliness but are stillharmless to oral tissues. It is, therefore,critical that dental professionals beknowledgeable about toothbrushes and toothbrushing, so that they can makeevidence‑based recommendations to theirclients and general public.

Clinical significance :

Abrasion, being a self‑inflicteddestructive process, the damage andmortality caused by this can be prevented byeffective oral health instructions andinspiration. In order to prevent this problemfrom becoming worse as a burden, we


should try to combat the problem from itsearly stages. Literacy and wakefulness areimportant steps in achieving good oralhealth among people.

Limitations and Suggestions :

The literature favors a multifactorialetiology in the development of NCCLs.Incorrect methods and frequency of toothbrushing may be one factor responsible forabrasions. Factors of possible importance todental abrasion initiation and progressionwhich were omitted in the study are theduration of tooth brushing, pressure appliedwith the toothbrush, and indirect etiologieslike acidic oral environment, easy enameldissolution, and medication. Some of thebiological factors, such as saliva, toothcomposition and structure, occlusion andbehavioral factors were not considered.Further studies and continuous follow‑upshould be carried out in future to find theassociation between these factors and theoccurrence of dental abrasion.

References :

1. Nguyen C, Ranjitkar S, Kaidonis JA,Townsend GC. A qualitativeassessment of non‑carious cervicallesions in extracted human teeth.Aust Dent J 2008;53:46‑51.

2. Oginni AO, Olusile AO, Udoye CI.Non‑carious cervical lesions in aNigerian population: Abrasion orabfraction? Int Dent J2003;53:275‑9

3. Tomasik M. Analysis of etiologicalfactors involved in noncariouscervical lesions. Ann Acad MedStetin 2006;52:125‑36.

4. Aw TC, Lepe X, Johnson GH, ManclL. Characteristics of noncariouscervical lesions: A clinical

investigation. J Am Dent Assoc2002;133:725‑33.

5. Voronets J, Jaeggi T, Buergin W,Lussi A. Controlled toothbrushabrasion of softened human enamel.Caries Res 2008;42:286‑90.

6. Litonjua LA, Bush PJ, Andreana S,Tobias TS, Cohen RE. Effects ofocclusal load on cervical lesions. JOral Rehabil 2004;31:225‑32.

7. Spranger H. Investigation into thegenesis of angular lesions at thecervical portion of the teeth. ReviewQuintessence Intenational1995;26:149‑54.

8. Attin T, Siegel S, Buchalla W,Lennon AM, Hannig C, Becker K.Brushing abrasion of softened andremineralised dentin: An in situstudy. Caries Res 2004;38:62‑6.

9. Daly RW, Bakar WZ, Husein A,Ismail NM, Amaechi BT. The studyof tooth wear patterns and theirassociated aetiologies in adults inKelantan, Malaysia. Arch Orofac Sci2010;5:47‑52.

10. Ashley P. Toothbrushing: Why,when and how? Dent Update2001;28:36‑40.

11. Braem M, Lambrechts S, VanherleG. Stress‑induced cervical lesions. JProsthet Dent 1992;67:718‑22.

12. Sewerin I. Complex toothbrushabrasions. Tandlaegebladet1970;74:489‑97.

13. Christensen LB, Petersen PE,Krustrup U, Kjøller M. Self‑reportedoral hygiene practices among adultsin Denmark. Community DentHealth 2003;20:229‑35.

14. Taiwo JO, Ogunyinka A, OnyeasoCO, Dosumu OO. Tooth wear in theelderly population in South EastLocal Government Area in Ibadan,


Nigeria. Odontostomatol Trop2005;28:9‑14.

15. Wirdatul RD, Wan ZB, Husein H,Masrtura N, Ismail B, Amaechi T.The study of toothwear pattern andtheir associated etiologies in theadults in Kelentan, Malaysia.Archives of Orofacial sciences2010;5:47‑52.

16. Bergström J, Lavstedt S. Anepidemiological approach totoothbrushing and dental abrasion.Community Dent Oral Epidemiol1979;7:57‑64.

17. Spranger H. Investigation into thegenesis of angular lesions at thecervical region of teeth.Quintessence Int 1995;26:149‑54.

18. Oginni AO, Olusile AO. Theprevalence, aetiology and clinicalappearance of tooth wear: TheNigerian experience. Int Dent J2002;52:268‑72.

19. Saerah NB, Ismail NM, Naing L,Ismail AR. Prevalence of tooth wearamong 16‑year‑old secondaryschool children in Kota BharuKelantan. Arch Orofac Sci2006;1:21‑8.

20. Attin T, Hornecker E. Toothbrushing and oral health: Howfrequently and when should toothbrushing be performed? Oral HealthPrev Dent 2005;3:135‑40.

21. Wiegand A, Köwing L, Attin T.Impact of brushing force on abrasionof acid‑softened and sound enamel.Arch Oral Biol 2007;52:1043‑7.

22. Ullman A, Long D, Horn D, LewisP. Need a toothbrush? The oralhealth of critically ill children. AustCrit Care 2010;23:30‑1.

23. Litonjua LA, Andreana S, Bush PJ,Tobias TS, Cohen RE. Wedgedcervical lesions produced by

toothbrushing. Am J Dent2004;17:237‑40.

24. Radentz WH, Barnes GP, CutrightDE. A survey of factors possiblyassociated with cervical abrasion oftooth surfaces. J Periodontol1976;47:148‑54.

25. Özgöz M, Arabaci T, Sümbüllü MA,Demir T. Relationship betweenhandedness and toothbrush‑relatedcervical dental abrasion in left‑ andright‑handed individuals. J Dent Sci2010;5:177‑82.

26. Hawkins BF, Kohout FJ, LainsonPA, Heckert A. Duration oftoothbrushing for effective plaquecontrol. Quintessence Int1986;17:361‑5.

27. Akgül HM, Akgül N, KaraoglanogluS, Ozdabak N. A survey of\ thecorrespondence between abrasionsand tooth brushing habits inErzurum, Turkey. Int Dent J2003;53:491‑5.

28. Yadav NS, Saxena V, Reddy R,Deshpande N, Deshpande A,Kovvuru SK. Alliance of oralhygiene practices and abrasionamong urban and rural residents ofCentral India. J Contemp Dent Pract2012;13:55‑60.

29. Borcic J, Anic I, Urek MM, FerreriS. The prevalence of non‑cariouscervical lesions in permanentdentition. J Oral Rehabil2004;31:117‑23.

30. Masato H, Hirotomo K, Tamenari E,Shoichi I, Akira S. Influences ofbrushing force on toothbrushabrasion of human dentin. J GifuDent Soc 2012;38:129‑34.


PERIODONTAL HEALTH STATUS OF DIFFERENT SOCIO-ECONOMICGROUPS : CROSS SECTIONAL STUDY

*Dr. Ripal Shah **Dr. Shalini Gupta ***Dr. Vasumati Patel*****Dr. Vishal Sahayata *Dr. Kinjal Gabani *Dr. Sagar patel

ABSTRACT :Aims & Objective: To assess the oral health awareness and periodontal health status in differentsocio-economic groups in outpatient department of periodontology and oralImplantology,Faculty of Dental Science, Dharmsinh Desai University, Nadiad, India.Materials and Methods: This cross-sectional study was conducted on 100 subjects of 30-60years age group with different socio-economic status classified according to modifiedKuppuswamy scale (2012). Subjects were interviewed by the questionnaire and CommunityPeriodontal Index was recorded.Result: This study showed that the Community Periodontal Index (CPI) code 2 and code 3 ismore in lower socio-economic status (p =0.115 and p=0.079 respectively). Significantassociation was seen in code 0, code 1 & code 4 (p<0.01) which is indicative that upper classhave more healthy periodontal status than lower.Conclusion: Significant association exists between oral health awareness and periodontal healthwith the socio-economic status of the individual.

Keywords: Oral health, Periodontal status, Socio-economic status

IntroductionIn India, periodontal disease is still

the leading cause for the tooth loss inadults.1 It is a chronic inflammatory diseasewhich leads to loss of attachment anddeepening of the gingival sulcus that furthercauses

* 3rdyear Post-Graduate Student**Professor

***Professor & Head****Reader

*****Senior lecturerDepartment of Periodontology and OralImplantologyFaculty of Dental Science,Dharmsinh Desai University,Nadiad.

loss of alveolar bone ultimately leading totooth loss.. Periodontal health status isassociated with age, smoking, systemicdiseases, gender, genetics and utilization ofthe dental care.2,3 It has been seen that thepoor oral health is related to the lowereconomic status.

Corresponding Author :Dr. Ripal Shah (MDS) 3rdyear Post-Graduate StudentDepartment of Periodontology and OralImplantology“Shreejikrupa” Above Corporation Bank,Viththal Kanya Vidhyalay Road, Nadiad-387001. Gujrat,India.Email : [email protected](M) : 9909212223


In developing countries whereilliteracy rates are quite high, educationstatus plays determining role in the health ofa particular individual. Health ismultifactorial, influenced by factors likegenetics, environment, lifestyle, socio-economic status (SES) and many others.Economic status of the individual alsodetermines the utilization of the healthservices in a particular population.4,5

Evidences have proven the existence ofinadequate oral health in lower SES groupas compared with higher SES groups.5

Materials and methodsThe present cross-sectional study

was carried out in the Department ofPeriodontics and Oral Implantology, DDU,Nadiad. Total 100 subjects of 30-60 yearsage group with different socio-economicstatus classified according to modifiedKuppuswamy scale were taken for the study,Subjects were interviewed by thequestionnaire and Community PeriodontalIndex was recorded. Patient with history ofsystemic disease (diabetes, kidney, liver,heart, muscle or joint disease) or usingtobacco in any form were excluded fromstudy. A pretested questionnaire wasinterviewed to each participant asking abouttheir personal information, socio-economicstatus and oral hygiene habits also askingabout use of toothbrush , tooth paste , toothpowder and the frequency of changing theirtooth brush. Modified Kuppuswamy SESScale (2012) was used for categorizing theindividuals under different socio-economicgroups.7,8 It is based on education profile,occupation and monthly income.

