comparative efficacy of tea tree oil nanoemulgel and...

Indian Journal of Comprehensive

Dental Care

JULY- DEC 2017 • VOL 7 • ISSUE 2I J C D C

953Indian Journal of Comprehensive Dental Care

CONTENTS

ORIGINAL ARTICLES

COMPARATIVE EFFICACY OF TEA TREE OIL NANOEMULGEL AND TEA TREE OIL GEL AGAINST CANDIDA ALBICANS. 963*Jasjeet K. Narang **Raman Deep Singh Narang ***Anmol Dogra ****Adesh Manchanda *****Balwinder Singh

COMPARISON OF ROOT CANAL TRANSPORTATION, CANAL CENTRING ABILITY, MAINTENANCE OF 968CANAL CURVATURE AND ALTERATION IN WORKING LENGTH USING CONE BEAM COMPUTED TOMOGRAPHY AND APEX ID APEX LOCATOR IN MESIOBUCCAL CANALS OF MOLARS- AN IN-VITRO AND IN-VIVO STUDY*Sukhmandeep Kaur **Shantun Malhotra ***Rajesh Khanna ****Ashish Handa

“AN ANALYSIS OF KNOWLEDGE REGARDING, ORAL HEALTH OF CHILDREN 974THROUGH PRE AND POST EDUCATION QUESTIONNAIRE SURVEY AMONG THE CARE GIVERS *Amaninder K Randhawa **Harleen Kaur ***Gurleen Kaur ****Rajeshwar Singh Randhawa*****Charanjit Singh ******Princejit Kaur *******Paviterjot kaur

TO EVALUATE THE APPLICABILITY OF HOLDAWAY'S SOFT TISSUE NORMS AMONGST 979 DIFFERENT MALOCCLUSIONS IN AMRITSAR POPULATION*Sukhdeep Singh Kahlon **Parvinder Singh Dhingra ***Jasmine kaur ****Jasleen kaur *****Jasdeep kaur Cheema

CASE REPORTS

STEREOLITHOGRAPHIC IMPLANT SURGICAL GUIDE FOR ACCURATE IMPLANT PLACEMENT 984-A CASE REPORT*Harinder Kuckreja **Harman Kuckreja ***KBS Kuckreja

IMPLANTS IN THE AESTHETIC ZONE: A CASE REPORT 987*Sahibtej Singh **Ashish Verma ***Navneet Singh Randhawa ****Ramandeep Singh Narang *****Suveera

TREATMENT OF A PERIODONTAL ABSCESS BY MODIFIED KIRKLAND FLAP COMBINED 990WITH OSSEOUS REGENERATIVE THERAPY UTILISING AN ALLOPLASTIC GRAFT: A CASE REPORT *Supreet Kaur **Vandana ***Navneet Singh Randhawa

MANAGEMENT OF GINGIVAL GRANULOMA PYOGENICUM: A CASE REPORT 994*Vandana **Supreet Kaur ***Prableen Arora ****Sahil Sharma

SUBMANDIBULAR SALIVARY GLAND SIALOLITHIASIS MANAGEMENT :A CASE REPORT 998*Mehak Malhotra **Jasmine Kaur ***Amit Dhawan ****Tejinder Kaur

MODIFIED IMPRESSION TECHNIQUE FOR MAXILLARY FLABBY RIDGE 1002* Akash Duggal ** Aman Arora *** Navjot Kaur

THERMOPLASTIC ENDODONTIC OBTURATION – THERMAFIL SYSTEM: CASE REPORTS 1005*Navdeep **Prashant Monga *** Pardeep Mahajan ****Shikha Baghi Bhandari

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CONTENTS

RENAL DISEASE AND ITS ORAL MANIFESTATIONS : REVIEW AND CASE REPORT 1009* Preeti Chawla Arora ** Aman Arora ***Sukhpreet Singh Randhwa ****Tanveen Kaur *****Manpreet Kaur

REVIEW ARTICLES

UNIVERSAL PRECAUTIONS OF INFECTION CONTROL AGAINST BLOOD BORNE PATHOGENS 1014* Sumir ** Yashmeet Kaur *** Sarika Kapila ****Ramandeep Singh Bhullar *****Tejinder Kaur

EMERGENCY CARE IN PATIENTS WITH HEAD AND NECK INJURIES 1018*Era Arora **Amneet Sandhu ***Tejinder Kaur ****Ramandeep Singh Bhullar

PROSTHODONTIC MANAGEMENT OF GAGGING : A REVIEW 1026*Simrat Kaur ** Harshveer Kaur *** Heena Sharma ****Nitika Kaur

UNFINISHED ROOT CANAL AND RISK OF CARDIOVASCULAR DISEASES 1030 : A REVIEW AUTHOR SEQUENCE*Harshita ** Pratibha Handa *** Harsimranjit Kaur ****Amitoj Kaur Walia

QUIZ 1039


Dental Care

JULY- DEC 2017 • VOL 7 • ISSUE 2

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DR SUKHDEEP SINGH KAHLON


Dental Care


DR. RAJESH KHANNA

DR. KAVIPAL SINGH (Principal S.G.R.D.)

DR. KAMALDEEP SHARMA

DR. ADESH MANCHANDA

PROFESSOR KIRPAL SINGH JI BADUNGAR

Indian Journal of Comprehensive Dental Care

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Sending a revised manuscript

COMPARATIVE EFFICACY OF TEA TREE OIL NANOEMULGEL AND TEA TREE OIL GEL AGAINST CANDIDA ALBICANS.

ABSTRACTS:

Fungal skin infections are caused by different types of fungi, including

dermatophytes and yeasts. Increased use of antibiotics and

immunosuppressive drugs such as corticosteroids are major factors

contributing to higher frequency of fungal infections. Fungi can infect almost

any part of the body including skin, nails, respiratory tract, urogenital tract,

alimentary tract, or can be systemic. Anyone can acquire a fungal infection, but

the elderly, critically ill, and individuals with weakened immunity, due to

diseases such as HIV/AIDS or use of immunosuppressive medications, have a

higher risk. Nanoemulsion based gel is a promising approach. The present

study was aimed to compare an in vitro efficacy of nanoemulgel, tea tree oil gel

and placebo carbopol 934 P gel by cup-plate method. Tea tree oil loaded

nanoemulgel was formulated using 1% w/w carbopol 934P in optimized

nanoemulsion formulation. The antifungal study was carried out using Candida

albicans strain (MTCC NO: 227). The zone of inhibition for tea tree oil

nanoemulgel (37±1.3 mm) was found to be significantly higher (p≤0.05) as

compared to tea tree oil gel (19±1.5 mm) and placebo carbopol 934 P gel

(00±1.1 mm). Based on the observations, it was concluded that tea tree oil in

nanoemulgel formulations due to its nanosize is able to inhibit the growth of

candida albicans more efficiently as compared to tea tree oil normal gel.

Keywords: Tea tree oil gel, nanoemulgel, carbopol 934 P, cup plate method, C.

albicans

963

Corresponding author:Name: Dr. Jasjeet Kaur NarangAddress: Associate Professor, Department of Pharmaceutics, Khalsa College of Pharmacy, Amritsar, IndiaE mail: [email protected] no:+91 183 2450215

1. Associate Professor, Department of Pharmaceutics, Khalsa Col lege of Pharmacy, Amritsar, Punjab, India

2. Professor& Head, Department of Oral and Maxillofacial Pathology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India.

3. Assistant Professor, Department of Pharmaceutics, Khalsa Col lege of Pharmacy, Amritsar, Punjab, India.

4. Re a d e r D e p a r t m e nt o f O ra l a n d Maxillofacial Pathology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India.

5. Department of Oral Medicine and Radiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India.

Introduction a relatively limited impact on quality of life. However, if a

fungal infection enters systemic circulation, consequences Fungi are identified to be a cause of serious infection with 4,5

1 can be deadly.increased frequency during the past two decades. Over 40 2million people have suffered from fungal infections. Although several species of fungi are potentially pathogenic

Progression of infections can be rapid and serious due to in humans, candida (esp. Candida albicans) is the organism 3 responsible for most fungal infections. Candida, which is compromise with immune function.

normally present within the human body, is usually Fungal infections can range in severity from superficial to harmless. Candida is a type of fungus that can cause an life-threatening. For example, fungal infections affecting infection in skin also. In normal conditions, skin may host only the top layers of the skin are readily treatable and have


I J C D C1. Jasjeet K. Narang2. Raman Deep Singh Narang3. Anmol Dogra4. Adesh Manchanda5. Balwinder Singh

/Date of Submission : 11/9/19 Date of Acceptance :10/10/16


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Indian Journal of Comprehensive Dental Care 964

small amounts of this fungus, but problems arise when it The fungus thrives in warm, moist, and sweaty conditions.

begins to multiply and creates an overgrowth. Candida skin Normally, the skin acts as an effective barrier against

infections can occur on almost any area of the body, but are infection, but any cuts or breakdown in the superficial layers

more commonly found in intertriginous regions—where two of the skin may allow the fungus to cause infection. The

skin areas may touch or rub together—such as armpits, the prognosis for candidal infections is often very good.

groin, skin folds, and the area between the fingers and toes. Generally, the condition isn't serious and can be easily

Table 1: Zone of inhibition for different formulations against Candida albicans strain

Strain No. Formulation Zone of Inhibition (mm) Mean ± S.D

(n=3)

Inference

24 hrs 48hrs 72 hrs

MTCC No.

227

Tea tree oil

Nanoemulgel

37± 1.3 36.5± 1.3 36±1.4 Fungicidal

action

MTCC No.

227

Tea tree oil

gel

19± 1.5 18.5±1.3 17.8±1.6 Fungicidal

action

MTCC No.

227

Placebo

carbopol 934

P gel

00 00 00 No action


6treated. composition. Tea tree oil shows promise as a topical

antifungal agent, with recent clinical data indicating efficacy Fungal Infections can also invade deeper tissues as well as 11 in the treatment of dandruff and oral candidiasis. Data from blood causing life threatening systemic infections. Therefore,

an animal model also indicate that it may be effective in the it is very necessary to treat not only the superficial infections, 8

7 treatment of vaginal candidiasis. These clinical uses are but also the deeper ones.8,12supported by a wealth of in vitro susceptibility data.

Tea tree oil has been used medicinally in Australia for more Further in vitro work has shown that tea tree oil and

than 80 years, with uses relating primarily to its antimicrobial components cause the leakage of intracellular compounds 8,9 10 and anti-inflammatory properties. The oil is obtained by 13and inhibit respiration in bacteria. In the present study, the

steam distillation from the Australian native plant Melaleuca efficacy of tea tree oil loaded nanoemulgel is compared with

alternifolia, and contains ∼100 components, which are tea tree oil loaded gel and placebo carbopol 934 P gel using mostly monoterpenes, sesquiterpenes and related alcohols. cup and plate microbiological assay method.Compositional ranges for 14 of the major components are

Materials and Methodsstipulated in the International Standard (ISO 4730) and as Nanoemulsion and Nanoemulgel componentssuch, oils compliant with the standard vary little in chemical

Figure 1: Comparison of zones of inhibition for different formulations during in vitro anti-fungal activity against Candidaalbicans (MTCC No: 227)Table 2: Observations of Zones of Inhibition for different formulations evaluated against strain of Candida albicans at different time intervals

Incubation

Time

(hrs)

Observations of Zone of Inhibition for different formulations

Candida albicans (MTCC No. 227)

24

48

72

Where, N.E.G = Nanoemulsion Gel, P.C.G = Placebo carbopol 934 P Gel, T.T.O.G= Tea tree oil Gel


Tea tree oil was procured from Sigma Aldrich Pvt Ltd plate method.

(Bangalore, India). Carbopol 934P was purchased from Sigma Determination of zones of inhibition by using cup and plate Aldrich Pvt Ltd (Bangalore, India). Transcutol P was obtained methodas a gift sample from Gattefosse (Saint Priest, Cedex, France).

The zones of inhibition that appeared around the Tween 20 was purchased from Central Drug House, New

formulations evaluated on the S.D.A plate were measured. Delhi, India. All other chemicals and reagents were of

The zone of inhibition for tea tree oil nanoemulgel (37±1.3 analytical grade and procured from Merck (Mumbai, India)

mm) was found to be significantly higher (p≤ 0.05) as and S.D. Fine Chem. (Mumbai, India).

compared to tea tree oil gel (19±1.5 mm) and placebo Strain, growth media and culture conditions carbopol 934 P gel (00mm). The larger zone of inhibition for

Candida albicans MTCC No. 227 was procured from IMTECH tea tree oil loaded nanoemulgel could be attributed to the

(Institute of microbial technology, Chandigarh). Candida presence of tea tree oil in nanosize in the gel, which resulted

albicans was grown in suspension of YME (Yeast Malt Extract) in a greater diffusion of tea tree oil through S.D.A which

and incubated at 28°C in B.O.D incubator shaker. Where inturn resulted in a higher penetration of tea tree oil through

necessary, the concentrations of viable cells in suspensions fungal cell walls, which ultimately resulted in higher

were confirmed by viable counts. fungicidal effect due to greater inhibition of synthesis of

ergosterol, a sterol, which is required for maintaining the Preparation of nanoemulgel, tea tree oil gel and placebo integrity of cell wall of fungi. The results are given in table 1, carbopol 934 P geltable 2 and figure 1.

The tea tree oil nanoemulgel was prepared by using aqueous Inference: The zone of inhibition for tea tree oil nanoemulgel titration method by incorporating carbopol 934 P as a gelling (37±1.3 mm) was found to be significantly higher (p≤0.05) agent. Tea tree oil gel and placebo carbopol 934 P gel were as compared to tea tree oil gel (19±1.5 mm) and placebo also prepared at Khalsa College of Pharmacy, Amritsar.carbopol 934 P gel (00 mm). It can thus be concluded that

In vitro antifungal activity using cup and plate methodnanoemulgel of tea tree oil significantly increases the

This study was done as per the procedure given by Maebashi antifungal activity of tea tree oil against Candida Albicans as et al 1995 and Vijayaet al 2014. From the candida albicans compared to tea tree oil gel and placebo carbopol gel.

7suspension (1x10 cfu/ml ), 50 µl suspension was taken and

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Journal 2015;2(1);41-50. activity of the components of Melaleuca alternifolia

(tea tree) oil. Journal of Applied Microbiology 8. Mondello F, De Bernardis F, Girolamo A et al. In vitro 2003;95;853–60.and in vivo activity of tea tree oil against azole-

susceptible and resistant human pathogenic yeasts. 13. Cox SD, Mann CM, Markham JL. et al. The mode

J o u r n a l o f A nt i m i c ro b i a l C h e m o t h e ra p y of antimicrobial action of the essential oil of

2003;51;1223–9. Melaleuca alternifolia (tea tree oil). Journal of

Applied Microbiology 2000;88;170–5.9. Carson CF, Mee BJ, Riley TV. Mechanism of

action of Melaleuca alternifolia (tea tree) oil on 14. Maebashi K,Itoyama T, Uchida K, Suegara N,

Staphylococcus aureus determined by time-kill, Yamaguchi Hl. A novel model of cutaneous

lysis, leakage, and salttolerance assays and electron candidiasis produced in prednisolone treated

m i c ro s c o p y. A n t i m i c ro b i a l A g e n t s a n d guinea pigs. Journal of Veternary and Mycology

Chemotherapy 2002;48;1914–20. 1995;19;390-392.

10. Brand C, Townley SL, Finlay-Jones JJ. et al. Tea 15. Vijaya R, Kumar SS, Kamalakannan S. Preparation

tree oil reduces histamine induced oedema in and in vitro evaluation of miconazole nitrate

m u r i n e e a r s . I n f l a m m a t i o n R e s e a r c h nanoemulsion using tween 20 as surfactant for

2002;51;283–9. effective topical / transdermal delivery. Journal of

Chemica l and Pharmaceut ica l Sc iences 11. Jandourek A, Vaishampayan JK, Vazquez JA. Efficacy 2014;8(1);92-98.of Melaleuca oral solution for the treatment of

fluconazole refractory oral candidiasis in AIDS

patients. AIDS 1998;12;1033–7.

COMPARISON OF ROOT CANAL TRANSPORTATION, CANAL CENTRING ABILITY, MAINTENANCE OF CANALCURVATURE AND ALTERATION IN WORKING LENGTHUSING CONE BEAM COMPUTED TOMOGRAPHY ANDAPEX ID APEX LOCATOR IN MESIOBUCCAL CANALSOF MOLARS- AN IN-VITRO AND IN-VIVO STUDYABSTRACT:

Aim: The aim of this study was to compare the canal transportation, canal

centering ability, change in curvature and loss of working length after

instrumentation with Revo S and K3XF file system by using cone beam

computed tomography (CBCT).

Materials and Methods: Hundred mesiobuccal canals of first and second

molars with an angle of curvature ranging from 15 to 45 degrees were divided

according to the instrument used in canal preparation into two groups of fifty

samples each: Revo S (group I) and K3XF (group II). The teeth were

instrumented according to manufacturer's guidelines, with all groups being

prepared to size 25, 0.06 taper master apical file. Canals were scanned using

CBCT scanner before and after preparation to evaluate the transportation,

centering ratio at 3 mm, 6mm and 9 mm from the apex and change in canal

curvature. The change in working length was measured with Apex ID (Sybron

Endo) apex locator in thirty patients after instrumentation with Revo S (group

III) and K3XF (group IV) file system. The data collected were evaluated using

student 't' and Mann-whitney test.

Results: K3XF file system showed less mean canal transportation, better canal

centering ability values and maintained the original canal curvature well as

compared to Revo S file system but the results were statistically insignificant (p

> 0.05). There was no significant difference between two groups regarding

change in working length after instrumentation.

Conclusion: Although the canal transportation, centring ability, change in canal

curvature and loss of working length was less for K3XF file system but the

results were statistically insignificant.

968

Corresponding author:Name: Dr. Sukhmandeep KaurAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.Phone no.: +919815621434

1. Post graduate student, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. Reader, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. Prof. & Head Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

4. Reader, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

INTRODUCTION The mechanical preparation of curved canals remains a

challenge for both novices and skilled clinicians. The Thorough cleaning and shaping of the root canal is a prime Glossary of Endodontic Terms of American Association of criterion for successful endodontics. Variations of canal Endodontists defines transportation as “the removal of sections, canal irregularities and associated curvature canal wall structure on the outside curve in the apical half of diversity render procedure failures almost inevitable. The the canal due to tendency of files to restore themselves to goal of instrumentation is to produce a continuously

2their original linear shape during canal preparation.”tapered preparation that maintains the canal anatomy 1without any deviation from original canal curvature. Canal centring ability is defined as the ability of the


I J C D C1. Sukhmandeep Kaur2. Shantun Malhotra3. Rajesh Khanna4. Ashish Handa

Date of Submission : 18-09-2016 Date of Acceptance : 30-10-2016


Dental Care



instrument to stay centred in the canal. Various parameters revolutionized root canal treatment by reducing time

that affect the canal centring ability include the alloys used in required to finish preparation and other procedural errors manufacturing instruments and instrument design which associated with root canal instrumentation. Revo-S

3further include cross-section, taper and tip of instrument. (Micromega, Besancon, France) is one such recently

introduced rotary file system. These files have asymmetrical The advent of nickel-titanium rotary file system has

TABLE I shows the statistical analysis of intergroup comparison of canal transportation.

Canal

Transportation

Group I

Mean ± SD

Group II

Mean ± SD

Z value# P value# ‘t’ value$ P value$

At 3 mm 0.054 ± 0.155 0.014 ± 0.109 1.555 0.120NS 1.491 0.139NS

At 6 mm 0.042 ± 0.149 0.034 ± 0.167 0.215 0.945NS 0.247 0.806NS

At 9 mm 0.022 ± 0.153 0.010 ± 0.202 0.346 0.729NS 0.335 0.739NS

#Mann-Whitney test; $ Student 't' test; NS; p > 0.05; Not Significant; *p < 0.05; Significant

TABLE II shows the statistical analysis of intergroup comparison of canal centring ability.

Canal Centring

Ratio

Group I

Mean ± SD

Group II

Mean ± SD

Z

value#

P value# ‘t’ value$ P value$

At 3 mm 1.3332 ± 0.758 1.2826 ± 0.705 0.242 0.809NS 0.346 0.730NS

At 6 mm 1.5280 ± 0.806 1.4052 ± 0.979 0.945 0.345NS 0.685 0.495NS

At 9 mm 1.3592 ± 0.749 1.2452 ± 0.765 0.346 0.729NS 0.753 0.453NS


TABLE III shows statistical analysis of intergroup comparison of change in canal curvature

Group Change in Canal Curvature

Mean ± SD

Z value# P value

# ‘t’ value

$ P value

$

Group I 2.320 ± 1.203 0.463 0.643NS 0.487 0.627NS

Group II 2.200 ± 1.262



cross section with three sharp cutting edges.The K3XF rotary The coronal access was made using round bur under water

file system has been developed in 2011 by Sybron Endo spray cooling high speed handpiece (NSK, Japan) followed by

(Orange, CA). These files were designed with a wide radial the straight line access of the walls with an Endo-Z bur

land to make the instrument more resistant to torsional (Dentsply Maillefer, Switzerland). The working length was

stresses. determined by inserting #10 K file (Dentsply Maillefer,

Switzerland) in mesiobuccal canal until it was visible through Several methodologies have been used to evaluate the apical foramen and then 1mm was subtracted from the efficacy of nickel-titanium instruments in remaining centred recorded length. Sample of hundred teeth were randomly during preparation. These include radiographic imaging, divided into two groups with fifty teeth in each group: cross-sectioning, longitudinal cleavage of teeth. More

recently the use of cone beam computed tomography has Group I: Fifty teeth were instrumented using Revo-S

been suggested for this purpose with good results because it (MicroMega, Besancon, France) rotary file system in the 2 rdis a non-destructive method. sequence of: SC1 (25/0.06) was taken into canal upto 2/3 of

working length, SC2 (25/0.04) and SU (25/0.06) was taken up The aim of this study was to evaluate the efficacy of two new to working length.nickel-titanium rotary instruments in maintaining canal

centring ability, root canal transportation and canal Group II: Fifty teeth were instrumented using K3XF

curvature in mesiobuccal canals of extracted molars with the (SybronEndo, Orange, CA) rotary file system in a given

help of cone beam computed tomography and to evaluate sequence: # 25/0.12 followed by # 25/0.10 and # 25/0.08 was

change in working length by using apex locator in patients taken into canal until resistance and # 25/0.06 was taken

undergoing root canal treatment. upto working length.

MATERIALS AND METHODS: All the mesiobuccal canals were instrumented with crown

down technique at a speed of 350rpm and a torque control In vitro study:level of 2.5Ncm by using 16:1 reduction handpiece powered

The in-vitro study was conducted on freshly extracted one by an endodontic motor (Endo-Mate DT; NSK, Japan). After

hundred molars collected from the Department of Oral and the use of each file the root canals was irrigated with 5%

Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental sodium hypochlorite.

Sciences and Research, Sri Amritsar. The selected teeth were The postoperative scan was done using same parameters as cleaned and washed off all debris and were stored in 10% in preoperative scan. Canal curvature was evaluated by using formalin.Schneider's technique and the comparison was made

Occlusal surfaces of all the teeth were flattened upto roof of between canal curvature before and after instrumentation

pulp chamber using diamond disc and straight handpiece with two different rotary file systems. Canal centring ability

(NSK, Japan). The selected teeth had root curvatures and canal transportation was evaluated at three sections of

between 15 degree to 45 degree. In case of maxillary molars root canal: at 3mm (apical third), 6mm (middle third), 9mm

distobuccal and palatal roots and in mandibular molars distal (coronal third) from the root apex.

roots were sectioned at furcation level and discarded. The The following formula was used for the calculation of canal specimen were embedded in acylic. Cone Beam Computed transportation:Tomographic (CBCT) images for all prepared teeth were

obtained before instrumentation, with CS9300 equipment [(M1 – M2) - (D1 – D2)]

(Carestream Healthcare India (P) Ltd) in the high resolution And centring ability was calculated by using following ratio:dental mode at 84 kV, 5mA and 20s. Image assessment was

(M1 – M2) / (D1 – D2) or (D1 – D2) / (M1 – M2).performed by a using the CBCT software tools (DICOM

where, M1 is the shortest distance from the mesial edge of software).

TABLE IV shows statistical analysis of intergroup comparison of loss of working length

Group Loss of Working Length

Mean ± SD

Z value# P value

# ‘t’ value

$ P value

$

Group III -0.1933 ± 0.171 1.245 0.213NS 0.545 0.590NS

Group IV -0.1667 ± 0.082



the root to the mesial edge of the uninstrumented canal, D1 table II but the results were statistically insignificant (p>0.05).

is the shortest distance from distal edge of the root to the The mean value of change in canal curvature as tabulated in

distal edge of the uninstrumented canal, M2 is the shortest table III was more for group I than group II but insignificant

distance from the mesial edge of the root to the mesial edge results were found. The mean value of loss of working length

of the instrumented canal, D2 is the shortest distance from was less for group IV than group III as summarized in table IV

distal edge of the root to the distal edge of the instrumented but the results were statistically insignificant (p>0.05).

canal. DISCUSSION:

According to this formula, a result other than 0 indicates that Successful endodontic therapy is based on the classical triad transportation has occurred in the canal. According to this of diagnosis, adequate biomechanical preparation and formula, a result of 1 indicates perfect centralization capacity obturation. The second stage of the endodontic triad, i.e. and closer the result to zero the worse the ability of the biomechanical preparation, is one of the most important instrument to keep itself in the canal central axis. aspects of endodontics. In straight root canals, it is relatively

In vivo study: simple to achieve this but in curved canals, maintaining the

original canal anatomy constitutes a great challenge, The in-vivo part of study was conducted on patients visiting especially with traditional hand instruments made of the Department of Conservative Dentistry and Endodontics stainless steel. Studies have shown that nickel–titanium of Sri Guru Ram Das Institute of Dental Sciences and instruments have two to three times higher elastic flexibility, Research, Sri Amritsar for root canal treatment of molars. shape memory property as compared to conventional The study was undertaken to further evaluate change in

4stainless steel instruments. working length with Apex ID apex locator (SybronEndo) in

clinical conditions. The coronal access was made under local Table 1 shows the statistical analysis of intergroup

anesthesia with rubber dam isolation using round bur under comparison of canal transportation. The findings of present 10water spray cooling high speed handpiece followed by the study are in concurrence to Hashem AA, et al. (2012) who

straight line access of the walls with an Endo-Z bur (Dentsply found that the mean value canal transportation of Revo S at Maillefer, Switzerland). Before instrumentation working apical third was 0.044 ± 0.015mm which is almost similar to length was taken with #10 K file (Dentsply Maillefer, the findings of present study. The results of present study are

18Switzerland) using Apex ID (SybronEndo) apex locator. in contrary to Jain D, et al. (2015) who reported that the According to rotary file system used two groups were taken mean canal transportation value of Revo S at apical third was with fifteen teeth in each group: 0.024mm which is less as compared to present study

(0.054mm). This could be attributed to the reason that the Group III: Fifteen teeth were instrumented using Revo-S instruments of this system except SC2 has asymmetrical (MicroMega, Besancon, France) rotary file system in the

rd cutting edges thus providing more flexibility through sequence of: SC1 (25/0.06) was taken into canal upto 2/3 of decreasing core diameter and thus working by fitting to the working length, SC2 (25/0.04) and SU (25/0.06) was taken to original canal.working length.