Modified Kuppuswamy Scale

(A) Education Score

1 Profession or honors 7

2 Graduate or post

graduate

6

3 Intermediate or post

high school diploma

5

4 High school certificate 4

5 Middle school

certificate

3

6 Primary school

certificate

2

7 Illiterate 1

(B) Occupation Score

1 Profession 10

2 Semi-profession 6

3 Clerical, farmer,

Shop owner

5

4 Skilled worker 4

5 Semi-skilled worker 3

6 Unskilled worker 2

7 Unemployed 1


Clinical Examination CPI Index:

Code 0: No periodontal diseaseCode 1: Bleeding observed during or after

probing

Code 2: Calculus or other retentive factorseither seen or felt during probing

Code 3: Pathological pocket 4 to 5 mm indepth

Code 4: Pathological pocket 6 mm or more indepth

Community Periodontal Index (CPI)9

was recorded by a single, trained, calibratedexaminer with the use of CPITN probe,mouth mirror and under good illumination.

Result :The results showed that use of

toothbrush and toothpaste for cleaning ofteeth is more in upper and upper middleclass that is 86.6% and 90% respectively ascompared to middle, lower/upper lower andlower class with values 30%, 69% and 72 %respectively, as appreciated in table-1.Individuals with habit of brushing twice in aday belongs to mainly upper and middleclass that is 26% & 25% respectivelycompared to 1% of lower/upper lower class.On the evaluation of periodontal status it isrevealed that code 2 and code 3 of CPIIndex is more in Lower socio-economicstatus that is lower, upper – lower and lower– middle class which is statisticallysignificant. (p = 0.115 and p = 0.079respectively). When evaluating therelationship between socio-economic status(SES) and CPI index, significant associationwas seen in Code 0, code 1 and code 4(p<0.01) which is indicative that upper classhave a more healthy periodontal status thanlower class.(table-2)

(C) Monthly Income(In Rs) INR

Score Modified for 1998in Rs

Modified for 2012in Rs

1 ≥32050 12

2 16020 – 32049 10

3 12020 – 16019 06

4 8010 – 12019 04

5 4810 – 8009 03

6 1601 – 4809 02

7 ≤ 1600 01

Totalscore

Modified for1998 in Rs

Modified for2012 in Rs

Socio-economicclass

26-29 Upper (I)

16-25 Upper Middle (II)

11-15 Middle/Lowermiddle (III)

5-10 Lower/Upper lower(IV)

<5 Lower (V)


Table 1: Distribution of the participants according to socio-economic status & oral hygieneaids used

Socio-economicstatus

TotalHow do do youclean your teeth?

Ch-sqvalue

P value

Toothbrush& toothpaste

Toothbrush&

toothpowder

Once Twice

Upper (I) 15 13(86.8%)

2(13.3%)

11(73%)

4(26%)

42.452 <0.001

Upper Middle(II)

20 18(90%)

2(10%)

15(75%)

5(25%)

Middle/Lowermiddle (III)

25 20(80%)

5(20%)

22(88%)

3(12%)

Lower/Upperlower (IV)

23 16(69%)

7(30.4%)

22(95.4%)

1(4.3%)

Lower (V) 18 13(72%)

5(27.7%)

1(5.55%)

0

Table 2: Relationship between socio-economic status & CPI code

Socioeconomicstatus

Relationship between socio-economic status & CPI code

Total Code 0 Code 1 Code 2 Code 3 Code 4

Upper (I) 15 4(26.6%)

4(26.6%)

2(13.3%)

4(26.6%)

1(6.6%)

Upper Middle (II) 20 6(30%)

7(35%)

3(15%)

2(10%)

2(2%)

Middle/Lowermiddle (III)

23 5(21.7%)

5(21.7%)

8(34.7%)

3(13.04%)

2(8.69%)

Lower/Upperlower (IV)

24 1(4.1%)

7(29.1%)

8(33.3%)

3(12.5%)

5(20.8%)

Lower (V) 18 1(5.55%)

4(22.2%)

5(20%)

5(20%)

3(33.3%)

How often youBrush your Teeth?


Discussion :Health is multifactorial and

multidimensional influenced by factors suchas genetics, lifestyle, environment, socio-economic status (SES), and many others. 10

Oral hygiene behavior and seeking oralhealth care depend on a number of factors.Patients comply better with oral health careregimens when informed and positivelyreinforced. Lack of information is amongthe reasons for nonadherence to oral hygienepractices. Further, oral health attitudes andbeliefs are significant for oral healthbehavior. 11 A higher likelihood of seekingpreventive dental care is found to beassociated with dental health knowledge. 12

India is a country with diverse variations inits social, cultural and economic aspects. 1,2

Most of the lower socio-economic groupshave lack of oral health awareness, fear andanxiety towards dentist and also fewer visitsto the dentist so, most of the treatment iscurative rather than preventive in thisgroup.2 Various studies have shown animpact of socio-economic status on the oralhealth of an individual. It has been proven

that a significant association exists betweenthe individual’s oral health and awarenessabout the same.3,4 Individuals with lowersocio-economic group have less awarenessand access to the oral health care 1,2 and theyare unable to use the oral hygiene aids likemouthwash, interproximal brushes, andvarious medicated toothpaste because oftheir high cost. Comparatively Individualsfrom higher economic status have access toall the above mentioned oral health aids andalso the awareness of its role in improvingperiodontal health.3 Similar study was doneby Chandra Shekar BR et al.6 where hefound that all the subjects in the upper SESwere using brushing with toothpaste and oralhygiene aids like, mouthwash, interdentalbrush, and irrigation device for cleaning

their teeth. The upper socio-economic statussubjects tend to use the oral health servicesmore frequently. The frequent dental visitsfacilitate the subjects in the upper class togain more knowledge on the causes for oraldiseases and their prevention, which is notthe case among the lower class people. Theresults of the present study are similar to thestudy done by Gautam DK et al.7 that haveshown a positive correlation between theperiodontal status of an individual andsocio-economic status. The study has shownmore prevalence of CPI index code 2 andcode 3 in lower socio-economic groupindividuals. Gundala et al 8 has also shownmore prevalence of code 2 and code 3 in thelower socio-economic group. The studydone by Bertoldi C et al.2 & Gundala R8 alsoshows similar results and significantassociation between the periodontal healthstatus and socio-economic status of theindividual. The results of the study showedthat lower socio-economic status have lessaccess to the utilization of the dentalservices and also have a poor periodontalhealth status compared to upper class ofsocio-economic status. Our results were inagreement with the findings of studies byNewman et al.13 and Sanders et al.14 Thedental visits were more frequent among thesubjects in the upper class. Majority of thesubjects in the upper class who visiteddentist in the last 1 year did so for a routinedental check-up without any specificcomplaints, whereas a major bulk of thelower class people visited dentist to getremedy for an acute oral health problem.15

A look at the reasons for not having a dentalvisit reflected high cost and lack of attitudeand motivation among the subjects in thelower class and lack of time among upperclasses.16 The social pressure to retain thenatural teeth and a pleasing appearance drivethe upper class people into preventiveaction, whereas the high cost ofsophisticated dental services may discourage


the subjects in the lower class not to have adental visit on a routine basis.17

They reserve the dental visit for an acuteproblem when all other possible methods toalleviate the existing problem havecompletely failed. 18 This in the long runmay result in the development of a negativeattitude toward dentist and dental proceduresamong the people in lower classes. Thedirect relationship between SES and oralhygiene practices has been documented inthe studies by Davidson et al.19 and Ronis etal.20 The level of dental health knowledge,positive dental health attitude, and dentalhealth behaviors are interlinked andpositively associated with the level ofeducation and income as demonstrated bystudies in the past. 21,22,23,24 All these studieshave found the level of education to play avital role, as, an educated individual gainsthe requisite knowledge from multiplesources. This in turn will drive these peopleto have a positive dental health attitude andbehavior.25 The result of the present studyare in contrary with a study done by theOpeodu OI3 which shows that there is nosignificant relationship between theperiodontal health status and socio-economic group of the individual.

Conclusion :The study revealed that oral hygiene

awareness and periodontal conditions aresignificantly associated with socio-economic status of an individual.

References :1. Shaju JP, Zende RM, Das M.

Prevalence of periodontitis in the Indianpopulation: A literature review. JIndian Soc Periodontol. 2011;15(1):29–34.

2. Bertoldi C, Lalla M, Pradelli JM,Cortellini P, Lucchi A, Zaffe D. Riskfactors and socio-economic conditioneffects on periodontal and dental health:

A pilot study among adults over fiftyyears of age. Eur J Dent. 2013;7(3):336-

3. Opeodu OI, Arowojolu MO. Effect ofSocial Class on the Prevalence andSeverity of Periodontal Disease. Ann IbPostgrad Med. 2007; 5(1):9-11.

4. Gupta R. Smoking, educational status& health inequity in India. Indian JMed Res. 2006;124(1):15-22.

5. Park K. Concepts of Health andDisease. Textbook of preventive andsocial medicine. 17th Ed. Jabalpur,India: Banarsidas Bhanot Publishers;2002. p. 11

6. Chandra Shekar BR, Reddy C,Manjunath BC, Suma S. Dental healthawareness, attitude, oral health-relatedhabits, and behaviors in relation tosocio-economic factors among themunicipal employees of Mysore city.Ann Trop Med Public Health. 2011;4(2): 99-106.

7. Gautam DK, Vikas J, Amrinder T,Rambhika T, Bhanu K. Evaluatingdental awareness and periodontal healthstatus in different socio-economicgroups in the population ofSundernagar, Himachal Pradesh, India.J Int Soc Prev Community Dent. 2012;2(2):53-57.

8. Gundala R, Chava V. Effect of lifestyle,education and socio-economic status onperiodontal health. Contemp Clin Dent.2010; 1(1):23–6.

9. Mahajan K, Methods in Biostastics , 6th

edition Soben Peter; Essential ofPreventive and Community dentistry.

10. Bratthall D, Hansel-Peterson G,Sundberg H. Reasons for the cariesdecline: What do the experts believe?.Eur J Oral Sci. 1996;104:416-22

11. Tash RH, O'Shea MM, Cohen K.Testing a preventive-symptomatic theoryof dental health behaviour. Am J PublicHealth Nations Health. 1969;59:514-21


12. Tsai AI, Chen CY, Li LA, Hsiang CL,Hsu KH. Risk indicators for earlychildhood caries in Taiwan. CommunityDent Oral Epidemiol. 2006;34:437-45

13. Newman JF, Gift HC. Regular pattern ofpreventive dental services: A measure ofaccess. Soc Sci Med. 1992;35:997-1001.

14. Sanders AE, Slade GD, Turrell G, JohnSpencer A, Marcenes W. The shape ofthe socioeconomic-oral health gradient:Implications for theoretical explanations.Community Dent Oral Epidemiol.2006;34:310-9

15. Cavelaars AE, Kunst AE, Geurts JJ,Crialesi R, Grötvedt L, Helmert U, etal. Educational differences in smoking:International comparison. BMJ.2000;320:1102-7

16. Davidson PL, Rams TE, Andersen RM.Socio-behavioral determinants of oralhygiene practices among USA ethnicand age groups. Adv Dent Res.1997;11:245-53

17. Agarwal AK. Social classification: Theneed to update in the present scenario.Indian J Community Med. 2008;33:50-1.

18. Monaghan N, Heesterman R. Dentalcaries, social deprivation and enhancedcapitation payments for children. BrDent J. 1999;186:238-40.

19. Davidson PL, Rams TE, AndersenRM. Socio-behavioral determinants oforal hygiene practices among USAethnic and age groups. Adv Dent Res.1997;11:245-53.

20. Ronis DL, Lang WP, Farghaly MM,Passow E. Tooth brushing, flossing, andpreventive dental visits by Detroit-arearesidents in relation to demographic andsocioeconomic factors. J Public HealthDent. 1993;53:138-45

21. Al-Wahadni AM, Al-Omiri MK,Kawamura M. Differences in self-reported oral health behavior betweendental students and dental

technology/dental hygiene students inJordan. J Oral Sci. 2004;46:191-7

22. Kawamura M, Iwamoto Y, Wright FA.A comparison of self-reported dentalhealth attitudes and behavior betweenselected Japanese and Australianstudents. J Dent Educ. 1997;61:354- 60.

23. Barrieshi-Nusair K, Alomari Q, Said K.Dental health attitudes and behaviouramong dental students in Jordan.Community Dent Health. 2006;23:147-51.4

24. Kawamura M, Spadafora A, Kim KJ,Komabayashi T. Comparison of UnitedStates and Korean dental hygienestudents using hiroshima university-dental behavioural inventory (HU-DBI). Int Dent J. 2002;52:156-62.

25. Mahajan BK. Social environment.Textbook of preventive and socialmedicine. 1 st ed. New Delhi; JaypeeBrothers Medical Publishers (P) Ltd;1991. p. 82-87.


NANOROBOT - The next generation of Dentistry

*Dr. Taruna Sharma *Dr.VirajTalsania **Dr. Shalini Gupta

Abstract:Nanorobtics is the technology which uses nanorobots that allow precision interaction with

nanoscale objects. Treatment possibilities may include permanent hypersensitivity cure, permanentorthodontic realignments during single office visit, local anaesthesia, dentition renaturalisaton,continuous oral health maintenance using mechanical dentifrobots. Dental nanorobots could beconstructed to destroy caries-causing bacteria or to repair blemishes of tooth where tooth decayhas begun by using computer. These have a strong potential to revolutionise dentistry and might beprogrammed to crawl through human tissue with navigational precision, to acquire energy to senseand manipulate their surroundings to diagnose and treat diseases. Although the research is still inits preliminary stage, the future of this technology has countless uses.

Introduction:

More than half a century ago, at the annualAmerican Physical Society meeting (1959),the physicist Richard Feynman, Nobel Prizewinner in Physics, presented his work“Plenty of Room at the bottom” which dealtwith the matter of Manipulating andcontrolling small scale things, a field whichhe thought would have “a great deal oftechnical applications.” The infected rootcanal space cannot be disinfected with thestandard root canal protocol with theaggressive use of endodontic files.

*Intern**Professor,

Department of Periodontology

Faculty of Dental Science,


Nadiad.

The physicist suggested that using regularmachine-tools, only smaller, and so on, stepby step, till the production of molecularmachines.1 High- tech and effectivemanagement at microscopic level, termednanotechnology, is predicted to be animportant part of future dental andperiodontal health.The word nano is derived from the Greekword ‘dwarf’, a nanometer being a billionthof a meter. Nanomaterials are those withparts less than 100nm in at least onedimension including clusters of atoms,grains less than 100nmin size, fibers lessthan100nm in thickness.2


Taruna Sharma

Address of Corresponding Author:

B-1 Avakar apartment, behind Ganesh

crossing, Anand-388001, Gujarat

(M) +91 7405695435

Email :- [email protected]


In an article published by theJournal of American Dental Association,nanomedicine is defined as the ‘science andtechnology of diagnosing, treating andpreventing disease and traumatic injury; ofrelieving; and of preserving and improvinghuman health through the use ofnanotechnology and genetic engineering andeventually complex molecular machinesystems and nanorobots. Also, in the samearticle, the concept of nanodentistry definedas the science and technology that will makepossible the maintenance of near perfect oralhealth through the use of nanomaterials,biotechnology including tissue engineeringand nanorobotics.3

Materials and Methods :

We’ve searched electronic databasesincluding “Google Scholar”,” JAYPEEjournals”, “Google Books” and MEDLINE,using the keywords: “nanodentistry”,“dental nanorobots”,” nanotechnology”,“dental nanomedicine”. Adding to that, thearticles quoted in the first research havebeen added to the review. From the collectedmaterials, we have conceived a summary ofthe data regarding their application in dentaland medicine.

Results :

The field of dental nanomedicineimplies the use of three classes of molecularstructures; nanomaterials, non-biologicalnanoparticles, materials and instrumentsbased on biotechnology and non-biologicalinstruments including nanorobotics, all fortherapeutic and diagnostic purposes. Themost effective domain of the three classes ofthe dental nanomedicine technology isconsidered to be one of the nanorobotics.4 In

the years 2000 the devices necessary forbuilding nanorobots began to bemanufactured (micro engines, micro-pumps,micro-impellers, manipulating micro armsand even molecular computers.5,6 In 2008,C. Edeler, research scientist of theDepartment of Microrobotic Engineer ofOldenburg University from Germanyannounced the creation of a mobile platformwhere nanorobots are already beingmanufactured.7

Applications of nanorobots in dentalnanomedicine:

Research scientists appreciate that dentalnanorobots could accomplish numeroustasks such as inducing local anesthesia,desensitizing teeth, correct positioning ofperiodontal tissue and poorly aligned teeth,restorative dental procedures, and curativepreventive procedures at the oral cavitylevel.3,8,9

1. Inducing anesthesia: As known,local anesthesia used in dentalmedicine is a painful procedurewhich causes patient discomfort andcan be sometimes accompanied bycomplications, manufacturinganesthetic dental nanorobots willhave a large impact on patients as aresult of the numerous advantages. Acolloidal suspension containingmillions of anesthetic dentalnanorobots will be applied to thepatient’s gingiva which will reachthe pulp in approximately 100seconds and interrupt the traffic ofthe nervous impulse, under thecontrol of the dentist through theintermediate of the nanocomputeraboard the nanorobots.9 After theprocedure is completed, the dentist


orders the nanorobots to restore allsensation and egress from the tooth.Nanorobot analgesia offers greaterpatient comfort, reduces anxiety, noneedles, greater selectivity,controllability of analgesic effect,fast and completely reversible action,avoidance of side effects andcomplications.3,10,11,12

2. Tooth repair: This will includemanufacturing and installation of abiologically analogous wholereplacement teeth by using geneticengineering, tissue engineering, thatincludes both mineral and cellularcomponents, i.e. ‘complete dentitionreplacement therapy’ should becomefeasible within the time andeconomic constraints of a typicaloffice visit through the use of anaffordable desktop manufacturingfacility, which would fabricate a newtooth in the dentist’s office.Scientists took advantage of theselatest developments in the area ofnanotechnology to simulate thenatural biomineralization process tocreate the hardest tissue of thehuman body i.e dental enamel, byusing highly organizedmicroarchitectural units of nanorodlike calcium hydroxyapatite crystalswhich will be arranged roughlyparallel to each other.