According to present study the mean value of apical Group IV: Fifteen teeth were instrumented using K3XF transportation for K3XF (group II) was 0.014 ± 0.109mm (SybronEndo, Orange, CA) rotary file system in a given which was less than the Revo S (group I), although the results sequence: # 25/0.12 followed by # 25/0.10 and # 25/0.08 was were statistically insignificant. This was in concurrence with taken into canal until resistance and # 25/0.06 was taken

12 the study by Maitin N, et al. (2013) who reported that the upto working length.mean value of canal transportation by K3 rotary file system at

Canals were prepared with rotary file systems using crown apical level was less than other instruments used for

down technique at a speed of 350rpm and a torque control preparation in their study. This may be related to fact that

level of 2.5Ncm by using 16:1 reduction handpiece powered K3XF is manufactured using R-phase technology. The

by an endodontic motor (Endo-Mate DT; NSK, Japan). After manufacturer states that the R-phase heat treatment

the use of each file the root canals were irrigated with 5% improves the flexibility and cyclic fatigue resistance of K3XF

sodium hypochlorite.The second measurement of working instruments.

length was recorded and difference between it and the initial Although the mean canal transportation at middle third was measurement was calculated. more for Revo S but the results were non significant (p>0.05).

RESULTS: 18The findings of present study are contrary to Jain D, et al. The mean value of canal transportation was greater for (2015) who found that the mean value of canal group I than that in group II as summarized in table I but the transportation of Revo S file at middle third was 0.022mm results were statistically insignificant (p>0.05). The mean which is less as compared to the findings of present study . centring ability of group II was better than group I as shown in This could be attributed to the fact that Revo S file has


asymmetrical cross section which increases its flexibility. curvature well as compared to Revo S but the results were

statistically insignificant (p>0.05). The findings of present The mean canal transportation at cervical third was more for 16study are in concurrence with Cai HX, et al. (2014) who Revo S but the result was statistically non significant (p>0.05).

compared the root canal shaping ability of K3 with other file The findings of present study are in concurrence with study 11 system. The above findings are contrary to Batouty KM and by Elsherief SM, et al. (2013) who concluded that the canal

7Elmallah WE. (2011) who evaluated that K3 showed higher transportation was more for Revo S file system when value of mean change in canal curvature than Twisted file. compared with individual file systems. In present study, the This may be related to the fact that K3 has 45 degree rake mean canal transportation at cervical third was less for K3XF angle. Because dentin is a dense and resilient material, file system (0.010 ± 0.202mm). The results are in concurrence

12 instrument having a positive rake angle actually works like a with Maitin N, et al. (2013) who reported that the mean shaver on dentin surface.value of canal transportation by K3 rotary file system at

coronal level was less than the other instruments used for The findings of present study are in concurrence with 15preparation in their study. The results of present study are in Burklein S, et al. (2014) who found that Revo S showed

13contrary to Zhao D, et al. (2013) who reported that the highest mean value of canal straightening after

mean value of canal transportation by K3 at cervical third was instrumentation in comparison with other two file systems.

more (0.056 ± 0.055mm) in comparison to our findings This could be attributed to the fact that Revo S file has

(0.010 ± 0.202mm). extended cutting part in coronal region. The results are 18contrary to Jain D, et al. (2015) who evaluated that mean TABLE II shows the statistical analysis of intergroup

change in canal curvature with Revo S was 1.68 ± 0.53 comparison of canal centring ability. The centring ability is degrees which is less as compared to present study.less for Revo S group than for K3XF but the results were

statistically non significant (p>0.05). The above findings are TABLE IV shows statistical analysis of intergroup 8in concurrence with Aguiar CM, et al. (2012) who reported comparison of loss of working length.

similar value of centring ratio for Revo S at apical third as in The mean loss of working length was less for K3XF file system 9present study. The results are contrary to Fayyad DM, et al. in comparison to Revo S file system but the results are

(2012) who found that the centring ability of Revo S was statistically non significant (p>0.05). This may be related to better than the other file system with which it was compared. fact that K3XF is manufactured using R- phase technology.

The mean centring ability of Revo S is less than K3XF (1.4052± The findings of present study are in concurrence with Martin-60.979). The findings of present study are in concurrence with Mico M, et al. (2009) who found that the mean loss of

14 Arora A, et al. (2014) who found that the centring ability of working length after preparation with K3 was significantly

Revo S at 6mm was less than other file systems used for less when compared with ProTaper, Mtwo and RaCe file 17instrumentation in their study. The results are not in systems. The results are contrary to Olivieri JG, et al. (2014)

18concurrence with Jain D, et al. (2015) who reported that the who evaluated that the mean change of working length with

centring ability of Revo S file system at middle third was best K3XF file system was zero. This could be attributed to the fact

when compared to individual file systems. This could be that in above study, they evaluated working length change in

attributed to the fact that Revo S has the progressive pitch manikin model using digital radiography.The results of 15which avoids screwing effects while working in canal as present study are accordingly to Burklein S, et al. (2014)

stated by manufacturers. who found that Revo S showed significantly more loss of

working length than Hyflex CM. The findings of present study The mean value of centring ratio for Revo S at 9mm was 1are in contrary to Celik D, et al. (2013) who reported that the 1.3592 ± 0.749 and for K3XF was 1.2452 ± 0.765. The above

8 mean loss of working length by Revo S was 0.142 ± 0.077mm findings are in concurrence with Aguiar CM, et al. (2012) which is less as compared to present study (0.1933 ± who reported almost same value of centring ratio for Revo S 0.171mm). This finding might be attributed to the difference at cervical third as in present study. Observing the results of of methodology, especially evaluation technique. present study, the centring ability of K3XF file system was

better as compared to other system. These results are in CONCLUSION:5concurrence with Al-Sudani D and Al-Shahrani S. (2006) who Within the limitation of the present study, the

found that the centring ability of K3 was more as compared to following conclusions can be drawn: individual file systems of their study. This could be attributed

Both K3XF and Revo S file systems showed canal to the fact that K3 has three radial lands. The third radial land

transportation. Although the mean value of canal helps to prevent instrument from threading itself into the

transportation by K3XF file system was less as compared to canal.

Revo S but the result was statistically insignificant.TABLE III shows statistical analysis of intergroup comparison

The centring ability of K3XF file system was better of change in canal curvature. K3XF maintained canal


than Revo S file system but the difference was statistically 10) Hashem AA, Ghoneim AG, Lutfy RA, Foda MY, Omar

insignificant. GA. Geometric analysis of root canals prepared by four

rotary NiTi shaping systems. J Endod 2012; 38(7): 996-K3XF file system maintained the original canal 1000.curvature well as compared to Revo S file system but

insignificant results were found. 11) Elsherief SM, Zayet MK, Hamouda IM. Cone-beam

computed tomography analysis of curved root canals Although the mean value of loss of working length after mechanical preparation with three nickel after instrumentation with K3XF file system was less as titanium rotary instruments. J Biomed Res 2013; compared to Revo S file system but the results were 27(4): 326–335.statistically insignificant.

12) Maitin N, Arunagiri D, Brave D, Maitin SN, Kaushik S,

Roy S. An ex vivo comparative analysis on shaping REFERENCES:

ability of four NiTi rotary endodontic instruments 1) Celik D, Taşdemir T, Er K. Comparative study of 6 rotary using spiral computed tomography. J Conserv Dent

nickel-titanium systems and hand instrumentation for 2013; 16(3): 219–223.root canal preparation in severely curved root canals

13) Zhao D, Shen Y, Peng B, Haapasalo M. Micro-computed of extracted teeth. J Endod 2013; 39(2): 278-282.

tomography evaluation of the preparation of 2) Özer SY. Comparison of root canal transportation mesiobuccal root canals in maxillary first molars with

induced by three rotary systems with noncutting tips Hyflex CM, Twisted Files, and K3 instruments. J Endod using computed tomography. Oral Surg Oral Med Oral 2013; 39(3): 385-388.Pathol Oral Radiol Endod 2011; 111(2): 244-250.

14) Arora A, Taneja S, Kumar M. Comparative evaluation of Kandaswamy

shaping ability of different rotary NiTi instruments in 3) D, Venkateshbabu N, Porkodi I, Pradeep G. Canal- curved canals using CBCT. J Conserv Dent 2014; 17(1):

centering ability: An endodontic challenge. J Conserv 35-39.Dent 2009; 12(1): 3–9. Peters OA

15) Bürklein S, Börjes L, Schäfer E. Comparison of 4) Current challenges and concepts in the preparation of preparation of curved root canals with Hyflex CM and

root canal systems: a review. J Endod 2004; 30(8): Revo- S rotary nickel-titanium instruments. Int Endod 559-567. J 2014; 47(5): 470-476.

5) Al-Sudani D and Al-Shahrani S. A comparison of the 16) Cai HX, Cheng HL, Song JW, Chen SY. Comparison of canal centering ability of ProFile, K3, and RaCe Nickel Hero 642 and K3 rotary nickel-titanium files in curved Titanium rotary systems. J Endod 2006; 32(12): 1198- canals of molars and a systematic review of the 1201 literature. Exp Ther Med 2014; 8(4): 1047-1054.

6) Martín-Micó M, Forner-Navarro L, Almenar-García A. 17) Olivieri JG, Stober E, Font MG, Gonzalez JA, Bragado P, Modification of the working length after rotary Roig M, et al. In vitro comparison in a manikin model: instrumentation: a comparative study of four systems. increasing apical enlargement with K3 and K3XF rotary J Clin Exp Dent 2009; 1(1): e19-23. instrument. J Endod 2014; 40(9): 1463-1467. Jain

7) Batouty KM and Elmallah WE. Comparison of canal 18) D, Medha A, Patil N, Kadam N, Yadav V, Jagadale H. transportation and changes in canal curvature of two Shaping Ability of the Fifth Generation Ni-Ti Rotary nickel-titanium rotary instruments. J Endod 2011; Systems for Root Canal Preparation in Curved Root 37(9): 1290-1292. Canals using Cone-Beam Computed Tomographic: An

In Vitro Study. J Int Oral Health 2015; 7(Suppl 1): 8) Aguiar CM, Faria CG, Camara AC, Frazao M. 57–61. Comparative Evaluation of the Twisted File and Revo-S

Rotary Systems Using Cone Beam Computed

Tomography. Acta Stomatol Croat 2012; 46 (3): 222

229

9) Fayyad DM, Sabet NE, El-Hafiz EM. Computed

tomographic evaluation of the apical shaping ability of

Hero Shaper and Revo-S. Endod Practice Today 2012;

6(2): 119-124.

“AN ANALYSIS OF KNOWLEDGE REGARDING, ORAL HEALTH OF CHILDREN THROUGH PRE AND POST EDUCATION QUESTIONNAIRE SURVEY AMONG THE CARE GIVERS

ABSTRACT

Aim. The study was carried out to assess (or scrutinize) the knowledge

regarding child's oral health among the caregivers and to uplift their awareness

regarding the same , through education sessions .

Material and methods : A questionnaire based survey was conducted among

100 caregivers. A pre-education questionnaire survey was conducted to

evaluate initial knowledge , followed by education session, thereafter a post

education questionnaire survey was conducted to assess the knowledge and

awareness acquired through the session.

Results : The difference in percentage of caregivers answering the

questionnaire correctly before and after the education session was significant

implying considerable gain in knowledge and awareness about children's oral

health.

Discussion: In our study, care-givers showed some degree of knowledge about

child's oral health before the education session , but increase in awareness as

implied in post-education sessions points to the importance of educating the

mothers in preventing the childhood caries and maintaining good oral health.

974

Corresponding author:Name: Dr.Amaninder K Randhawa Address: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.Phone no.: 09876697694Email: [email protected]

1. MDS, Reader, Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. Intern , Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. Intern, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

4. BDS

5. MDS, Associate Professor, Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

6. Lecturer , Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

7. Ex-Intern , Sri Guru Ram Dass Institute of Dental Sciences and Research ,Amritsar

INTRODUCTION and its consequences. Such parents often wait until caries in

primary teeth become symptomatic and then subsequent It is widely acknowledged that the attitudes and behaviour visit to dentist. Management of such conditions are invasive of parents, and in particular, mothers, affects their and parents tend to avoid subsequent treatment until their children's health. The adoption of good oral health habits in children's need again become extreme. The etiology of the childhood often takes place with parents, especially with condition is a combination of frequent consumption of mothers. Childhood caries is more prevalent in low-income fermentable carbohydrates as drinks, with on-demand populations due to their lack of knowledge about the caries breast- or bottle-feeding, oral colonization by cariogenic


I J C D C

1. Amaninder K Randhawa2. Harleen Kaur3 Gurleen Kaur4 Rajeshwar Singh Randhawa5 Charanjit Singh6 Princejit Kaur 7 Paviterjot kaur

Date of Submission : 9/9/16 Date of Acceptance : 10/11/16


Dental Care



1bacteria, poor oral hygiene, and poor parenting. Hence, the present study is undertaken to know the

education level of the caregivers and to evaluate the Prevention of nursing caries can be achieved mainly by effectiveness of educating caregivers and their role in education of parents and by identification of “high-risk” identification and prevention of dental diseases in children.children. The common approach in caries prevention is

educating the parents, however, traditional health education MATERIALS AND METHOD

may be insufficient to change parents' behaviour in relation This research was a survey study designed to explore to their high-risk children, as parents do not go to health mothers /guardians/caregivers knowledge about dental or professionals in a state of readiness to change patterns of oral health and various methods to promote their wards

1behaviour that are well-established. health and to evaluate the efficacy of education given to

them .. Studies indicating an increase in severity of dental caries also

suggest that mothers neither stress upon teaching their This study was conducted in the department of Pedodontics children, healthy lifestyles from birth. They are also said to and Preventive dentistry at SGRD Dental college , Amritsar . undervalue the importance of continuing consistency in Data was collected from 100 mothers /female guardians . action in child rearing. Maternal attitudes are likely to modify Two structured formats consisting of 15 (same) behaviours and thus, play an important part in the uptake of questions,titled , pre-education and post education formats favourable dental health practices. Mothers low education were prepared for face to face interview. All the interviews level, her age, rural domicile of the mother and infrequent were conducted by one female interviewer who had been tooth cleaning, the presence of plaque on the child's teeth, carefully trained to avoid leading questions and to use the and frequent sugar consumption by the children have been exact wording of the questions . The data collection was

2assosciated with poor oral health of the children.

Table 1-PRE-EDUCATION SESSION QUESTIONNAIRE

S.No QUESTIONS TRUE FALSE DON’T KNOW

1 Pregnant women should not wait until, after giving birth to see

dentist

69 31 00

2 Caregivers should wipe infant’s gums with soft clothes 80 20 00

3 Brushing should be started as soon as first tooth erupts 20 80 00

4 Hard Brush should be used for cleaning teeth 22 78 00

5 Children need help brushing teeth even after age 2 92 08 00

6 Dental Caries are caused by Bacteria 84 16 00

7 Adults should help children brushing teeth until age 8 64 32 00

8 Mouth Rinsing should be done after eating sweet things 94 06 00

9 Brushing should be done once a day 78 22 00

10 Brushing should be done after heavy meals 83 17 00

11 Babies should not be put to bed with bottles 76 24 00

12 Putting Children to bed with milk/formula/juice harm their

teeth

69 31 00

13 Deciduous Teeth to be prevented from decay 81 19 00

14 Children with high tooth decay risk can use fluoride toothpaste 22 17 61

15 Community water Fluoridation reduce tooth decay 15 16 69


conducted in the waiting area while the children received 80% of the caretakers thought that infant's gums should be

dental treatment .No names or other identifying information wiped with soft clothes and other 20% disagreed. Only 20%

was collected . of the subjects agreed that brushing should be started as

soon as first tooth erupts, rest 80% do not share the same For each respondent first pre-education questionnaire was opinion. Also, 22% of the care-givers favoured the use of hard filled , and then a small education lecture was given after brush to clean teeth, but rest 78% were aware, to, not use which , second that is post education questionaiirre hard brush for cleaning teeth, so responded negatively. 92% consisting of same questions was given to evaluate the of the care-givers share the opinion of helping children, difference between pre-education and post- education brushing even after age 2 and rest 8% deny the same .84% of questionnaire.the care-givers believed that dental caries are caused by

bacteria but 16% were unaware of this. 64% of the care-RESULTS takers were of the opinion that adults should help children in

brushing their teeth until age 8 whereas 36% do not share A total of 200 questionnaires were distributed for 100 the same opinion. It was observed that 94% of the subjects subjects, one each before the education session and one were already aware that mouth rinsing is important after after the session.eating sweet things. 78% of the subjects thought that it is The results of the study as implied from pre education sufficient to clean their teeth only once a day whereas 22% session questionnaire (Table 1) are discussed first. 69% of the thought it to be insufficient. Majority of the subjects (83%) caregivers responded positively with the statement that assumed that brushing after every meal is important but the pregnant women should not wait until, after giving birth to rest 17% considered it unnecessary. 76 out of 100 care-see a dentist whereas the other 31% responded negatively.

Table 2 -POST EDUCATION-SESSION QUESTIONNAIRE

S.No QUESTIONS TRUE FALSE DON’T KNOW

1 Pregnant women should not wait until after giving birth to see

dentist

97 03 00

2 Caregivers should wipe infant’s gums with soft clothes 100 00 00

3 Brushing should be started as soon as first tooth erupts 98 02 00

4 Hard Brush should be used for cleaning teeth 04 96 00

5 Children need help brushing teeth even after age 2 100 00 00

6 Dental Caries are caused by Bacteria 99 01 00

7 Adults should help children brushing teeth until age 8 100 00 00

8 Mouth Rinsing should be done after eating sweet things 100 00 00

9 Brushing should be done once a day 54 46 00

10 Brushing should be done after heavy meals 97 03 00

11 Babies should not be put to bed with bottles 92 08 00

12 Putting Children to bed with milk/formula/juice harm their

teeth

98 02 00

13 Deciduous Teeth to be prevented from decay 100 00 00

14 Children with high tooth decay risk can use fluoride toothpaste 99 01 00

15 Community water Fluoridation reduces tooth decay 99 01 00


takers did not favour the use of bottle while sleeping but the This study has focused on assessing the knowledge of care-

rest 24% favoured the same. 69% agreed with harmful givers based on sequential questionnaire regarding oral

effects of putting children to bed with milk/formula/juice health of children followed by thorough discussion and

while 31% disagreed. 81% of the care-givers were delivery of knowledge on aspects which were lacking in care-

affirmative, when asked whether healthy milk teeth are providers after which a post-education session

important and 19% disagreed.22% of care-takers agreed to questionnaire was held, to know the differences in the level

the benefits of fluoridated tooth pastes in preventing tooth of awareness.

decay, 17% disagreed whereas 61% knew nothing about Oral health measures are to be taken right from the time fluoride tooth pastes. 15% of the care-takers believed that when a mother is pregnant. As depicted in various studies, community water fluoridation helps in reducing tooth decay, there is a strong co-relation of a pregnant mother's oral 16% disagreed whereas 69% were not aware of community health and the unborn child. When first asked, only 69% of water fluoridation. the care-takers believe that during pregnancy, there should

Results, as alluded from the post-education session be no delay in visiting a dentist if one encounters a dental

questionnaire (Table 2) are as follows. Surprisingly, 100% of problem whereas rest 31% were in the favor of delaying. This

the care-takers answered in favour of: implies lack of knowledge regarding importance of mother's

oral health on unborn child's oral health. However after 1. Care-givers should wipe infant's gums with soft clotheselaborated discussion , 97% care-takers replied in affirmative

2. Children need help while brushing teeth even after age 2of the same statement. Following this knowledge regarding

3. Adults should help children brushing teeth until age 8 cleaning infant's gums was assessed, 80% of the subjects

were aware that gums are to be wiped with wet soft cloth 4. Mouth rinsing should be done after eating sweet things7which was lower than Akpabioetal and lower than reported 5. Deciduous teeth need to be prevented from decay. 99%

8by Tagooetal . Brushing should be started as soon as first of the care-takers agreed with following statements:tooth erupts but only 20% of care-givers were aware of this

1. Dental caries are caused by bacteriafact before they were told for the first time about this during

2. Fluoridated tooth pastes are beneficial in children tour education session. 22% of the respondents didn't knew with high risk of tooth decay that hard brushes should be avoided for cleaning the teeth.

The effects of using hard brush and using brush in wrong way 3. Community water fluoridation reduces tooth decaywere discussed with the care-givers after which number

98% of the subjects, conceded with the fact that brushing favoring use of hard brush reduced to 4. It was not less than a

should be started as soon as the first tooth erupts and also surprise that 92% of the respondents were in favor of helping

a d m i tte d t h at p u tt i n g c h i l d re n to b e d w i t h children in cleaning teeth even after age 2. This indicates the

milk/formula/juice can harm their teeth. 97% of the awareness and knowledge of respondents that even after 2

respondents answered in favour that pregnant women years of age children are not able to properly maintain their

should not wait until after giving birth to see the dentist and oral hygiene and need assistance. 84% of the subjects

with the fact that brushing should be done after every meal. believed that causative agent for caries was bacteria

96% became aware that hard brush should not be used for whereas rest has no clue that caries itself is a disease caused

cleaning teeth and 92% apprehended that babies should not by bacteria. Following education session 99% population got

be put to bed with bottles. 46% of the subjects conceded that to know about the causative agent.

brushing only once a day is not sufficient but 54% still denied Following this, knowledge about the causative aspects of the fact.caries was assessed. The finding that 94% of the respondents

Discussioncorrectly knew that rinsing should be done after eating sweet

Oral diseases particularly early childhood caries can be things was encouraging. There is a positive relationship prevented to a great extent, if parents are adequately between the mother's own tooth brushing frequency and informed and motivated.Lack of awareness is one of the the child's brushing frequency 2. 78% of the respondents important factors affecting oral health. Poor health answered in favour that brushing should be done only once a knowledge is associated with poorer opinions of health, day, rest 22% considered brushing twice as the right answer. decreased utilisation of services and poorer understanding The recommended frequency of brushing is twice daily and

3,4of verbal and written instructions of self care .Maternal subjects were made aware of the same. In our study 83% of attitude towards oral health is significantly correlated to the the subjects agreed to the fact of cleaning teeth after every

5,6oral health of their children meal. Knowing that putting children to bed with milk/ juice /


formula is a big predisposing factor for early childhood References

caries, the fact that only 69 % of care givers were aware 1) Assery M K:Effectiveness of Providing Dental Health about it which was found to be less than as reported by Education to Mothers in Controlling Dental Diseases in

7Akpabio ,which was alarming and required elaborated Children;Journal of International Oral Health discussion with mothers. Parents did show good degree of 2015;7(11):1-4knowledge about role of deciduous teeth with regards to

2) Sufia S, Ali Khan A, Chaudhry S: Maternal Factors and effect on permanent teeth with 81% favouring prevention

Child's Dental Health;Journal Oral Health Comm Dent of deciduous teeth from decay,( which was found to be lower

2009;3(3);45-488than as reported by Togoo )and not only permanent teeth 3) Jackson R. Parental Health Literacy and Childrens Dental before education session and response was 100% after

Health : Implications for the Future . Pediatr Dent 2006 education session. ;28(1):72-75

In the end, an important preventive aspect was analyzed, the 4) Yin HS, Johnson MA, Abrams MA, Sanders LM, Dreyer B importance of fluoride tooth paste and community water

;The Health Literacy of Parents in the United States : A fluoridation in preventing tooth decay but 69% of subjects National ly Representat ive Study. Pediatr ics had no clue of any of these.(which was found to be less than

7 2009:124(suppl 3) 289-298as reported by Akpabio etal ) whereas 22% of subjects

favoured use of fluoridated tooth paste in preventing decay 5) Abiola Adeniyi A, Eyitope Ogunbodede O, Sonny 8(which was found to be less than as reported by Togoo etal ) JebodaO,Morinike Folayan O. Do Maternal factors

Following this, a session regarding role of fluoride, amount to influence the dental health status of Nigerian Preschool

be used and how to be used was held with each subject, Children? Int J Paediatr Dent 2009:19(6):448-454

following which 99% of the subjects responded correctly 6) Wigen TI, Espelid I, Skaare AB,Wang NJ,. Family post session questionnaire. characteristics and caries experience in Preschool

This study was an attempt to understand the knowledge Children .A Longitudinal Study from Pregnancy to 5 years

about the oral health of children among caregivers and to of AGE . Community Dental Oral Epidemiol

know the aspects which require awareness nationwide. The 2011:39(4):311-317

study implied a positive correlation of education session and 7) Akpabio A,Klausner CP etal:mother/guardian's increased awareness about oral health of children among knowledge about promotingChildrens oral health care givers as majority of the statements were answered :Jounal of dental Hygiene .vol 82, no 1,2008,2-11correctly with a percentage of >90 following the education

8) Togoo RA,M Zakirulla etal:Cross sectional study of session. As proved in the previous studies as well on the

Awareness and knowledge of causative factors for Early same topic , the oral health behavior and knowledge of care

Childhood caries among Saudi Parents : A Step Towards givers effects the children's oral health and are positively

Prevention : International Journal of Health Sciences & related, regular and frequent oral health sessions must be

Research, vol 2(3),2012:2-7held to ensure active role of care givers in maintaining good

oral health of younger generation.

TO EVALUATE THE APPLICABILITY OF HOLDAWAY'SSOFT TISSUE NORMS AMONGST DIFFERENTMALOCCLUSIONS IN AMRITSAR POPULATION

ABSTRACT:

Soft tissue paradigm determines the goals and limitations of modern

orthodontic treatment. The study of soft tissue norms becomes imperative for

achieving aesthetic goals. The racial variations play a key role for applicability of

norms in different populations. Since Angle's Class II Division 2 and Division 1

are commonly reported in Amritsar population,present study focuses on

studying soft tissue norms in Amritsar population among Class I and Class II

(div1 and div2) malocclusions.

979

Corresponding author:Name: Dr. Sukhdeep Singh Kahlon, M.D.S., Professor and Head, Department of Orthodontics and DentofacialOrthopaedics, Sri Guru Ram Das Institute of Dental Sciences andResearch, Amritsar. PIN 143001Email id. [email protected]

1. M.D.S., Professor and Head, Department of O r t h o d o n t i c s a n d D e n t o f a c i a l Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

2. M.D.S., Senior Lecturer, Department of O r t h o d o n t i c s a n d D e n t o f a c i a l Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

3. B.D.S, Intern, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.



INTRODUCTION a prime consideration, which has led to a shift of focus to

achieve balanced soft tissue relationship and adjust teeth In twentieth century, orthodontic treatment plan was and jaws accordingly.primarily based on Angle's paradigm, in which primary goal

was achieving ideal occlusion and the ideal jaw relationship For comprehensive diagnosis and treatment planning, 3was secondary. According to Angle's paradigm, achieving cephalometric soft tissue analysis is essential.

ideal hard tissues proportions would produce ideal soft Orthodontists may not reach all the desired soft tissue goals 1tissues. but the adaptation of facial tissues to underlying skeletal

discrepancy holds significance among different races. The However, in modern orthodontics, this concept has been cephalometric values for soft tissue keep varying from one replaced by soft tissue paradigm, which states that both the ethnic group to other. The racial groups must be treated goals and limitation of modern orthodontics and according to their own characteristics. The goals and orthognathic treatment are determined by the soft tissues adaptation for soft tissue also varies as per the underlying of the face and not by the teeth or bones and ideal soft skeletal pattern and on basis of based on gender..tissues proportions define ideal hard tissue.