3. Treatment of dentinehypersensitivity: A relativelyfrequently encountered pathology indental practice is the dentinehypersensitivity characterized by adiffuse symptomatology, slightlypainful, caused by pressure,hydrodynamically transmitted to the

pulp through the dentinal tubules ofthe exposed dentin. It seems that inthis condition, the hypersensitiveteeth have a density of dentinaltubules 8 times bigger, and they havea diameter twice the size of dentinaltubules of non-sensitive teeth.8,9,13

Reconstructive dental robots usingnative biological materials couldselectively and precisely occludespecific dentinal tubules withinminutes, offering a quick andpermanent cure.14,15

On reaching the dentin, nanorobotsenter the dentinal tubular openingsthat are 1-4micron in diameter andproceed towards the pulp, guided bya combination of chemical gradients,temperature differentials and evenposition of navigation, all under thecontrol of onboard nanocomputer asdirected by the dentist. Nanorobotscan complete the journey into pulpchamber in approximately 100s. Thepresence of natural cells that areconstantly in motion around andinside the teeth, including humangingival, pulpal fibroblasts,cementoblasts, odontoblasts andbacteria inside dentinal tubules,lymphocytes within the pulp orlamina propria suggests that suchjourney be feasible by cell-sizednanorobots of similar mobility.16

4. Orthodontic treatment: Nowadays,orthodontic treatment has a lot oflimitations among which the need towear the orthodontic appliance formonths or years being the mostimportant, to which we can add theunaesthetic aspect of the smile, as


well as the discomfort of the patientin terms of speaking and eating. Inthe era of the orthodonticnanorobots, they will be able tomanipulate directly the periodontaltissues, including gingiva,periodontal ligament, cementum andalveolar bone, allowing a quick andpainless uprighting, rotating orvertical positioning within minutesor hours.8,9

5. Aesthetic dental treatment:Nowadays, aesthetic dental medicineuses the tooth implant placed insidethe maxillary or the mandibular jaw(on the spot of a former dental root),in order to help replacing one orseveral missing teeth. This isfollowed by a period of osteo-integration and abutment (aprosthetic joint) is attached to theimplant on top of which the doctorcan place the crown, the bridge orthe prosthetic, that will replace themissing tooth (teeth). This restoringtechnique has a lot of advantages,but a lot of disadvantages the mostcommon of which is inducingdiscomfort to the patient as it is asurgical procedure and requiresseveral sessions stretched alongseveral months, and the implant canbe rejected by the individual. Thereconstructive nanodental techniqueswill imply genetic engineeringprocedures, tissue engineering,nanorobotic manufacturing for thegrowth of a new tooth in vitro,followed by its installation in thedental alveoli with the help ofreconstructive dental nanorobots.The nanotherapy of completereplacement of the dentition with

biological teeth, including bothmineral and cellular compounds, willhave the advantage of being possiblein the dental practice in onesession.3,8,9,13 Reconstructive dentalnanorobots will maintain the naturaltooth and will improve its aestheticaspect (in terms of color and texture)and durability by means of replacingthe upper layers of the enamel withartificial biocompatible materials,such as sapphire and diamond, with ahardness of 20-100 times larger thanthe natural enamel and thus, a largerfracture resistance.8,9 The numerousreconstructive dental nanorobots,controlled from a distance andworking together will be able toexcavate old amalgam restorationsand will be used to prepare thecavities and restore the teeth withbiological materials, so that thenewly formed tooth could not bedifferentiated from the original one.8

6. Diagnosis of oral cancer:A) Nanoelectromechanical systems

(NEMS): nanotechnology basedNEMS biosensors that exhibitexquisite sensitivity andspecificity for analyte detection,down to single molecule level arebeing developed. They convert(bio) chemical to electricalsignal.17

B) Oral fluid sensor test(OFNASET): The oral fluidnanosensor test technology isused for multiplex detection ofsalivary biomarkers for oralcancer. It has been demonstratedthat the combination of twosalivary proteomic biomarkers(thioredoxin and IL-8 and four


salivary mRNA biomarkers(SAT, ODZ, IL-8 and IL-1b) candetect oral cancer with highspecificity ad sensitivity.18

C) Optical nanobiosensor: Thenanobiosensor is a uniquefiberoptics- based tool whichallows the minimally invasiveanalysis of intracellularcomponents, such as cytochromeC, which is a very importantprotein to the process whichproduces cellular energy and iswell-known as the proteininvolved in apoptosis, orprogrammed cell death.19

7. Treatment of oral cancer:nanotechnology in field of cancertherapeutics has offered highlyspecific tools in the form ofmultifunctional dendrimers andnanoshells. The unique propertydendrimers, such as their high degreeof branching, multivalence, globularstructure and well-defined molecularweight make them promising incancer therapeutics.

8. Nanoshells are miniscule beads withmetallic outer layers designed toproduce intense heat by absorbingspecific wavelength of radiations thatcan be used for selective destructionof cancer cells leaving aside intactand adjacent normal cells.20,21

Photodynamic therapy: hydrophobicporphyrins are potentially interestingmolecules for the photodynamic

9. Oral hygiene and halitosis:Properly configured dentifrobots(dentifrice+nanorobots) couldidentify and destroy pathogenicbacteria residing in plaque and

elsewhere, while allowing the 500 orso species of harmless oralmicroflora to flourish in a healthyecosystem. Dentifrobots also wouldprovide a continuous barrier tohalitosis, since bacterial putrefactionis the central metabolic processinvolved in oral malodor. They willbe programmed to avoid the occlusalareas and will be deactivated ifchewed.8,12,21

10. Surgical nanorobotics: A surgicalnanorobot guided by a dentist, couldact as a semi-autonomous onsitesurgeon inside the human body. Sucha device could perform variousfunctions like searching forpathology and then diagnosing andcorrecting lesions bynanomanipuation, coordinated by anonboard computer, whilemaintaining contact with thesupervising surgeon via codedultrasound signals.23

11. Bone replacement materials: thesecan be used in maxillofacial injuriesrequiring bone graft, cleft patient andosseous defect in periodontalsurgeriesA) Hydroxyapatite nanoparticle used

to treat bone defects are OstimR

B) VITOSSO (beta tricalciumphosphate bone graft material)

C) NanOSSTM(hydroxyapatitebased bone graft)

Benefits vs risks in the use of dentalnanorobots:

Rapid development in the field ofnanorobotics in the last two decades hasgenerated controversies over the safety oftheir application as well as the toxic effect of


the medical nanorobots on the human beingor the medium24 and it seems we arewitnessing the birth of a new discipline:nanoethics.25 The benefits of using dentalnanorobots could be as numerous as therecould be probably as many applications ofthese minute instruments as there are needsin dental medicine. The possibletoxicological risks on the human body arebeing also discussed,26 the possibledisappearance of homo sapiens sapiens ifthe nanorobots will not be eliminated fromthe human body, but also the possibledisappearance of the biosphere if thenanorobots will evolve towards the capacityof continuous auto-replication, resulting inthe appearance of clusters consuming anyliving creature on Earth, leaving behind auseless gray mass (the so-called gray-gooscenario).27

Conclusions:

In the 1950s, nanorobotics was at afictional stage, now we are at the theoreticalstage but the years 2020 will be called the“decade of the medical nanorobots”.Nanorobots, considered even now asrevolutionary instruments are beingexpected with a lot of enthusiasm and hopes,but also with some fear as they will radicallychange the 21st century dental medicine.Nanotechnology is part of a predicted futurein which dentistry and periodontal practicemay become more high-tech and moreeffective looking to manage individualdental health on a microscopic level byenabling us to battle decay where it begins.Role of periodontitis will continue to evolvealong the lines of currently visible trends.For example, simple self-care neglect will

become fewer, while cases involvingcosmetic procedures, acute trauma, or raredisease conditions will become relativelymore commonplace. Treatment options willbecome more numerous and exciting. Oncewidely used, the role of the dentist willchange visibly. More than ever, he will haveto possess technical capabilities and a quickand correct professional judgment. Besides,patients will ask for more aesthetic dentaltreatments. As a result, dental nanorobots,today somewhat fictional, will bringsignificant benefits in oral health,contributing to achieving painless, quick andhigh precision dental treatments.Technology should be able to target specificcells in a patient suffering from cancer orother life-threatening conditions.

Acknowledgements:

A debt of gratitude to our respectedDean Dr.Hiren Patel for providing us withthis opportunity.

We also would like to thank Dr. VasumatiPatel, HOD Periodontology for her constantsupport.

References:

1. R. Feynman, There's Plenty ofRoom at the Bottom. An invitationto Enter a New Field Of Physicshttp://www.zyvex.com/nanotech/feynman.html.

2. AbhilashM. Potential applications ofnanoparticles. Int J PharmaBiosci2010; 1(1):1-10.

3. AbhilashM. Potential applications ofnanoparticles. Int J PharmaBiosci2010; 1(1):1-10.

4. R.A. Freitas. Jr., ComputationalTasks in Medical Nanorobotics, in


M.M. Eshaghian-Wilner (ed.), Bio-inspired and Nano-scale IntegratedComputing, John Wiley & Sons,New Jersey, USA, 2009;1:391-428

5. R.A. Freitas, Jr., Current Status ofNanomedicine and MedicalNanorobotics, Journal ofComputational and TheoreticalNanoscience, 2005, 2: 1-25

6. C. Edeler, I. Meyer, S. Fatikow,Simulation and Measurement ofStick-Slip-Microdrivers forNanorobots, in DoinaPisla, MarcoCeccarelli, Manfred Husty (eds.),New Trends in Mechanism Science:Analysis and Design, SpringerScience+Business Media B.V.,2010;1:109

7. M.J. Schulz, V.N. Shamov, Y.Yun(Eds.), Nanomedicine Design ofParticles, Sensors, Motors, Implants,Robots, and Devices, Artech House,2009;1:10

8. Sujatha V, Suresh M, Mahalaxmi S,Nanorobotics - a futuristic approach,SRM University Journal of DentalSciences. 2010, 1(1):86-90

9. KumarS.R. Vijaylakshmi R.Nanotechnology in dentistry. IndianJ. Dent. Res. 2006;17:62-69

10. Estafan DJ. Invasive and non-invasive dental analgesiatechniques. Gen Dent1998;46(6):600-601

11. Herzhog A. Of Genomics, cyborgsand nanotechnology: a look into thefuture of medicine. ConnecticutMedicine 2002;66(1):53-54

12. Patil M., Mehta DS, Guvva S.Future impact of nanotechnology onmedicine and dentistry, 2008; 12(2): 34-40

13. S. Gorav, VasudevaKamlesh, P.Nidhi, Nanodentistry - the futureahead, BFUDJ, 2010, 1(1):43-45

14. Mjor IA, Nordahl I. The density andbranching of dentinal tubules inhuman teeth. Arch Oral Biol1996;41(5):401-412.

15. Sumikawa DA, Marshall GW, GeeL, et al. Microstructure of primarytooth dentin. Pediatric Dentistry1999;21(7):439-444

16. Freitas R.A. Jr. Exploratory designin medical nanotechnology: amechanical artificial red cell.Artificial Cells Blood SubstituteImmobile Biotechnology1998;26(4):30-32

17. Li Y, Denny P, Ho CM. The Oralfluid NEMS/MEMS chip(OFMNC): diagnostic andtranslational applications. Adv DentRes 2005; 18(1):3-5

18. Gau V, Wong D. Oral Fluidnanosensortest(OFNASET) withadvanced electrochemical-basedmolecular analysis platform. AnnNY AcadSci 2007;1098(3):401-410

19. Song JM, Kasili PM, Griffin GD,Vo-Dinh T. detection of cytochromeC in a single cell using an opticalnanobiosensor. Anal Chem 2004;76(9):2591-2594.

20. Tumor gets selective withnanoparticles: Nano Today2007;2(5):35

21. Mubben, Singh A. Nanotechnologyin the field of oral medicine anddiagnosis: a review: Indian DentistResearch and Review 2010;5(3):41-43

22. Vargas A, Pegaz B, Debefve E.Improved photodynamic activity ofporphyrin loaded into nanoparticles:An in vivo evaluation using chickembryos. Int J Pharm 2004;286(1-2):131-145

23. Cavalcanti A. Assembly automationwith evolutionary nanorobots withcensor based control applied to


nanomedicine. IEEE Transactionson Nanotechnology 2003;2(2):82-87

24. Singh Surya, NalwaHS.Nanotechnology and healthsafety toxicity and risk assessmentsof nanostructured materials onhuman health, JNanosciNanotechnol. 2007;7(9):3048-3070

25. Leontis VL, Agich GJ. Freitas ondisease in nanomedicine:implications for ethics, Nanoethics,2010,

26. Carbon nanotubes in medicalnanorobots, Int J Nanomedicine.2007; 2(3): 361 372

27. Drexler KE. Engines of Creation:The Coming Era ofNanpotechnology, AnchorPress/Doubleday, New York, 1986,p. 78http://edrexler.com/d/06/00/EOC/EOC_Chapter_11.html#section01of05


REVIEW ARTICLE

Caries risk assessment: A new horizon in preventive approach

*Dr.Heena Pandya **Ishani Thakkar ***Dr.Jitendra Akhani

AbstractThis review discusses the rationale for Caries Risk Assessment (CRA) and the role various riskindicators play in dental caries occurrence. The purpose of CRA is to find out caries risk level ofeach patient and encourage them to undertake measures that will move them from high/moderaterisk category to low risk category. It also provides an overview of different CRA methods andpreventive protocols for risk based clinical management of dental caries. Recognition, reductionand regeneration can lead to early determination of the lesion, minimizing caries risk thusleading to reversal of incipient lesion.Keywords: Caries risk, caries risk assessment, management protocol

Introduction

Dental caries is the most common chronicdisease worldwide. Until now, it was a normto consider only cavitated lesions for thetreatment of caries. But caries, as we knowit, don’t arise de nova, they are preceded bywhite spot lesion, which are a risk indicatorfor future caries development.In Indian dental practice, a variety ofpatients can be observed. On one end, thereare literate patients who come to the dentistbeing well aware about caries treatmentprotocols.

*Reader, Head** Intern***Tutor,

Department of Public Health DentistryFaculty of Dental Science,Dharmsinh Desai University,College road, Nadiad

Unfortunately on the other end, there aremany myths regarding dental treatment thatlurk amongst mindset of patients. Factorslike poor education and low socioeconomicstatus misguide the patient to have a casualattitude towards carious lesions, which leadsto an increased proportion of complications.This lack of awareness is the chief reasonbehind caries associated morbidity.Dental caries is an infective andtransmissible disease. Carious lesiondevelops when cariogenic bacteria colonizeson the susceptible tooth surface in presenceof dietary fermentable carbohydratesespecially sucrose.

Corresponding Author:Dr Heena Pandya,Head of the Department of Public HealthDentistry,Faculty Of Dental Science, DharmsinhDesai University, Nadiad.EMAIL:[email protected]: +91987955968


Thus, CRA plays a vital role not only inprediction of disease but also helps inprevention, elimination and reversion of thelesion at an early stage.Caries risk has been defined by Hausen asthe probability that an individual willdevelop a certain number of carious lesions(cavitated or noncavitated) or reach a givenlevel of disease progression, over a specificperiod of time, provided his or her exposurestatus remains the same during thisperiod.1Assessing a patient’s caries riskstatus is an essential component in themodern day management of dental caries,where the emphasis on anonoperative/preventive approach, ratherthan just the surgical or restorativeintervention to the disease process.2,3

Several factors play an important role in thedevelopment and prevention of caries,therefore it is important to understand howthese factors affect the disease process. Arisk factor is a behavioral, biological andenvironmental factor that, if present,increases the probability of a diseaseoccurring, and if absent or removed reducesthe probability.4 Assessing all the riskfactors helps to find the etiology of thedisease and gives a more accurate analysisof the risk of developing caries in aparticular patient. CRA is based more onindividual prevention. Thus it is veryimportant for a dentist to make the patientunderstand to keep the tooth healthy. Mostdentists today assess the caries risk in eachpatient usually, but it is not certain ifdentists systematically use this informationin their treatment decisions. Anyway, “asdentists we have to look at the patient as awhole. People have caries; teeth havelesions”.4After an extensive review of literature oncaries risk indicators, Zero, Fontana, andLennon concluded that no single indicator orcombination of risk indicators couldconsistently be a good predictor of caries

risk status when applied across differentpopulations and age groups.5Caries etiologyis multivariate between pathologic factorslike cryogenic bacteria and frequent sugarexposure that play a major role in causingdental caries along with contributing factorslike oral self care methods, diet habits,medical history, fluoride exposure andgenetics. It is not possible to evaluate therisk from looking at just one risk factor; onehas to evaluate all the factors together.

Caries risk assessment methods:

Since caries is a chronic multifactorialinfectious disease which is a worldwideproblem, many CRA methods have beenproposed.In 1997, The Cariogram model was firstpresented by Brathall as a graphicalillustration of an individual’s risk ofdeveloping new caries lesions in the future.It also simultaneously expresses the extentto which the different etiological factors ofdental caries affect caries risk for thatparticular individual.8Cariogram describesthe percentage chance to avoid caries whichis easy for a patient to understand.Caries Questionnaire in combination withClinical Observations 6

Based on the concept that caries is aninfectious disease, Featherstone et al.6

evolved a consensus statement to assessindividual caries risk from a questionnairethat addresses issues such as maternal dentalhistory, family dynamics, socioeconomicfactors, oral hygiene measures, fluorideexposure, and frequency of sugar exposures.Along with the questionnaire, clinicalobservations were made by visual, tactile,and radiographic examination of teeth. Onceindividual risk status was determined, theysuggested using a minimally invasive cariesmanagement protocol that includedappropriate preventive and therapeuticrecommendations.


CAMBRA – Caries Management by RiskAssessmentThe CAMBRA model was published in2003 by a group of experts from the UnitedStates. In CAMBRA the focus is ondiagnosis, prognosis and risk analysis. InCAMBRA they combine diagnosis andrisk/prognosis assessment to get animproved treatment plan. There are fourtreatment groups and each of them has theirown protocol for managing the diseaseprocess and recall times. CAMBRA alsofocuses on minimal operative intervention ofcavitated lesions and defective restorations.14

AAPD’s Caries-risk Assessment Form. 7

The AAPD modified its original CariesriskAssessment Tool (CAT) 10into a moresensitive and practical tool to assist dentalpractitioners, physicians, and non dentalhealthcare providers in assessing the levelsof risk for caries development in infants,children, and adolescents. 7

Caries risk Assessment forms wereformulated that can be used by the dentiststo assess caries risk status for 0-5 year oldand ≥ 6‑year‑old children. Risk assessmentcategorization of low, moderate, or high isbased on the preponderance of factors forthe individual. However, clinical judgmentmay justify the use of one factor (e.g.,frequent exposure to cryogenic snacks, ≥1interproximal lesions, and low salivary flow)in determining the overall risk. 7

Amongst the various methods describedabove, Cariogram is more effective indetermining caries risk because of its highspecificity and positive predictability. Thepie diagram presenting percentage chance toavoid caries makes it easy for the dentist todemonstrate the patients about minimizingcaries risk.Cariogram gives an individual treatmentplan. On the other hand, CAMBRA hasgeneralized treatment plan along withperiodic follow-ups for each group. But, the

individual cost and time constraints imposedby multiple test protocol restricts their use inclinical practice.Caries Questionnaire in combination with

Clinical Observations 6 is a method whichcan be used by both dental and non dentalhealth care providers, only the clinicianmust be familiar with clinical presentation ofcaries and factors related to caries initiationand progression.AAPD’s Caries risk assessment tool is ameans of classifying caries risk at aparticular time. It should be periodicallyapplied to assess changes in an individualrisk status. It assesses all three componentsof caries risk-clinical conditions,environmental characteristics and generalhealth conditions. It has developed one ofthe best clinical protocols for themanagement of caries in different agegroups.14

Although there is no completely reliable andprecise method of CRA to date, the use of ahealth questionnaire for medical, dental anddietary history remains fundamental to bestclinical practice by the majority of dentalpractitioners. 15

Caries Prevention:

The treatment plan varies as per the methodimplemented but the management protocolslike diet, oral hygiene maintenance andfluoride application covers the basics ofevery treatment plan but the outcome variesaccording to the individual risk. When acaries risk assessment has been done,regardless of the method that has been used,the dentist should make a preliminarytherapy plan and a definitive therapy plan,and inform the patient about the prognosis.The preventive treatment plan for theindividual should be given in both verbaland written form. It is important to explainto the patient that it is possible for him/herto move to a lower risk group to increase the


percent of avoiding caries by self ‐administered home care and professionalhelp.After finding the risk level, the dentistshould describe the basic characteristics forcaries development and how to prevent it,like avoiding eating things containingordinary sugar between meals, brush theteeth twice a day with fluoride toothpasteand using dental floss. And then, we shouldexplain individually what the patient shoulddo to reduce his/her own risk, such as extrafluoride supplements, special dietary adviceand stimulate the saliva when needed.CRAis equally important for both children andadults. Root caries is commonly found inelderly patients and is an alarming sign inthem as it is asymptomatic, has rapidprogression and is difficult to restore.In general the indication for restorative or

surgical treatment becomes strong atincreasing risk. Even if a patient is“deemed” to be at low risk of future caries ata particular examination, there is a need formaintenance care.11Little information isavailable about the efficacy of cariesmanagement and preventive interventionsamong high risk individuals.12The patient’scooperation plays a vital, indispensable rolefor these management protocols to beeffective.