Based on ethnic and racial variations, cephalometric soft Most people seek orthodontic treatment with aesthetics as


I J C D C1. Sukhdeep Singh Kahlon2. Parvinder Singh Dhingra3. Jasmine kaur4. Jasleen kaur 5. Jasdeep kaur Cheema



Dental Care



tissue norms have been studied in different populations in focuses on studying soft tissue norms in Amritsar population

many studies. However, ideal occlusion has been taken a among Class I and Class II (div1 and div2) malocclusions. The

standard criteria in most studies. A higher frequency of proportions of soft tissue integument of the face and

Angle's Class II Division 2 followed by Division 1 has been relationship of the dentition to the lips and face are the major

reported in the region as per a previous study, thus an determinants of ideal facial appearance, which is the prime 3evaluation for soft tissue norms in these malocclusions was orthodontic goal.

2essential . In view of lack of many studies in different

malocclusions in north Indian population, the present study

Table 1: Skeletal Cephalometric values

CLASS 1 CLASS II DIV 1 CLASS II DIV 2

CEPH VALVE MEAN SD MEAN SD MEAN SD

SNA 82 1.89 82.03 12.67 80.70 16.26

SNB 79.78 1.65 76.11 11.79 76.29 10.08

ANB 2.22 1.38 5.76 8.45 4.41 7.15

Table 2 : Holdaway soft tissue variables of Angle's Class I Malocclusion

CLASS 1 MAXIMUM MINIMUM MEAN SD

SOFT TISSUE FACIAL

ANGLE

97 77 90.4 45.9

NOSE PROMINENCE 19 9 12.08 37.6

SUPERIOR SULCUS

DEPTH

6 1 2.84 33.2

SOFT TISSE SUB

NASALE TO H LINE

8 1 4.76 30.4

SKELETAL PROFILE

CONVEXCITY

5 0 1.72 28.4

BASIC UPPER LIP

THICKNESS

19 11 15.2 26.9

UPPER LIP STRAIN

MEASUREMENT

15 1 4.32 25.6

H ANGLE 24 7 15.12 24.6

LOWER LIP TO H

LINE

4 -5 0.16 23.8

INFERIOR SULCUS

TO H LINE

10 0 5.56 23.04

SOFT TISSUE CHIN

THICKNESS

15 8 12.32 22.38


MATERIAL AND METHOD The selection criteria for Class II Division 1 included bilateral

Class II molar relationship with proclined maxillary incisor The study was carried out in the department of Orthodontics 0teeth (atleast two incisors), ANB>4 , no congenitally missing and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of

teeth, congenital anomalies or facial asymmetry, no missing Dental Sciences and Research, Sri Amritsar. A sample teeth(except third molars).consisting of 75 cephalometric radiographs from both

genders and age group 15 to 30 years with pleasing profile The selection criteria for Class II Division 2 included bilateral

from records. These included 25 with Angle's Class I, 25 with Class II molar relationship with retroclined maxillary incisor 0was taken Angle's Class II Division 1 and 25 with Angle's Class teeth (atleast two incisors), ANB>4 , no congenitally missing

II Division 2 malocclusion. During sample selection, the teeth,congenital anomalies or facial asymmetry, no missing

radiographs of Class III, cleft lip/cleft palate and syndrome teeth(except third molars).

were excluded from the study. Analysis: Each cephalogram was traced and soft tissue values

The selection criteria for Class I included pleasing soft tissue were recorded.

profile,bilateral Angle's Class I molar relationship, normal RESULTSoverjet and overbite,well aligned maxillary and mandibular

The various measurements made on the sample are arches with <2mm crowding or spacing,no congenitally

compiled in Table 1, 2, 3 and 4.missing teeth, congenital anomalies or facial asymmetry, no

rdmissing teeth (except 3 molar).

Table 3 : Holdaway soft tissue variables of Angle's Class II Division 1 Malocclusion

CLASS II DIV 1 MAXIMUM MINIMUM MEAN SD

SOFT TISSUE

FACIAL ANGLE

94 83 88.88 44.8

NOSE

PROMINENCE

16 1 9.19 38.8

SUPERIOR SULCUS

DEPTH

8 0 3.57 34.7

SOFT TISSE SUB

NASALE TO H LINE

11 1 5.69 31.8

SKELETAL PROFILE

CONVEXCITY

8 0 4.19 29.7

BASIC UPPER LIP

THICKNESS

20 12 15.73 27.9

UPPER LIP STRAIN

MEASUREMENT

5 -10 -4.96 20.6

H ANGLE 32 17 23.84 25.7

LOWER LIP TO H

LINE

4 -5 -0.34 22.7

INFERIOR SULCUS

TO H LINE

10 4 6.76 23.9

SOFT TISSUE CHIN

THICKNESS

14 8 10.65 23.1


DISCUSSION The mean values for SNA, SNB and ANB of class I patients

were 82, 79.78, 2.22 degrees respectively, for class II division The first impact of any face is the soft tissue, which is the 1 malocclusion SNA SNB and ANB were 82.03, 76.11 and 5.76 primary consideration in present day diagnosis and degrees respectively and for Angle's Class II division 2 angles treatment planning. The facial skeleton and its overlying soft were 80.7, 76.29 and 4.41 degrees respectively.tissues determine facial harmony and balance.

A decrease of facial angle is suggestive of Class II dental and For the assessment of patient, only cephalometric dento-skeletal pattern. For angular measurements, the mean facial skeletal analysis is not sufficient and often leads to aesthetic

0 0 0angle was found to be 90.4 , 88.8 and 89.08 respectively for problems. Therefore, profile analysis for soft tissue Angles Class 1, Class II Division 1 and Angle's Class II Division 2 structures and their proportions becomes imperative as a respectively. This was comparable to the values reported by part of routine diagnosis. There have been studies done on Holdaway analysis, which was originally carried out for soft tissue for different populations but the consideration of Caucasian population and in previous study on Indian ethnic variations is important for the applicability of standard

3,44-8 population.measurements in any population. Due to higher frequency

of Angle's Class II in the region as reported in previous study, For linear measurements, nose prominence is measured

the study for soft tissue norms in various malocclusions in from the most prominent nasal point to the H-Line and this 2Amritsar population was essential. Thus, the present study came out to be average 12.08mm in Class I, 9.19mm in Class II

was carried outon 75 patients with equal distribution of division1 and 12.58 in Class II division2. Upper lip thickness

skeletal class I and skeletal class II div 1, div 2 to assess the soft was found to be 15.2mm for Class I, 15.73 mm for Class II

tissue proportion in Amritsar region. Division 1 and 15.12mm for Class II division 2. Inferior sulcus

depth was found to be came out to be 5.56mm in Class I,

Table 4: Holdaway soft tissue variables of Angle's Class II Division 2 MalocclusionCLASS II DIV 2 MAXIMUM MINIMUM MEAN SD

SOFT TISSUE

FACIAL ANGLE

93 85 89.08 41.6

NOSE

PROMINENCE

19 6 12.58 36.05

SUPERIOR SULCUS

DEPTH

6 0 2.875 32.2

SOFT TISSE SUB

NASALE TO H LINE

9 2 5.33 29.5

SKELETAL PROFILE

CONVEXCITY

6 0 3.04 27.5

BASIC UPPER LIP

THICKNESS

18 11 15.12 25.9

UPPER LIP STRAIN

MEASUREMENT

16 -4 0.54 24.6

H ANGLE 28 10 19.29 23.6

LOWER LIP TO H

LINE

6 -4 1.79 22.7

INFERIOR SULCUS

TO H LINE

11 4 7.33 21.9

SOFT TISSUE CHIN THICKESS 15 9 11.58 21.2


6.76mm in Class II division1 and 7.33mm in Class II division2. response to the skeletal malrelation.

Basic upper lip thickness was reported as 15.2mm in Class I, Thus, the present norms should be followed when 15.73mm in Class II division1 and 15.12mm in Class division diagnosing or planning treatment for any case belonging to 2.The values were in normal ranges of Holdaway (14-24 mm the population studied. The study implies that ethnic and for nasal prominence, 15mm for upper lip thickness and geographic population values emphasise the need for 5+2mm for inferior sulcus depth respectively) suggesting individual studies for different populations.that lip and nasal soft tissue prominence and their esthetic

As the study was limited to a smaller sample, further studies acceptance is similar in the population studied when

are required on larger population sample to validate the compared with the results obtained in previous studies in

norms obtained. In view of lack of adequate number of Class 3,4,5different population groups.III patient records, further studies must include Class III

Superior sulcus depth was found to be 2.84mm in Class I, population group for any variation in the malocclusion group.3.57mm in Class II division1 and 2.8mm in Class II division2,

CONCLUSIONwhich was lesser than the normal values reported in

The soft tissue norms vary for Amritsar population when Holdaway's analysis (5+2mm).The values of Lip Strain was compared with standards laid down for Caucasian reported as 4.32mm in Class I, -4.96mm in Class II division 1 population.and 0.54mm in Class II division 2. This value was reportedly

higher for the Class I malocclusion group than the average Further studies with greater sample size are required to values reported by Holdaway's. These are suggestive relative validate the same.prominence of hard tissue with reduced sulcular depth and REFERENCES:-increased lip strain in presently studied population. The

1. ProffitWr; Contemporary Orthodontics. Missouri 2000; Angle's Class II Division 1 population group reported the

2-3.maximum strain conferring to the integral proclination of

2. Kahlon SS , Gupta S , Dhaliwal HS , Kaur N , Kaur G , Singh maxillary anterior teeth.S. Prevalence of malocclusion in Amritsar population,

Skeletal Profile convexity is suggestive of the skeletal India. IJCDC July-Dec 2013;3(2): 426-430.

relationships of the jaws. In the present study, the value for 3. Rehan A , Iqbal R , Ayub A , Ahmed I. Soft tissue analysis in convexity was found to be 1.72 in Class I, 4.19 in Class II

class I and class II skeletal malocclusions in patients division1 and 3.04 in Class division 2. These are suggestive of reporting to department of orthodontics, Khyber college comparative profile in the present population in comparison of dentistry, Peshawar. Pakistan oral and dental journal. to the standards laid for Caucasian population (-2 to 2mm by 2014; 34(1): 87-90.Holdaway's analysis). Profile convexity reported was

comparative lesser in Angle's Class II Division 2 in comparison 4. Gupta A , Anand N , Garg J , Anand R. Determination of to Division 1 suggestive of compensation by retroclination of holdaway soft tissue norms for the north Indian anterior teeth and treatment plan must take this into population based on panel perception of facial esthetics. account. J Pierre Fauchard Academy (India section). 2013; 27(1):

18-22.When recording the relation of upper lip to chin, H angle was 0 0recorded as 15.12 in Class I, 23.84 in Class II division1 and 5. SachanA ,Srivastav A , Chaturvedi TP. Soft tissue

019.29 in Class division 2 suggestive of a relative prominence cephalometric norms in a north Indian ethnic of lip to chin in the present population.The value of lower lip population. J Orthod Sci. 2012; 1(4): 92-97.6.to H-Line was 0.16mm in Class I, -0.34mm in Class II Division 1 KalhaAS , Latif A , Govardhan SN. Soft tissue and 1.79mm of Class II Division 2 maloccclusion and soft cephalometric norms in a south Indian ethnic tissue subnasale to H-Line value of 4.76mm for Class I, 5.69 population. American journal of orthodontics and mm for Class II Division 1 and 5.33 for Class II division 2 were Dentofacial orthopedics. 2006; 133(6): 876-881.in average soft tissue ranges reported for Caucasian

7. Maurya RP , Sharma VP , Tandon P , Nagar A , Verma SL. 0population. (Average H-Angle 7-15 , 5+2mm for subnasale to

Soft-tissue characteristics of class II division 2 H-line and -1 to 2mm for lower lip to H-Line)

malocclusion in north Indian adult population: A The soft tissue in relation to chin was recorded as chin comparative study. J orthodontic research. 2014; 2(2): thickness, which was found as a mean value of 12.32 mm in 97-104.Class I, 10.65mm in Class II Division 1 and 11.58mm in Class II

8. Raghav S , Baheti K , Hansraj V , Rishad M , Kanungo H , Division 2. This value was slightly higher than those reported

Bejoy PU. Soft tissue cephalometric norms for central in other studies. The least value of soft tissue chin thickness

India (malwa) female population. J Int. Oral Health. was in Angle's Class II Division 1 malocclusion suggestive of

2014; 6(5): 51-59.

STEREOLITHOGRAPHIC IMPLANT SURGICAL GUIDE FOR

ACCURATE IMPLANT PLACEMENT-A CASE REPORT

ABSTRACT:

The placement of dental implants is a challenge for clinicians because of

existing anatomy and high esthetic and functional demands1,2. This article

presents a case for implant placement for complete oral rehabilitation with

implants.

Guided surgery is accepted as the most accurate way to place an implant and

predictably relate the implant to its definitive prosthesis, although few

clinicians use it.3Virtual Implant placement was planned using CBCT scan, casts

with trial denture bases, Implant planning software and prosthetic designing

software were used fabricate a stereolithographic surgical guide..

The article describes the successful application of digital technology in the

production of the surgical template for accurate placement of Osseo integrated

implants.

Keywords: Computer-aided design, computer-assisted manufacture, surgical

template, guided implant surgery.

984

Corresponding author:Name: : Dr. Harinder Kuckreja, Ludhiana. (M) 919815366273Email- [email protected]

1. Professor and Head , Department of Prosthodontics, Baba Jaswant Singh Dental College, Hospital and Research Institute Ludhiana, (Punjab) India.

2. Prosthodontist and Consultant, The Tooth Place, Ludhiana

3. Prosthodontist and Consultant, The Tooth Place, Ludhiana

CASE REPORT: established vertical height was done and try in completed

for adequate occlusal relation and functional verification. A 65 year old male reported in clinic for restoration of his

failing dentition. Full mouth rehabilitation was planned due The CBCT (cone beam coaxial tomography) was done to

to vertical dimension loss and mobility and deterioration of adequately get a 3D volumetric data of the alveolar bone in

his existing teeth and prostheses. the maxillary implant site. The cbct was analysed with Nobel

Clinician software.Vertical dimension was corrected and his anterior dentition

was rehabilitated with re established vertical dimension. The maxillary cast and trial denture base was surface

Right maxillary premolars and molars were already scanned with Nobel Procera 2G scanner and the surface

extracted with the failed prostheses. Left maxillary posterior scan exported to the Nobel clinician software for fusing the

restorations were removed and teeth extracted. model scan and the cbct generated data for prosthetic

planning and accurate three dimensional implant Maxillary posterior implant restorations were planned. placement . Diagnostic casts were prepared and diagnostic wax up at the


I J C D C1. Harinder Kuckreja 2. Harman Kuckreja

3. KBS Kuckreja



Dental Care



The implant location and type were finalised after fusing the for Nobel Active Implant.

cbct and Procera scanner generated surface scan. The Nobel The surgical guide was checked for fit and seating. The guided Active Implants were selected and surgical guide template surgical kit for Nobel active implants was used in the surgical was generated within the software planning in Nobel protocol and implant insertion achieved using the prescribed Clinician. drill sets for the selected implants .

The software generated surgical guide STL (Stereo The implant insertion was achieved in a flapless environment Lithography file format) fi le was exported and and immediate transmucosal healing abutments were stereolithographic 3D printed surgical guide was fabricated placed. The immediate post operative intraoral periapical

Fig 1. a. Pre operative image as the patient presented,

b. Vertical dimension re established

Figure 2. CBCT generated 3D image of maxilla Figure 3. Surface scan STL file from Nobel Procera 2G Scanner

Figure 4. Surface scan, diagnostic wax-up and CBCT data fused for implant simulation

Figure 5. Surgical guide simulationon the Software

Figure 6 . Surgical guide final design

Figure 7. Stereolithographic surgical guide Figure 8. Guided Surgical Kit Figure 9. Surgical guide inposition for implant insertion

Figure 10. Periapical radiographs for verification of implant insertion and position


xray views were taken to verify the implant placement. The REFERENCES

patient was recalled for check up and next phase of 1. Babbush CA, Kutsko GT, Brokloff J. The all-on-four prosthetic rehabilitation immediate function treatment concept with

NobelActive implants: a retrospective study. The

Journal of oral implantology 2011;37:431-445. Digital technology has proved an invaluable tool in the way 1,3,6we diagnose the condition and plan the treatment. 2. Sarment DP, Sukovic P, Clinthorne N. Accuracy of implant

However, even the best of plans seems worthless if not placement with a stereolithographic surgical guide. Int J

properly executed. Anatomical limitation and better Oral Maxillofac Implants 2003;18:571-577.

prosthetics demands the clinician to gain more precision in 3. Malo P, de Araujo Nobre M, Lopes A. The use of computer-5,6surgical positioning of dental implants. During oral implant guided flapless implant surgery and four implants

placement, the drill (position, depth and angulation) must be placed in immediate function to support a fixed guided by the clinician according to the final form of the denture: preliminary results after a mean follow-up prosthetics. Ideal placement facilitates the establishment of period of thirteen months. The Journal of prosthetic favourable forces on the implants and the prosthetic dentistry 2007;97:S26-34. component. In this regard, surgical guides have shown better

4. D'Urso PS, Atkinson RL, Lanigan MW, Earwaker WJ, Bruce predictability of placement improving better prosthetic

IJ, Holmes A, et al. Stereolithographic (SL) biomodelling results. Several guides have been reported in the literature

in craniofacial surgery. British journal of plastic surgery such as self/light cure acrylic resin, metal reinforced acrylic

1998;51:522-530. templates, vacuum formed polymers, milling, CAD-CAM

5. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically prosthesis, stereo lithographic models. Out of these; Milling, directed implant placement using computer software to CAD-CAM prosthesis or stereo lithographic models have ensure precise placement and predictable prosthetic provided good results. outcomes. Part 3: stereolithographic drilling guides that

do not require bone exposure and the immediate Prosthetically driven implant restorations insures good delivery of teeth. Int J Periodontics Restorative Dent esthetics, function and hygiene maintenance enabling long 2006;26:493-499. time success. Accuracy in treatment planning and execution

6. Ramasamy M, Giri, Raja R, Subramonian, Karthik, of planned treatment is vital for this success. Continious

Narendrakumar R. Implant surgical guides: From the advancements that have occurred in planning treatment

past to the present. J Pharm Bioallied Sci 2013;5:S98-(virtual software) for implant prosthesis have generated an

102equal rise in transferring the planned therapy to surgical

realization. In this regard, surgical templates have enabled

clinician to deliver predictable surgical & prosthetic results.

Surgical guides have not only decreased the chances of

operator driven damage of critical anatomic structures; they

also increase the aesthetic and functional advantages of

restoration-driven implant therapy. If clinician is considered

a pilot, then surgical guide is his navigator.

Discussion

CONCLUSION:

IMPLANTS IN THE AESTHETIC ZONE: A CASE REPORT

ABSTRACT:

The predictability of aesthetic success depends on the tissue loss present at the

initiation of treatment. Replacement of single as well as multiple missing teeth

in the aesthetic zone is challenging particularly when the three dimensional

architecture of the existing bone and soft tissue is deficient. The bony housing

in this instance would require augmentation to provide a configuration that

permits placement of implants in optimal positions which in turn would result

in pleasing aesthetics. The purpose of this case report is to evaluate the stability

and aesthetics of a single tooth implant placed in the anterior maxillary region

with a bony defect through grafting of autogenous bone and use of a growth

factor.

KEYWORDS: Single tooth implant, autogenous bone graft, platelet rich fibrin,

growth factors

987

Corresponding author:Name: Dr. Navneet Singh Randhawa, M.D.S. Student, Dept of Periodontology, Sri Guru Ram Das Institute ofDental Sciences and Research, AmritsarE-mail id.:- [email protected]

1. M.D.S., Senior lecturer, Department of Periodontology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2 . M . D . S . , R e a d e r, D e p a r t m e n t o f Periodontology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. M . D . S . S t u d e n t , D e p a r t m e n t o f Periodontology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

4. M.D.S., Professor and Head, Department of Oral Pathology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar .

5. BDS, Ex-Student, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2,3 INTRODUCTION: the jaw bone.

Achieving aesthetics with implant restorations is The successful integration of an implant is not sufficient to

significantly more challenging. Diagnosis and appropriate declare success; implants placed in poor restorative

treatment planning are critical in obtaining a successful positions result in unaesthetic restorations that provide

outcome. It is not the specific implant design, surface little satisfaction for the clinician or the patient.The

characteristics or type of abutment that will guarantee an predictability of the aesthetic outcome of an implant

aesthetic result. It is rather the time spent on data collection restoration is dependent on many variables including:

in reaching a correct diagnosis that pays dividends in terms 1) Patient selection and smile line 1 of function and aesthetics.

2) Tooth position Root form cylindrical implants placed following surgical

3) Root position of the adjacent teeth techniques described by Branemark et al. have proven to be

4) Biotype of the periodontium and tooth shapea predictable method for anchoring replacement teeth to


I J C D C1. Sahibtej Singh2. Ashish Verma3. Navneet Singh Randhawa4. Ramandeep Singh Narang5. Suveera



Dental Care



5) The bony anatomy of the implant site Intra oral examination: Intra oral examination of the patient

revealed missing maxillary left central incisor. Clinical 6) The position of the implant.examination of the alveolar ridge revealed that it was of

CASE REPORT:inadequate width as well as height. No other deformities of

A 35 year old male businessman presented to the outpatient the oral cavity were seen.department of the department of Periodontology and Oral

Radiographic examination: Radiographic examination of the Implantology of Sri Guru Ram Das Dental College, Amritsar

patient was done through orthopantomograph (OPG) and it with a missing left maxillary central incisor due to trauma.

was ascertained that the alveolar ridge height in the region of General physical examination: Extra oral examination of the left maxillary central incisor was inadequate and ridge patient revealed no gross physical deformities, no extra oral augmentation would be performed.swelling, sinus formation or any asymmetrical features of the

Lab investigations: Lab investigations of the patient revealed face.

normal leukocyte count with normal clotting and bleeding

Figure 1 Clinical examination revealing missing maxillary left central incisor

Figure 4 Autogenous bone graft being harvested from the symphysis menti region

Figure 2 Radiographic examination revealing inadequate ridge height

Figure 5 Harvested autogenous bone graft

Figure 3 Mucoperiosteal flap elevation of bony defect

Figure 6 Bony defect over maxillary centralincisor region being grafted with autogenous bone

Figure 7 Donor site of autogenous graft sutured Figure 8 Platelet Rich Fibrin derived from patient's blood to aid as growth factor

Figure 9 Formation of bone at site of missing tooth grafted with autogenous bone

Figure 10 Implant Surgery performed at grafted site

Figure 11 Implant placed and site sutured

Figure 13 Crown given after 5 monthsFigure 12 Implant placed along with cover screw


time and haemoglobin also within normal range. treatment time, requiring a provisional restoration during

implant integration, requiring surgical placement of the Discussion: Both clinical and radiographic examination of the implant, requiring surgical uncovering of the implant, patient's maxillary left central incisor region revealed requiring a provisional restoration after the implant is inadequate dimensions for placement of implant. So in this uncovered and having a higher cost. But inspite of these case it was decided to go for grafting of the bone at the site of disadvantages when one or more of the adjacent teeth are the missing tooth so as to provide adequate primary stability unrestored or in need of only a minor restoration, the single to the implant.tooth implant should be considered the restoration of

It was decided upon autogenous bone grafting in this case. choice.

Autogenous bone grafting was first was pioneered by 4 REFERENCES:Hegedus in 1923 . The main sites for procuring an

autogenous graft are ramus of mandible, symphysis region, 1. Sullivan R M. Perspective on aesthetics in implant

edentulous sites, healing extraction wounds, and also dentistry. Compendium 2001; 22: 685-692.

regions where osteoplasty and osteotomy has been 2. Adell R, Eriksson B U, Branemark P I, Jemt T. A long term 5,6performed . follow up study of osseointegrated implants in the

treatment of totally edentulous jaws. Int J Oral Although various studies have shown that intra oral grafts

Maxillofac Implants 1990; 5: 347-359. from the mandibular ramus region are more successful as

and have less complications as compared to other areas, but 3. Belser U C. Esthetic checklist for the fixed prosthesis. Part 7,8grafts from the symphysis region are easy to procure . II: Biscuit bake try in. In Scharer P, Rinn L A, Kopp F R

(Eds). Esthetic guidelines for restorative dentistry. pp During procedure, a crestal incison was given at the site of

188-192. Chicago: Quintessence, 1982. the maxillary left central incisor and consequently a

mucoperiosteal flap was raised. This revealed that a bony 4. Hegedus Z: Rebuilding of alveolar process by bone defect was present over the buccal plate which required a transplantation, Dent Cosmos : 65: 736, 1923graft.

5. Carraro JJ, Sznajder N, Alonso CA: Intraoral cancellous For this purpose, a block was harvested from the symphysis bone autografts iin treatment of infrabony defects, J Clin area of the mandible and grafted over the defect along with Periodontol 3:104, 1976platelet rich fibrin derived from the patient's own blood to

6. Halliday DG: The grafting of newly formed autogenous 9serve as a growth factor .bone in the ttreatment of osseous defects, J Periodontol

The area was then sutured up and patient recalled after 1 40: 511, 1969month. After 2 months the grafted site was evaluated and

7. Misch CE: Maxillary sinus augmentation for Endosteal evidence of bone formation was found.

implants: organized alternative treatment plans, Int J It was then decided to place an implant in the region with the Oral Implantol 4:49-58,1987newly formed bone. The implant when evaluated after a

8. Hallman M, Hedin M, Sennerby L, et al: A prospective 1-period of 5 months was found to have adequate primary

year clinical and radiographic study of implants placed stability when percussion test was done. In light of stable

after maxillary sinus floor augmentation with bovine placement of implant in the left maxillary central incisor

hydroxyapatite and autogenous bone, J Oral Maxillofac region it was decided to place a crown and complete the

Surg 60:277-284; discussion 285-276,2002restoration.