Conclusion:

To conclude, the CRA tools in generaldental practice is not yet systematicallyadopted. The leading caries expertsrecommend that CRA can become anintegral component of minimumintervention dentistry and a new paradigmfor caries management. Thus, at such aunique juncture of dental evolution, if thedentist can utilize these methods along withclinical experience, then caries riskassessment protocols not only help the

dentists to bridge the information gap butalso prevent caries at an early stage.Thus, CRA makes it easier for the patient tounderstand why they develop caries andwhat can be done about it. Every individualshould not only strive to get the cariesmanagement done, but also aim to keeptooth healthy.

References:

1. Hausen H. Caries prediction – State of theart. Community Dent Oral

Epidemiol 1997; 25:87‑96.

2. Anderson MH, Bales DJ, Omnell KA.Modern management of dental caries:The cutting edge is not the dental bur. J Am

Dent Assoc 1993; 124:36‑44.

3. Pitts NB. Are we ready to move from

operative to non‑operative/Preventivetreatment of dental caries in clinical

practice? Caries Res2004; 38:294‑304.

4. Steinberg S: Adding caries diagnosis tocaries risk assessment: The next step incaries management by risk assessment(CAMBRA)

5. Zero D, Fontana M, Lennon AM. Clinicalapplications and outcomes of usingindicators of risk in caries management. J

Dent Educ 2001; 65:1126‑32.

6. Featherstone JD, Adair SM, AndersonMH, Berkowitz RJ, Bird WF, Crall JJ, et al.Caries management by risk assessment:Consensus statement, April 2002. J Calif

Dent Assoc 2003; 31:257‑69.


7. American Academy of PediatricDentistry. Guideline on caries riskassessment and management for infants,children, and adolescents. Pediatr Dent2013; 35:E157‑64.

8. Bratthall D, Hänsel Petersson G.Cariogram – A multifactorial riskassessment model for a multifactorialdisease. Community Dent OralEpidemiol2005; 33:256‑64.

9. Young DA, Featherstone JD, Roth JR.Curing the silent epidemic: Cariesmanagement in the 21st century and beyond.J Calif Dent Assoc2007; 35:681‑5.

10. American Academy of PediatricDentistry. The use of a caries riskassessment tool (CAT) for infants, childrenand adolescents. PediatrDent 2002; 24-7Suppl: 15‑7.

11. Clarkson JE, Amaechi BT, Ngo H,Bonetti D: Recall, reassessment andmonitoring, Monogr Oral Sci. Basel,Karger, 2009, Vol 21, pp 188 – 198.

12. Bader JD, Shugars DA, Bonito AJ: Asystematic review of selected cariespreventive and management methods,Community Dent Oral Epidemiol, 2001: 29:399 – 411.

13. Public Health Dentistry Soben peterbook arya medi publication

14. Suneja ES, Suneja B, Tandon B, PhilipNI.An overview of caries risk assessment:Rationale, risk indicators, riskassessmentmethods, and riskbased caries managementprotocols. IndianJ Dent Sci 2017; 9:2104.S

15. Sarmadi R, Gabre P, Gahnberg L.Strategies for caries riskassessment inchildren and adolescents at public dentalclinicsin a Swedish county. Int J PaediatrDent 2009; 19:135–140.


IMPLANT RETAINED OVERDENTURE WITH BAR ATTACHMENT- ACASE REPORT

*Dr. Khushali Patel **Dr. Somil Mathur ***Dr. Rakesh Makwana****Dr. Snehal Upadhyay ****Dr. Vinit Shah

Abstract:Edentulous arches must be rehabilitated in order to improve mastication, esthetics as well as tofill in the psychological dent created due to missing teeth. Though complete dentures have beenused for rehabilitation of edentulous patients, mandibular implant retained overdenture providesmechanically, biologically and psychologically much better option for these patients. This articlepresents the case report of rehabilitation of completely edentulous patient by means of twoimplant retained mandibular overdenture with Hader bar attachment.Keywords: implant retained overdenture, implant overdenture, bar attachment, hader bar

Introduction

Edentulism is an unresolved health careissue of sustained significance andprevalence in the aged population. Theprosthetic management of the edentulouspatient has always been a major challenge.The infected root canal space cannot bedisinfected with the standard root canalprotocol with the aggressive use ofendodontic files.Complete maxillary and mandibulardentures have been the traditional treatmentoption. However, most of the patients reportproblems adapting to the mandibular denturedue to lack of comfort, retention andstability.

*Post Graduate Student**Professor & Head of the Department

***Reader****Senior LecturerDepartment of Prosthodontics, Crown &Bridgework and Oral Implantology,Faculty of Dental Science,Dharmsinh Desai University,Nadiad.

For decades, natural teeth have beenretained in patient’s mouth in order topreserve alveolar bone and derive supportfor overdentures. However, in cases where,extraction of the natural teeth is inevitable,implant-supported overdentures have been awell established treatment for edentulouspatients.According to “The Mc Gill ConsensusStatement on Overdentures” the restorationof the edentulous mandible with aconventional denture is no longer the mostappropriate choice of prosthetic treatment.Two implant supported overdenture hasbecome the standard of care. 1

Corresponding Author Name:

Dr. Khushali Patel

Address of Correspondence:

41/A, Karmacharinagar-1, Ghatlodiya,Ahmedabad.380061, Gujarat.

[email protected]

(M)+918128946080


Different attachment systems have beenavailable for the implant overdentures.2

Ball attachments Bar attachment

- Hader bar- Dolder bar

Locator attachment Magnetic attachment

Two implant retained overdentures are veryreliable for the patients with an edentulousmandible. It is appropriate to use twoimplants with an interconnecting bar parallelto the hinge axis. In patients with resorbedmandibular ridge, where there is anavailability of sufficient interarch space toaccommodate attachments, denture base anddenture teeth, those are good candidates forthe use of bar attachment for overdenturefabrication.3,4

The success rate of implant overdenturevaries, depending on a host factors that differfrom patient to patient. However, comparedwith traditional methods of toothreplacement, the implant overdenture offersincreased longevity, improved function, bonepreservation and better psychologicalcomfort.

CASE REPORT:A 45 years old, male patient reported

to the Department of Prosthodontics, Crown& Bridgework and Oral Implantology,Faculty of Dental Science, Dharmsinh DesaiUniversity, Nadiad with the chief complaintof missing upper and lower teeth.On intraoral examination patient wascompletely edentulous in relation tomaxillary and mandibular arch for past oneyear (Illustration 1,2).Two implant retained overdenture wasplanned for the patient as it improvesretention of the denture as well as reduces theresidual bone resorption and provides aeconomical treatment option compared to fullarch fixed dental prosthesis.

Illustration 1 : Preoperative edentulousmaxillary arch

Illustration 2 : Preoperative edentulousmandibular arch.

Illustration 3 : Panoramic radiographtaken after implant placement.

Surgical implant placement was done in themandibular arch. Site for implant placementwas selected by provisional denturefabrication. Two implants (D 3.8 × L 11Myriad Plus, Equinox Medical Technologies,Netherlands) were placed in the B and Dregion, by dividing interforaminal region intofive segments from A to E and were allowedto osseointegrate for four months (Illustration




























3). After osseo-integration of implants,healing abutments were placed and a weeklater primary impressions were made(Illustration 4,5).

Illustration 4 : Edentulous mandible withhealing abutments.

Illustration 5 : Primary impressions

Illustration 6 : Fabrication of custom trays

Custom trays were fabricated for makingfinal impressions (Illustration 6). Open trayimpression copings were placed and splintedintraorally with pattern resin (Pattern Resin;GC Corp, Tokyo, Japan) (Illustration 7,8).

Illustration 7 : Radiograph showingcomplete seating of impression copings.

Illustration 8 : Splinting of impressioncopings with pattern resin

Maxillary final impression was made withZinc Oxide-Eugenol impression paste (DPIImpression Paste; Mumbai, India) and pouredwith dental stone (Class III; Kaldent,Kalabhai Karson Pvt. Ltd, Mumbai, India)(Illustration 9).Mandibular final impression was made withpolyvinylsiloxane impression material(Honigum; DMG, Germany).


Illustration 9 : Maxillary final impression.

Impression was poured with die stone (ClassIV; Kalrock, Kalabhai Karson Pvt. Ltd,Mumbai, India) (Illustration 10).

Illustration 10 : Mandibular finalimpression with lab analogs.

Illustration 11 : Facebow transfer

Orientation jaw relation was recorded withface-bow (Hanau Spring-Bow; Whip MixCorp., Louisville, KY USA) and maxillarycast was secured on a semi-adjustablearticulator (Hanau Wide Vue II; Whip MixCorp., Louisville, KY USA) (Illustration 11).

Illustration 12 : Jaw relation record.

Centric relation was recorded using Hight’sgothic arch tracers and mandibular cast wasarticulated. Horizontal condylar guidancewas adjusted by means of protrusive record(Illustration 12).

Illustration 13 : Pattern for bar attachmentlingual view


Illustration 14: Pattern for bar attachmentocclusal view

Anterior teeth arrangement was completedand putty index (Honigum; DMG, Germany)was made. Trial denture was removed fromthe cast and pattern for Hader bar wasattached to the castable abutment by meansof pattern resin (Pattern Resin; GC Corp,Tokyo, Japan) (Illustration 13). Assessmentof restorative space for accommodation ofdenture base and teeth was carried out withreference to index, after fabrication of barattachment pattern (Preci-Horix PlasticPattern; Ceka, Waregem, Belgium) whichwas then casted into Co-Cr metal (Illustration14). Bar attachment trial was done to checkfor passive fit of the attachment (Illustration15).

Illustration 15 : Try-in of bar attachment

New record base was made and clip (Preci-Horix Rider; Ceka, Waregem, Belgium) is

transferred into the record base. Teetharrangement was completed and intraoral try-in was done to evaluate for the retention ofthe denture before final processing(Illustration 16).

Illustration 16 : Try-in

Blockout was done with dental stone (ClassIII; Kaldent, Kalabhai Karson Pvt. Ltd,Mumbai) around bar attachment and dentureswere acrylized using heat cure acrylic resin(Meliodent Heat Cure; Kulzer GmbH,Germany) (Illustration 17,18).

Illustration 17 : Block-out of barattachment


Illustration 18: Acrylized mandibulardenture with retentive clip.

Illustration 19 : Bar attachment insertion.

Bar attachment was fitted intraorally with atorque of 25N and dentures were inserted(Illustration 19,20).

Illustration 20 : Insertion of denture.

Illustration 21 : Comparison of pre-operative and post-operative results.

DISCUSSION:Completely edentulous patients find moredifficulties in adapting to complete dentures,problem arises particularly with themandibular dentures due to lack of retention,stability and support.5

Complete denture is no longer considered thefirst treatment option for the completelyedentulous mandibular arch. Two implantsupported overdenture is considered thestandard of care for the same.1

The ideal treatment plan is based on thepatient’s needs, desires and the best possibletreatment option. Not all patients should betreated with the same type or design of theoverdenture. Broad knowledge, properpatient selection, better psychologicalunderstanding, proper pre-surgical prostheticplanning and a very good biomechanicalbackground are the main components forachieving proper overdenture design.6

Implant overdenture is supported or retainedby the implants by means of variousattachment systems either splinted or non-splinted.Two implants can be used individually innon-splinted manner with a ball, Locator,magnetic or telescopic attachments.However, patient satisfaction regardingretention and stability of implant- retainedoverdentures have been declined significantlywith the use of two non-splinted ball


attachments, while patient satisfaction withsingle-bar and triple-bar (two and fourimplants) attachments did not change withtime.7 Two implants, when splinted togetherwith a straight bar, will permit denturemovement vertically, thus the implants aswell as the mucosa will be involved in thedissipation of the occlusal forces.7,8 Whencompared to mandibular conventionaldentures, two implant retained overdenturewith bar attachment significantly improvedpatient comfort, masticatory efficiency andspeech.9

There are a wide range of commerciallyavailable bar attachments which are eitherpre-fabricated from type IV gold or othertype of bars which comes in castable andpre-milled plastic patterns. The selection ofattachments varies from patient to patient, onthe basis of number and position of implants,available restorative space, shape of the arch,loading protocols and economics. Mostcommonly used attachments are ball and barattachments.10,11,12 In the present case, barattachment (Ceka Waregem, Belgium) wasselected, as it can be casted into any alloy ofchoice, soft snap of the clips over barproviding better patient comfort as well asease of replaceability of the clips.Though implant overdenture improvesretention, stability and support, it has certainlimitations as it needs replacement of clipevery one year. The shorter the bar segment,the greater the chance of clip loosening. Alsothe bone density around dental implantsshould be checked every 1,3,5,7,10,15 and 20years recall period for satisfactory treatmentoutcome.13

CONCLUSION:The use of osseointegrated implants

as a foundation for the prosthetic replacementof missing teeth has become widespread inthe last few decades. Overdentures supportedby implants offer better stability, support,

retention, improved function and patientacceptance. Complete denture is no longerthe best treatment option for mandibular arch,however implant overdenture is a bettertreatment option. By appropriate selection ofattachment systems, based on the patientcriteria, successful treatment outcome can beachieved. Hence, two implant retainedoverdentures were considered standard carefor edentulous mandible situations providingsatisfactory outcome of the treatment.

REFERENCES:1. Feine J. S., Carlsson G. E., Awad M.A.,

Chehade A., Duncan W. J., Gizani S. et al.McGill Consensus Statement onOverdentures. Int J Oral MaxillofacImplants 2002;17(4):601-602.

2. Mensor M. Classification and selection ofattachments. J Prosthet Dent1973;29(5):494-497.

3. Prasad D, Prasad DA, Buch M. Selection ofattachment systems in fabricating animplant supported overdenture. Journal ofDental Implants 2014;4(2):176-181.

4. Trakas T, Michalakis K, Kang K, HirayamaH. attachment systems for implant retainedoverdentures: a literature review. ImplantDentistry 2006;15(1):24-32.

5. Burns D, Unger J, Elswick R, Giglio J.Prospective clinical evaluation ofmandibular implant overdentures: Part II—patient satisfaction and preference. JProsthet Dent 1995;73(4):364-369.

6. Chee W, Jivraj S. Treatment planning of theedentulous mandible. Brit Dent J2006;201(6):337-347.

7. Arbree N, Chapman R. A comparison ofmandibular denture base extension inconventional and implant-retained dentures.J Prosthet Dent 1991;65(1):108-111.

8. Warreth A, Alkadhimi AF, Sultan A, ByrneC, Woods E, Mandibular implant-supportedoverdentures: attachment systems, numberand location of implants.part-II. J Irish DentAssocia 2015;61(3):144-148.


9. Awad M, Lund J, Dufresne E, Feine J.Comparing the efficacy of mandibularimplant-retained overdentures andconventional dentures among middle-agededentulous patients: satisfaction andfunctional assessment. Int J Prosthodont2003;16:117-122.

10. Vogel RC. Implant overdentures: A newstandard of care for edentulous patients-current concepts and techniques. Cont EduCompend 2008;29(5):270-277.

11. Naert I, Alsaadi G, Quirynen M Prostheticaspects and patient satisfaction with two-implant-retained mandibular overdentures: a10-year randomized clinical study. Int JProsthodont 2004;17(4):401-410.

12. Williams B, Ochiai K, Hojo S, Nishimura R,Caputo A. Retention of maxillary implantoverdenture bars of different designs. JProsthet Dent 2001;86(6):603-607.

13. Kollar AR, Huber S, Stern RM. Mandibularimplant overdentures followed for over 10years: patient compliance and prostheticmaintainence. Int J Prosthodont 2010;23:91-98.


FULL-MOUTH REHABILITATION OF PARTIALLY EDENTULOUSPATIENT WITH SEVERELY WORN DENTITION: A CASE REPORT

*Dr. Pankti Naik **Dr. Somil Mathur ***Dr. Rakesh Makwana****Dr. Snehal Upadhyay ****Dr. Vinit Shah

Abstract:Severe tooth wear is frequently multifactorial and variable. The severe wear of anterior teethfacilitates the loss of anterior guidance and collapse of posterior teeth further results in the loss ofnormal occlusal plane and the reduction of the vertical dimension. This case report describes 77-year-old male, who had the loss of anterior guidance, severe wear of dentition along withreduction of the vertical dimension. The decision of increasing vertical dimension was made byanatomical landmarks, facial and physiologic measurements. Once the compatibility of the newvertical dimension had been confirmed, interim fixed restoration and the permanentreconstruction was initiated. This case reports that a satisfactory clinical result was achieved byrestoring the vertical dimension with an improvement in esthetics and function.

Keywords: tooth wear, vertical dimension of occlusion, full-mouth rehabilitation

Introduction

The gradual wear of the occlusalsurfaces of teeth is a normal process duringthe lifetime of a patient. However, excessiveocclusal wear can result in pulpal pathology,occlusal disharmony, impaired function, andesthetic disfigurement.1 Tooth wear can beclassified as attrition, abrasion, erosion andabfraction depending on its cause.

*Post Graduate student**Professor and Head of Department

***Reader****Senior Lecturer

Department of Prosthodontics, Crown &Bridgework and Oral ImplantologyFaculty of Dental ScienceDharmsinh Desai University,Nadiad.

A differential diagnosis is not alwayspossible because, in many situations, thereexists a combination of the processes.2

Therefore, it is important to identify thefactors that contribute to excessive wear andto evaluate alteration of the verticaldimension at occlusion caused by the worndentition.3

Corresponding Author:Dr. Pankti NaikA/9, Sainath Residency,Opposite Nisarg Apartment,Sainath marg,Old padra road,Baroda – 390015. Gujarat.Email: [email protected](M) +91 9725503864


In many cases, the vertical dimension ofocclusion (VDO) is maintained by tootheruption and alveolar bone growth. As teethare worn, the alveolar bone undergoes anadaptive process and compensates for theloss of tooth structure to maintain thevertical dimension of occlusion. Therefore,vertical dimension of occlusion should beconservative and should not be changedwithout careful approach.4,5Especially,increasing the vertical dimension ofocclusion in bruxers puts a severe overloadon the teeth and often results in destructionof the restorations or teeth themselves.4

Management of worn dentition using fixedor removable prostheses is complex andamong the most difficult cases to restore.Assessment of the vertical dimension isimportant for the management, and carefulcomprehensive treatment plan is required foreach individual case. Articulated study castsand diagnostic wax-up can provideimportant information which is helpful forthe evaluation of treatment options.Tolerance of changes to vertical dimensionofocclusion is usually confirmed with theclinical evaluation of the patient having adiagnostic splint or provisional prosthesis.5

This clinical report describes an approachtowards rehabilitation of worn dentition withmetal ceramic restorations and cast partialdenture.

Case report:A 77-year-old man was referred for

the treatment of severely worn dentition. Hecame with a chief complaint of inability tochew due to missing posterior teeth andworn out anteriors.Intraoral examination revealed a generalizedloss of dental substance that was greater onthe palatal aspect of maxillary anterior teethand the incisal edges of mandibular anteriorteeth. Mandibular molars were missingbilaterally along with missing maxillary leftsecond premolar and maxillary left molars.

Maxillary right second premolar had palatalcusp fracture, so was indicated for extractionand maxillary right molars weresupraerupted. All anterior teeth showedsharp enamel edges, dentinal craters, andattritional wear due to the loss of posteriorsupport (Illustration 1,2).