9. Nevins, Camelo M, Nevins ML, et al: Periodontal When evaluated according to Kois's criteria for aesthetic

regeneration in humans using recombinant human 10restoration, it satisfied all the requisite conditions .platelet-derived growth factor- BB( rhPDGF- BB) and

CONCLUSION: allogenic bone, J Periodontol 74:1282,2003

When a patient has a missing anterior tooth and desires 10. Kois J C. Predictable single tooth peri-implant aesthetics: replacement some choices for the patient include a Five diagnostic keys. Compendium 2004; 25: 895-905. conventional fixed partial denture, a resin bonded fixed

partial denture or an implant borne restoration. Implants

used to replace missing teeth in the aesthetic zone have

many advantages from preservation of unrestored adjacent

teeth, halting the resorption of edentulous spaces and

providing support. At present it has the disadvantages of long

TREATMENT OF A PERIODONTAL ABSCESS BY MODIFIEDKIRKLAND FLAP COMBINED WITH OSSEOUSREGENERATIVE THERAPY UTILISING AN ALLOPLASTICGRAFT: A CASE REPORT

ABSTRACT:

A case of recurrent abscess was seen in a 28 year old male driver with poor oral

hygiene and copious amounts of supragingival and subgingival plaque and

calculus. Clinically there was evidence of moderate amount of bone loss which

was f ascertained by radiographic examination by utilising Gutta Percha point

no. 30 as radio opaque marker. The patient was then educated about the

shortcomings of his oral hygiene routine and advised oral prophylaxis along

with surgical treatment. A modified Kirkland flap procedure was performed

whereupon it was seen that a vertical defect was present mesial to the lower

right lateral incisor. Subsequently bone grafting was done with an alloplastic

graft material with further restorative treatment planned at follow up.

KEYWORDS: Periodontal abscess, angular bone loss, alloplastic graft material,

pus

990

Corresponding author:Name: Dr. Navneet Singh Randhawa,M.D.S. Student, Dept of Periodontology, Sri Guru Ram Das Instituteof Dental Sciences and Research, AmritsarEmail id.:- [email protected]

1. M . D . S . R e a d e r, D e p a r t m e n t o f Periodontology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. M.D.S. , Professor, Department of Periodontology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.


INTRODUCTION: abscesses of the periodontium, the periodontal abscess is

the most important one. It is a destructive process occurring Periodontitis has been defined as an infectious microbial in the periodontium, resulting in localised collections of disease resulting in inflammation, bleeding (which may be

4pus .elicited either by probing or may occur spontaneously),

pocket formation, clinical attachment loss, bone loss, and Poor Oral hygiene has been proven to be a major aetiological 1tooth mobility . factor in causation of periodontitis as it provides a

3favourable environment for biofilm formation .Chronic generalised periodontitis is an inflammatory

condition of the gingiva affecting more than 30% of the CASE REPORT:

teeth in the oral cavity concomitant with clinical attachment A 28 year old male driver reported to the outpatient 2loss and bone loss . Department of Periodontology and Oral Implantology, Sri

Among several acute conditions that occur in periodontal Guru Ramdas Institute of Dental Sciences and Research,

tissues, the abscess calls for special attention. Among all Amritsar, with chief complaint of pain and swelling in right


I J C D C1. Supreet Kaur2. Vandana3. Navneet Singh Randhawa



Dental Care



lower region pf the jaw and bleeding from gums since 6 and also out of position. The lateral incisor showed no

months. On detailed history patient told that this swelling evidence of fracture and was not tender on percussion but

was recurrent and earlier was associated with pain which showed Grade 1 mobility when assessed according to

later on decreased and then subsided. Glickman's Tooth mobility Index.5General examination: General physical examination of the Lab investigations : Lab tests were performed and used to

patient revealed that the patient was systemically healthy, confirm the presence of a suspected infection. Tests showed

with no extremes of age, stress or fatigue, with no ongoing elevated levels of leukocytes and also an increase in blood

medication or had taken any medication taken for any neutrophils suggestive of an inflammatory response of the

disease since the past 6 months. body to microbial toxins.6Intra oral examination: Intra oral examination revealed that Radiographic examination : Intra oral periapical radiographs

patient had extremely poor oral hygiene with gross stains and clarified the presence of vertical defect mesial to the lower

calculus along with sinus formation with respect to lower right lateral incisor and distal to the mandibular right central

right lateral incisor. Probing depth between the mandibular incisor. A Gutta Percha point no. 30 was inserted into the

central and lateral incisors was found to be 6mm, compared sinus so as to determine the exact pathway and source of the

with a generalised probing depth of around 4.5mm-5.5mm. purulent discharge.

The tooth was non carious, slightly extruded out of position, The source of the abscess was determined to be intrapulpal. whereas the adjoining central incisor was distally deviated So the patient was promptly referred to the department of

Figure 1 Pre operative radiographshowing sinus in relation to

lower right lateral incisor

Figure 2 Radiogaph with Gutta Percha Point

Figure 3 Root CanalTreatment performed

Figure 4 Clinical determinationof sinus pathway

Figure 5 Revealed vertical defectafter raising mucoperiosteal flap

Figure 6 Insertion of alloplastic graft

Figure 7 Suturing the flap afterinsertion of graft material

Figure 8 Healing of the area after 1 week


Endodontics and Conservative dentistry for Root Canal V. No relief of pain after endodontic treatment

treatment. 6. Root Fracture10Differential Diagnosis : The differential diagnosis of the Root fracture can be differentiated by the presence of:

periodontal abscess is a clinically important step that allows I. Heavily restored crown

the dentist to clearly understand the condition, assess II. Non vital tooth with mobilityreasonable prognosis, eliminate any life threatening

condition and help in treatment planning until the condition III. Post crown with threaded post

subsides. The periodontal abscess was ruled out from the IV. Possible fracture line and halo radiolucency around the following similar conditions and lesions: root

1. Gingival Abscess V. Localised deep pocketing

Features that differentiate the gingival abscess from the DISCUSSION: periodontal abscess are:

The treatment of periodontal abscess follows the I. History of recent trauma management of simple dental infections albeit with some

7II. Localisation to the gingival modifications :

III. No periodontal pocketing 1. Local measures:

2. Periapical Abscess I. Drainage

Periapical abscess can be differentiated by the following II. Maintain drainagefeatures III. Eliminate cause

I. Located over the root apex 2. Systemic measures in conjunction with the local II. Non- vital tooth, heavily restored or large filling measures:

III. Large caries with pulpal involvement The management of a patient with periodontal abscess can

be divided into three stages:IV. History of sensitivity to hot and cold food

I. Immediate managementV. No signs / symptoms of periodontal diseases

II. Initial managementVI. Periapical radiolucency on intraoral radiographs

III. Definitive therapy3. Perio-Endo Lesion

Immediate ManagementThe Perio-endo lesion shows:

Immediate management is advocated in:I. Severe periodontal disease which involves furcation

1. Space infections of orofacial regionsII. Severe bone loss close to the apex, causing pulpal

infection 2. Diffuse spreading infections

III. Non-vital tooth which is sound or minimally restored In non-life threatening conditions, systemic measures such

as oral analgesics and antimicrobial chemotherapy will be 4. Endo-Perio Lesionsufficient to eliminate the systemic symptoms.

Endo-Perio lesion can be differentiated by:Antibiotics are prescribed empirically before the

I. Pulp interaction spreading via the lateral canals into the microbiological analysis and before the antibiotic sensitivity

periodontal pocketstests of the pus and tissue specimens.

II. Tooth usually non-vital, with periapical radiolucency The common antibiotics which are used are:

III. Localised deep pocketing1. Phenoxymethylepenicillin 250 -500 mg qid 5/7 days

5. Cracked tooth syndrome2. Amoxycillin 250 - 500 mg tds 5-7 days

Cracked tooth syndrome can be differentiated by:3. Metronidazole 200 - 400 mg tds 5-7 days

I. History of pain on percussionInitial Therapy

II. Crack line noted on the crownThe initial therapy is usually prescribed for the management

III. Vital tooth of acute abscesses without systemic toxicity or for the

IV. Pain upon release after biting on cotton roll or rubber residual lesion after the treatment of the systemic toxicity

disc and the chronic periodontal abscess.


The treatment options for periodontal abscess under initial Patient was recalled after 7 days for suture removal and

therapy: asked to come for follow up after 6 months.

1. Drainage through periodontal pocket There are several aetiologies for abscess formation. Poor oral

hygiene linked chronic periodontitis is one of the most Drainage through the pocket is the treatment of choice if the common. Due to chronic accumulation of plaque and abscess is not complicated by other factors. In such patients, subsequent mineralization there exists a congenial the use of systemic antibiotics with short term, high dose environment for micro organisms to flourish leading to regimens is recommended. Antibiotic therapy alone, periodontal breakdown and also abscess formation.without subsequent drainage and subgingival scaling is

contraindicated. CONCLUSION:

2. Drainage through an external incision The patient was not following proper oral hygiene

procedures leading to plaque and calculus accumulation If the lesion is sufficiently large, pin-pointed and fluctuating, causing periodontitis and subsequent abscess formation.an external incision can be made to drain the abscess. It is

recommended to use systemic antibiotics as the only initial

treatment in order to avoid the damage to the healthy REFERENCESperiodontium. In such conditions, once the acute condition

1. Flemmig T. Periodontitis. Ann Periodontol 1999; 4: has receded, mechanical debridement including root

12:16planning is performed.

2. Chronic Periodontitis, Carranza FA. In Newman, 3. Periodontal surgery

K l o k k e v o l d , Ta k e i , C a r r a n z a . C a r r a n z a ' s th I. Surgical therapy has also been advocated mainly in Periodontology,11 edition, 2009

abscesses which are associated with deep vertical defects, 3. Microbiology of the oral cavity, Quirynen V. In Newman,

where the resolution of the abscess may only be achieved by th Takei, Carranza. Carranza's Periodontology,10 edition, 8a surgical operation .

2002; II. Surgical flaps are also proposed in cases in which the

4. Huan Xin Meng. Periodontal Abscess. Ann Periodontal calculus is left subgingivally after treatment.

1999; 4: 79-82III. The main objective of therapy is to eliminate the

5. Herrera D, Roldan S, Sanz M. T he periodontal abscess:a remaining calculus and to obtain drainage at the same time.

review. J Clin Periodontol 2000; 27:377–386.9DEFINITIVETREATMENT

6. Smith RG,Davies RM. Acute lateral periodontal The treatment following reassessment after the initial abscesses. Br Dent J 1986; 161: 176-178therapy is to restore the function and aesthetics and to

7. Dello Russo NM. The post –prophylaxis periodontal enable the patient to maintain the health of the

abscess; Etiology and treatment. Int J Periodontal periodontium. Definitive periodontal treatment is done

Restorative Dent 1985; 5:29-37according to the treatment needs of the patient.

8. Kareha MJ, Rosenberg ES, DeHaven H. Therapeutic After thorough clinical, radiographic examination with

considerations in the management of a periodontal subsequent lab tests, which showed the presence of a deep

abscess with an intra bony defect. J Clin Periodontol pocket along with angular defect mesial to lower right lateral

1981;8:375-386incisor and leukocytosis, coupled with pain and swelling in

9. Dewitt GV, Cobb CM, Killoy WJ. The acute periodontal the region since long duration and the presence of an abscess: microbial penetration of tissue wall. Int J otherwise sound tooth with no restoration a diagnosis of Periodontal and Restorative Dent1985;1:39:51chronic periodontal abscess was made.

10. Patel PV, G Sheela Kumar, Patel A. Journal of Clinical and Since it was associated with a deep vertical defect, it was Diagnostic Research, 2011 Apr, Vol-5(2): 404-409decided to treat the patient after raising a mucoperiosteal

flap. Patient was informed about the diagnosis and then

explained about the treatment modality, then recalled for

open flap debridement in the form of Modified Kirkland flap

combined with regenerative therapy applying a non bone

graft material in the form of an Alloplastic graft consisting of ™Tricalcium Phosphate particles or TCP (RTR -France).

MANAGEMENT OF GINGIVAL GRANULOMA

PYOGENICUM: A CASE REPORT

ABSTRACT:

Pyogenic granuloma is one of the inflammatory hyperplasias seen in oral cavity.

It is exaggerated as a response to any minor trauma, low-grade local irritation,

poor oral hygiene and is commonly seen during pregnancy. Pyogenic

granuloma of oral cavity is known to involve the gingiva commonly.

Extragingivally, it can occur on the lips, tongue, buccal mucosa and palate. It is

frequently associated with difficulty in mastication and esthetic problems.

Present case report describes the treatment of a 28-year old patient with

Pyogenic granuloma. Treatment included Phase I therapy followed by

electrosurgery and supportive periodontal therapy. Following electrosurgery,

healing was uneventful with no recurrence post-operatively. Histopathological

examination revealed pyogenic granuloma.

Key words: soft tissue enlargement, phase I therapy, excision, electrocautery,

pyogenic granuloma.

994

Corresponding author:Name:Dr. VandanaM.D.S., Dept of Periodontology, Sri Guru Ram Das Institute of DentalSciences and Research, AmritsarE-mail id.:- [email protected]

1. M.D.S. , Professor, Department of Periodontology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. M . D . S . R e a d e r, D e p a r t m e n t o f Periodontology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.



INTRODUCTION Granulation tissue-type hemangioma, Granuloma

gravidarum, Lobular capillary hemangioma, Pregnancy Soft tissue enlargements of oral cavity often present a tumor and Tumor of pregnancy. It was first reported in 1844 diagnostic challenge, as diverse groups of pathologic

3in English literature by Hullihen. Pyogenic granuloma in processes produce such lesions. Among these lesions is a human was first described in 1897 and was termed as group of reactive hyperplasias, which develop in response to

1 botryomycosis hominis by Poncet and Dor. Hartzell in 1904 a chronic, recurring tissue injury that stimulates an was credited for giving the current term of "pyogenic exuberant or excessive tissue repair response. Pyogenic

granuloma" or "granuloma pyogenicum", but the term granuloma being one of the most common entities causing 1 “pyogenic granuloma” is a misnomer because it is not a true soft tissue enlargements .

granuloma. It is not associated with pus and histologically Pyogenic granuloma or granuloma pyogenicum is a

also it resembles angiomatous lesion rather than relatively common benign non-neoplastic mucocutaneous 4granulomatous lesion.2lesion . It is also known as Eruptive hemangioma,

Pyogenic granuloma may appear anywhere on the skin or


I J C D C1. Vandana2. Supreet Kaur3. Prableen Arora4. Sahil Sharma



Dental Care



mucous membrane, but is especially common on gingiva interfering with mastication. Patient's past dental, medical 5(approximately 75%). Chronic low grade trauma, physical and drug history were non-contributory.

trauma, hormonal factors, poor oral hygiene, bacteria, Extra oral examination was non-significant.viruses and certain drugs have been implicated as causative

Intraoral examination revealed a large pedunculated 4factors in the development of pyogenic granulomas . gingival overgrowth approximately 2.5x1.3cm in size,

Clinically it is a smooth or lobulated painless mass, size extending on lingual surface of 31,32,41,42,43,44. It was

varying from few millimeters to several centimeters in whitish pink in colour and was firm in consistency. Growth

diameter which tends to bleed easily because of its extreme was non tender but caused discomfort to the patient while vascularity. It is usually pedunculated, although some lesions mastication. The surface was lobulated with no ulcerations.

are sessile. Its colour ranges from red to pink to purple, Although patient exhibited poor oral hygiene, mobility of

depending upon the age of lesion. Young pyogenic teeth was not an associated feature.

granulomas are highly vascular in appearance and older 6 Radiographic feature: There were no visible abnormalities lesions tend to become more collagenized and pink.

and alveolar bone in the region of the growth appeared Treatment of this soft tissue lesion includes removal of normal.causative irritating factor that may be present, followed by

complete excision of the growth and microscopic study of the Treatment: The patient did not have any systemic history so

tissue. the case was prepared for surgery on the basis of the clinical

and radiographic evidence. Excision and biopsy of lesion was We are hereby presenting a case of pyogenic granuloma on planned.lingual aspect of mandibular anterior teeth and highlighting

its clinical characteristics, histopathology, differential Treatment plan was explained to the patient and written

diagnosis with special emphasis on its diagnosis and consent was obtained. Scaling and root planing of adjacent

treatment. teeth was completed to remove all the local irritants, which

could have been the primary etiologic factors in the present CASE REPORTcase and the lesion was excised under aseptic conditions.

A 28 year old male patient reported to the department of Excision was performed under local anesthesia (2%

Periodontology and Oral Implantology, Sri Guru Ram Das lignocaine with 1:2,00,000 adrenaline) using an

Institute Of Dental Sciences And Research, Sri Amritsar with a electrocautery, followed by curettage and thorough scaling

chief complaint of swelling in lower anterior teeth since 1 of involved teeth. Periodontal dressing was placed and the

year. Since it was asymptomatic, patient neglected it. History patient was recalled after 1 week for removal of pack. Patient

revealed that initially the gingival growth was minimal in size was prescribed antibiotics and analgesics. Oral hygiene

but it gradually increased to reach up to the present size instructions were given and chlorhexidine gluconate 0.12%

Fig:1 Pre-operative view- 1 week after

scaling and root planing

Fig:2a,b: Excision performed with electrocautery

Fig:3 Post-operative view -

1 week after electosurgery


mouthwash was prescribed. 7. Electrode cuts on its side as well as on its tip.

Histopathological examination: Excised tissue was sent for 8. Hemostasis is immediate and consistent.

histological evaluation. It revealed parakeratinized stratified 9. Healing discomfort and scar formation are minimal.squamous epithelium. Section exhibited highly cellular

10. Wound is nearly painless and the tip is self connective tissue stroma composed of numerous

8,9disinfecting .proliferating endothelial cells, budding capillaries, blood

After excision, recurrence occurs in upto 16% of the lesions. vessels and fibroblasts. The stroma was densely infilterated Recurrence is believed to result from incomplete excision, by chronic inflammatory cells. A final diagnosis of pyogenic failure to remove etiological factors or re-injury to the area. It granuloma was rendered. should be emphasized that gingival cases show more

DISCUSSION10recurrence rate than lesions from other oral mucosal sites.

Pyogenic granuloma is a common tumor-like lesion of the Differential diagnosis of Pyogenic Granuloma:

oral cavity. It is considered to be non-neoplastic and shows a 1. Peripheral giant cell granulomahighly vascular proliferation, sometimes organized in lobular

7 aggregates. Oral pyogenic granuloma occurs over a wide 2. Pregnancy tumourrange of 4.5 to 93 years with highest incidence in second and

3. Peripheral ossifying granulomafifth deacades, females being slightly more affected than

1 4. Metastasis of malignant tumorsmales. Due to its behavioral alterations such as rapid growth, 5. Hemangiomamultiple occurrence and frequent recurrence of pyogenic

granuloma, some investigators regard it as a benign 6. Inflammatory gingival hyperplasianeoplasm but it is mostly considered to be a reactive tumor-

7. Angiosarcoma like lesion as a response to various stimuli such as traumatic

7 8. Kaposi's sarcomainjury, hormonal factors or certain kinds of drugs.

9. Non-Hodgkin's lymphomaManagement of pyogenic granuloma depends on the 10 Peripheral giant cell granuloma is an exophytic lesion that is severity of sympoms. Many treatment techniques have

seen exclusively on gingiva, is more likely to cause bone been described for Pyogenic granuloma. But, before treating

resorption, with appearance of multinucleated giant cells. any case, the etiology must be clearly identified and

Diagnosis of pregnancy tumor is valid clinically in describing eradicated. Before attempting surgical excision of the lesion,

a Pyogenic granuloma occurring in pregnancy, with no a thorough oral prophylaxis should be performed because 2

local factors such as plaque and calculus are the most clinical or histological differences. Ossifying fibroma or

important etiologic factors for Pyogenic granuloma. If the peripheral odontogenic fibroma occurs exclusively on the

lesion is small and painless, oral prophylaxis, removal of gingiva; however, it has a minimal vascular component unlike

causative irritants (foreign materials, source of trauma) and a pyogenic granuloma. Metastatic tumors of the oral cavity

follow-up are advised, whereas lesions of large size are are rare and attached gingiva is commonly affected, clinically

treated by a thorough oral prophylaxis followed by surgical they resemble reactive or hyperplastic lesions such as 3 pyogenic granuloma, but microscopically they usually excision.

resemble the tumor of origin, which usually is distant from Different treatment modalities such as scalpels, Nd: YAG the metastatic lesion seen in the oral cavity. Due to laser, carbon dioxide laser, flash lamp pulse dye laser, proliferating blood vessels differential diagnosis of pyogenic cryosurgery, electrodessication, sodium tetradecyl sulfate

4 granuloma from a hemangioma is made histologically in sclerotherapy and use of intra lesional steroids can be used. which Hemangioma shows endothelial cell proliferation In the present study electrosurgery is being used.without acute inflammatory cell infiltrate, which is a

Advantages of use of electrosurgery: common finding in pyogenic granuloma. Conventional

1. A clear view of the surgical site is provided. hyperplastic gingival inflammation resembles pyogenic

granuloma in histopathologic sections and it is impossible for 2. Tissue separation is clean with little or no bleeding.the pathologist to reach a diagnosis and in such cases the

3. The technique is pressureless and precise.4surgeons description of the lesion is relied on.

4. Planing of soft tissue is possible. Angiosarcoma shows lobular growth pattern, well defined

5. Access to difficult-to-reach areas is increased. vessels, and cytologically bland endothelial cells. Kaposi's

sarcoma of AIDS shows proliferation of dysplastic spindle 6. Chair time and operator fatigue are reduced.cells, vascular clefts, extravasated erythrocytes and


intracellular hyaline globules, none of which are features of 4. Gomes SR, Shakir QJ, Thaker PV, Tavadia JK. Pyogenic 2Pyogenic granuloma. granuloma of the gingiva: A misnomer? - A case report

and review of literature. J Indian Soc Periodontol This present case reveals that poor oral hygiene could have 2013;17:514-9been the primary etiological factor of pyogenic granuloma,

so oral prophylaxis followed by excision of the growth was 5. Mitchell DF. Gingival pyogenic granuloma. J Periodontol

the line of treatment. The procedure was simple, essential 1956;27:4;273-76

for final diagnosis and provided a rapid result. There was no 6. Neville BW, Damm DD, Allen CM, Bouquot JE.Oral and scar formation and patient was satisfied with the treatment maxillofacial pathology. Second edition, WB Saunders, outcome. Philadelphia, 447-449.

CONCLUSION 7. Rezvani G, Azarpira N, Bita G, Zeynab R. Proliferative

Although pyogenic granuloma is a non-neoplastic growth in activity in oral pyogenic granuloma: A comparative

the oral cavity, proper diagnosis, prevention, management immunohistochemical study. Indian J Pathol Microbiol

and treatment of the lesion are very important. Inspite of 2010;53:403-7.

various treatments, recurrence is quite frequent so in many 8. Yalamanchili PS, Davanapelly P, Surapaneni H. cases re-excision may be necessary. Electrosurgical applications in Dentistry. Sch. J. App.

REFERENCES Med. Sci., 2013; 1(5):530-534.

1. Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: 9. Funde S, Baburaj MD, Pimpale SK. Comparison between

various concepts of etiopathogenesis. J Oral Maxillofac Laser, Electrocautery and Scalpel in the Treatment of

Pathol.2012;16(1): 79-82 Drug-Induced Gingival Overgrowth: A Case Report. IJSS

Case Reports & Reviews 2015;1(10):27-30.2. Sandhu M, Wadhwan V, Sachdeva S. Management of

Pyogenic Granuloma- A case report Journal of 10. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral

Innovative Dentistry 2011;1(3). pyogenic granuloma: a review. J Oral Sci. 2006;48:167-

175.3. Adusumilli S, Yalamanchili PS, Manthena S. Pyogenic

granuloma near the midline of the oral cavity: A series of

case reports. J Indian Soc Periodontol 2014;18:236-9.

SUBMANDIBULAR SALIVARY GLAND SIALOLITHIASISMANAGEMENT :A CASE REPORT

ABSTRACT:Sialolithiasis is a common disease of salivary glands. The

submandibular gland is affected by a number of disease processes that may

be difficult to distinguish clinically. Its superficial location makes it ideal for

ultrasound evaluation and a useful adjunct to clinical examination.There is a

slight male predominance. More than 80% of salivary calculi occur in the

submandibular gland or its duct.This occurrence along with more deep and

proximally placed common calculi in submandibular gland may occasionally

cause a dilemma in selection of the appropriate surgical approach in the

present era of sialoendoscopic surgery. Excision of the submandibular gland

with the stone in such a situation should still be preferred as the goldstandard

of treatment.The accepted method for submandibular gland excision

traditionally includes ligation of the facial artery . Preservation of the Facial

Artery may be significant in reconstructive procedures of the head and neck

and its ligation may altogether be obviated

998

Corresponding author:Name: Dr. Jasmine KaurAssoc. Professor, Department of Oral and Maxillofacial SurgerySri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

1. Post graduate student, Department of Oral and Maxillofacial Surgery Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. M.D.S, Assoc. Professor, Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. M.D.S, Assoc. Professor, Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

4. M.D.S, Professor & H.O.D, Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

4INTRODUCTION duct. Traditional and recent etiopathogenetic factors

include a reduced salivary flow rate, a change in pH, Sialolithiasis is the most common disease of the salivary dehydration, duct anomalies, and the retrograde migration glands in middle-aged patients. It is estimated that of foods bacteria or foreign bodies from the oral cavity sialolithiasis affects 12 of every 1000 patients in the adult

51 favoring stone formation.population. More than 80% of the salivary gland calculi

appear in the submandibular gland, but they can also be CASE REPORT

located in the glandular parenchyma and more frequently in A 48-year-old male reported to the Department of Oral and 2the excretory duct. More than 80–95 % of the salivary gland Maxillofacial Surgery at Sri Guru Ram Das Institute Of Dental

calculi appear in the submandibular gland, parotid gland Sciences and Research with a history of intermittent, dull, 35–20 % and 1–2 % in sublingual and minor salivary glands. aching pain and swelling in his right submandibular area

The submandibular gland is most frequently involved since the past 1 month. The patient also gave a history of because of its anatomic location, long and tortuous duct similar episode around 10 years back which resolved with with a narrow orifice compared to the main portion of


I J C D C1. Mehak Malhotra2. Jasmine Kaur3. Amit Dhawan4. Tejinder Kaur



Dental Care



medication. On extraoral examination, there was a localized the facial nerve.The skin flap was raised . The subcutaneous

swelling in the right submandibular region measuring fat was stripped with firm pressure with a swab from the

approximately 3.5cm × 2cm .The swelling was tender with no underlying muscle for approximately 1 cm on each side of the

color change in the overlying mucosa .On bimanual milking of incision. The underlying platysma was then incised to the full

the gland ,frank pus was expressed from ductal extent of the skin incision. The underlying investing layer of

opening.General clinical history revealed that the patient the deep cervical fascia was next divided, with scissors, after

was in good health; no other signs, symptoms, or the fascia was tented outwards with toothed forceps.

abnormalities were found. Subplatysmal flap was elevated superiorly and inferiorly and

the marginal mandibular nerve was identified and gently Orthopantomogram and right lateral oblique view of retracted with the upper part of the flap. The delicate capsule mandible were advised.The radiographs revealed two well overlying the gland was then lifted with toothed dissection defined radio opacities in the involved region ,suggestive of forceps and opened with scissors . The loose connective sialoliths.Ultrasonography of right submandibular gland tissue was separated with scissors to expose the surface of revealed an enlarged submandibular gland measuring the gland.The left submental vein was identified at the 39×23mm with presence of two hyperechoic foci and superior border of submandibular gland and submental echopoor collection measuring 2.8×1cm in size deep to right artery was deep to the gland.The vascular branches to the submandibular gland. A definitive diagnosis of gland were meticulously dissected and clamped. The submandibular gland sialolithiasis with acute sialadenitis anterior belly of the digastric muscle and the mylohyoid was made. Patient was prescribed antibiotics Injection muscle were detached. The facial vein and facial artery were Cefotaxime Sodium (Taxim) 1g I/V twice a day , Injection preserved. The dissection continued to mobilize the Amikacin Sulphate (Mikacin) 500mg I/V twice a day , Tablet posterior pole of the superficial lobe of the gland which is Metronidazole(Metrogyl) 400mg three times a day, Tablet then gently retracted posteriorly. The posterior border of the Limcee 500mg once a day along with good fluid intake for mylohyoid lies within the groove of superficial and deep acute sialadenitis .After the acute phase subsided , the lobes. It was gently freed with scissors and then retracted patient was posted for surgical interventionforward with a Langenbeck retractor. The submandibular

The right submandibular gland removal was done under salivary gland was then now be pulled downwards revealing

general anaesthesia .A 7 cm long incision was placed 3cm the V-shaped lingual nerve which was retracted carefully. The

below the inferior border of mandible along the natural skin submandibular duct was clamped, divided and ligated as

crease in order to avoid damage to the mandibular branch of anterior as possible with just enough remaining to drain the

Figure 1 Ultrasound of

submandibular gland

Figure 2 Orthopantomogram of the

patient depicting sialolith

Figure 3 Skin Marking done during

the surgical procedure

Figure 4 Figure 5 Sparing of Facial artery done Figure 6 Excised Submandibular

gland along with 3 sialolith


sublingual gland .The gland was liberated from the 1) Intraoral sialolithotomy (traditional approach),

submandibular ganglion thus freeing the lingual nerve & was 2) For large sialoliths that are located in the close proximal then removed. duct managed by extracorporeal shock wave lithotripsy

DISCUSSION (ESWL) (ultrasound to break the stone),

The salivary calculi develop as a result of deposition of 3) Endoscopy intracorporeal shock wave lithotripsy (EISWL)

mineral salts around a nidus of bacteria, mucus, or is also gaining importance because of less damage to the

desquamated cells. The sialoliths are mainly made up of adjacent tissues during the procedure,

calcium and phosphate with smaller quantities of ammonia, 4) Sialendoscopy, which is a non-invasive technique, can be potassium and magnesium. The parotid stones generally used to manage large sialoliths and duct obliteration,comprise of 49 % inorganic material and 51 % organic

5) The extra oral approach might required some times mainly material whereas, the submandibular stones consist of 82 %

when dealing with a large stone 6inorganic and 18 % organic material6) A large sialolithesp in the gland requires excision of the

The aetiologic factors implied in the sialolith formation can 10gland.be classified in two large groups: a) saliva retention due to

Patients presenting with sialolithiasis may benefit from trial morphoanatomic factors (salivary duct stenosis, salivary duct 11of a conservative approach. Various published reports of diverticuli, etc.) and b) saliva composition factors (high

7 minimally invasive techniques makes the time tested supersaturation, crystallisation inhibitors deficit, etc.)excision of salivary gland in glandular calculi unpopular.

The predisposing factors in calculus formation are salivary However, authors believe that surgical excision of the gland

stagnation, increased alkalinity of saliva, infection or with the calculi is still the gold standard of treatment for

inflammation of the salivary duct or gland, and physical intraglandular calculi with associated non-functional gland.

trauma to the salivary duct or gland. It results in swelling, In our case, we decided to do a total excision of the gland with

pain and recurrent infections of the associated gland by removal of calculi as the calculi was intraglandular. Although

causing the obstruction of salivary flow. Stones are believed the arterial supply of the face is abundant, gland was excised

to be more common in submandibular duct system and the following the preservation of facial vessels.The preservation

reasons cited for that are: (1) the submandibular excretory of the Facial vessels does not significantly prolong the

duct is wider in diameter and longer (2) the salivary flow in procedure or leads to complications, the time honored

the submandibular gland is against gravity (3) the 12principle of 'do no harm' should be adhered to.

submandibular salivary secretion is more alkaline compared BIBLOGRAPHYwith pH of parotid saliva (4) the submandibular saliva

8contains a higher quantity of mucin proteins.

Investigations like sialography, occlusal radiographs,

orthopantomogram, ultrasonogram, CT scan and MRI Neck

have been advocated. In our case, an ultrasound,

orthopantogram and a lateral oblique view of calculi in the

gland was done to accurately confirm the length and total

dimension of the calculus .9According to Tepan complete obstruction of the duct causes

constant pain and swelling with associated pus draining from .the duct On palpation a tender ,firm to hard submandibular

10.gland indicates a longstanding infection of the gland Our

patient also reported with pain in the right submandibular

area which was aggravated by eating or in response to other

salivary stimuli. Further,due to long standing obstruction,

fibrosis of the gland was present.The swelling was hard and

firm when palpated extraorally and on bimanual milking,

frank pus was expressed indicating an acute infection.

5. Raskin SZ, Gould SM, William AC (1975) Submandibular

Treatment options for sialolithiasis are duct sialolith of unusual size and shape. J Oral Surg

1. Leung AK, Choi MC, Wagner GA. Multiple sialoliths and a

sialolith of unusual size in the submandibular duct.A

case report. Oral Surgery, Oral Medicine, Oral Pathology,

Oral Radiology, and Endodontology. 1999 Mar

31;87(3):331-3.

2. Ledesma-Montes C, Garcés-Ortíz M, Salcido-García JF,

Hernández-Flores F, Hernández-Guerrero JC. Giant

sialolith: case report and review of the literature. Journal

of oral and maxillofacial surgery. 2007 Jan 31;65(1):128-

30.

3. Arunkumar KV, Garg N, Kumar V. Oversized

submandibular gland sialolith: a report of two cases.

Journal of maxillofacial and oral surgery. 2015 Mar

1;14(1):116-9.

4. Capaccio P, Marciante GA, Gaffuri M, Spadari F.

Submandibular swelling: Tooth or salivary stone?. Indian

Journal of Dental Research. 2013 May 1;24(3):381.


33:142–145 techniques. Open access atlas of otolaryngology, head &

neck operative surgery.:1-0.6. Arunkumar KV, Garg N, Kumar V. Oversized

submandibular gland sialolith: a report of two cases. 10. Tepan MG, Rohiwal RL. Multiple salivary calculi in

Journal of maxillofacial and oral surgery. 2015 Mar Wharton's duct. The Journal of Laryngology & Otology.

1;14(1):116-9. 1985 Dec 1;99(12):1313-4.

7. Trivedi BD. Surgical removal of submandibular gland 11. Hazarika P, Punnoose SE, Singh R, Arora S. Deep and

sialolithiasis in a 9-year-old girl: A case report. pediatric unusual sialolithiasis of submandibular duct and gland: a

dental journal. 2014 Aug 31;24(2):111-4. surgical dilemma. Indian Journal of Otolaryngology and

Head & Neck Surgery. 2013 Dec 1;65(4):309-13.8. Grases F, Santiago C, Simonet BM, Costa-Bauzá A.

Sialolithiasis: mechanism of calculi formation and 12. Markey JD, Morrel WG, Wang SJ, Ryan WR. The effect of

etiologic factors. Clinica Chimica Acta. 2003 Aug submandibular gland preservation during level 1B neck

31;334(1):131-6. dissection on postoperative xerostomia. Auris Nasus

Larynx. 2017 Apr 24.9. Witt R. Sialolithiasis: traditional & sialoedenoscopic

MODIFIED IMPRESSION TECHNIQUE FORMAXILLARY FLABBY RIDGE

ABSTRACT:

Fibrous or flabby ridge is a mobile or extremely resilient alveolar ridge which

becomes displaceable due to fibrous tissue deposition. It is more prevelant in

anterior maxillary region. Conventional impression making leads to

compression of the flabby rigde which tends to recoil and result in inadequate

support, stability and retention of complete denture. This article presents a

case report of modified impression technique for managing flabby tissue in

anterior maxillary region which helped in recording flabby tissue with minimal

displacement and hence enhanced the stability, support and retention of the

denture.

Key words: Flabby ridge, Kelly syndrome, Window technique

1002

Corresponding author:Name: : Dr Akash Dev DuggalAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar(M) +91 8054853531Email: [email protected]

1. Department of Prosthodontics and Crown & Bridge, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. Department of Prosthodontics and Crown & Bridge, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. M.DS. Oral medicine and radiology Department of Prosthodontics and Crown & Bridge, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

Introduction demonstrated in up to 24% of edentulous maxillae, and in

5% of edentulous mandibles. In the edentulous patient, it is Edentulous ridges that are mobile or resilient with little found in the anterior region more commonly in both arches. evidence of underlying supportive bone, may give the

1 It is often related to the degree of bone resorption and in appearance of being “flabby”. Fibrous or flabby ridge is a severe cases this can be to the level of the anterior nasal superficial area of mobile soft tissue affecting the maxillary

2spine.and mandibular ridges. Such a situation arises in some

complete denture wearer where alveolar bone has been Masticatory forces can displace this mobile denture-bearing

replaced by fibrous tissue. It is particularly evident in tissue, leading to altered denture positioning and loss of

maxillary anterior region especially when only the natural peripheral seal. If the flabby tissue is compressed during

mandibular anterior teeth remain, a so called combination conventional impression making, it will later tend to recoil 1or Kelly syndrome. and dislodge the resulting overlying denture. Clearly, an

impression technique is required which will compress the The reported prevalence has varied, but has been non-flabby tissues to obtain optimal support, and, at the


I J C D C1. Akash Duggal2. Aman Arora3. Navjot Kaur

Date of Submission : Date of Acceptance :


Dental Care



same time, will not displace the flabby tissues. Thus this case wax with additional wax relief of two uniform thicknesses

report presents a modified impression technique for flabby given in the flabby area from canine to canine region. (Fig 2)

tissues in the anterior maxillary region. 3) A maxillary custom tray was fabricated using

Case Report autopolymerising acrylic resin covering the tissues except

the area that was flabby. Over the “open” area of the tray A 65 year old male patient reported to the department of another “supporting tray” of acrylic was made thus covering Prosthodontics and Crown and Bridge of Sri Guru Ram Das the flabby ridge. Institute of Dental Sciences and Research with a chief

complaint of replacement of missing teeth in upper and 4) Handle of the tray should be placed on the centre so that

lower arches. The patient was a denture wearer for the last 6 relief holes can be drilled in the region of flabby tissue. (Fig 3)

years and described the existing dentures as “loose.” On 5) The maxillary borders were recorded by border moulding examination the patient was completely edentulous in upper using green stick compound. The relief wax was removed and and lower arches. The anterior canine to canine region in multiple holes were drilled in the “supporting tray''. maxilla was flabby. (Fig 1) Placement of multiple relief holes was done to ensure

All the treatment options including implant supported prevention of pressure build-up in the flabby area thereby

prosthesis and surgical removal of the flabby tissue was leading to inadvertent tissue compression. (Fig 4)

suggested to the patient but patient was not willing for the 6) A final impression was made with light body silicone 3 same. So it was decided that upper and lower complete impression material. (Fig 5)

dentures will be fabricated with a different impression Discussion

technique.The flabby ridge occur as a result of a maxillary complete

Technique denture opposing mandibular anterior natural teeth leads to

1) A primary impression of the upper and lower arches was anterior hyperocclusion resulting in excessive forces in the taken with irreversible hydrocolloid and the primary casts anterior region. Excessive anterior forces can also result were generated and the displaceable tissues were identified when porcelain anterior teeth are used in same denture with on the cast. acrylic posterior teeth .The low wear resistance of acrylic

2) On the maxillary cast, dental wax was applied as an “I” resin teeth result in hyperocclusion of anterior porcelain

shaped spacer along the mid palatine raphe using modelling teeth. It may also arise due to unplanned or uncontrolled

Fig. 1 Fig. 2

Fig. 3 Fig. 4 Fig. 5


dental extractions. Lynch and Allen — described a technique where impression

compound is applied to a modified custom tray. The The treatment options available in such cases are surgical thermoplastic properties of this material are then removal of flabby tissue, bone grafting or placement of manipulated to simultaneously compress the 'normal dental implants. Surgical debulking of flabby tissue has some tissues', while avoiding displacement of the 'flabby tissues' of the difficulties as many complete denture patients are using the same material and impression tray. The problem elderly or have complex medical histories for which any form with all these techniques is that they rely on materials such as of surgery is contraindicated. It may also result in shallow 'plaster of Paris', impression compound, and zinc-oxide and ridges which hampers the retention of the resultant

4eugenol. Crawford and walmsley mentioned controlled complete denture. Surgical removal of tissue is lateral pressure technique for fibrous posterior ridge with contraindicated where little or no bone is available.

2light body silicone impression material. Similarly implant placement is also not without risks. It is

Many general dental practitioners now rely on 'newer', more clear that if there has been excessive bone resorption and 'easy-to-use' materials, such as low viscosity silicone replacement by flabby tissues, then there will be little bone elastomer used particularly for fixed prosthodontics. The remaining into which dental implants can be placed. While it materials used in this technique are commonly used in would be technically possible to augment the remaining general dental practice. This technique does not require ridge with bone grafts, the prognosis of such treatment additional clinical visit. It doesn't require extra time for the would be questionable. Furthermore, there are a group of specialised impression technique as compared to the patients who for a variety of clinical or medical reasons are conventional impression procedures. Thus, it can be easily unsuited for dental implant treatment. There are also some

2performed by general dental practitioner.patients who do not wish to have surgically invasive 4procedures such as placement of dental implants. References

In Conventional Prosthodontics, various techniques have 1. George Zarb,John Hobkirk, Steven Eckert, Rhonda

been recommended and there is controversy as to whether a Jacob:Prosthodontic.Treatment for Edentulous

mucodisplacive technique which compresses the mobile Patients.13th Edition

tissue aiming to achieve maximum support from it or 2. R.W. I. Crawford and A.D.Walmsley, “A review of whether a mucostatic technique with the aim of achieving prosthodontic management of fibrous ridges,” British maximum retention should be employed. This case report Dental Journal, vol. 199, pp. 715–7719, 2006.describes a simple technique to record flabby tissues in their

3. Pai UY, Reddy VS, Hosi RN.A single step impression undisplaced state using readily available clinical materials

technique of flabby ridges using monophase like low visicosity silicone impression material.

polyvinylsiloxane material: a case report. Case Rep A multitude of impression techniques have been described Dent. 2014; 2014:104541for overcoming the problem of the flabby ridge. Liddlelow

4. C. D. Lynch and P. F. Allen, “Management of the flabby described a technique whereby two separate impression

ridge:using contemporary materials to solve an old materials are used in a custom tray (using 'plaster of Paris'

problem,” British Dental Journal, vol. 200, no. 5, pp. over the flabby tissues, and zinc oxide and eugenol over the

258–261, 2006. 'normal' tissues). Osborne described a technique whereby

two separate impression trays and materials are used to

separately record the 'flabby' and 'normal' tissues, and then

related intra-orally. Watson described the 'window'

impression technique where a custom tray is made with a

window or opening over the (usually anterior) flabby tissues.

A mucocompressive impression is first made of the normal

tissues using the custom tray and zinc oxide and eugenol.

Once set, it is removed, trimmed, and re-seated in the

mouth. A low viscosity mix of 'plaster of Paris' is then painted

onto the flabby tissues through the window. Once set, the

entire impression is removed. Each of these techniques

might be considered cumbersome, and the difficulties

associated with their manipulation could lead to

inaccuracies. Watt and McGregor — recently revisited by

THERMOPLASTIC ENDODONTIC OBTURATION

– THERMAFIL SYSTEM: CASE REPORTS

ABSTRACT:

Success of non-surgical root canal treatment is predicted by meticulous

cleaning and shaping of the root canal system, three-dimensional obturation

and a well-fitting‚ leakage-free coronal restoration. Various techniques have

been developed to achieve the proper obturation of root canal system

including the lateral compaction, vertical compaction and carrier based

obturation. Over the years, pitfalls with one technique have often led to the

development of newer methods of obturation. This article presents the case

report of endodontic obturation by means of thermoplasticized gutta percha

by using ThermaFil system along with Thermaprep oven in two different cases

to achieve 3- dimensional hermetic seal. Thermafil provides a void free

obturation with higher degree of homogeneity and less working time.

Keywords- Obturation, ThermaFil system, thermoplastification, curved canals.

1005

Corresponding author:Name: Dr. Prashant Monga Address: Department of Conservative Dentistry and Endodontics,Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab.Phone numbers:9780623558E-mail address : [email protected]

1. Post Graduate student, Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab.

2. MDS, Reader, Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab.

3.. MDS, Professor and Head, Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab.

4. MDS, Reader, Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab.

INTRODUCTION biocompatibility, dimensional stability, plasticity and ease of

removal whenever necessary.Root canal treatment consists of cleaning, disinfection and

obturation of the root canal. The primary objective of Schilder first introduced the vertical condensation

obturation is to prevent communication of bacteria from the technique with heated gutta-percha and since that, 1oral cavity through the root canal system into the periapical thermoplast ic methods have been proposed.

1 tissues. Additionally obturation prevents the ingress of Thermoplastic method use gutta percha in alpha phase and

apical tissue fluids and the growth of any residual bacteria system used in these case reports is ThermaFil (Dentsply

left in the canal system. Complete filling of the root canal Maillefer, Ballaigues, Switzerland).

system using a semisolid core such as gutta-percha (GP) and ThermaFil System sealer is critical in accomplishing these goals. An inadequate

In 1978, Johnson introduced an obturation technique using seal can result in contamination of the canal system and can 2 a carriers coated with alpha phase gutta-percha (ThermaFil

lead to periapical disease. The gutta-percha has been the 3Endodontic Obturator, Dentsply Maillefer, Switzerland). most commonly used filling material due to its


I J C D C1. Navdeep2. Prashant Monga 3. Pardeep Mahajan4. Shikha Baghi Bhandari



Dental Care



ThermaFil is a patent endodontic obturator consist of a files. Size verifiers are available to aid in selection of the

flexible central carrier that is uniformly coated with a layer of appropriate carrier and which should fit passively at the 2“alpha phase” gutta-percha. When heated, the “alpha corrected working length.

phase” gutta-percha becomes sticky and tacky, with ThermaPrep plus ovenexcellent flow characteristics and thus obturates the main

The ThermaPrep Plus Oven (Dentsply Maillefer, Switzerland) canal as well as available lateral and accessory canals. The has been specially developed for heating ThermaFil ThermaFil carrier is a flexible 25mm biocompatible

5endodontic obturators for use in root canal obturation.radiopaque plastic material with a .04 taper. The greatest

feature of ThermaFil is that it is so quick and easy to learn and Before obturation, turn the oven on by the power on and the

no longer there is the need to use lateral spreaders and green stand-by indicator will light up. Put both obturator 4 holders in the upper position. After disinfecting the multiple accessory gutta-percha points.

obturator and setting the silicone stop according to working ThermaFil obturators are designed to correspond to the ISO length, place the ThermaFil endodontic obturator in the left standard file sizes, various tapered nickel–titanium rotary

Case report - 1

Fig 1: Preoperative IOPA Fig 2: Working length determination Fig 3: Verifiers placed in

canals after BMP

Fig 4: Verifiers on IOPA

Fig 5: Corresponding obturator

heated in the oven

Fig 6: Obturators in canals Fig 7: Complete obturation

Case report - 2

Fig 8: Preoperative IOPA Fig 9: Working length determination Fig 10: MTA apical plug and

thermoplasticized obturation done

Fig11: Follow up at 3 month


obturator holder and silicone stop must be under the holder. was used to restore the pulp chamber and advise for coronal

Push the holder down (arrow down) until it sounds a click. restoration (fig 7).

Push the button which corresponds to the size of the Case-2: ThermaFil endodontic obturator to be heated. Then push the

“start left” button. The obturator is now being heated. The

heating time depends on obturator size varies from 20 to 45

seconds and is regulated automatically.

After the first signal beep, the obturator is ready for use. Push

the obturator holder (arrow up) and take the obturator

carefully out of the holder by pulling it towards and not to

scrape the obturator on any part of the holder. The oven will

“beep” every 15 seconds to remind, that the obturator is still

in the oven but after 90 seconds, the heating element will

switch off automatically. If more obturators are required,

alternatively use the left and right holders. Wait until after

the signal “beeps” for the first holder, then immediately start

to heat the other one. It is unable to heat both sides at the

same time.

Case reports in the article presents the obturation of root

canal with ThermaFil system.

CASE REPORTS

Case-1: A 31 year old patient visited the Outpatient DiscussionDepartment of Conservative Dentistry and Endodontics in

Genesis Institute of Dental Sciences and Research, Ferozepur, The main aim of endodontic treatment is to fill the space of

Punjab with chief complaint of pain in upper right back teeth root canals with the best possible adaptation to the walls,

region since 10 days. After taking history and performing through the use of a homogeneous mass of gutta-percha and

various diagnostic tests, it was decided to go for root canal a thin layer of endodontic cement. Piati et al. stated that the

treatment of 16 (fig 1). seal must be sufficient to prevent reinfection by fluids and

bacterial byproducts. The obturation techniques assist in this After explaining all procedure to patient, access cavity was process, but the strong influence of the anatomical variability made and working length was determined under rubber dam of root canals may lead to failure.isolation. Biomechanical preparartion of root canals were

completed by using universal ProTaper system in crown Gutta-percha is the trans isomer of polyisoprene (rubber)

down manner, following the instructions recommended by and exists in two crystalline forms (a and ß). In the unheated

manufacturer. Instrumentation was under copious irrigation ß phase the material is a solid mass that is compactable.

with 3% sodium hypochlorite (Prevest DenPro Ltd) followed When heated the material changes to the a phase and

by 17% EDTA(Prime dental product Ltd) . MB canal was becomes pliable and tacky and can be made to flow when

prepared upto F2, DB upto F3 and palatal upto F3, but after pressure is applied. A disadvantage to the a phase is that the

apical gauging it was extended to apical size 35no. Canal sizes material shrinks on setting, same, when a-phase gutta-

were verified by verifers of corresponding sizes and the percha is heated and cooled it undergoes less shrinkage,

matching obturators were selected (fig 3,4). After making it more dimensionally stable for thermoplasticized

confirming the verifiers on radiograph, canals were dried techniques. The use of a-phase gutta-percha for obturation

with sterile paper points has increased as thermoplastic techniques have become 2One by one more common.

obturators were placed into Thermaprep oven, when heated Ribeiro et al. stated that the thermoplastification aims to obturators were securely placed into canals and left promote greater amount of gutta-percha, better adaptation undisturbed for 2 minutes to set warm gutta percha (fig 5,6). to irregularities and consequently, the smaller amount of Remaining carriers were removed by shearing off from the cement as compared to those that use cold gutta-percha canal orifices with round bur. Post obturation radiograph lateral condensation and vertical condensation and the shows well defined sealed canals. Composite restoration 7single cone. Internal root resorption presents as an irregular

A 23 old male patient visited the Out Patient

Department of Genesis Institute of Dental Sciences and

Research, Ferozepur, Punjab with chief complaint of

fractured and discolored upper right front tooth. Patient gave

history of accident at the age of 11 year. Clinical examination

revealed Ellis class III fracture and discolored 11. After

performing various diagnostic tests, root canal treatment

was indicated for 11. In this case of internal resorption, H files

were used for biomechanical preparation of root canals (fig

9).

Due to wide apex, MTA apical plug was made by placing MTA

with help of amalgam carrier and condensed with hand

plugger upto 5mm and over it a moist cotton pellet was kept

and temporary restoration (Orafill –G, Prevest Dent pro) was

placed. After 48 hours, patient was recalled and setting of

MTA was checked to form a hard mass of cement (fig 11).

After a apical plug was made, same procedure was followed

to obturate the canal with ThermaFil system. After 3 month

follow up, tooth was asymptomatic and well secured in a

dentition (fig 12).

and a thin layer of zinic oxide

eugenol based sealer was applied to canal walls.


resorptive defect in root canals. In the presented case report References

2 , maxillary central incisors with internal resorptive cavities 1. Schilder H. Filling root canals in three dimensions. Dent located in the middle third of the root was obturated with Clin North Am. 1967;11:723-44.ThermaFil system, as it is difficult to achieve 3D obturation

8 2. W.T Johnson and J.C.Kulild. Obturation of the cleaned with other obturation techniques.

and shaped root canal system, in Cohen's Pathways of Various studies shows obturation of curved root canals with the Pulp, K. M. Hargreaves and S. Cohen, Eds., pp. Thermafil, results in a more dense and well adapted root 349–351, Mosby, St. Louis, Mo, USA, 10th edition, 2010.canal filling throughout the entire canal system, than lateral

3. Johnson B. A new gutta-percha technique. J Endodon condensation with standard gutta-percha. The

1978; 4: 184–8.predisposition for extrusion of filling materials with the

4. Gavan O'Connell , Thermafi l CLINICAL HINTS ThermaFil obturation technique is observed when the apical

[email protected], www.dentsply.com.auforamen was not patent. Prevention of this occurrence is to

be done by the use of an apical dentine matrix plug, that has 5. Maalouf S, Attieh- Abikanaan, Qunsi HF. Thermafil: a 9been demonstrated by Scott & Vire (1992). Emmanuel conventional technique in endodontics. Dental News

Samson et al, evaluated that the apical seal by ThermaFil 1996;3:27-31.obturating technique shows minimum mean apical dye

6. www.dentsplymaillefer.compenetration as compared to Obtura II and lateral

10 7. Ribeiro MA, Queiroz ACFS, Silva PG, Yoshinari GH, condensation.Guerisol i DMZ, Pereira KFS. Estudo comparativo da área

Once the Thermafil obturation is completed, Pro-Post drills apical preenchida pela gutapercha nas técnicas de

(DENTSPLY Tulsa Dental Specialties) are recommended if post obturação TC, ThermaFil e condensação lateral. Revista

space is required for restoration of the tooth. The unique de Odontologia da UNESP: 2009; 38(1):65-71.

eccentric cutting tip keeps the instrument centered in the 8. Agarwal M, Rajkumar K, Lakshminarayanan L. canal while friction softens and removes the gutta-percha

Obturation of internal resorption cavities with 4 and plastic carrier. When retreatment is necessary the different techniques: An in-vitro comparativeStudy, thermafill plastic carrier has a groove along its length to Endodontology 2002;14:3-8.provide an access point for placement of a file. Chloroform

and hand files can be used to remove the gutta-percha 9. J. L. Gutmann, W. P. Saunders, E. M. Saunderst & L. surrounding the carrier. All aspects are covered in Thermafil Nguyen. An assessment of the plastic Thermafil system for making it universally accepted even if post core obturation technique, Part 1 -Radiographic evaluation of and retreatment is to be done. It all contributes to its adaptation and placement, International Endodontic versatile nature and mechanically well accepted in journal 1993;26:173-8.obturating the complex root canals anatomies.

10. Samson E, Kulkarni S, Sushil K C, Likhitkar M. An In-Vitro Conclusion Evaluation and Comparison of Apical Sealing Ability of

Three Different Obturation Technique - Lateral The ThermaFil system of thermoplastification obturation is Condensation, Obtura II, and Thermafil. J Int Oral Health effective in different clinical situations regardless of the 2013; 5(2):35-43.curvature, number of root canals and resorptive defects, thus

providing its versatility. The technique is fast contributing for

a shorter working time, if previous training is delivered.