Illustration 1: Maxillary arch

Illustration 2: Mandibular arch

The previous mandibular and maxillaryremovable partial denture had lost itsretention and support and the patient was nolonger able to chew comfortably using thosedentures. There was no temporo-mandibulardisorder history or soreness of themastication muscles, but the discrepancybetween centric occlusion (CO) and


maximum intercuspal position (MIP) wasfound when the patient was guided to centricrelation (CR) with bimanual palpationtechnique.To determine whether vertical dimension ofocclusion had been altered, the followingaspects were investigated:1,5

1. Loss of posterior support: mandibularposterior teeth were missing, and the patientdid not use the mandibular partial denture.Posterior collapse resulted in excessive wearand fracture of teeth.2. History of wear: Physiologic wear can becompensated by tooth eruption in general,but the accelerated wear may exceed the rateof eruption.3. Phonetic evaluation: If the distancebetween the incisal edge of the mandibularincisors and palatal surface of the maxillaryincisors is about 1 mm, it makes normal “s”sound. The patient’s increased freewayspace had altered “s” sound.4. Interocclusal rest space: The patient’sinterocclusal rest space, measured betweennose tip and chin tip, was 5 - 6 mm whichwas greater than the normal value, 2 - 4 mm(Illustration 3).

Illustration 3: Interocclusal rest space

The possible causes of patient’s worndentition which might include posterior lossof support, parafunction, eating habit, anddental ignorance were explained to thepatient. The treatment options were fullmouth rehabilitation with metal ceramicrestoration after endodontically treating theteeth followed by crown lengthening

procedure and rehabilitating mandibular andmaxillary edentulous posterior region withimplants or removable partial denture.However, the orthopantomograph (OPG)showed inadequate bone height in maxillaryand mandibular edentulous span. Since, thepatient didn’t want to undergo extensiveprocedures like sinus lift and grafting,restoring the edentulous regions with a castpartial denture was preferred.As there wasclinical evaluation of reduced verticaldimension of occlusion, full mouthrehabilitation withincreasing verticaldimension of occlusionwas planned. Onlymandibular anterior teeth were indicated forcrown lengthening procedures to obtain asufficient clinical crown length and ferruleeffect.The patient’s casts were secured on a semi-adjustable articulator (HanauTM ModularArticulator; Whip Mix Corp., Louisville,USA) using a face-bow record and aninterocclusal record that was made with theaid of a Lucia jig and Alu Wax biteregistration material (Illustration 4).

Illustration 4: Casts secured on a semi-adjustable articulator

The new vertical dimension of occlusionwas set by 3 mm increase in the incisalguidance pin of the articulator. Because thepatient’s interocclusal rest space was 2 - 3mm larger on the premolar area than normaldistance, the actual increase weredetermined 3 mm in the anterior teeth and 1- 2 mm in the posterior teeth. After taking


CR record using Lucia jig and wax-rim,diagnostic wax-up was performed(Illustration 5, 6, 7).

Illustration 5: Diagnostic wax up (Frontalview)

Illustration 6: Diagnostic wax up(Right lateral view)

Tooth preparation for all the present teethwas carried out (Illustration 8, 9) and Bis-acryl provisional crowns (Cool Temp;Coltene, Switzerland) were fabricated directtechnique using a polyvinyl siloxane puttyindex that was produced from the diagnosticwax-up (Illustration 10).

Illustration 7: Diagnostic wax up(Left lateral view)

The provisional fixed restorations werecemented with temporary cement (FreegenolTemporary Pack; GC Corp., Tokyo, Japan),and the patient’s adaptation was monitored.

Illustration 8: Tooth preparation formaxillary teeth


Illustration 9: Tooth preparation formandibular teeth

Maxillary and mandibular interimremovable partial dentures were fabricatedand delivered for posterior edentulous span.

Illustration 10: Interim restoration inplace

For three months, interim restorations wereadjusted, and used as a guide for thedefinitive oral rehabilitation. During thisperiod, the patient’s condition and functions,such as muscle tenderness, discomfort oftemporo-madibular joint (TMJ), mastication,range of the mandibular movements,swallowing, and speech, were evaluated.Improvement in mastication, speech, andfacial esthetics confirmed the patient’stolerance to the new mandibular positionwith the restored vertical dimension ofocclusion. The anterior guidance andposterior disclusion on excursive movementwere established. Adjusted occlusion was

transferred to customized anterior guidetable, which was made with resin (PatternResin; GC Corporation, Tokyo, Japan).Maxillary cast partial denture with closedhorse-shoe major connector design andmeshwork shaped minor connector wasplanned. Embrasure clasps were designedfor maxillary right molars and Rest-Proximal plate-I bar (RPI) system wasplanned for maxillary left first premolar.The auxillary cingulum rest was placed onmaxillary canine for additional support. Thedesign for mandibular cast partial denturewas planned with lingual bar majorconnector and a meshwork minor connector.RPI system was planned for secondpremolars bilaterally along with theauxillary rests on first premolars bilaterally.Final tooth preparations were performedafter three months, and definitiveimpressions were made withpolyvinylsiloxane impression material(Illustration 11, 12). Bite registration wasmade using provisional crown and occlusalregistration material (Honigum; DMG,Germany). Porcelain fused to metalrestorations were fabricated usingcustomized anterior guide table andcemented with glass ionomer cement.

Illustration 11: Final impression –maxillary arch


Illustration 12: Final impression –mandibular arch

Because the patient’s anterior guidance tablewas used in the production of definitiverestoration, the amount of occlusaladjustment on the lingual surface ofmaxillary anterior teeth was minimal. Theanterior maxillary and mandibular teethwere restored first followed by the posteriormandibular and maxillary teeth (Illustration13). Surveyed crowns were given formaxillary left first premolar, maxillary rightmolars and mandibular premolarsbilaterally. All the restorations were checkedfor their respective esthetic and functionalrequirements.Thereafter, individual polyvinylsiloxaneimpresssions (Honigum; DMG, Germany)were made for fabrication of maxillary andmandibular cast partial denture.

Illustration 13: Metal-ceramic restorationin all present teeth

The try in for metal framework of castmaxillary and mandibular cast partialdenture was performed (Illustration 14, 15)followed by teeth arrangement and final tryin.Definitive maxillary and mandibular castpartial dentures were fabricated anddelivered withminor occlusal adjustments(Illustration 15, 16, 17, 18, 19, 20, 21).

Illustration 14: Cast partial dentureframework try in – maxillary arch


Illustration 15: Cast partial dentureframework try in – mandibular arch

The prostheses were designed using canineguided occlusion. Oral hygiene instructionand regular check-up were administered.

Illustration 16: Final prosthesis (centricocclusion)

Illustration 17: Final prosthesis (LeftLateral)

Illustration 18: Final prosthesis (Rightlateral)

Illustration 19: Final prosthesis (Lateralexcursion)

Illustration 20: Final prosthesis (Lateralexcursion)


Illustration 21: Final prosthesis(Protrusion)

Discussion:In 1984, Turner1 classified the

treatment of a severely worn dentition by theamount of the loss of VDO and availablespace to restore. The classification andconventional treatment, which includesraising VDO with multiple crown-lengthening procedures, have been widelyused up to present. However, the etiology oftooth wear is multifactorial, and clinicalcontrolled trials of restorative andprosthodontic approaches are limited inquantity and quality. In addition, lack ofevidence regarding the long-term outcomesof treatment methods and materials causedifficulty in clinical decision-making.6

Because of these unclear guidelines,adhesive strategy, that is more conservativeand reversible, is increasing.6,7,8

Nonetheless, the composite resin restorationcould not be used for the patient in this case.The remaining tooth structures were toosmall to have sufficient retention ofcomposite resin, and the surveyed crowns tosupport removable partial denture werenecessary. Therefore, the conventionaltreatment modality that includes provisionalrestoration, careful monitoring, anddefinitive prosthesis, was chosen.The rehabilitation using restoration ofanterior crowns and removable partialdenture providing posterior support isaffordable and common for many patientswho require the treatment of teeth wear.6

However, the restored anterior teeth can beeasily exposed to excessive occlusal loads ifthe patient does not wear the removablepartial denture or resorption of residual ridgeproceeds. Because the compliance ofpatients in wearing free-end saddle dentureshas been shown to be poor,9 the educationon wearing removable partial denture isnecessary. Regular check-up for the occlusaladjustment and removable cast partialdenture fitting is essential.

Conclusion:In this clinical report, raising vertical

dimension of occlusion using removableocclusal overlay splint and following fixedprovisional based on accurate diagnosisshowed successful full mouth rehabilitationfor severely worn down dentition.

References:1. Turner KA, Missirlian DM. Restoration of

the extremely worn dentition. J ProsthetDent 1984;52:467-74.

2. Smith BG. Toothwear: Aetiology anddiagnosis. Dent Update 1989;16:204-12.

3. Prasad S, Kuracina J, Monaco EA Jr.Altering occlusal vertical dimensionprovisionally with base metal onlays: Aclinical report. J Prosthet Dent2008;100:338-42.

4. Dawson PE. Functional Occlusion - FromTMJ to smile design. 1st ed. New York;Elsevier Inc.; 2008. p. 430-52.

5. Jahangiri L, Jang S. Onlay partial denturetechnique for assessment of adequateocclusal vertical dimension: a clinical report.J Prosthet Dent 2002;87:1-4.

6. Johansson A, Johansson AK, Omar R,Carlsson GE. Rehabilitation of the worndentition. J Oral Rehabil 2008;35:548-66.

7. Hemmings KW, Darbar UR, Vaughan S.Tooth wear treated with direct compositerestorations at an increased verticaldimension: results at 30 months. J ProsthetDent 2000;83:287-93.


8. Darbar UR, Hemmings KW. Treatment oflocalized anterior toothwear with compositerestorations at an increased occlusal verticaldimension. Dent Update 1997;24:72-5.

9. Witter DJ, Van Elteren P, Ka¨yser AF, VanRossum GM. Oral comfort in shorteneddental arches. J Oral Rehabil 1990;17:137-43.

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