RENAL DISEASE AND ITS ORAL MANIFESTATIONS

: REVIEW AND CASE REPORT

ABSTRACT:

Chronic renal disease is a condition defined as the progressive and irreversible

loss of renal function, leading to marked reduction in the glomerular filteration

rate. This condition manifests oral consequences very frequently. About 90 %

of the patients with renal failure have oral symptoms like dry mouth, mucosal

pallor, stomatitis, uremic odor, change in taste, glow salivary flow. Moreover,

candidiasis and recurrent herpes are more common in chronic renal disease.

The aim of the article is to familiarize the dental clinician with the oral signs of

patients with renal disorders through these case reports. Dental treatment

plan should be made taking into consideration, that these patients have a

greater tendency of bleeding, hypertension, anemia, drug intolerance and

increased susceptibility to infections.

KEYWORDS: Renal disease, chronic renal failure, uremia, uremic stomatitis

1009

Corresponding author:Name: Dr. Preeti Chawla AroraAddress: Sri Guru Ram Das Institute of Dental Sciences andResearch, Amritsar.Phone no.: 8146425170Email: [email protected]

1. MDS, Reader, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. MDS, Reader, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. BDS, Ex- Intern, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

4. Intern, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

5. BDS, Ex- Intern, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

INTRODUCTION :

All the diseases affecting the human body tend to show

their manifestations mostly in the oral cavity. Making a

thorough assessment of oral status of a patient is a must in

diagnosing sometimes an underlying systemic cause.

Acute and Chronic renal failure result from an inability of the

kidneys to adequately filter metabolic wastes from the

blood. This results in reduced GFR and an accumulation of 2ammonia and uric acid causing systemic imbalance.

Chronic Renal Disease is defined as the structural and

Kidneys are the vital organs for maintaining a stable internal functional abnormality of kidneys including with/without

environment i.e. haemostasis. The renal system comprises GFR leading to kidney damage. It includes abnormalities in

an essential part of the normal physiology of human body urine and blood composition. GFR less than 60 mL/min. per 2 and causes maximum cases of mortality and morbidity 1.73 m for 3 months or more, with or without kidney

worldwide. There are two main diseases related to kidneys damage is indicative of chronic renal disease. It leads to

namely Chronic renal disease and End stage renal disease clinical syndrome called uremia. Signs of uremia are

(ESRD), which are approximately 25-40 %. Chronic renal hematological changes, bone metabolism changes and 1disease is the twelfth leading reason of death. The various alteration in immune status. This condition is measured by

functions of kidneys include excretion of metabolic waste, creatinine clearance which gives an acceptable 3blood pressure control, Vitamin D activation and electrolyte approximation of the value of GFR.

2 regulation.


I J C D C1. Preeti Chawla Arora2. Aman Arora3. Sukhpreet Singh Randhwa4. Tanveen Kaur5. Manpreet Kaur



Dental Care



The function of kidneys can be assessed indirectly to the ORAL MANIFESTATIONS

plasma creatinine levels. Normal value of serum creatinine is The patient can present with enlarged salivary glands 0.5-1.4 mg/dL. Diabetes mellitus, arterial hypertension and accompanied by a decrease in salivary flow causing an glomerulonephritis are the most important etiological increased tendency to dental caries. Dry mouth or

3factors for chronic renal disease. Treatment of chronic renal xerostomia is a common manifestation accompanied by a insufficiency include dietary changes, correction of systemic very frequent complaint of halitosis caused by a breakdown complications and dialysis or renal graft.About 90% of renal of urea into ammonia. This is the most predictable outcome failure patients have oral symptoms, which may be because of an increase in urea levels in patients with chronic consequences of dialysis and renal transplantation and renal failure. The patient also complains of a metallic taste in

4etiological factors causing chronic renal failure. mouth. Dry mouth also results in difficulty in speech, 5,8

This article highlights the scenario of improper regulation of mastication and swallowing.

the excretory system and its effects on the other aspects of If the renal failure occurs in growing stages of life, altered or health with a focus on ill effects on oral health. It also reviews delayed eruption occurs alongwith enamel hypolplasia with the various precautionary measures to be taken in a dental or without brown discoloration. Calcification of pulpal set up. chamber in adult patients can also occur. There is increased

ETIOLOGY AND PATHOGENESIS: calculus formation requiring meticulous oral prophylaxis

from the dentist and the patient to prevent further bacterial Patients may report with a variety of oral complaints prior to 2complications.or with the appearance of oral symptoms.

The mucosa is pale with low grade gingival inflammation. It

can be induced by cyclosporins or calcium channel blockers.

It principally affects labial and interdental papilla. It can

become extensive involving the gingival margins, lingual and 6palatal surfaces.

The patient also has a frequent occurrence of petechiae,

ecchymosis and gingival bleeding caused due to increased 7bleeding tendencies because of impaired platelet functions.

Due to continuous administration of immunosuppressive

drugs, lichenoid reaction (drug induced) and pyogenic

granuloma are frequently observed in CRF patients.

Moreover, due to drug related immunosuppression, oral

hairy leukoplakia can be observed. These lesions lack Ebstein

Barr Virus (EBV) but appear similar clinically and 7histopathologically.

CLINICAL PRESENTATION: Oral candidiasis may affect 20-30 % transplant patients.

Candidal infections may present as angular cheilitis, Patients with acute or chronic renal failure present with the pseudomembranous and erythematous ulcerations or clinical symptoms when it starts affecting the gastrointestinal chronic atrophic infections. Viral infections such as Herpes system, it causes nausea, vomitting, ammonical taste and Simplex Virus (HSV) used to be common in transplant halitosis. Neuromuscular symptoms vary from headache, recipients. The use of anti-herpetic agents such as 5% peripheral neuropathy to seizures in some cases. Blood Acyclovir has significantly reduced the frequency of these picture shows lymphocytopenia, increased bleeding

5infections.tendencies in several patients.

The risk of oral squamous cell carcinoma in the patients Endocrinal symptoms are similar to that of secondary receiving hemodialysis is generally similar to that of hyperthyroidism also impairing growth. Renal failure can otherwise healthy individuals in the general population. affect the cardiovascular system causing congestive heart Although there have been reports suggesting that therapy failure, pericarditis. Bone changes are presented as bone following renal transplantation predisposes to epithelial resorption, osteitis fibrosa, delayed growth, rickets and

1 dysplasia and carcinoma of lip. Any increased risk of oral delayed tooth eruption.malignancy in renal failure probably reflects the effects of

iatrogenic immunosuppression which increases liability to

On several

occasions, frank uremia, metabolic acidosis and

hypertensive crisis is present. These symptoms indicate

chronic renal failure followed by hemodialysis which further

complicates the situation causing various oral 2,4manifestations.

Once diabetic nephropathy is established in a patient,

continuous ambulatory peritoneal dialysis follows which can

further cause repetitive bacterial peritonitis. This is also

accompanied by complaints of hypoacusis and 1neurosensorial cochlear deafness in some patients.

After years of evolution, the patient can present with

glaucoma in the eyes. The patient can also show

complications due to diabetes mellitus and peripheral

v a s c u l a r p r o b l e m s a n d s i g n s o f s e c o n d a r y 1hyperparathyroidism.


virally associated tumors such as Kaposi sarcoma or non with 9Hodgkin lymphoma.

Finally, uremic stomatitis is an oral complication of unknown

aetiology and it is relatively uncommon, usually seen in

patients with an end stage or untreated renal disease. The

onset may be abrupt with white plaque, distributed

predominantly on buccal mucosa, tongue and floor of

mouth. The clinical appearance has been known to mimic 1oral hairy leukoplakia.

RADIOGRAPHIC FEATURES

Demineralisation of bone may be seen along with loss of

bony trabeculations.

a ground glass 10 CASE REPORT 2:appearance in some areas.

Another patient , a male aged 62 years of age reported to the Socket sclerosis is seen in most areas which causes tooth department of Oral Medicine and Radiology with the mobility in most of the cases. Bone osteodystrophy follows

decrease or loss of cortical bone observed at the

mandibular angle and around the maxillary sinuses, mental 10foramen and mandibular canal.

CASE REPORT 1:

A 45 yr old male reported to the Department of Oral

Medicine and Radiology for bleeding in the oral cavity. He

had a medical history of chronic renal failure since 3 years

and was on periodic hemodialysis, which he underwent

irregularly. The patient presented with extreme pallor, cold

clammy skin, excessive weight loss and tremors. Regarding

the dental history, the patient presented with a strong

malodor and ulcers in the oral cavity covered with a white

pseudomembrane suggestive of uremic stomatitis and there These may present either as generalized demineralization or

were white scrapable patches indicating candidal infection. as frank intrabony lesions (in more advanced stages),

(Fig 1,2 and 3). The patient had an increased serum sometimes containing focal tumors that are histologically

creatinine levels of 12.6 mg/dL and blood urea of 381 mg/dLsimilar to giant cell tumors of the bone giving

Fig. 1,2 : Ulceration seen on the right lateral border of the tongue and the right buccal mucosa covered by a white pseudomembrane.

Fig. 3 : White scrapable patches suggestive of candidiasis seen onthe right buccal mucosa alongwith deep periodontal

pockets and gross calculus deposition.

Fig 4 : Fig 4 : Ulceration on lateral aspect of tongue covered by necrotic slough on the tongue.


complaint of multiple mobile teeth. He was a known case of cyclosporine. As for dental considerations and management

chronic renal failure since 1 year, undergoing haemodialysis. strategies for these patients, we should take into account

The oral examination showed irregular ulceration on the that the drug dose adjustment must be done using creatinine

tongue with lack of an erythematous halo and was covered clearance; before invasive dental procedures, a blood test

with necrotic slough.(Fig 4) The patient had abnormal serum must be requested. The well supervised treatment protocols,

chemistry with high level of serum potassium. in the dental management of individuals with chronic renal

failure can be effective and safe.DENTAL CONSIDERATIONS IN PATIENT WITH RENAL

DISEASE REFERENCES :

As a dentist, precautionary measures need to be considered 1. Hamid, Dummer, Pinto LS. Systemic conditions, Oral

before, during and after treatment. It is although always Findings and Dental Management of Chronic Renal

preferable to avoid any dental treatment if the disease is Failure Patients: General Considerations and Case

unstable because untreated dental infections in Report. Braz Dent Journal 2006; 17(2) : 166-270.

immunosuppressed individuals can potentially contribute to 2. Haider SR ,Tanwir F,Momin I A. Oral Aspects of Chronic mortaliy and transplant rejections. Regular nonsurgical oral Renal Failure. Pakistan Oral and Dental Journal. 2003 ; prophylaxis is indicated in these patients for accurate oral 33 (1): 87-90.hygiene. Infection is poorly controlled in immunosuppressed

patients, which may spread locally or systemically as

bacteremia. Antimicrobial considerations include

Erythromycin and Cloxacillin in standard doses. Penicillin,

metronidazole, cephalosporin should be given in low doses,

as they are inadequately metabolized. Since very high serum

level can be toxic to central nervous system, Aspirin and

other NSAIDs should be avoided as they increase

gastrointestinal irritation and bleeding associated with renal 11failure.

To minimize the risk of adrenal crisis in individuals who have

taken large doses of corticosteroids (10mg prednisolone 6. Chuang SFAE, Sung JMB, Kuo SCC, Huang JJB, Lee SYD. daily) and undergoing major surgical procedures (such as Oral and dental manifestations in diabetic and extractions of more than one tooth), appropriate nondiabetic uremic patients receiving Hemodialysis. corticosteroid cover should be administered before Oral Surg Oral Med Oral Pathol Oral Radiol Endodont treatment. 2005; 99:689-695.

In patients with increased bleeding tendencies, the 7. Lauttamus A, Kasanen A, Oksala E, Tammisalo E. Oral treatment should be carried out only when the effect of manifestations in uremia. Proc Fin Dent Soc 1974;70 heparin is minimum, which is one day after dialysis. Careful :50-6. haemostasis should be ensured in various surgical 8. Kho HS, Lee SW, Chung SC, Kim YK. Oral manifestations procedures. If bleeding is prolonged, desmopressin can and salivary flow rate, pH and buffer capacity in patients provide haemostasis for upto 4 hours. If this fails, with end-stage renal disease undergoing hemodialysis.

3cryoprecipitate may be effective. Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Routine annual dental radiographs should be done to 1999;88 :316- 9.

establish and follow manifestations of osteodystrophy.

Therapy for xerostomia should be continued and routine

recall maintenance must be ensured.

CONCLUSION :

The prevalence of chronic renal failure is increasing day by

day. Oral and systemic complications can occur as a result of

chronic renal failure and its treatment. Upto 90 % of patients

with chronic renal disease show oral signs and symptoms, 11. De Rossi SS, Glick M. Dental considerations for the such as bleeding tendencies, greater susceptibility to patient with renal disease receiving hemodialysis. J Am infections and gingival overgrowth produced by

3. Alamo SM, Esteve CG, Perez M G S. Dental

considerations for the patient with renal disease. J CLin

Exp. Dent. 2011 ; 3(2) :e112-19

4. Patil S, Khandelwal S , Doni B, Rahman F , Kaswan S. Oral

Manifestations in Chronic Renal Failure Patients

Attending Two Hospitals in North Karnataka , India.

OHDM 2012; Vol. 11 (3):100-106.

5. Proctor R, Kumar N, Stein A, Moles D, Porter S. Oral and

dental aspects of chronic renal failure. J Dent Res.

2005;84: 199-208.

9. Peterson LJ, Ellis E III, Hupp JR, Tucker MR.

Contemporary oral and maxillofacial surgery. 3rd ed. St.

Louis: CV Mosby Co.; 2000.

10. Mozaffari P.M. , M. Amirchaghmaghi, Mortazavi H. Oral

Manifestations Of Renal Patients Before and After

Transplantation: A Review of Literature. DJH 2009; 1(1):

1-6.


Dent Assoc. 1996; 127: 211-9. 2007;12: 305-10.

12. Davidovich E, Davidovits M, Eidelman E, Schwarz Z, 14. Sharma DC, Pradeep AR. End stage renal disease and its

Bimstein E. Pathophysiology, therapy, and oral dental management. N Y State Dent J. 2007; 73: 43-7

implications of renal failure in children and adolescents: 15. Greenwood M, Meechan JG, Bryant DG. General an update. Pediatr Dent. 2005; 27: 98-106. medicine and surgery for dental practitioners Part 7:

Sobrado Marinho JS, Tomás Carmona I, Loureiro A, Renal disorders. British Dental Journal.2003; 195: 181-

Limeres Posse J, García Caballero L, Diz Dios P. Oral 184.

health status in patients with moderate-severe and

terminal renal failure. Med Oral Patol Oral Cir Bucal.

13.

UNIVERSAL PRECAUTIONS OF INFECTION CONTROL AGAINST BLOOD BORNE PATHOGENS

ABSTRACT:

Barrier precautions are a fundamental component of any blood borne

pathogen strategy and a critical aspect of all isolation systems. Many

infections are transmitted from patient-to-patient via the hands of personnel

and gloves and gowns are widely recommended to provide an extra measure

of protection against cross-infection. Barrier precautions may also fail if

infected patients are not identified promptly. Universal precautions were

designed to protect personnel, not to provide barriers to cross-infection and

are prone to misinterpretation and misapplication.

1014

Corresponding author:Name: Dr. Yashmeet KaurAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.Phone no.:9876186764

1. Post graduate student, Department of Oral and Maxillofacial Surgery Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. M.D.S, Reader , Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. M.D.S, Reader, Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

4. M.D.S , FICS, Dean Academics, Professor, Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

5. M.D.S, Professor and Head of Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciances and Research Amritsar

3INTRODUCTION hepatitis C virus (HCV).

The practice of barrier precautions to prevent cross- Dental professionals are exposed to a wide variety of

infection, particularly the use of gloves, has all the microorganisms in the blood and saliva of patients. These 1characteristics of a typical ritual . It would be difficult for a microorganisms may cause infectious diseases such as the

person living in an industrialized society during the common cold, pneumonia, tuberculosis, herpes, hepatitis B, 4twentieth century not to have been exposed to concepts of and acquired immune deficiency syndrome( AIDS) .

2.public and personal hygiene Hepatitis A,B and C viruses and the delta agent are

In the last decade, health professions have reassessed responsible for most infectious hepatic diseases. Although

infection control and the ethics of the provision of hepatitis types A and C are spread primarily by contact with

healthcare as a result of professional and public concern the faeces of infected individuals, Hepatitis B can be spread 3regarding bloodborne pathogens such as human by contact with any human secretion . The Hepatitis B virus

immunodeficiency virus (HIV) , hepatitis B virus ( HBV) ,and therefore, has the most serious risk of transmission for the


I J C D C1. Sumir2. Yashmeet Kaur3. Sarika Kapila4. Ramandeep Singh Bhullar5. Tejinder Kaur



Dental Care



dentist, staff, and patients. It is usually transmitted by the important method of preventing HBV infection . The number

introduction of infected blood into the bloodstream of a of vaccinated dentists is increasing constantly. Unvaccinated

susceptible person, but infected individuals may also secrete dentists are five times more likely to be infected than

large amounts of the virus in their saliva, which can enter an vaccinated dentists. Transmission of blood-borne pathogens

individual through any moist mucosal surface or epithelial following an exposure depends on the concentration of virus 5wound . Minute quantities of the virus have been found in the blood or body fluid, the volume of infective material

5 7 inoculated, the loss of infectivity during transfer of capable of transmitting disease( only 10 to 10 virions/ml of 5

blood). Unlike most viruses , it is exceptionally resistant to inoculate and the port of entry .2desiccation, and quaternary ammonium compounds . Since dentists who perform oral surgical procedures are

exposed to blood and saliva, the dental surgery team should KNOWLEDGE OF DENTISTS AND PATIENT'S

wear barriers to protect from contaminating any open The acquisition of Hepatitis B virus infection by health service wounds on hands and any exposed mucosal surfaces. This staffs or from patients is an occupational hazard , which can includes wearing of gloves, face mask, and eyeglasses, be estimated by comparing infection rates in health service

10during surgery .The dental staff should continue to wear staff with the general population. During normal dental these protective devices when cleaning instruments and practice , dentists are at risk of infection from micro-when handling impressions, casts, or specimens from organisms carried by patients. Injuries in dental offices patients. The current climate in today's society regarding happen because of a confined space, the frequent patient infectious diseases, in particular herpes, hepatitis, and HIV movement and the variety of sharp dental instruments used

2 infections, dictates that the dental profession must close the in normal dental practice .door to any possible transmission of infection in the dental

Universal precautions of infection control apply to blood, surgery and incorporate within their practices accepted

other body fluids containing visible blood, semen, and 6infection control techniques. vaginal secretions. Universal precautions also apply to

An injury caused by needle or blade can be prevented by tissues and to the following fluids : cerebrospinal , synovial, holding the sheath with an instrument during resheathing of pleural, peritoneal, pericardial, and amniotic fluids . needles after use, taking care never to apply or remove a However, Universal precautions do not apply to faeces, nasal blade from a scalpel handle or a needle from a syringe precautions, sputum, sweat, tears, urine,and vomitus unless

5 without an instrument, and disposing of used blades and they contain visible blood.needles into rigid ,well marked receptade box, container

Patient's attendance in dental clinics exposes them to two specially designed for contaminated sharp objects. Post

risks: first, the probability of cross-infection from one patient exposure prophylaxis refers to comprehensive management

to another from an infected dental instrument and second : given to minimize the risk of infection following potential

the potential hazard of an infected dentist, whereby the 7exposure to blood-borne pathogens (HIV, HBV, HCV).pathogen can be transmitted from the operator to the

PROTOCOL FOR NEEDLE STICK INJURY patient.

A) FIRST AIDIMPORTANCE OF PREVENTION IN DENTISTRY

Immediately following any exposure , whether or not the The recommendation to use universal, precaution systems source is known to pose a risk of infection.form a necessity for treating all patients, as though they are

infected with HIV, HCV, or HBV. Thus additional precautions 1) The wound should be washed immediately and thoroughly

for infected patients are unnecessary. Dental surgeons, who with soap and water.

wear glasses and work with ultrasonic and rotary 2) Antiseptics are not necessary as there is no evidence of instruments, are aware of the amount of droplet spread of their efficacy.saliva , blood and water because of deposits on their glasses.

3) Wounds should not be sucked.Blood-borne infections such as HBV have a occupational risk

4) For mucosal contact such as spillage into the conjuctiva, of a percutaneous exposure to HBV as estimated to be 2% for 7 the exposed part should also be washed immediately and HBeAg- negative and about 30% for HBeAg-positive blood .

8liberally with clean running water .Dentists are among the most at high risk of exposure of

MANAGEMENT OF ACCIDENTAL EXPOSURE TO HEPATITIS B Hepatitis B virus. Reusing local anesthetics syringes following VIRUS (HBV)recapping, and cleaning instruments were the two most

important causes of needlestick injuries in dental students 1) The management of an incident of accidental exposure to and dental hygienists . Currently , vaccination is the most Hepatitis B virus involves proper risk assessment, counseling


7tailored to the needs of individual, and the prescription of her own HIV serostatus . Therefore the exposed person 6postexposure prophylaxis as appropriate . should always be encouraged to have baseline blood taken

for HIV antibody after receiving pre-test counseling and 2) For the best protection , all health care staff with potential giving consent.risk of exposure to blood and body fluids are advised to

receive hepatitis B vaccination as soon as possible for their 3) The HIV status of the source person is not always

obtainable. Therefore , the likelihood of HIV infection has to own safety. Subjects with anti-HBs titre ≥ 10 mI/mL 1-4

be estimated based on clinical clues in the setting: months after vaccine completion are considered as

responders. Non-responders are those with no detectable a) HIV prevalence of the community group which the anti HBs and hypo-responders refer to those whose anti-HBs source belongs totitre are between 0-10 mIU/mL. Both non and hypo-

b) HIV-related risk behaviours e.g unprotected sex, responders should complete a second 3-dose vaccine series

multiple sex partners, needle –sharing for drug injection.and retested at the completion of the second vaccine series.

c) HIV related illnesses, e.g Pneumocystis jiroveci Non-responders to the initial 3-dose vaccine series have a 6 pneumonia, oral thrush etc.41% chance of responding to a second 3-dose series .

4) To date, Zidovudine is the only drug for which there is Two types of products are available for prophylaxis against evidence of a reduction in risk of HIV transmission following HBV infection. Hep B vaccine which provides long term occupational exposure and it continues to be a reasonable protection against HBV infection . HBIG( Hepatitis B choice as component of PEP.immunoglobulin) provides temporary protection ( i.e for 3-6

months) . Both passive and active PEP with HBIG and CONCLUSION

hepatitis A vaccination and active PEP with hepatitis B It's a multifactorial approach as improvement of infection vaccine alone has been demonstrated to be highly effective control practice requires continual assessment of the group's in preventing transmission after exposure to HBV. stage , intervention and prophylaxis assessment of

If percutaneous exposure ( e.g bite or needlestick injury ) appropriate intervention supporting individual and group 11Administer Hepatitis B vaccine and Hepatitis B creativity . Because of the complexity of the change process,

immunoglobulin. it is not surprising that single behavioural theory but are out

of organizational or individual context- often fail . More MANAGEMENT OF ACCIDENTAL EXPOSURE TO HCVeducation is required to promote a more realistic perception

1) One principle of Hepatitis C virus post-exposure of the risk of cross-infection with HIV and HBV and the use of

management is to identify those with acute Hepatitis C virus Universal Precautions. This may allay fears related to 9infection and refer them to specialists for further evaluation . personal risk and facilitate access to care for patients with

At baseline , Hepatitis C virus antibody should be tested for bloodborne pathogens.

both the source and the exposed. Sera should be stored for BIBLIOGRAPHYat least one year. For the exposed , testing should be

repeated at 6 months , 12 months if the source is HIV-HCV 1. Goldmann et al “The role of barrier precautions in

co-infected. infection control”,1991 J. Hosp. Inf, 515-523

2) Currently, there is no effective vaccine or 2. Hupp J, Textbook of Oral and maxillofacial surgery

chemoprophylactic agent for Hepatitis C virus infection “Principles of asepsis”, 1988, vol 1: 71-81

after accidental occupational exposure. 3. Gillian M et al, “The infection control practices of

3) Hepatitis C virus often causes persistent infection , and General dental Practitioners” Inf. Cont. Hospital

is important factor in the etiology of fibrosis, cirrhosis , and Epidemiology, june 2016: vol.18, no. 10:699-7039hepatocellular carcinoma(HCC). 4. Council on Dental Materials Instruments and

MANAGEMENT OF ACCIDENTAL EXPOSURE TO HIV Equipment Council on Dental practice, “ Infection

control recommendations for dental office and dental 1) Occupational injuries may be divided into: laboratory” . JADA, vol.116. Feb 1988:241-24

a) Percutaneous exposure ( from needles, instruments, 5 . CDC Guidelines “Universal precautions for prevention of bone fragments, human bite with breach of skin.)

transmission of HIV and other Bloodborne infections” b) Exposure via broken skin ( abrasions, cuts, eczema.)

1987c) Exposure via mucous membranes including the eyes.

6. Cottone A “Selection for dental practice of chemical 2) A person infected with HIV may not be aware of his or disinfectants and sterilants for hepatitis and AIDS”


Aust.Dent.J(1987):32(5); 368-74 10. Daniel M Laskin (1989) Textbook of Oral and

maxillofacial surgery : vol1:346-3617. NACO Guidelines Post-Exposure Prophylaxis

11. Kretzer K et al, Larson L et al “Behavioural interventions 8. WGO practice guideline, “ Needle stick injury and to improve infect ion contro l Pract ices” accident exposure to blood”;2005American.J.Inf.Cont ,June 1998:vol 26: 245-253.

9. Chan Kwon Y “Hepatitis C virus infection:

Establishment of chronicity and liver disease

progression” American.J.Inf.Cont. 2014 : 13: 977-996

EMERGENCY CARE IN PATIENTS WITH HEAD AND NECK INJURIES

ABSTRACT:

Trauma accounts for a significant proportion of annual mortality world-wide.

Being the most exposed part of the body, face is more vulnerable to such

injuries. Multimodal optimization of surgical care significantly improves

patient's physical and psychological function with reduced patient morbidity

and mortality after surgical procedure. The physical examination begins with

revaluation of the patient's vital signs. If the patient's vital signs are worsening

or if there is a deterioration of any system evaluated during the primary survey,

the secondary survey is halted and resuscitation is continued. The Advanced

Trauma Life Support Programs (ATLS) were built around three core concepts

which represented a dramatic change in traditional “medical” thinking. The

first concept defines the ATLS approach. Treat the greatest threat to life first.

The loss of an airway kills faster that the loss of intravascular volume which kills

faster than an acute intracranial bleed. This principle is simplified as the

“ABCDE” approach to the trauma evaluation. The second principle is that an

indicated treatment should not wait for a definitive diagnosis. And third, an

extensive history is not a critical component of the initial evaluation of the

injured patient. Life threatening injuries must be managed appropriately,

prioritized evaluation and intervention are essential.

1018

Corresponding author:Name: Dr. Tejinder KaurAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.Phone no:9814010528Email: [email protected]

1. Post graduate student, Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. M.D.S, Reader, Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. M.D.S, Professor & H.O.D, Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

4. M.D.S, FICS, Professor & Dean Academics, Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

INTRODUCTION increasing number of road traffic accidents with injuries to

craniofacial skeleton being the most challenging, alarming With the advent of modernization and backed by a thriving and disfiguring. Adding to the factors are interpersonal economy, India over the past few decades has seen violence, occupational and sports injuries which also considerable increase in motorization development and contribute to the already increasing number of craniofacial production. However, not being backed by proper road trauma. administration, proper understanding of machinery and lack

of traffic rule enforcement has led to proportionately .

Maxillofacial trauma is commonly associated with

multiple system injuries and occurs in 33% of severely

injured trauma victims brought into emergency rooms


I J C D C1. Era Arora2. Amneet Sandhu3. Tejinder Kaur4. Ramandeep Singh Bhullar



Dental Care



Studies have found that in maxillofacial region, along with

the nasal bone, mandible is one of the most vulnerable facial

bone to trauma due to its projection and prominent position 1with reported incidences of 24.3 to 75% .

The overall management consists of a rapid primary survey,

resuscitation of vital functions, a detailed secondary survey,

and lastly the initiation of definitive care. The primary survey

immediate management of critical injuries are imperative

first steps in the successful resuscitation of a trauma victim.

EARLY ASSESSMENT AND MANAGEMENT OF THE TRAUMA Definitive facial PATIENT

fracture repair may be delayed until life-threatening injuries

are corrected or the respiratory, neurologic, and

cardiovascular status of the patient has been stabilized. Early

assessment of organ systems that are life-sustaining and the

4Figure 1 Mallampati classification Figure 2 Anatomical considerations6for cricothyroidotomy

6Figure 3 Incision for cricothyroidotomy

10Figure 4 Surgical open tracheostomy.

This requires a 3-cm vertical skin incision initiated below the inferior

cricoid cartilage. The strap muscles are retracted laterally. The thyroid

isthmus is retracted either superiorly or inferiorly or divided. An

incision is created in the anterior trachea at the first or second tracheal

rings. A sideways “H” incision at the level of the second tracheal ring is

ideal and provides an open-book exposure without resection

4Figure 5 Parts of laryngeal mask airway 11Figure 6 Combitube placement


identifies injuries in a systematic fashion. · E – Exposure/Environmental control with temperature

controlThe mnemonic ABCDE defines the specific prioritized

evaluations and interventions should be followed in all Although the steps in the assessment and early management 2injured patients : of trauma patients are outlined in a linear fashion, during the

primary survey, life threatening conditions are identified and · A – Airway maintenance with cervical spine protectionmanagement is begun simultaneously. The patient's airway is

B – Breathing and ventilationevaluated and protected before moving forward to assess

C – Circulation with hemorrhage control breathing, circulation, and disability. The secondary survey

involving tests and observations does not begin until the D – Disability: neurologic status

·

·

·

TABLE 1: INDICATIONS FOR TRACHEOSTOMY PLACEMENT 7 -:

· Ventilator dependence/respiratory failure · Prolonged intubation (>1 week)

· Inability to protect airway

· Inability to generate sufficient respiration · Upper airway obstruction

· Definitive therapy of obstructive sleep apnea and obesity · Hypoventilation syndrome

· Where there is severe maxillo-facial trauma

· Where a patient can no longer manage their own secretions. · Where mucous membranes may become inflamed and swell so much that they

may occlu de airways. Inflamed membranes also secrete large amounts of mucous.

· Where an aspirated object may cause laryngeal muscles to spasm (making it difficult to pass an endotracheal tube)

· When long term intubations are required · Where a decreased level of consc iousness causes upper airway obstruction due

to relaxation of structures

TABLE 2: Percutaneous tracheostomy: indications and contraindications8

Indications · Inability to maintain/protect airway

· Upper airway obstruction/cancer (laryngectomy)

· Prolong ventilator requirements Absolute contraindications

· Unstable cervical spine injuries

· Coagulopathy · Emergency airway

· Pediatric age (<15 years old) Relative contraindications

· Obesity

· Short neck · Enlarged thyroid isthmus/goiters · High-riding innominate artery · Previous tracheostomy

· High positive end-expiratory pressure requirement


primary survey (ABCs) is completed, resuscitation is initiated, the Mallampati classification 1983, which assigns three

and the patients ABCs are re-evaluated gradations of increasing difficulty in visualizing the posterior

pharyngeal structures in order to predict difficult laryngeal Resuscitation4exposure (Fig 1)

A. Airway Evaluation in the Trauma PatientOnce it has been identified that the patient has an

All patients of trauma should be suspected to have an altered 3inadequate airway, one can adopt :or compromised airway till ruled out. They should continue

1. Simple airway strategyto receive supplemental oxygen and have cervical

immobilisation done using manual-inline stabilisation during 2. Definitive airway strategy (endotracheal intubation 3examination and airway management. or surgical airway), or

The most utilized predictive scheme for airway assessment is 3. Semi-definitive airway strategy for making the

TABLE 3: RISKS OF TRACHEOSTOMY PLACEMENT9

Standard Surgical Risks Tracheostomy-Specific Risks Pain Infection Bleeding Need for additional procedures Damage to surrounding structures Scar

Hemopneumothorax Damage to trachea or esophagus (including tracheoesophageal fistula) Tracheal stenosis Inability to decannulate Mucous plug Tracheoinnominate fistula/erosion

TABLE4: Composition of common crystalloids14

Crystalloid 0.9% Saline Hartmann’s Plasmalyte 5% Dextrose 4%

Dextrose in

0.18% Saline

7.5% Saline

Osmolality (mOsm kg¯1)

300

280

299

278

286

2400

pH

5.0

6.5

5.5

4.0

4.5

+Na

mmol l¯1

150

131

140

0

31

1250

K+

mmol l¯1

0

5.0

5

0 0

HCO3-

mmol l¯1

0

29a

50b

0

0

Cl ̄

mmol l¯1

150

111

98

0

31

1250

Ca2+

mmol l¯1

0 2 0 0

31

a - HCO is provided as lactate3

b - 1 - 1 27 mmol l as acetate and 23 mmol l as gluconate


airway patent as per existing situation device availability and presence of operator with necessary

expertiseSIMPLE AIRWAY STRATEGY

1. Direct laryngoscopy and tracheal intubation.This includes Head tilt and Chin lift (avoid in patients with

cervical trauma)/jaw thrust or the use of basic adjuncts such 2. Video laryngoscopy and intubation.

as oropharyngeal airway in unresponsive patients without 3. Fibreoptic tracheal intubation. gag reflex, and/or nasopharyngeal airway in patients with

4. Lightwand-guided tracheal intubation.more active reflexes but without evidence of fracture of base

3 5. Intubating LMA/C-Trac-aided tracheal intubation of skull.36. Blind nasal intubationDEFINITIVE AIRWAY STRATEGY

Surgical airway should be resorted when there is severe This includes either endotracheal intubation(ETI) or a glottis oedema and/or oropharyngeal haemorrhage, surgical airway. Options for achieving ETI may include any fracture of the larynx and when endotracheal tube fails to be one of the following airway aids depending on the situation,

TABLE 5: Glasgow Coma Scale (GCS) by Teasdale G.and Jennett B.16

Eye opening Spontaneous – 4 To speech – 3 To pain – 2 None – 1

Motor response Obeys commands – 6 Localizes to pain – 5 Normal flexion (withdrawal) – 4 Abnormal flexion (decorticate) – 3 Abnormal extension (decerebrate) – 2 Flaccid – 1

Verbal response Oriented – 5 Confused conversation – 4 Inappropriate words – 3 Incomprehensible sounds – 2 None – 1

TABLE 6: Traditional classification of hypothermia and

revised definitions for the trauma patient17

Degree of

hypothermia

Traditional classification

(

Trauma

classification ( C)

Mild

Moderate Severe

Profound

Deep

32—35

28—32 20—28

14—20

<14

34—36

32—34 <32

C)


passed through the vocal cords. 1% of trauma patients develops if, after chest wall or lung injury, a one-way valve 3requiring intubation require a surgical airway . Surgical mechanism exists that allows air to enter the pleural space

airway techniques include-: without exit. There is an eventual shift in the mediastinum to

the contralateral side and compression of the major vessels Cricothyrotomy entering the chest. With compression, there is a decrease in

Surgical cricothyrotomy has potential applications in patients venous return to the heart and resulting decline in cardiac

who require an elective or emergency surgical airway. In output. This lesion is suspected in the patient with signs of

cases where intermaxillary fixation is needed or when nasal chest trauma, absence of breath sounds on one side,

or submental intubation is not desired, it allows hyperresonance of the chest wall, hypotension, and shift of

intraoperative and postoperative intermaxillary fixation the trachea to the contralateral side. The treatment is

5without compromising the airway.immediate decompression of the pleural space with a large-

Cricothyrotomy can be performed using the following three bore needle inserted through the second intercostals space techniques(Fig.2- 3): along the mid-clavicular line, followed by the formal

insertion of a thoracostomy tube. Intubation and positive A. A needle using a 12-14 gauge cannula. The cannula, after pressure ventilation can cause a relatively small withdrawing the needle, is connected to 40- 50 psi source pneumothorax to expand rapidly. Breathing should be delivering oxygen at 15L/minute. Intermittent insufflation, 1 repeatedly evaluated with auscultation of the chest and a second on and 4 second off, can provide satisfactory jet

2chest radiograph should be obtained as soon as possible.insufflation.

C. Circulation B. A needle airway procedure as above, but where the

ventilation is provided by low pressure ventilation. Hemorrhage and hemorrhagic shock that account for 30 to

40% of trauma deaths, are more amenable to interventions C. “Surgical Airway” where a cuffed tube is inserted into the 13to reduce mortality and morbidity. Furthermore, about 25% trachea through the cricothyroid membrane and ventilation

of CNS injuries are complicated by shock. Among those with is performed through a self-inflating bag or other ventilating 6 multiple injuries, brain injury remains the primary cause of technique. (Fig.4)

death, but hypotension increases mortality in this group two- Tracheostomy

12to three-fold.Tracheostomy is a commonly performed elective procedure

Early Mortalitythat is indicated in patients experiencing prolonged tracheal Hemorrhage leads to death during the prehospital period in intubation for mechanical ventilatory support or as an 33 to 56% of cases, and exsanguination is the most common emergent procedure in the event of sudden loss of an airway

7 cause of death among those found dead upon the arrival of that cannot be secured by conventional methods. 12emergency medical services (EMS) personnel. Hemorrhage (Table 1-3)

accounts for the largest proportion of mortality occurring SEMI-DEFINITIVE AIRWAY STRATEGYwithin the first hour of trauma center care, over 80% of

4Currently, the LMA , the ProSeal laryngeal mask airway operating room deaths after major trauma, and almost 50% (PLMA) (Fig.5), the laryngeal tube (LT), the laryngeal tube of deaths in the first 24 hours of trauma care. After first few with integrated suctioning tube (LTS) and the oesophageal hours of trauma care, CNS injury replaces hemorrhage as the

11tracheal combitube (OTC) Fig.6 are the best evaluated and leading cause of trauma mortality. Very few hemorrhagic most widespread devices. Both the LMA and the PLMA have deaths occur after the first day. There are multiple potential been shown to be perfectly suitable for routine anaesthesia sources of bleeding in the trauma patient. External blood loss and emergency airway management. is managed during the primary survey with pressure on the

12B. Breathing wound.

After a definitive airway is confirmed, the patient's breathing Late Mortality and Morbidity

is evaluated. The chest wall should be exposed to allow for a The presence of hemorrhagic shock is a predictor of poor thorough inspection. Inspection will confirm appropriate outcome in the trauma patient. As the amount of blood loss

chest movement with respiration. Palpation and percussion increases, so do resuscitation requirements and physiologic will confirm diaphragmatic excursion and may detect signs of 12 derangements including hypotension and acidosis.

2blood or air in the pleural space. Hemorrhage is defined as an acute loss of circulating blood Diminished or absent breath sounds may indicate a volume. The average adult blood volume isapproximately 7%

pneumothorax or hemothorax. A tension pneumothorax of body weight (70 ml/kg). Children have estimated blood


volumes of 8–9% of body weight and infants estimated blood the initial fluid bolus then ongoing fluid resuscitation is

volumes are 9–10% of body weight. Blood loss of 10–15% of a anticipated. It is likely that the patient will require blood

healthy person's blood volume can generally be tolerated transfusion but type-specific blood may be available. In the

without clinical sequelae. Shock is defined as an abnormality patient with severe hemorrhage (over 40% of estimated

in the circulatory system that results in inadequate tissue blood volume) immediate transfusion is required. In this

perfusion and oxygenation. Early signs of a collapsing situation type O blood will be used until type-specific blood is 2circulatory system are tachycardia and peripheral available.

vasoconstriction. As the system continues to fail, perfusion to D. Disability (neurologic evaluation)central organs and muscle decreases in order to preserve

A decline in the patient's level of consciousness may be due 2cerebral perfusion.to a decrease in cerebral perfusion or cerebral oxygenation,

TYPES OF FLUID or may be due to an intracranial injury. The first response to

Intravenous fluids may broadly be classified into colloid and an altered mental status is to re-evaluate airway, breathing,

crystalloid solutions. They have very different physical, and circulation. A rapid neurologic assessment should 2chemical and physiological characteristics. include an evaluation of sensory and motor function.

Crystalloid solutions The Glasgow Coma Scale is a rapid objective clinical measure

of neurologic function. The scale was initially published in Solutions of inorganic ions and small organic molecules 1974, by two neurosurgeons (Graham Teasdale and Bryan dissolved in water are referred to as crystalloids (Table 4).

15-16Jennett) at the University of Glasgow. (Table.5)The main solute is either glucose or sodium chloride (saline)

and the solutions may be isotonic, hypotonic or hypertonic The scale assesses eye opening, motor response, and verbal

with respect to plasma. Isotonic saline has a concentration of response. Each category is scored based upon best response

0.9% w/v (containing 0.9g NaCl in each liter of water). and the scores are tallied to determine a Coma Score. The

Potassium, calcium, and lactate may be added to more highest score obtainable is 15 (indicating an unaltered, 2closely replicate the ionic makeup of plasma. Crystalloids awake patient) and the lowest is 3 (indicating deep coma).

with an ionic composition close to that of plasma may be E. Exposure/environmental control13referred to as “balanced” or “physiological”.

The primary survey concludes with complete exposure of the Colloid solutions patient. During the resuscitation, and particularly once the

A colloid is a homogeneous non-crystalline substance patient is undressed, it is critical to protect the patient from

consisting of large molecules or ultramicroscopic particles of developing hypothermia. Hypothermia develops in up to

one substance dispersed through a second substance - the 70% of trauma patients at some point during resuscitation.

particles do not settle and cannot be separated out by Exposure, paralysis, and fluid administration all contribute to

ordinary filtering or centrifuging like those of a suspension lowering the patient's core temperature. Hypothermia can

such as blood. Colloid solutions used in clinical practice for produce a relative coagulopathy. It alters platelet function,

fluid therapy are divided into the semisynthetic colloids the coagulation cascade, and the fibrinolytic system. A drop

(gelatins, dextrans and hydroxyethyl starches) and the in the core temperature of just a few degrees is enough to 1naturally occurring human plasma derivatives (human produce a marked decrease in clotting ability. (Table.6)

albumin solutions, plasma protein fraction, fresh frozen Hypothermia also produces a dramatic increase in oxygen plasma, and immunoglobulin solution). Most colloid consumption. Decrease in the core temperature of 0.3ºC solutions are presented with the colloid molecules dissolved produces a 7% increase in oxygen consumption and a in isotonic saline but isotonic glucose, hypertonic saline and decrease of 1.2ºC, produces a 92% increase in oxygen isotonic balanced or “physiological” electrolyte solutions are consumption. Hypothermia can produce negative inotropic

13also used. changes in the heart and respiratory depression, and

Further fluid resuscitation and the need to transfuse blood exacerbate hyperglycemia by decreasing insulin production

are based upon estimates of the volume of blood loss and the and creating end-organ insulin resistance. Hypothermia,

patient's response to the initial fluid bolus. If the patient had along with acidosis and coagulopathy, has been identified as

minimal blood loss (10–15% of estimated blood volume) and a component of the ''lethal triad'' in injured patients, and has

a rapid response to the initial fluid with a return to normal been shown to contribute to increased mortality in these 1vital parameters they are not likely to require blood patients.

transfusion. If the patients had moderate blood loss (20–40% Rewarming of the trauma patient can be undertaken using of estimated blood volume) and only a transient response to


either passive or active methods. Passive rewarming consists 6. Wolfe MM, Davis JW, Parks SN. Is surgical airway

of optimizing environmental conditions while allowing the necessary for airway management in deep neck

patient's own heat generating capabilities to correct the infections and Ludwig angina? Journal of Critical Care

decrease in core temperature. Active rewarming includes 2011; 26: 11-14

external methods of rewarming as well as methods directed 7. Oreadi D, Carlson ER. Morbidity and mortality associated at rewarming the core. External rewarming techniques with tracheostomy procedure in a university medical include the use of heating blankets, convective air blankets, centre Int J Oral Maxillofac Surg 2012;41:974-977

17-18reflective blankets, and radiant heat shields.8. Liao L, Myers. Percutaneous Dilatational Tracheostomy

SUMMARY Atlas Oral Maxillofacial Surg Clin N Am 2015;23:125–129

The treatment of trauma requires the rapid assessment of 9. Taylor C, Otto R. Open Tracheostomy Procedure Atlas injuries and institution of life-preserving therapy. Because Oral Maxillofacial Surg Clin N Am 2015;23: 117–124Timing is crucial, a systematic approach that can be rapidly

10. Cheung NH, Napolitano L. Tracheostomy: Epidemiology, and accurately applied is essential. This approach is termed

indication, timing, technique, and outcomes. the “initial assessment” and includes the following elements:

Respiratory care 2014;59(6):895-919Preparation, Triage, Primary survey (ABCDEs), Resuscitation,

11. Mercer MH. An assessment of protection of the airway Adjuncts to primary survey and resuscitation. Specifically, from aspiration of oropharyngeal contents using the appropriate monitoring and repeated clinical assessment are combitube airway. Resuscitation 2001; 51: 135-138required, along with support for all major organ systems,

including cardiorespiratory function, renal function and fluid 12. Kauvar DS, Lefering R, Wade CE Impact of hemorrhage on and electrolyte balance. Multimodal optimization of surgical trauma outcome: An overview of epidemiology, clinical care significantly improves patient's physical and presentations and therapeutic considerations J trauma psychological function with reduced patient morbidity and 2006;60:S3-S11mortality. 13. Grocott MP, Mythen MG, Gan TJ Perioperative fluid BIBLIOGRAPHY management and clinical outcomes in adults Anesth

Analg 2005;100:1093-11061. Andersson L.Oral and maxillofacial surgery 2010

14. Nolan J Fluid resuscitation for the trauma patient 2. Fattahi T. Perioperative laboratory and diagnostic Resuscitation 2001;48:57–69testing- what is needed and when? Oral Maxillofacial

Surg Clin N Am 2006;18:1-6 15. Gill M, Windemuth R, Steele R, Green SM A comparison

of the Glasgow coma scale score to simplified alternative 3. Khan RM, Sharma P, Kaul N. Airway management in scores for the prediction of traumatic brain injury Annals trauma Indian Journal of Anaesthesia 2011; 55(5):463-of Emergency Medicine 2005;45(1):37-42469

16. Teasdale G, Jennett B. Assessment of coma and impaired 4. Orebaugh SL. Difficult airway management in the consciousness The Lancet 1974:81-83emergency department. The Journal of Emergency

Medicine 2002; 22: 31-48. 17. Tsuei BJ, Kearney PA Hypothermia in the trauma patient

Int J carre injured 2004;35:7-155. Teo N, Garrahy A. Elective surgical cricothyroidotomy in

oral and maxillofacial surgery Br J Oral Maxillofac Sur 18. Bailey & Love's. Short practice of surgery (ed 21)2013;51:779-782

PROSTHODONTIC MANAGEMENT OF GAGGING: A REVIEW

ABSTRACT:

The gag reflex is a complex physiologic phenomenon. The problem

compromises the quality of dental treatment and is a barrier to optimal patient

care. The function of the reflex is protective in nature. When the reflex is

abnormally active, the dentist may be presented with a bewildering and

frustrating problem in various dental procedures, resulting in a strong potential

for compromised treatment. The purpose of this paper is to describe methods

of managing the gagging patient that has a sound rationale based on modified

treatment approaches.

Key words: Gagging, trigger zones, vomiting, reflex, management.

1026

Corresponding author:Name: Dr. Simrat Kaur Address: Sri Guru Ram Das Institute of Dental Sciences andResearch, Amritsar.Phone no.:9988944863Email: [email protected]

1. M . D . S , R e a d e r, D e p a r t m e n t o f Prosthodontic and Crown and Bridge Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.




1 INTRODUCTION vomiting.

Gagging is an involuntary contraction of muscles of soft It is a reflex mechanism in which afferent signals are carried

palate or pharynx that results in retching. It is a normal by trigeminal, glossopharyngeal and vagus nerves from

protective reflex designed to protect the airway and remove receptors around the mouth, tongue, soft palate to the brain

irritant material from the posterior oropharynx and upper in medulla oblongata. Efferent signals are carried out by

GIT tract. Gagging reaction ranges from mild choking to trigeminal, facial, vagus , hypoglossal and sympathetic 2violent, uncontrolled retching which may/may not precede nerves which results in gagging.


I J C D C1. Simrat Kaur2. Harshveer Kaur3. Heena Sharma4. Nitika Kaur



Dental Care



Some people have a reduced or absent reflex, whilst others construction of plateless dentures which are not covering

have a pronounced one. Pronounced gag reflexes can palatal vault but it is satisfactory only if maxillary ridge is well

compromise all aspects of dentistry, from the diagnostic formed.

procedures and radiography to any form of active treatment. CAUSES OF GAGGINGIn some patients with marked gagging reflexes, it can lead to

5 Intraoral areas are known to be "Trigger Zones": avoidance of treatment.palatoglossal and palatopharyngeal folds, base of tongue,

Active gag reflex upsets the patient, compromises quality of palate, uvula and posterior pharyngeal wall. Sensitivity to 8treatment and frustrates the dentist. Effective management these areas is known to cause gag reflex. Various factors are

of gagging depends on treatment of the cause and not as follows:merely the symptoms. By thorough examination, taking

CLASSIFICATION OF GAGGING adequate medical history, conversation with the patient, the

ACC. TO KROLL (1963): Psychogenic or somatic in origindentist needs to determine cause for gagging which can be

because of iatrogenic factors, organic disturbances, ACC. TO FAIGENBLUM (1968): On the basis of severity of the 3anatomic or psychological factors. problem: mild or severe retching

REVIEW OF LITERATURE ACC. TO DAVIS: Physiological or psychological4Schote et al (1959) gave the relationship of gag reflex to the MANAGEMENT OF GAGGING REFLEX

vomiting reflex and describe that vomiting centre lies in the The aim of treatment is to allow the patient to receive dental

dorsal portion of the lateral reticular formation of medulla care such as restorative treatment or wearing of dental

oblongata. prosthesis with minimum of anxiety and stress. (6) The

5Singer et al (1973) tried to place glass marbles in mouth various management strategies are as follows:prior to the treatment of denture patients.

1. Psychological intervention6Murphy et al (1975) surveyed gagging and analyzed medical

2. Prosthodontic managementhistory. He attributed the problem to complete or partial

3. Pharmacological measuresmaxillary dentures. he treated gagging patients by

construction of clear acrylic training plate combined with 4. Surgical interventionrelaxation therapy.

5. Acupressure and Acupuncture7Flamer and Connely (1984) suggested technique for

1. PSYCHOLOGICAL INTERVENTION

ETIOLOGICAL FACTORS

ANATOMIC FACTORS:

A. Atonic and relaxed soft

palate

B. Long soft palate

C. Sudden drop at the

junction of soft and hard

palate

D. Undue sensitivity of the

soft palate, uvula, fauces,

posterior pharyngeal wall

and tongue

MEDICAL FACTORS A. Nasal obstruction B. Postnasal drip C. Catarrh D. Nasal polypE. mucosal congestion of upper respiratory tract F. Chronic gastrointestinal diseases notably chronic gastritis, peptic ulcers and carcinoma of stomachG. Hiatus hernia and uncontrolled diabetes

PSYCHOLOGICAL FACTORS

A. Stress

B. Phobia

C. Alcoholism

D. Fear

E. Visual and olfactory

stimuli

DENTAL FACTORS

A. Thin consistency

impression material

B. Oversized impression

tray

C. Inadequate posterior

palatal seal

D. Restricted tongue space

in denturesE.. Poor retention.F.Surface finish of acrylic resin.G.Inadequate free way space.H. Poor execution of intra oral procedures


Psychotherapy includes: relaxation, distraction and prevent gagging. It is easy to use these trays using disposable

desensitization procedures saliva ejectors at distal aspect so that excess impression

material flow through these areas without triggering the soft a) RELAXATION: Gag reflex may be a manifestation of an 9palate.anxiety state. Relaxation techniques are helpful in reducing

the gag reflex like ask the patient to tense and relax certain 2. Recording jaw relations: Vertical dimension of

muscle groups, starting with legs and working upwards, occlusion should be appropriately recorded because when

while continually providing reassurance in calm atmosphere. vertical dimension decreases space for tongue also

decreases due to which tongue will fall back and it can lead to b) DISTRACTION: These techniques are to divert the patient gagging.attention and to allow short dental procedures to be

performed by engaging the patient in conversation, by 3. In known gagger Marble technique is suggested.

asking the patient breathe audibly through the nose and at The patient is asked to keep 5 marbles in their mouth , as

the same time rhythmically tap the right foot on the floor , by often as possible , in a week prior to the commencement of 9 9instructing to patient to raise one leg and hold it in air. prosthodontic treatment

2. PROSTHODONTIC MANAGEMENT 4. TRAINING BASES: In desensitization technique, a

patient is progressively supplied with series of small to full 1. During the initial steps of impression making sized denture bases. A thin acrylic denture base without following points should be considered:teeth is fabricated and the patient is asked to wear it at home,

a) Selection of tray: Tray size should be appropriate. gradually increasing the length of the time the training base is

Oversized tray can lead to gagging.worn.

b) Material selection: Impression material of thin 5. ROOFLESS DENTURE- maxillary denture can be

consistency should be avoided. Use of fast setting material is reduced to a U-shaped border situated approximately 10mm

advocated. Tray should not be overloaded with impression from the dental arch. Denture wearers with the above type of

material.dentures reported that reduction of the palatal coverage

c) Posterior palatal seal should be appropriately recorded influences their sense of taste positively, and reduces or

and should not be underdamed or overdamed. eliminate gagging tendency.

d) Modified maxillary custom tray can also be used to 6. MATTE FINISH DENTURE- Jordan in 1954 suggested

ACUPUNTURE (Fig. 1) FIg. 2

Fig. 3. Neiguam Point, concave area at medial aspect

of forearm below the palm

Fig. 4. Hegu point, concave area between first and

second metacarpal bones


that a smooth highly polished surface coated with saliva may REFERENCES

produce a slimy sensation which is sufficient to cause gagging 1. The academy of Prosthodontics foundation. The in some patients; a matte finish has been advocated as more glossary of Prosthodontic Terms. J Prosthet Dent acceptable in this situation. 2005;94(1):40

7. CONTROLLED BREATHING METHOD- This method 2. Dickinson CM, Fiske J. A Review of Gagging Problems in advocated by the National Child Birth Trust for use by women Dentistry: 1. Aetiology and Classification. Dent Update in labour in similar to that advocated by Morphy. All patients 2005; 32:26-32.were instructed in controlled rhythmic breathing and told to

3. R.D.Savage and A.R.Macgregor: Behaviour Therapy in practice it for one or two weeks before prosthetic treatment Prosthodontics J.Prosthet Dent; 24(2):126-131,1970.commenced. The breathing was slow, deep and even, and

4. Schote M.T. Management of the Gagging J. Prosthet. the rhythm maintained by concentrating the mind upon a

Dent., 4; 578, 1959.particular verse or tune with an even tempo.

5. Singer J.L. The marble technique: method for treating 3. PHARMACOLOGICAL METHODS

the hopeless gagger for complete dentures. J. Prosthet. When clinical and prosthodontic procedures fail, Dent., 29;149,1973.pharmacological assistant is taken to control the gagging.

6. Murphy JK. Clinical evaluation of the gagging denture Drugs used are classified as peripherally acting which include

patient. J. Prosthet Dent., 25;615,1975topical and local anesthetics and centrally acting drugs are

antihistamines, sedatives, tranquilizers and CNS 7. Flames and Coney. The radiological anatomy of patients depressants. who gag with dentures. J. Prosthet. Dent., 45;127,1984.

4. SURGICAL CORRECTION 8. Meeker HG, Magalee R. The conservative management

of the gag reflex in full denture patients. N Y State Dent J Leslie reported that persistent gagging result from atonic

1986; 52: 11-4and relaxed soft palate which is found in nervous patient. So

he advocated an operation to tighten and shorten the soft 9. K S Laxman, D Esha. Gagging a review. NUJHS Vol 4, No.1, 10palate. Mach 2014 ISSN22497110

5. ROLE OF ACUPUNCTURE: Acupuncture is a system of 10. J Fiske and C Dickinson : The role of acupuncture in medicine in which a fine needle is inserted through the skin controlling the gagging refle using a review of ten causes to a depth of a few millimeters, left in place for a time, British Dent. Journal; 01190(11):611-613,2001.sometimes manipulated and then withdrawn. There is a

specific, recognized anti-gagging point on the ear. The

needles are not disturbed during access to the mouth for

dental treatment. (Fig. 1)

6. ACUPRESSURE TECHNIQUE: Acupressure caves are

sensitive points in the human body that feel soreness

distention, when deep pressure is applied for five to twenty

minutes. These points are left and right concave area at

medial aspect of the forearm and concave area between first

and second metacarpal bones. Acupressure points for

gagging are Yingtang, Neiguan, Hegu. ( Fig 2,3 and 4)

CONCLUSION

Overt gagging can be distressing for both the patient and

clinician. There appears to be no universal remedy for the

successful management of the gagging patient. A wide

variety of management strategies have been described and

these should be tailored to suit the needs of individual

patients. This can only be ascertained by taking a detailed

history. In many situations a combination of treatment

techniques is required.

UNFINISHED ROOT CANAL AND RISK OF CARDIOVASCULAR DISEASES : A REVIEW AUTHOR SEQUENCE

ABSTRACT:

Root canal treatments (RCTs) aim to eradicate pulpal diseases and save the

infected teeth by eliminating microorganisms from the root canal system.

Starting but not finishing an RCT can perpetuate a dead space for bacterial

growth, which can spread to other sites in the body and develop systemic

symptoms. Cardiovascular diseases (CVD) have a complex etiology determined

by risk factors, which are in turn associated to a strong genetic component and

to environmental factors. In the biological background for the development of

CVD, low-grade chronic inflammation plays a role as a pathogenetic

determinant of atherosclerosis.

Bacterial etiology has been confirmed for common oral diseases such as caries

and periodontal and endodontic infections. Bacteria causing these diseases are

organized in biofilm structures, which are complex microbial communities,

composed of a great variety of bacteria with different ecological requirements

and pathogenic potential. The biofilm community not only gives bacteria

effective protection against the host's defense system but also makes them

more resistant to a variety of disinfecting agents used as oral hygiene products

or in the treatment of infections. Successful treatment of these diseases

depends on biofilm removal as well as effective killing of biofilm bacteria.

Keywords: Root canal treatment, biofilm, endodontic infections,

cardiovascular diseases

1030

Corresponding author:Name: Dr. Pratibha HandaAddress: Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India.Phone numbers: 7837088922E-mail address : [email protected]

1. Post Graduate student, Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab.

2. MDS, Senior Lecturer, Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab.

3. Post graduate student, Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab.

4. Tutor, Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab.

4INTRODUCTION atherosclerosis and CVD events.

Cardiovascular disease (CVD) is one of the leading causes of Inflammatory and immune responses are initiated in the 1mortality worldwide, approximately 30% of all deaths and pulp tissue or periapical area when antigens are introduced

5 have a complex etiology determined by risk factors, which into the root canal. Exudate is often found in it.

are in turn associated to a strong genetic component and to Periodontal and pulpal diseases are 2 major low-grade 2

1environmental factors. chronic inflammatory infectious diseases of the oral cavity.

Atherosclerosis is the main cause of coronary heart and Periodontal disease is a chronic gram-negative anaerobic

cerebrovascular disease which, in turn, are the most infection of the tooth-supporting structures with an 3 6common causes of death in the industrialized world. In estimated prevalence of as high as 75% in adults in the US.

recent years, low-grade chronic inflammation and bacterial Apical periodontitis is caused by bacteria residing inside the or viral organisms involved in chronic inflammation have root canals of the diseased teeth, and organized in a bio film, been proposed as strong factors associated with as a consequence of pulpal infection, which is usually the


I J C D C1. Harshita2. Pratibha Handa3. Harsimranjit Kaur4. Amitoj Kaur Walia



Dental Care



2 1ultimate result of a deep carious lesion. Clinically, it is systemic circulation.

diagnosed from patient symptoms, clinical signs, and Ischemic heart disease, Dysrhythmias, and Infective radiographic images; chronic apical periodontitis, and is Endocarditis are some of the cardiovascular conditions most

10confirmed through observation of periradicular commonly seen among the population.7radiolucencies on affected teeth.

A comprehensive treatment plan should be constructed Additionally, acute endodontic inflammation also plays a role keeping in view all the pros and cons related to patient's

8in CHD risk. Links between endodontic inflammation and medical condition.cardiovascular outcomes are biologically plausible,

DIFFERENT MICROBES FOUND IN ENDODONTIC INFECTIONconsidering the predominance of Gram-negative anaerobes

The rationale for endodontic treatment is to eradicate the associated with endodontic infections (Baumgartner, 1991), infection, to prevent microorganisms from re-infecting the evidence of cytokine production in inflamed pulp and root or periradicular tissues. Thus, a thorough understanding periapical granulomatous tissues (Miller et al, 1996) , and of the endodontic microbiota is the basis for the success of observations of elevated systemic levels of inflammatory

11endodontic treatment.mediators (Marton et al, 1988).

Intraradicular infectionsBacterial infection of the dental pulp ultimately results in

the formation of dental periapical lesions consisting of The endodontic pathogens that cause primary intraradicular granulomas and cysts, which represent two different infections are:

9stages of development of the same inflammatory lesion. 1) Black pigmented Gram negative anaerobic rods Cytokines are produced in inflamed pulp and periapical (Bacteroides melaninogenicus). granulomatous tissues, and systemic levels of inflammatory (a) saccharolytic – Prevotella intermediamediators have been observed in patients undergoing RCT. A

(b) asaccharolytic – Porphyromonas gingivalis.plausible mechanism is that infectious processes associated 122) Tannerella forsythia with the root canal system may not only cause local

manifestations of oral cavities but also extend to nearby and 3) Fusobacterium nucleatumdistant body compartments along anatomic pathways or

4) Spirochetes are highly motile, gram negative bacteria. All

7

Procedure Prevelance of Bacteraemia

Extraction

·

Single

51%

·

Multiple

68-100%

Periodontal surgery

·

Flap procedure

36-88%

·

Gingivectomy

83%

Endodontics

·

Intracanal instrumentation

0-31%

· Extracanal instrumentation 0-54%

Endodontic surgery

· Flap reflection 83%

· Periapical curettage 33%

29Table No: 1 prevelance of bacteraemia arising after various types of dental procedures and oral cavity.


13 oral spirochetes fall into the genus Treponema. The most common Gram positive bacteria are:

· Treponema denticola · Lactobacilli

· Treponema socranskii · Staphylococci

6) Gram positive anaerobic rods: · E. faecalis

· Actinomyces spp. · Eubacterium

· Eubacterium spp. Extraradicular infections

7) Gram positive cocci that are present in endodontic Intraradicular microorganisms usually constrain themselves

infection: in the root canal and can overcome the defense barrier and

establish an extraradicular infection. This may lead to · Streptococcus mitisdevelopment of acute apical abscess in periapical tissue. The

· Enterococcus faecalis. 14dominant microorganisms present are anaerobic bacteria :Bacteria persisting intracanal disinfection procedures and

· Actinomyces spp.after root canal treatment

· Porphyromonas gingivalisThe most common Gram negative anaerobic rods are:

· Prevotella spp.· Fusobacterium nucleatum

PATHWAYS OF INFECTION· Prevotella spp.

Kakehashi et al stated that there are so many ways by which

Regimen Drugs

Standard regimen Adults: 2.0 gm Amoxicillin

Children: 50 mg Amoxicillin

Patients allergic to

penicillin or

already taking

penicillin class of

medication

Adults: 2.0 cephelexin Or

600 mg Clindamycin

Or 500 mg Azithromycin or Clarithromycin

Children: 50 mg Cephlexin Or 20 mg/kg Clindamycin or 50 mg

Azithromycin

Alternative im/iv

regime for patients

allergic to penicillin

and unable to take

oral medications

Adults: 1.0 gm im or iv Cefazolin or Ceftriazone

Or 600 mg im/iv Clindamycin

Children: 50 mg im/iv Cefazolin/ Ceftriazone

Or

20mg im/iv Clindamycin within 30 minutes before the procedure

o

35Table No: 2 Describes recommended antibiotic regimens for antibiotic prophylaxis.


11 the microorganisms reach the pulp. The various routes are: by the dissemination of microorganisms or toxic products 18from a focus of infection.1. Dentinal tubules: After a carious lesion or during dental

19procedures, microorganisms may use the pathway in a Rosenow (1917) reinforced the concept of a focus of

centripetal direction to reach the pulp. Bacteria gain access infection from which microorganisms could enter the blood

to the pulp when the dentin distance between the border of stream causing systemic illness. He insisted that enclosed 15carious lesion and the pulp is 0.2 mm. lesions that could only drain into the circulation, such as a

necrotic pulp, were the most dangerous foci of infection.2. Periodontal membrane: Microorganisms from gingival

sulcus may reach the pulp chamber through the periodontal Fish Theory

membrane, using a lateral channel or the apical foramen as a In 1939, Fish theorized that the zones of infection are not an pathway. This pathway becomes available to microorganisms infection by themselves but the reaction of the body to during a dental prophylaxis, due to dental luxation, as a result infection. He concluded that this response occurred

20of the migration of epithelial insertion to the establishment regardless of the virulence of the organisms. Zones of Fish 11of periodontal pockets. theory are:

3. Faulty restoration: Studies have proven that salivary Zone of Infection: This is the nidus of infection at the foramen contamination from the occlusal aspect can reach the where the bacteria are confined; characterized by PMN's

20periapical area in less than 6 weeks in canals obturated with and microorganisms along with the necrotic cells.16 guttapercha and sealer. Three possible metastatic pathways

Zone of contamination: This zone is characterized by death of can be responsible for the consequences of oral infections on

normal tissue cells, due to high concentration of toxins and 2systemic diseases such as CVD. 20lymphocytes.1. Metastatic spread of infection from the oral cavity

Zone of irritation: This zone consists of some normal tissue 2. Metastatic injury by circulating oral microbial toxins cells that have survived due to lower concentration of toxins.

3. Metastatic inflammation arising from an immune Osteocytes and histiocytes resorb bone and isolate the 20response to oral microorganisms. infection at its center. No bacteria are present in this zone.

Cardiovascular diseases are one of the main causes of Zone of stimulation: This zone has a severe dilution of

mortality in the developed world. The two cardiovascular bacterial toxins; this stimulates fibroblasts and osteoblasts to 20conditions that cause most deaths are ischemic heart disease produce an irregular bone matrix.

17and cerebrovascular disease. Bacteraemia in nonsurgical root canal treatment:

Dental professionals may be the first line of defense in the Bender et al. (1963) showed that endodontic procedures detection and referral of a patient suspected of having with instrumentation beyond the apex produce bacteraemia cardiovascular disease, an uncontrolled disease status, or in 31% of cases, but, when instrumentation was confined

14oral adverse drug reactions, and they have a key role to play within the tooth, blood cultures were negative.10 in oral and systemic disease prevention and treatment.

ENDODONTIC BIOFILMSThe Focal Infection Theory

Biofilm is defined as aggregate of microorganisms in which A focal infection is a localized or generalized infection caused cells that are frequently embedded within a self produced

-Consultation: Type of heart disease, time elapsed from the cardiological event, clinical

complications, treatment received.

· Take the prescribed medication as usual

· If nitrates are used, the patient should bring them

Ø Take as a preventive measure before local anesthesia

Ø Take in case chest pain develops

-Before 4-6 weeks after infarction: only emergency procedures.

-Very anxious patients: premedication (5-10mg of diazepam the night before and after 1-2 hours

before treatment.

-Anesthesia: not to inject into a blood vessel and a maximum of two carpules with vaso-constrictor.

Table No: 3 Dental management in patients with Ischemic heart disease.


matrix of extracellular polymeric substance (EPS) adhere to well transpire that random bacteraemia may be more 21 29each other or to a surface. causative in IE than dental surgeons carrying out treatment.

BIOFILMS IN ENDODONTIC INFECTION: Antibiotic prophylaxis (AP) may be defined as the use of an 22 antimicrobial agent before any infection has occurred for the Endodontic bacterial biofilms can be categorized as :

purpose of preventing a subsequent infection (Gerding 1996, · intracanal biofilms,

Titsas & Ferguson 2001). · extraradicular biofilms,

Bacteraemia is usually eradicated by the reticulo-endothelial · periapical biofilms and system within a few minutes and poses no threat to the

healthy patient. However, some medically compromized · biomaterial-centered infections.patients may be at risk from this transient blood-borne

Intracanal microbial biofilmsinfection, mostly infective endocarditis (IE) (Dajani et

They are microbial biofilms formed on the root canal dentin al.1997). 23of an endodontically infected tooth Major bulk of the

Thus, implementation of antibiotic prophylaxis (AP) has been organisms existed as loose collections of filaments,

advocated widely in an attempt to provide some degree of 21spirochetes.17protection for 'at-risk' patients.

Extraradicular microbial biofilmsEFFET OF PULP ON PERIODONTAL TISSUES

They are also termed as root surface biofilms which are Tissues of dental pulp and periodontium are interlinked from

formed on the root surface adjacent to the root apex of 30the embryonic stage.24 endodontically infected teeth. Extraradicular biofilms are

Pulp communicates with periodontal ligament via the apical reported with asymptomatic periapical periodontitis and in 25 foramen, auxiliary canals and dentinal tubules. The first chronic apical abscesses.

indication of periodontal involvement as a sequelae to pulp Periapical microbial biofilms

involved is the thickening of periodontal ligament space at They are isolated biofilms found in the periapical region of the apical end. Root canal system” is a complex anatomical endodontically infected teeth. These microorganisms have space within the root of the tooth. Main canals terminate in

2631 the ability to overcome host defense mechanisms. the PDL at an exit point close to the end of the root. When

Biomaterial-centered infection the pulp begins to break down, the bacterial by-products of

cellular necrosis egress from within the root canal system Biomaterial centered infection is caused when bacteria through the POE's into the surrounding PDL and bone. These adhere to an artificial biomaterial surface and form biofilm

27 toxins in turn will destroy the healthy peri-radicular tissues structures. In endodontics, biomaterial-centered biofilms 31and create bone loss. form on root canal obturating materials.

Relationship of cardiovascular disease and periodontitisBACTEREMIA

Periodontitis has been proposed as having an etiological or Bacteria were first demonstrated scientifically in the 10modulating role in cardiovascular diseases . Aerobic and diseased dental pulp by Miller (1894). William Hunter (1900)

anaerobic bacteria are the microorganisms found in theorized that microorganisms present in the oral cavity periodontal disease. The chronic activity of bacteria, their could disseminate throughout the body, resulting in systemic

22 toxins, followed by a host immune response, lead to a disease.progressive failure of periodontal attachment. The pro-

Dissemination of oral microorganisms into the bloodstream inflammatory cytokines TNF-alpha, IL-1beta, and gamma

is common, in less than 1 min after an oral procedure, interferon as well as prostaglandins reach high tissue

organisms from the infected site may have reached the heart, concentrations in periodontitis. The periodontium can 28lungs, and peripheral blood capillary system.therefore serve as a renewing reservoir, which can enter the

13 There are more than 10 microbes on all surfaces of thebody. circulation and induce systemic effects. Periodontal disease In the oral cavity there are several barriers to bacterial is believed to provide inflammatory cytokines, which

2penetration from dental plaque into the tissue: a physical promote atherosclerosis and thrombotic events. barrier composed of the surface epithelium; defensins,

Relationship of cardiovascular diseases with apical 28which are host-derived peptide antibiotics.

periodontitisIn many instances the occurrence of endocarditis does not

Apical periodontitis is a sequel to endodontic infection and relate to the so-called dental-induced bacteraemia. It may

develops as the host response to microbial infection that

.


32comes from the root canal system of the affected tooth. Guidelines

Endodontic infection that leads to apical periodontitis is Various guidelines have been proposed for AP, although it has caused by a mixture of oral bacterial species also found in not been possible to perform controlled clinical trials in dental plaque, dominated by obligate anaerobes. human beings to establish their effectiveness, because of

The proximity to the bloodstream of micro flora present in ethical issues of withholding AP from patients. Current

the root canal and periapical tissues can cause a transient guidelines from the British Cardiac Society (BCS) (Ramsdale

bacteremia during clinical dental procedures. Normally, et al. 2004), the AHA (Dajani et al. 1997) and the BSAC (Gould

microorganisms penetrated into the blood stream are et al, 2006) differ with regard to which antibiotic regimens 14eliminated by the host within minutes. However, it is known should be prescribed and for which dental procedures.

that in patients with valvular heart disease, a transient BSAC guidelines for antibiotic prophylaxis:bacteremia may lead to infective endocarditis and

1. Conditions predisposing to risk of infective endocarditis2myocardial infarction.· History of infective endocarditis

Endo-perio lesions· Ventricular septal defect

The pulp-periodontal interrelationship is a single or biologic · Patent ductus arteriosusunit in which there are so many paths of communication.

They can get affected individually or combined. Endodontic- 2. Patients not at risk from infective endocarditisperiodontal problems are responsible for more than 50% of · After coronary by-pass surgery

33tooth mortality today.· Six months after surgery for-

There are various pathways for the exchange of infectious Ø Ligated ductus arteriosus

elements and irritants from the pulp to periodontium or vice Ø Surgically closed atriolar ventricular septal defectsversa, leading to the development of endodontic periodontal

lesions. 3. Special risk patients

1. Pathways of developmental origin: *Apical foramen, Ø Those who require a general anaesthetic and have a accessory /lateral canals *Congenital absence of cementum prosthetic heart valve or are allergic to penicillin or who had

penicillin more than once in the previous month.2. Pathways of pathological origin: *Empty spaces created by

Sharpey's fibers *Root fracture following trauma American Heart Association Guidelines for antibiotic *Idiopathic root resorption - internal and external prophylaxis:

3. Pathways of iatrogenic origin: *Exposure of dentinal 1. High risk categorytubules * Accidental lateral root perforation *Root fractures

· Prosthetic heart valvesduring endodontic procedures.

· Previous bacterial endocarditisIt is easier to determine the origin of the lesion when a pulp

2. Moderate risk categoryvitality test is positive because this will rule out an

· Most other congenital cardiac malformationsendodontic etiology. However, pulp tests may not be always

reliable. If pulpal necrosis is associated with inflammatory · Hypertrophic cardiomyopathyinvolvement of the periodontal tissue, it presents a greater

3. Neglible risk categorydiagnostic problem. In this situation, the location of these

· Isolated secundum atrial septal defectpulpal lesions is most often at the apex of the tooth, but they

may also occur at any site where lateral canals exit into the · Previous coronary artery by-pass graft surgery33periodontium. Dental procedures for which antibiotic prophylaxis is

ANTIBIOTIC PROPHYLAXIS recommended to prevent infective endocarditis (AHA 29recommendations):Prophylaxis is recommended in all the dental procedures

involving the manipulation of gingival tissue, periapical Dental extractions

region or the perforation of the oral mucosa such as Periodontal proceduresextractions, endodontic treatment.

Dental implant placement Endodontic instrumentation or Prophylaxis in turn is not recommended in the routine surgery beyond the apex injection of anesthetic solutions in non-infected tissues,

Possible risks associated with antibiotic prophylaxis:dental X-rays or bleeding secondary to lip or oral mucosa

34 When antibiotics are given prophylactically to prevent traumatism.


Infective Endocarditis (IE), the clinician needs to consider the Management: Consultation with the supervising physician is

risk and cost benefit of such treatment. The most significant advised in order to know the current condition of the patient

adverse event associated with the penicillins is and the type of arrhythmia involved, as well as the 46hypersensitivity reactions. These can range from a medication prescribed. Anxiolytics can be used to lessen

troublesome rash to a life threatening anaphylactic stress and anxiety. It is very important to limit the use of a 29reactions. vasoconstrictor in local anesthesia. Sublingual nitrites are to

be administered in the event of chest pain. The patient The chance of a penicillin reaction following administration should be placed in the Trendelenburg position. The dental of the drug is in the range of 0.7–5 %.However, high doses of

team should be prepared for basic cardiopulmonary oral amoxycillin can cause an allergic rate similar to 41

36 resuscitation.intramuscular penicillin. Patients receiving penicillin

(amoxycillin) prophylaxis to prevent IE are 5 times more likely HEART FAILURE

to die from an anaphylactic reaction to the drug than to die Heart failure (HF) is defined as the incapacity of the heart to from contracting endocarditis. function properly, pumping insufficient blood towards the

The World Health Organisation has recognised antimicrobial tissues and leading to fluid accumulation within the lungs, 37 41resistance as a global problem. Approximately one third of liver and peripheral tissues.

all antibiotics are prescribed for prophylactic purposes and a Management: Dental treatment is to be limited to patients 38high proportion of these are for prevention of IE. who are in stable condition. Anxiety and stress are to be

The continued and repeated use of prophylactic antibiotics avoided during the visits. The patient should be placed in the

has caused selection of antimicrobial resistance in oral semi-supine position in a chair. In patients administered 39 digitalis, the vasoconstrictor dose is to be limited to two streptococci. Overprescribing of antimicrobials has made

40 anesthetic carpules. Aspirin can lead to sodium and fluid some antibiotic regimens less effective.

retention, and therefore should not be prescribed in patients DENTAL CONSIDERATIONS IN PATIENTS WITH HEART 41with heart failure.DISEASES

INFECTIVE ENDOCARDITISPatients suffering from cardiac diseases like ischemic heart

Infectious endocarditis (IE) is an infrequent condition disease, valvular disease are prone to angina or myocardial 35 resulting from the association of morphological alterations infarction.

41of the heart and bacteremia of different origins. Infective ISCHEMIC HEART DISEASE:endocarditis is a serious problem, with an estimated

Ischemic heart disease is the main cause of death in the incidence of 1.5-3.3 per 1000 intravenous drug abusers and

41developed world. This is characterized by a reduction in 475-10% mortality rate.coronary blood flow followed by thrombus formation that

Management: According to the European Society of occludes the arterial lumen. Angina is often precipitated by Cardiology and American Heart Association, antibiotic physical activity or stress and may radiate to the arm or jaw therapy of IE relies on monotherapy or combination of or may present as facial or dental pain. Fear and anxiety bactericidal drugs active on the microorganism involved, associated with a dental procedure may be a precipitating

42 administered intravenously, at high dosage and for up to 6 factor for angina in some patients. Chest pain (angina) weeks.occurs when coronary occlusion is partial and no necrosis is

CONCLUSIONproduced, while acute myocardial infarction is observed

when coronary occlusion is total and necrosis is produced as Unfinished RCTs are associated with a higher risk of CVD 43a result. hospitalization. An RCT can be left unfinished for several

reasons, including symptomatic teeth infected with gram-Management: Treatment for patients with ischemic heart 48negative anaerobic bacteria. The root canal flora of teeth disease should include morning appointments, short

with clinically intact crowns and necrotic pulps is dominated appointments, oral premedication with an anxiolytic drug or 49by obligate anaerobes. These microbes can indirectly nitrous oxide or oxygen sedation, limited use of

50 44 elevate inflammatory mediator levels and cytokines. vasocontrictors.

An unfinished RCT, involving a temporary restoration, can ARRHYTHMIAS

increase the risk of contamination of the oral cavity, leading Arrhythmias are variations in normal heart rate due to 45 to bacterial infection of the root canal system and apical cardiac rhythm, frequency or contraction disorders . Atrial

46 periodontitis when the inflammation progresses to the fibrillation is the most common type of cardiac arrhythmia.


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DENTAL DILEMMA-13

Dr Ramandeep S Narang, Professor & Head, Department of Oral Pathology & Microbiology, SGRD Institute of Dental Sciences and Research, Sri Amritsar.Dr.Balwinder Singh, Senior Lecturer, Department of Oral Medicine & Radiology, SGRD Institute of Dental Sciences and Research, Sri Amritsar.Dr.Adesh S Manchanda, Reader, Department of Oral Pathology & Microbiology, SGRD Institute of Dental Sciences and Research, Sri Amritsar.

QUESTION:

A 48 year old male complained of pain and bleeding from gums. Intra- oral examination showed diffuse

erythematous area involving free gingival margin of maxillary and mandibular teeth. The erythematous area

involved both anterior and posterior teeth bilaterally, which was suggestive of desquamative gingivitis. (Fig.1)

Histopathological examination revealedsubepithelial split in the epithelium and connective tissue was

infiltrated with chronic inflammatory cells.(H&E; X10).(Fig.2)

Identify the condition?

Answer to DENTAL DILEMMA 12 :-Ameloblastoma.

Figure1 Figure2.( H&E 10x)

comparative efficacy of tea tree oil nanoemulgel and...

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